Cross Validation of the Moorehead-Ardelt Quality of Life Questionnaire II with WHOQOL and SF36 andClinical Application

1

Bariatric & Metabolic International Surgery Center,E-Da hospital,Taiwan 2Department of Internal

Medicine,E-Da hospital,Taiwan
Huai-Ching

Kuo1,Chi-Hsien Lo1,Chih-Kun

Huang1,Chi-Yang

Chang2

Background: Obesity has become a major worldwide public health issue. There is a need for tools to measurepatient reported bariatric outcomes. The Moorehead-Ardelt Quality of Life Questionnaire II (MA-II)
contains six items. The objective of this study was to translate the MA II into Chinese and validate
it in patients with morbid obesity.
Methods: The MA-II was translated into Chinese and backtranslated into English by two language specialists
to create the Taiwan version, which was validated by correlations with two other generic questionnairesof health-related quality of life (HRQOL), Medical Outcomes Study 36-Item Short-Form Health Survey(SF-36), and World Health Organization Quality of Life (WHOQOL)-BREF Taiwan version. The convergent
validity was accomplished by a series of Spearman rank correlations. Reliability of the MA-II Taiwan
version was determined by internal consistency obtained by Cronbach alpha coefficient and test-retest
reliability obtained by intraclass correlation coefficient.
Results:One hundred subjects with morbid obesity were enrolled to test the MA II Taiwan version convergent
validity and internal consistency. Test-retest studies (2 weeks apart) were applied to 30 morbidly obese
patients. Satisfactory internal consistency was demonstrated by a Cronbach alpha coefficient of 0.79.
Good test&-retest reliability was shown by intraclass correlations ranging from 0.73 to 0.91. The totalsum of MA-II scores was significantly correlated with all four domains of the WHOQOL-BREF and two major
components of SF-36 . All six MA-II items showed significant correlations with each other , and totalsum of MA-II scores was negatively correlated with body mass index , indicating a one-dimensionalquestionnaire of HRQOL.
Conclusions:The MA-II Taiwan version is an obesity-specific questionnaire for QOL evaluation withsatisfactory reliability and validity. It has the advantages of extensive evaluation for HRQOL,
cross-cultural application, rapid completion, high response rates, and an advanced scoring system.

Change in Quality of life at 12 months after Bariatric Surgery in Morbidly Obese patients

1

The Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan

Kazuko Sonoda1,Kazunori Kasama1,Yosuke Seki1,Hideharu Shimizu1,Kikkawa Eri1,Tetsuya Nakazato1,Toshie
Shiraishi1

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard method in BariatricSurgery. However, considering that gastric cancer is one of the most common diseases in Asia, Kasama
has introduced Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass (LSG/DJB). Now LSG/DJB isbecoming an effective procedure for the treatment of morbidly obese patients in Japan. In this study,
we compared Quality of Life (QOL) and excess weight loss (EWL) 12 months after LRYGB and LSG/DJB.MethodsWe
compared 38 patients who under went LRYGB (Group B) and 25 patients who under went LSG/DJB (Group SB)
between June 2006 and March 2009. QOL factors assessed were Social Life, Confidence, Figure, Depression,
Healthiness, Activity and Exercise. We had given Q&A sheets to the patients and asked them to evaluate
their improvement in these factors. We have created an Improvement Score from 1 to 5 (5 being

the best

condition). We have also analyzed EWL in both groups.Results12 months after surgery, all QOL factors
were improved in both groups. There was no significant difference in mean score of QOL in all factors
between Group B and Group SB. There was no significant difference in EWL between both groups.
ConclusionLRYGB is considered to be the most popular procedure in Bariatric Surgery, but we suggest that
LSG/DJB could also be an effective procedure from a view point of QOL and EWL.

An Individual Surgeon versus a Team Approach: Surgical Outcomes of Laparoscopic Roux-en-Y Gastric Bypass

1

E-Da Bariatric & Metabolic International Surgery Center

Ya-WeiHuang1,Chi-Hsien Lo1,Chih-Kun

Huang1

Purpose: Laparoscopic Roux-5 en-Y gastric bypass (LRYGB) has been shown to improve both the health andquality of life of morbidly obese patients. We studied to compare the efficacy and safety of using ateam approach to LRYGB versus an individual surgeon.Materials and Methods:Data were retrospectively
collected from 200 consecutive patients undergoing LRYGB for morbid obesity between August 2005 andFebruary 2008. Group I (GI) and Group II (GII) included 50 patients who underwent surgery and were cared
for by the same surgeon. Group III (GIII) included the next 100 consecutive patients, who underwent LRYGB
by the same surgeon, but were cared for by a dedicated bariatric team.Results: Among the 76 males (38%)
and 124 females (62%) in the study, excess weight loss at 1and 3 months follow-up did not differ; however,it was significantly different at 6 months and 12 months. At mean follow-up, 30% in GI, 6% in GII, and
8% in GIII experienced complications. Most complications in the GI group occurred early and were related
to surgical technique, while in groups GII and GIII, complications related to technique were markedly
reduced. Males were 4.57 times as likely as females to have complications related to bariatricsurgery.Conclusions: A team-based approach is a better option for patients undergoing LRYGB than is caredby a single surgeon. With an experienced bariatric surgeon, the team approach resulted in shorter
operative times and hospital stays, better weight loss without increased complications.

Difference Between Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Regarding Weight Loss
Effect and Amount of Food Intake According to Level of BMI

Yotsuya Medical CubeEri Kikkawa , Kazunori Kasama , Yosuke Seki , Hideharu Shimizu , Tetsuya Nakazato , Kazuko Sonoda<Background>Laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients is gaining popularity in Japan. It’s
indications and long-term results are currently under evaluation, whereas laparoscopic Roux-en-Y gastricbypass (LRYGB) is the golden standard procedure with good long term outcomes. In addition, some articles
reported that LSG could not lead to sufficient weight loss for super morbid obesity. This study aimed
to compare the difference of excess weight loss (EWL) and amount of food intake of patients with BMI< 50 or ≧ 50 between LSG and LRYGB.
<Methods>
For this study, 123 patients who underwent LRYGB (48patients) or LSG (75 patients) were retrospectively
analyzed for 24 months after surgery. There are 101 patients with BMI < 50 in LSG group (n=60) or LRYGB
group (n=41), and 22 patients with BMI ≧ 50 in LSG group (n=15) or LRYGB group (n=7). We compare the
EWL and the amount of food intake after LSG to those after LRYGB according to BMI. We analyzed the amountof food intake by means of diet recall and a questionnaire.

We defined the preoperative amount of foodintake as 100% and calculated the rate of change after surgery.
<Results>
As for BMI < 50, the percentage of EWL and the rate of change of food intake at 24 –month follow up point
were 81.7% and 52% in LSG group and 82.8% and 47% in LRYGB group. As for BMI ≧ 50, the percentage of
EWL and the rate of change of food intake at 24-month follow up point were 29.8% and 54% in LSG group
and 62.3% and 58% in LRYGB group. This data show that the EWL of patients with BMI≧50 after LSG at 24-monthfollow up point is not comparable to the other results, but the rate of change of food intake of thesame group is comparable.
<Conclusion>
As for BMI≧50, we need to restrict the amount of food intake after LSG more than LRYGB for the purposeof bettering the EWL. However, it means that LSG can be a standalone procedure for morbidly obese patientswith BMI<50 as well as LRYGB, but LSG is not expected to be performed as a solo procedure for the patientswith BMI≧50.

Evaluation of the Clinical Pathway for Laparoscopic Bariatric Surgery

1

The Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, JapanMai Yamashita1,Kanako Yuasa1,Hideharu

Shimizu1,Yosuke Seki1,Kazunori Kasama1,Megumi Tanimura1<Background>Clinical Pathways (CPs) are comprehensive systematical patient care plans for specificprocedures. The CPs for morbid obesity were implemented in our department in February 2006. The aim of
this study is to evaluate the CPs for laparoscopic bariatric surgery.<Methods>The CPs were applied to
the 189 patients who underwent bariatric surgery. The assessment criteria included degree of compliancewith hospital stay, indicators of clinical care effectiveness, and comparison with the other CP reported
in Pubmed.<Results>Fig. shows the number and rate of noncompliance with hospital stay in different
bariatric procedures. The only reason for noncompliance with hospital stay was patient-dependent causes.
There was no staff-related or institution-related reason. This result was almost similar to that reported
in the past from Spain.<Conclusion>Our data show that compliance with hospital stay depends on the
difficulty of bariatric surgery. From the point of view of the reason of noncompliance with hospitalstay, clinical pathway which is controlled by a team with a wide experience in bariatric surgery canoffer our patients with morbid obesity bariatric surgery with the smallest possible range ofcomplications.

Singaporean Asian Patients have paradoxically higher rates of vitamin D deficiency compared to Western
Patients

1

Department of Endocrinology, Singapore General Hospital, Singapore 2Department of Surgery, Singapore

General Hospital
Daniel C. Wai1,Shanker Pasupathy2,Sonali Ganguly1,Kwang W. Tham1

Background: Vitamin D deficiency has been reported in between 57% to 65% of patients in Western countries
before bariatric surgery and can drop further after surgery, resulting in metabolic bone disease. No
studies have however reported vitamin D (vit-D) levels in patients before bariatric surgery in tropical
Singapore. Aims of Study: To retrospectively investigate vit-D and intact parathyroid hormone (iPTH)
levels in obese patients immediately before undergoing bariatric surgery in a tertiary hospital.Methods:
Baseline patient characteristics, preoperative Vit-D and iPTH levels were studied together with its
relationship to race, gender and body mass index (BMI). Results were presented as mean (standard
deviation).Results: 46 patients underwent bariatric surgery. 61% were female. There were 44% Chinese,
26% Malay, 24% Indian, and 7% were of other ethnicity. 78% had laparoscopic sleeve gastrectomy, 20%
Roux-en-Y gastric bypass, and 2% bilio-pancreatic diversion. The mean age was 39 (10.6) and the mean
BMI was 43.6 (9.8). The mean of vit-D was low at 17.4 ng/ml (8.6). 75% were deficient (<21 ng/ml), 21%
were insufficient (21-29 ng/ml), and only 4% had sufficient vit-D (>29 ng/ml). Mean iPTH was low at 6.5
pmol/l (3.5). 50% of the patients had raised iPTH. Vit-D levels were inversely correlated with BMI(r2=0.242, p=0.008). Non-Chinese patients had higher BMI (46.3 vs 40.0, p=0.032), lower vitamin D levels(13.6 vs 23.2 ng/ml, p=0.002) and higher iPTH (8.7 vs 4.4 pmol/l, p=0.007). Those were not different
between males and females.

Conclusion: The majority of obese patients, especially Malays and Indians,

had deficient and insufficient vit-D levels even before bariatric surgery. Alarmingly the proportionof patients deficient was higher than in Western countries despite the fact that Singapore has sunshine
all year round. Physicians in tropical countries therefore should routinely screen for its deficiency
preoperatively with appropriate repletion.

A Simple Clinical Scoring System to Identify Patients at Risk of NASH Before the Development of NASH

1

Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide, Australia 2Department

of Digestive Surgery, Osaka Medical Centre for Cancer and Cardiovascular Diseases, Osaka, Japan
Jacob A Chisholm1,Yosuke Seki2,James Toouli1,Jurgen Stahl1,Jane Collins1,Lilian Kow1

Background

Nonalcoholic fatty liver disease (NAFLD) is common in the morbidly obese. It is a condition

that can lead to progressive fibrosis and cirrhosis. A clinical scoring system to identify patients
predisposedtofibrosiswouldassistinselectingpatients

for

liver

biopsyandfurthermanagement.Methods Liver biopsies were taken from 370 consecutive patients who underwent laparoscopic
bariatric surgery. Clinical and biochemical parameters were then assessed for correlation withhistological features of non-alcoholic fatty liver disease.Results Sixty eight patients (18%) were foundto have non-alcoholic steatohepatitis (NASH). Raised insulin resistance, ALT and total bilirubin wereindependently associated with NASH. The presence of at least 2 of the 3 provided the best combinationof sensitivity (0.71) and specificity (0.71) for predicting NASH.Conclusion Raised insulin resistance,
ALT and total bilirubin are clinical indicators for the presence of NASH prior to the development offibrosis.

Bariatric surgery improves arterial stiffness of the patient with metabolic syndrome1

Department of Rehabilitation, Kamagaya General Hospital, Chiba, Japan 2Department of Diabetes andEndocrinology, Saitama Medical University, Saitama, Japan
Juntendo University Graduate School of Medicine, Tokyo, Japan3

Department of Ageing Control Medicine,
4

Department of obesity surgery, Kamagaya

General Hospital, Chiba, Japan
YuichiShinoda1,Ikuo

Inoue2,Takuji

Shirasawa3,Isao

Kawamura4

Obesity is an independent predictor of cardiovascular risk. Increased arterial stiffness, as reflectedby an increased pulse wave velocity (PWV), is significantly and independently associated with higher
risk for cardiovascular morbidity and mortality. According to recent reports, individuals with obesity
are likely to have an increase in aortic stiffness, independent of blood pressure (BP) level, ethnicity,
and age.

A 60-year-old Japanese woman with obesity (BMI 45.5) and metabolic syndrome was referred tous. Her diabetic status is under control after bariatric surgery. The PWV decreased significantly after
treatment (1528 vs 1211cm/sec) with reduction of visceral fat (100 vs 52 cm2). The bariatric surgery
could improve arterial wall stiffness in patients with metabolic syndrome. The pathophysiologic
mechanisms that link abdominal adiposity to arterial stiffening are should be investigated.

Case study : Partial Situs Inversus in a Morbidly Obese Female.
Sanjay Borude
Introduction
A 32 years old female presented with off & on mid chest pain and Morbid Obesity (BMI 41.41Sq.
Mtrs) & secondary infertility. One FTND & she had a h/o ? liver problem.
MethodCT Chest/Abd/Pelvis showed Enlarged Mediastinal Lymph nodes and Partial Situs Inversus since
there was no Dextr-Cardia.
Ba Meal FT also showed Situs Inversus. Haematology, Biochemistry, ECG, 2D Echo, Chest X-ray
were normal.
Patient planned for a Sleeve Gastrectomy in a supine reverse Trendenburg’s position. Primary
surgeon stood on the left of the patient. Camera 12 mm port in the supra-umbilical region, 12mm port in the line of umbilicus in (L) mid-clavicular line, 5 mm port right epigastrium forliver retraction, another two 5 mm working ports either side of the mid abdomen.
Intra-operative findings: Large stomach on the right of abdomen, Liver extending from left toright, Spleen in the RHC region. Devascularisation of the greater curvature started fromabout 6 cms from the Pylorus to the right crus. Stomach resected with 32 F Bougie in thestomach. Staple line burried with 2-0 Ethibond suture. Abdominal drain placed. Ryles tube
placed in the stomach.
ResultPatient’s recovery was uneventful. Patient started on oral liquids 20 hours after thesurgery. Ryles tube was removed after 24 hours and drain after 30 hours.
Conclusion
Patient was totally asymptomatic so far GI tract was considered. It was only the surgicaltask for the surgeon because of the “Mirror-Image” effect.

Laparoscopic Revisional Gastric Bypass after open bariatric surgeries

1Surgery Department, Riyadh Military Hospital, Riyadh, Saudi Arabia

Haider Alshurafa1

Objective: To confirm the feasibility of the laparoscopic revisional gastric bypass after open failed
bariatric operations.Method: Retrospective review of all patients who have underwent revisional gastricbypass after open bariatric operations, all of these operations were done by the author.Results: The
were 56 patients over 5 years had revisional gastric bypass, 28 patients had previous open bariatric
operations. They form 6% of all the patients who have underwent laparoscopic gastric bypass by the author,
50% of these were post open bariatric surgeries. Only 4 patients had converted to open procedures, one
was started open and it was at the early of the author experience. 55 patients were started laparoscopic
and 3 were converted to open due to sever adhesions, they were also in the early experience. Out of fpost open bariatric operations, 21 patients have failure to lose weight and/or weight regain, 4 patients
have complications, and 3 patients have both failure to lose weight and complications. There were no
mortality and no leakage. Only one patient have needed laparoscopic re-exploration due to twisting at
the jejuno-jejunal anastomosis three days post operation. There were only 8% minor complications, likewound infections, self controlled bleeding.Conclusion: Laparoscopic revisional gastric bypass is
feasible after open bariatric surgeries but these types of operations have high surgical skills demandand carry higher risks for the complications.

Revisional endoscopic surgery after gastric bypass

1

Bariatric surgery, University Hospital Brugmann , Brussels , Belgium 2monika lybeer

alex M.F. heylen1,monika E.B. Lybeer1

The importance of the restrictive component of gastric bypass procedures is well recognized.Dilatationof the pouch-outlet , the pouch volume itself
bypassare three factors

and the presence of a gastro-gastric fistula after gastricresponsible for substantial weight gain, volume per meal increases, rapid

pouch emptying invites for binge-eating. Revisional surgery should be avoided by doing the first operation
as it should , but if necessary it is often difficult and prone to at least double the morbidity of the
primary operation and with unknown long term results. Narrowing the stoma size , closure of a gastrogastricfistulaendoscopically with the OTSC clip is a very effective and safe alternative.Presentation of astudy on 118 patientsendoscopically treated either for stoma dilatation or gastrogastric fistula

between october 2008 and june 2009

Validity of sleeve gastrectomy for band failures

1

Al Taie center for laparoscopic and Obesity surgery,Dubai,UAE

Abdulsalam S. Al Taie1

Introduction:

Gastric banding is the one of the main restrictive procedures among the bariatric

operation. sleeve gastrectomy proved to be more than just a restrictive operation,and

proved to be

successful for patients who had failed to lose their weight with banding.Patients and Method: 52 patientswere included in this study. All had their bands done More than a year earlier.
Mean age 28( 18 -52).31 female and 21 male. theymean BMI

41 (38-49).

were with no significant co-morbidities. All had sleeve

gastrectomy done along with the removal of the band at the same session . The band was removed, thetunneling sutures is removed and the fundus was stretched back to its original anatomy after the excisionof the peri gastric fibrous ring at the band site. Then sleeve gastrectomy is performed in the usual
way using endo GIA stapling devise and we suture the proximal staple line with 2/0 vicryl . The
upfollow

ranges from 1 to 4 years (19)(14)(11) and (8) patients respectively.Results: There was no major

morbidity( Gastric leakage) ,no mortality, 3 wound infections, 1 chest infection. No convertions tolaparotomy. Mean hospital stay 3 days(2-4). At the end of the first year following the operation all
had significant weight loss 35-45% of the EBW. At 2 year 33 patients have lost 55% of the EBW. By thethird year 19 patients had 55% EBW loss,At 4 years 8 patients lost 65% of their EBW.Conclusion: Sleeve
gastrectomy can be regarded as a salvage procedure for band failure patients and sure it is more thana restrictive procedure , it is a valid metabolic operation and may be comparable to Gastric bypass forpatients with failed bands.

Laparoscopic pouch resizing, new gastro-jejunal anastomosis and strictly cardial adjustable band
placement for failed Gastric Bypass

1

General, Obesity, Endocrine and Oncologic Unit Centre Hospitalier de Dinant, Dinant , Belgium

Jean-Philippe M.m.K. Magema1,Virgil_A Dimbezel1,Isabelle_M Kellner1,Gael G Jacquemin1,Jean-P Boeur1

Bariatric surgery has developed and provides a great quantity of different procedures, some moreinnovative and still undergoing careful evaluation.We now face a growing number of long-term "failed"patients. For the RYGBP, literature usually rates from 20 to 35 %.Proximal pouch dilatation is a wellknown cause.We here describe a new approach: Laparoscopic pouch resizing, new gastro-jejunal anastomosisand strictly cardial adjustable band placement.To our knowledge this procedure has not been reported
in literature yet.A

58 years woman who underwent a LRYGBP surgery 3.5 years priorly, with primarily

good weight loss and resolution of type 2 diabetes, regained weight

and thus underwent this procedure.The

surgical technique, documented with patient s data, XR pictures and per-operative shootings, isdescribed.No early complications were reported. The patient is doing very well at 4 weeks follow-up.We
tend to gather more patients on more long term follow-up to assess scientific conclusions for what could
be an interesting "second chance" new procedure for those failed cases.

Laparoscopic Band Revision to bypass:A Single Stage procedure1

Department of Bariatric and Metabolic Surgery,Gem Hospital and Research Centre,Coimbatore,India

Praveen Raj1,Palanivelu Chinnusamy1

Background:As the number of Bariatric Surgeries increased, so did the number of Revisional Surgeries
too. As per the recent meta-analysis by Buchwald et al, the number of Bariatric procedures performedin Asia in 2008
Indians

is the least .As the number of procedures being done is on the rise , we Asians including

might have to start facing more number of Revisional Surgeries too.Video:In this High Definition

Video , we demonstrate one of our cases of a Laparoscopic Band Revision to bypass as a Single Stage
procedure for weight Recidivism in a 35 yr old Female.Steps:-The adhesions over the band was released,
the band was cut and removed along with the pseudo capsule after dividing the gastro-gastric sutures.-The
gastric pouch was created using linear staplers in the standard fashion and the anastamosis was doneusing standard limb lengths, 75cm biliopancreatic limb and 75cm alimentary limb.-The gastrojejunostomy
is being performed in antecolic fashion using linear staplers.-Mesenteric defects were closed as well.

Laparoscopic Revisional Roux en Y Gastric Bypass for Weight Recidivisim

1

Department of Bariatric and Metabolic Surgery,Gem Hospital and Research Centre,Coimbatore,India

Praveen Raj1,Palanivelu Chinnusamy1

Background:As the number of Bariatric Surgeries increased, so did the number of Revisional Surgeries.
As per the recent meta-analysis by Buchwald et al, the number of Bariatric procedures performed in Asia
in 2008is the least .As the number of procedures being done is on the rise , we Asians including Indiansmight have to start facing more number of Revisional Surgeries too. Roux en Gastric bypass is one procedure
with very few revisional alternatives.Video:In this High Definition video, we demonstrate a Revisional
Bypass for weight recividism , wherein the the large gastro-jejunal stoma was revised in a 22 yr old
female .The patient who on evaluation for weight recidivism was found to have a larger stoma than usualand hence had increased capacity to eat. Hence was taken for stomal revision by narrowing the stoma using
a linear staplers application over a 36 F bougie and excising a gastrojejunal sleeve thus narrowing thestoma. The patient is losing acceptable amount of weight postoperatively.

Bariatric Revision Surgeries
Sanjay Borude
Abstract
Introduction
REAL complications associated with the operation and SIDE EFFECTS associated with thealteration in the upper GI anatomy.
The preioperative mortality of bariatric surgery was 0% and worldwide is usually associatedwith
1. Anastomotic leaks with peritonitis (75%) or
2. Pulmonary embolism (25%).
MethodREVISION INDICATIONS - GASTRIC BAND SURGERY· Port Site Complications after GB· Port Leakage- Cracking of the kink-resistant tubing or Tube Disconnection· Port Site Pain
· Port Dislodging or Flipping· Bulging of the Port through the Skin
· Infection of the Fluid within the Band
· Infection of the Port – Either at Surgery or Band Fill or Erosion
REVISION INDICATIONS - SLEEVE GASTRECTOMY SURGERY· Pouch Enlargement· Staple Line Dehiscence· Stomach Perforation· Stricture· Volvulus
REVISION INDICATIONS - GASTRIC BYPASS SURGERY· Pouch Enlargement· Staple Line Dehiscence· Stricture· Perforation· Infection· Psychological· Associated Disease
Analysis
Early postoperative complications
·





PULMONARY EMBOLISM is the leading cause (1% to 2%) of perioperative death in bariatric
surgical patients.
The incidence of MAJOR WOUND INFECTION after gastric bypass ranges from 1% to 3%.
GASTROINTESTINAL BLEEDING within the 30-day perioperative interval may have a varietyof causes.
Small bowel obstruction (SBO) ranges from 1% to 2%
ACUTE GASTRIC DISTENTION

The incidence of intraoperative complications in our series 1.4%
Late complications







Incisional hernia (most common)
Symptomatic gallbladder disease ranges from 3% to 30%.
Vomiting.
The incidence of Late Staple-line breakdown varies from 2% to 23%.
Gastro-gastric fistulae after transsection ranges from 1% to 2%.
The incidence of marginal ulcer after RYGB ranges from 3% to 10%.

Conclusion
Complications following Bariatric Surgeries can be reduced to negligible if great care istaken Pre-Intra-and Post-operative period.

Preliminary Case Report on the Change in Metabolic Profile in Non-Obese Type 2 Diabetic Patients treatedwith Surgery in the Philippines

Dineros, Hildegardes C.

Background: The metabolic effects of bariatric surgery, particularly the remarkable resolution of TypeII DM are well established. Several mechanisms of action have been proposed in addition to weight loss
as the major factor causing such improvement in co-morbidities. The aims of this presentation are as
follows: 1. To describe a novel procedure, the Laparoscopic Sleeve Gastrectomy with Loop Duodeno-Jejunal
Bypass; and 2. To present the observed changes in metabolic panel in 3 patients before and after Metabolic
Surgery.
Methods:

From January 1, 2008 to December 31, 2010, three (62 and 56 y/o females, and a 43 y/o male)non-obese patients with medically uncontrolled Type 2 Diabetes Mellitus underwent Laparoscopic Sleeve
Gastrectomy with Loop Duodeno-Jejunal Bypass. Preoperative profile was taken and compared to 1,3, 6,
12 and 24 months.
Results: All 3 patients had 3 months follow-up data, 2 had 6 and 12 months follow-up data and 1 had 2
years follow-up data. Decrease in BMI ranged from 1-3 kg/m2.

Improvement of FBS, HbA1c was noted as

immediate as 1 month postoperatively with discontinued Oral Hypoglycemic medication and Insulin as earlyas 3 months after surgery. No surgical morbidities were noted.
Conclusion: Laparoscopic Sleeve Gastrectomy with Loop Duodeno-Jejunal Bypass can be performed safely.
There are multiple mechanisms for its euglycemic effect, a subject for further investigation.

Affiliations:
Department ofSurgery, St. Luke’s Medical Center, Philippines

Bariatric & Metabolic Institute, Cardinal Santos Medical Center, Philippines

Metabolic outcomes of bariatric surgery: a result from Thai Subjects

Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand 10330
Udomsawaengsup S, Tansawet A, Timratana P,

Prathanvanich P, Pungpapong S, Tharavej C, Navicharern P

Background: Obesity and its co-morbidities become to be one of the most important health care problems.
Weight loss surgery has been proved as the most effective and sustainable method to obtain long term
weight control and to achieve improvement of metabolic disorders. There are limited results contributing
from Asian subjects. We reviewed our metabolic outcomes of surgical treatment for morbidly obese patientsin our institute.
Methods: Data from all patients who underwent bariatric surgery in Chulalongkorn University werecollected and metabolic outcomes were reviewed.
Results:

From Jan 2003 to December 2010.

Fifty-five consecutive Thai patients underwent bariatricsurgery by the Chula Minimally Invasive Surgery Center. The mean age was 35.2 years (18-57 years). Twenty
four (56.4%) were men. The pre-op BMI was 49.2 kg/m.2 Roux en Y Gastric bypass was the most common procedure(78%). In RYGB group showed mean EWL of 64.2% at 2 years. 20 of 55 (36.3%) were type II diabetic, allof them were getting improvement post operatively; of which, 81.8% were completely resolved and 18.2%
were able to decrease dosage of hypoglycemic drugs.

28 of 55 (50.9%) were hypertensive, 46.7% of themwere able to discontinue antihypertensive drugs and 46.7% were decreasing dosage. 19 of 55 (34.5%) weredyslipidemia; 60% were resolved and 40% were improved.
Conclusion: Metabolic results in Thai patients undergoing bariatric surgery are excellent. This initial
data from Thai subject reflects a comparable result worldwide.

Comparison Between the Effects of Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric
Bypass on Type 2 Diabetes Mellitus in Morbidity Obese Japanese Patients: A Retrospective 1 Year Study

1

The Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan

Hideharu Shimizu1,Yosuke Seki1,Eri Kikkawa1,Kazuko Sonoda1,Tetsuya Nakazato1,Kazunori Kasama1<Background>Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides sustained weight loss and leads towell-documented remission of Type 2 diabetes (T2DM), whereas data on the effectiveness of laparoscopic
sleeve gastrectomy (LSG) on T2DM are scarce<Methods>We conducted a retrospective study on the therapeutic
effect on type 2 diabetes and biochemical characteristics in 16 morbidly obese T2DM subjects undergoing
LSG and 24 subjects undergoing LRYGB before and at 1, 3, 6, 12 months after surgery, matched for age,gender, BMI, fasting plasma glucose, HbA1c, insulin, C-peptide, HOMA-IR, DM duration<Results>The
preoperative median BMI was 40.8 kg/m2 in the LSG group and 44.9 kg/m2 in the LRYGB group and as for
T2DM, most subjects were not severe type from their history and biochemical markers. The percentage ofexcess weight loss at the 1, 3, 6, 12-month follow up points after LSG and LRYGB were 28.8 and 27.8,
46.2 and 47.0, 64.2 and 63.9, 74.2 and 71.8%, respectively. The remission rate of T2DM at the same follow
up

points

after

LSG

and

LRYGB

were

38

and

35,

75

and

73,

87

and

93,

93

and

100%,

respectively.<Conclusion>For not severe T2DM in Japanese morbidly obese Japanese patients, thetherapeutic effect of LSG and LRYGB on T2DM was comparable at 1-year interval.

Laparoscopic Duodenojejunal bypass with Sleeve gastrectomy- A novel procedure for resolution of Metabolic
Syndrome in patients with BMI <32.5:

1

Gem Hospital and Research Centre,

Praveen Raj1,C Palanivelu1

Background:Type II DM resolution in morbidly obese patients following Metabolic Surgery suggests thesemight benefit even non-morbidly obese patients with Metabolic Syndrome. Available literature favours
Combined Restrictive/Malabsorptive procedures over the others in control of Diabetes and otherco-morbidities. Laparoscopic Duodenojejunal bypass with Sleeve gastrectomy is one such procedure
performed in our series.Methods:Patients with < 32.5BMI, confirmed to be Type IIDM with HbA1C >7.5 were
included in the study. Patients with Sliding Hiatus Hernia and C-peptide levels < 1 were excluded.
Laparoscopic Duodenojejunal bypass was done in a retro colic fashion, anastomosis being done end-end,
single layer suturing with a 60 F Sleeve.Results:A total of 14 patients (8 women, 6men) included in the
study were prospectively evaluated. The mean age was 36.5yrs.The mean pre-operative BMI, (Fasting Blood
Glucose) FBG and HbA1C was 29.9,196.4mg/dl and 8.2%.The postoperative BMI,FBG and HbA1C at the end of
6mts and 1 year was 25.4,110.2,6.3% and 24.2,106.4,6.1% respectively. 12 out of 14 patients had complete
remission and 2 had reduced medication use.4 out of six patients who had Hypertension had complete
remission, 2 had no improvement. Conclusion:Laparoscopic Duodenojejunal bypass with Sleeve, which
combines the principles of Sleeve Gastrectomy and Foregut hypothesis, is an effective procedure forresolution of Diabetes and other co-morbidities even in lower BMI population. The stomach remnant isamenable to endoscopic surveillance for Carcinoma Stomach. Also with the possibility of altering thesize of the Sleeve, the procedure can be made less restrictive which is best suited for a country like
India with a low calorie-higher quantity food intake pattern, hence preserving the quality of eating.

SLEEVEGASTRECTOMY : METABOLIC AND BARIATRIC SURGERY

M.S., DLS(India), DLS(France), FAIS , Fellow

A

BLESSING FOR THE ASIANS:Bariatric surgery ,Cleveland Clinic ,USA

Institution : Ruby Hall Clinic , Pune , India .
Jayashree Todkar:

Dr L H Hiranandani Hospital , Mumbai, India .

1

OBESITY---GLOBALEPIDEMIC

 Pro-atherogenic disease

(WHO)
with

Dysmetabolic

stateSouth Asians around the globe have highest rate of Coronary Arterial Disease (CAD ) .
 There would be around 62 million pts of CAD

in India by 2015 and out of these 23 million would

be pts lesser than 40 yrs of age.
DM BURDEN IN INDIA Approx. 43 million adults are Diabetics
 Estimated to increase to 57.2 million by 2025.
Asian Consensus•

Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for
Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management:Normal BMI: 18.0-22.9 kg/m2,
Overweight: 23.0-24.9 kg/m2,
Obesity:> 25 kg/m2

JAPI

2009.
More CVD ,DMrisk at lower BMI

DIS-SENSITIVITY ,INDIANA

EXPERIENCE

in Asian population are due to : 1- BODY COMPOSITION, 2- INSULIN

3- CENTRAL DISTRIBUTION OF FAT.
OF SLEEVEGASTRECTOMY :. Effectiveness of laparoscopic sleeve gastrectomy on glycemic control in obese Indians with type2 diabetes mellitus
B . Long-term effects of laparoscopic sleeve gastrectomy in morbidly obese subjects with type 2 diabetes
mellitus
C . Impact of LSG on CVD risk reduction

using Framingham score

Improvement in Type 2 Diabetes Mellitus following Bariatric Surgery in morbidly obese individuals

1

Department of General Surgery, Singapore General Hospital 2Department of Endocrinology, Singapore

General Hospital
Shanker Pasupathy1,Chin Hong Lim1,Daniel Wai2,Kwang Wei Tham2

BACKGROUND: Weight loss has been shown to improve the control of type 2 diabetes mellitus (T2DM). AIMSOF STUDY: To evaluate the impact of bariatric surgery on T2DM in morbidly obese individuals. METHODS:
From August 2008 to November 2010, 47 consecutive patients underwent bariatric surgery at the Singapore
General Hospital. All patients documented to have T2DM prior to surgery were included in the
study.RESULTS: There were 16 patients suffering from T2DM (9 males). The median age was 43 years (range
32 - 54). 8 patients underwent laparoscopic sleeve gastrectomy (LSG) and 8 underwent laparoscopic gastricbypass (LGB). Median length of stay was 4 days (3-14). The median pre-operative weight was 116kg (85-171) and body mass index (BMI) 40 kg/m2(33 - 70). Median follow-up was 5 months (1 - 26). Patients who
underwent LSG had a median pre-operative HbA1c of 7.2% (6.4-8.2). All these patients were taking oral
hypoglycaemic agents (OHAs). Median post-operative HbA1c levels were 5.8% (5.5-6.1), and all OHAs werediscontinued. Patients who underwent LGB had a median pre-operative HbA1c of 8.2% (6.6-9.3). 5 patientswere on subcutaneous insulin injections, in addition to oral hypoglycaemic agents (OHAs). Medianpost-operative HbA1c levels were 6.1% (5.2-8.0), and although insulin was discontinued in all, 2 patientswere still taking OHAs. CONCLUSION: Bariatric surgery provided rapid and effective control of T2DM,
allowing all patients to reduce or eliminate diabetic medication completely. Bariatric surgery may beconsidered as an adjuvant therapy for T2DM in morbidly obese individuals.

DUODENOJEJUNAL BYPASS IN DIABETIC GASTRIC CNACER PATIENTS

Department of Surgery
Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
Daehyun Yang, Jiwon Kim, Kyungsuk Jung

(Objective) Metabolic surgery

in non-obese diabetics has been tried by various

methods. Effect of duodenojejunal bypass on diabetes could be studied by themodification of reconstruction after curative gastrectomy for diabetic gastric cancer
patients.
(Method)

From

June

2007

to

December2009

weperformed

ourmodifiedRY

gastrojejunostomy procedure of duodenojejunal bypass with bypassed proximal jejunumover 100cm after curative distal gastrectomy for 18 diabetic gastric cancer patients.
The bypassed proximal jejunum were 100-190cm ( 134.3cm in average ) as the sum ofReux and Y limbs. The durations of diabetes were 6.4 years in average, and diabetes
was managed by oral hypoglycemic agent in all of the patients.
(Result) Diabetes had been remitted in 7 patients among 18 patients ( 38.9% ) at the
1 year or more follow up, with HbA1c level of 7.0% or less without medication. The
serum ferritin and VB12 levels were within normal limt in most of patients.
(Conclusion)

Bypassofduodenumandlengthened

proximaljejunumwithdistalgastrectomy is acceptable in nutrition. Some portion of diabetic gastric cancer
patients could be in remission of diabetes with bypass of duodenum and long proximal
small bowel in gastric cancer surgery. Randomized prospective clinical trial of
metabolic surgery for diabetic gastric cancer patients is necessary to evaluate themetabolic effect of duodenojejunal bypass on non-obese diabetics.

ONE YEAR RESULTS OF AN ENDOSCOPIC, DUODENAL-JEJUNAL EXCLUSION DEVICE FOR WEIGHT LOSS AND CONTROL OF TYPE
2 DIABETES

1Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School,

Sao Paulo, Brazil

2

Gastro Obeso Center, Sao Paulo, Brazil

3

Digestive Surgery, Department of

Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil 4Endocrinology and Metabolism
Department; University of Sao Paulo Medical School; Brazil
Eduardo G H de Moura1,Bruno C Martins1,Guilherme S Lopes1,Ivan R B Orso1,Suzana L Oliveira1,Manoel P
Galvao-Neto2,Marco

Aurelio

Santo3,Marcio

C

Mancini4,Paulo

Sakai1,AlminoC

Ramos2,Arthur

B

Garrido-Junior3,Alfredo Halpern4,Ivan Cecconello3

Background:

The duodenal-jejunal bypass liner (DJBL, GI Dynamics, Inc., Lexington, MA) is an endoscopic

implant that mimics the intestinal bypass component of the Roux-en-Y gastric bypass.

Previously reported

studies have shown promising improvements in type 2 diabetes (T2D) and weight loss for up to 6 months.
This report describes improvements in T2D and metabolic changes in subjects with T2D who were implantedwith the DJBL for one year. Methods:

This is a prospective, non-randomized, open label study with 22

patients enrolled. Inclusion criteria:

Age higher 18 years and less 65 years, BMI higher 35 kg/m; andtype 2 diabetes with or without other co-morbidities, unsuccessful history with nonsurgical weight
reduction methods, candidates to bariatric surgery.

There were 9 early endoscopic removals due to device

movement (3), nausea/vomiting (1), abdominal pain (1), GI hemorrhage (1), non-device related abdominal
neoplasm (1) and Principal Investigator request (2).Results:

At one year (n=13 patients), observed

absolute weight loss of 20.4 kg (p less 0.0001), excess weight percentage loss of 35.3% (p less 0.0001),
body mass index of 7.4 kg/m2 (p less 0.0001) and waist circumference of 10.1cm (p=0.0001) was observed.
Likewise, glucose levels decreased from 175.6 to 126.7 mg/dL (p less 0.0001) and glycosilated hemoglobinfrom 8.8 to 6.4% (p less 0.0001). The use of diabetic medications, except metformin was reduced and 19.2%
of patients no longer required any anti-diabetic drugs.

Insulin (p=0.02) and C-peptide (p=0.015),

cholesterol (p=0.001), LDL (p=0.01), and triglycerides (p=006) levels were normalized at 1 year.
Conclusions: The endoscopic DJBL has a durable effect on glucose control, weight loss and metabolic
function for one year, suggesting this new device is a suitable option for the treatment of T2D and obesity.

Enteropeptidase: a gene associated to a starvation human phenotype as a novel target for the treatment
obesity and type II diabetes

1

ObeTherapy, Drug Discovery, Evry, France

Itzik Harosh1,Sandrine Braud1- Many obesity related genes have been proposed as targets for the treatment of obesity. However, theseobesity genes did not provide efficient drug therapy for obesity treatment. This is mainly due to theredundancy of the biochemical pathway involved in obesity and the lack of specificity of the gene targets.
It is therefore a challenge to identify crucial gene(s) targets involved in energy metabolism associatedwith lean or starvation phenotype. Congenital Enteropeptidase defficiency is an extremly rare pathology
which answer to all these criteria. Enteropeptidase catalyzes the conversion of inactive trypsinogen
into active trypsin via the cleavage of the acidic propeptide from trypsinogen We have generated knockout transgenic mice for enteropeptidase which shows the same phenotype like in human. These data andin vivo preclinical data using per os small molecule for long term treatment (9 weeks) will be presented.

Newly developed profiling of lipoproteins by PAGE to determine the heterogeneity of low-density
lipoproteins (LDLs)

1

Department of Rehabilitation,Kamagarya General Hospital, Chiba, Japan 2Department of Diabetes andEndocrinology, Saitama Medical University, Saitama , Japan 3Department of Biochemistry, Saitama Medical
University, Saitama , Japan 4ASKA Special Laboratory CO.,LTD., Kanagawa, Japan
Yuichi Shinoda1,Ikuo Inoue2,Takanari Nakano3,Makoto Seo3,Seiichiro Takahashi4,Takuya Awata2,Shigehiro
Katayama2

Aim: To explore the potential of newly developed polyacrylamide-gel disc electrophoresis (PAGE) for
lipoprotein profiling in clinical practice. Design and Methods: Blood samples were collected from 95
patients with metabolic syndrome. Lipid parameters were assayed by commercial (Lipophor) and newly
developed PAGE (Lipophor AS), including small, dense low-density lipoprotein (LDL) (n = 41), andtriglyceride-rich lipoprotein remnant cholesterol (n = 37). We also used a commercial kit to measuresmall, dense LDL (n = 41). Resutts: By PAGE, we obtained the percentage of the area under the curve (AUC %)of each peaks and calculated respective AUC% x total cholesterol (AUC%xTC) values. The calculated valuesof LDL-AUC%xTC, small LDL-AUC%xTC, and HDL-AUC%xTC values were correlated well with values fromhomogeneous assay for LDL-cholesterol, small, dense LDL-cholesterol, and HDL-cholesterol assays (r =0.94, 0.81, and 0.89, respectively). Lipophor AS is better corelation between TG and VLDL than Lipophor(r= 0.77, and 0.85, respectively). Conclusions: PAGE combined with measurement of total cholesterol andtriglycerides provides a rapid evaluation of anti- or pro-atherogenic lipoproteins and a simple profilingsystem for both the "quantity" and "quality" of lipoproteins, allowing a better assessment of the riskof coronary artery diseases.

leal interposition improves Glucose Tolerance and Insulin Resistance in Otsuka Long-Evans Tokushima Fatty
rats.

1

Division of Biological Regulation and Oncology, Department of Surgery, Tohoku University Graduate Schoolof Medicine, Sendai,Japan 2Department of Surgery, Sendai City Medical Center
Fumie Ikezawa1,Chikashi Shibata1,Hirofumi Imoto1,Daisuke Kikuchi1,Takeshi Naitoh1,Takashi Tsuchiya2,Iwao
Sasaki1

Backgrounds:

Ileal interposition (IT) is an operative procedure in which the distal ileum istransposed isoperistaltically into the proximal jejunum and considered as a procedure for metabolic or
anti-diabetic surgery.

Our aim was to study the effects of IT on glycemic control, fat metabolism, andhormonal changes in obese rats with spontaneous diabetes (OLETF rats).Methods:
into either an IT or a sham (SH) group.
and 8 weeks after the operation.

Animals were divided

They underwent oral glucose tolerance test (OGTT) before, 4,All animals were killed 10 weeks after operation for analyses of tissue

weight (liver, pancreas, epididymal fat, brown fat) and fasting plasma levels of glucose, insulin,
glucagon-like peptide (GLP)-1, peptide YY (PYY), glucose-dependent insulinotropic polypeptide (GIP),
and leptin.

Results:

After operation, body weight increased in both groups compared to theirpreoperative weight, but it did not differ between IT and SH.

A 8 weeks postoperatively, integrated

blood glucose levels during the OGTT were decreased in IT compared to SH (p<0.05).

Ten weeks after

operation, fasting plasma levels of insulin, GLP-1, and GIP did not differ between the two groups, but
PYY levels were greater in the IT group (P<0.01).

Weight of epididymal and brown adipose tissues,

homeostasis model assessment insulin resistance, and fasting plasma leptin levels were decreased in the
IT group (p<0.05).

Conclusions:

These results suggest that IT improves glucose and lipid metabolism

by decreasing blood glucose, insulin resistance, and epididymal fat, increases in plasma PYY might be
one of the mechanisms of these changes.

The effects of duodeno-jejunal bypass on glucose metabolism in obese type2 diabetic rat model.

1

Department of surgery, Division of biological-regulation and oncology, Tohoku university graduate schoolof medicine, Sendai, Japan
Hirofumi Imoto1,Shibata Chikasi1,Takeshi Naitoh1,Fumie Ikesawa1,Masayuki Kakyo1,Makoto Kinouchi1,Naoki
Tanaka1,Koh Miura1,Hitoshi Ogawa1,Iwao Sasaki1

BACKGROUNDS: Bariatric surgery, especially gastric bypass or duodenal switch, has been shown to improvetype 2 diabetes. However, its detail mechanisms are not well comprehended yet. There are two hypotheses
that are advocated to explain effects of bariatric surgery on glucose metabolism: the foregut hypothesis
and the hindgut hypothesis. The former theory is considered to depend on exclusion of duodenum and proximal
jejunum from the nutrients transit, possibly enhancing secretion of anti-incretin factors, while thelatter one is thought to be results from more rapid delivery of nutrients to the ileum, thereby enhancing
the release of hormones such as glucagon-like peptide-1 (GLP-1). Duodeno-jejunal bypass (DJB) might
include both theories, but it is still controversial which theory is dominant.METHODS: Male 20-week-old
OLETF rats were divided into 3 groups and they underwent sham operation or two types of DJB, which aredefined as DJB-J and DJB-I. These are differentiated by the length of alimentary limb (AL). In DJB-J,
the biliopancreatic limb (BPL) was anastomosed to the side of distal limb to make 2.5cm AL and it canbe considered as pure foregut model.

In DJB-I, the BPL was anastomosed to the distal limb 25cm proximal

to the ileum-end, and it can be thought as foregut plus hindgut model. All rats underwent OGTT at baseline,
4 and 8 weeks after surgery.RESULTS: There was some weight controlling effect in DJB-I group, but notin other groups. Regarding OGTT, DJB-I group demonstrated lower plasma glucose curve at 4 and 8weeks
after surgery comparing to other groups, but there were no significant difference between DJB-J and shamgroup. CONCLUSION: The improvement of glucose metabolism in DJB mainly depends on an inflow of bile andpancreatic juice to the ileum, and the exclusion of the duodenum may not contribute to the anti-diabetic
effect.

Differential increase in HDL-c post bariatric surgery for Singaporean Patients according to Glucose
Status.

1

Department of Endocrinology, Singapore General Hospital, Singapore 2Department of Surgery, Singapore

General Hospital
Daniel C. Wai1,Shanker Pasupathy2,Sonali Ganguly1,Kwang W. Tham1

Background: HDL-c is negatively correlated with cardiovascular risk. Patients with diabetes andpre-diabetes or abnormal glucose tolerance (AGT) have low HDL-c. Few studies have compared the change
of HDL-c post bariatric surgery between patients with normal glucose tolerance (NGT) and AGT.Aims of
Study: To compare the change of HDL-c post bariatric surgery between patients with NGT and AGT.

Methods:

HDL-c levels at 0, 3 and 6 months were transformed using the multivariate repeated measures model, withglucose tolerance being the between-subject factor.Results: 46 patients (61% females) underwent
laparoscopic bariatric surgery from September 2008 to November 2010. 78% had sleeve gastrectomy, 20%
gastric bypass, and 2% bilio-pancreatic diversion. The mean age was 39 years (+/-10.6) with a mean BMIof 43.6kg/m2 (+/-9.8). 54% had NGT versus 46% with AGT. Only 1 patient (4%) in the NGT group was on afibrate pre-op but none in the AGT group. Average weight loss at 6 months was 25.5kg and 22.2kg for NGT
and AGT respectively. HDL-c rose significantly in both groups (mean HDL-c for NGT were 1.06, 1.49 and1.68 mmol/L at 0, 3 and 6 months; mean HDL-c for AGT were 0.89, 0.92 and 1.08 mmol/L; within-subject
p=0.006). Thus HDL-c increased 58% in the NGT but only 21% in the AGT. HDL-c in the NGT was significantly
higher than in the AGT group throughout the 6 months (between-subject p=0.009).

EARLY EXPERIENCE WITH A NOVEL PROCEDURE FOR OBESITY: LAPAROSCOPIC SLEEVE GASTRECTOMY

1

Department of General Surgery, Singapore General Hospital2

Department of Endocrinology, Singapore

General Hospital, Singapore
Ser Yee Lee1,2,Shanker Pasupathy 1,Kwang Wei

Tham2,Sonali

Ganguly2,Wai Keong Wong 1

BACKGROUND:Bariatric surgery offers the morbidly obese substantial and sustainable weight loss andreduction in obesity- related co-morbidities when other conservative treatments have failed.
Laparoscopic sleeve gastrectomy is a new restrictive procedure in bariatric surgery.
AIMS: To evaluate our experience with laparoscopic sleeve gastrectomy (LSG), a new bariatric surgicalprocedure, with regards to safety and feasibility of the procedure and early weight loss.
METHODS: All patients who underwent LSG were studied in terms of their complications and early clinicalresults.

Patients' clinical data were retrieved from a prospective database.

RESULTS: Twenty-three patients underwent laparoscopic sleeve gastrectomy between the period of December
2008 and June 2010 with a mean age of 38 years (Range: 23 - 64). The mean pre-operative weight was 112kg(range 78-170) and body mass index (BMI) 42.1kg/m2(33 - 60). Diabetes mellitus was present in 39%,
hypertension in 43% and hyperlipidemia in 35% of the patients. Majority of patients had two or moreobesity-related co-morbidities (52%). The stomach was tubularised over a 38French calibration tube using
endoscopic staplers. Mean operative time was 142 mins (80 - 220). There were no conversions. 1 patient
required re-laparoscopy on the 1st post-operative day for bleeding from the gastric staple line. She
subsequently recovered well but developed a wound infection from one of the laparoscopic port sites.
There were no other morbidities. Median postoperative stay was 3 days (1-9). Mean weight 1, 3 and 6 months
post-operatively was 102, 90 and 79kg, a loss of 9, 20 and 30% respectively.
CONCULSION: Laparoscopic sleeve gastrectomy is a promising procedure for surgical treatment of obesitywith good early weight loss and low morbidity.

Introduction of laparoscopic vertical sleeve gastrectomy into bariatric practice1

John Flynn Private Hospital 2Bond University Medical School

William V. Braun1,Maree Kekeff2,Donna Tanchev2,Candice Silverman1,Laurent Layani1

Aim: LVSG has recently become popular as bariatric procedure, not only as first step in high risk or
superobese patients or in cases of failed restrictive operations, but mainly as a stand alone operationin morbidly obese. Our aim is to investigate safety, efficacy and consistency of LVSG in both weightloss and remission of patients comorbiditiesMethods: Retrospective and prospective analysis of all LVSG
performed at John Flynn private in Gold Coast from January 2008 until August 2010 was performed. Patients
telephone interviews were conducted to establish overall satisfaction with procedure and service Results:
106 LVSG were performed from January 2008 to August 2010. Male to female ratio to 1:1.1. Median age and
BMI were 47 (22 to 70), and 52 (35.5 to 81) respectively. 43 procedures were staged operations following
failed LGB (40) and open stapling gastroplasty (3). Mean operative time was 79 min (38 to 133 min). There
was no mortality. Postoperative complications included gastric leak (1), minor wound infection (4) andprolonged nausea (1). Median LOS was 2 (1 to 61 days). Follow-up was achieved in 97 patients (92%). MeanEWL was 69.1% (23 to 100%) at 6 to 12 months for primary VLSG and 38.5% (16.7 to 76.6) for staged operations.
Major comorbidities subsided. 93 (88%) patients provided their feed back over telephone with overallsatisfaction rate 100%Conclusions: LVSG is safe and efficacious procedure. It achieves excellent resultsin weight loss and sustainable short and midterm improvement of overall patients health. Serious
complications do however occur and pose high demands on care providers as well as patients and theirfamilies

Comparison Between the Results of Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric
Bypass for Morbid Versus Super Morbid Obesity

Yotsuya Medical Cube
Hideharu Shimizu, Yosuke Seki, Eri Kikkawa, Kazuko Sonoda, Tetsuya Nakazato, Kazunori Kasama

Background
Data on the effectiveness of laparoscopic sleeve gastrectomy (LSG) for super morbid obesity in patientswith body mass index (BMI) ≧50 are scarce. Whether LSG alone can replace laparoscopic Roux-en-Y Gastric
Bypass (LRYGB) as a standard bariatric procedure is questionable.

Methods
For this study, 129 morbidly obese patients who underwent LSG (68 patients) or LRYGB (61 patients) between
2006 and 2009 were retrospectively analyzed. We compared the weight loss effect of LSG to that of LRYGB
according to BMI.

Results
The percentage of excess weight loss (EWL) at the 1-, 3-, 6-, 12-, 24-month follow up points of the patients
who underwent LSG and LRYGB were comparable. According to BMI, The percentage of EWL of the patientswith an initial BMI≦35 in LSG (n=14) and LRYGB (n=11) group at 1-, 3-, 6-, 12-month follow up points
were 36.1 and 31.2, 74.2 and 70.8, 78.8 and 99.0, 92.7 and 89.1%, respectively. As for 35<BMI≦40, thepercentage in LSG (n=20) and LRYGB (n=25) group at the same follow up points were 40.7 and 23.7, 50.0
and 47.2, 64.7 and 69.0, 76.9 and 78.3, 83.6 and 85.6%, respectively.

As for 40<BMI≦50, the percentage

in LSG (n=20) and LRYGB (n=27) at the same follow up points were 22.6 and 20.4, 43.8 and 40.9, 72.5 and
59.6, 80.5 and 75.2, 72.0 and 80.7%, respectively. There was no significant difference between bothgroups. However, the percentage of EWL of the patients with 50< initial BMI<60 in LSG (n=7) and LRYGB(n=5) group were 14.7 and 20.9 (P=0.21), 27.9 and 35.3 (P=0.14), 36.3 and 56.1%(P=0.04), 35.5 and 69.7%(P=0.01), 32.5 and 60.9% (P=0.02) at 1-, 3-, 6-, 12-, 24-month after operation. Compared with LSG, LRYGB
obtained better weight loss outcomes for super morbid obesity (50<BMI≦60).

Conclusions
LSG can be a standalone procedure for morbidly obese patients with BMI<50 as well as LRYGB, but LSG is
not expected to be performed as a solo procedure for the patients with BMI over 50.

Early results from a specialized Metabolic and Bariatric Surgery service

1

Department of General Surgery, Singapore General Hospital 2Department of Anaesthesia and Surgical

Intensive Care, Singapore General Hospital 3Department of Endocrinology, Singapore General Hospital
Shanker Pasupathy1,Ruban Poopalalingam2,Daniel Wai3,Kwang Wei Tham3

BACKGROUND: Bariatric surgery is one of the most effective weight loss interventions for morbidly obese
individuals. However, surgery in morbidly obese patients involves potentially significant risk and should
be undertaken by specially trained teams.AIMS OF STUDY: The experience of a specialised metabolic andbariatric surgery service is described.METHODS: In 2008, a dedicated metabolic and bariatric surgery
service was set up at the Singapore General Hospital. Patients were managed according to a clinical pathway
which included pre-surgical evaluation, surgical admission and post-surgical follow-up.RESULTS: From
August 2008 to November 2010, 47 patients underwent bariatric surgery. The mean pre-operative weightwas 119 kg (range 78- 209) and body mass index (BMI) 44 kg/m2 (32.5-74). 21 patients had impaired glucose
tolerance or type 2 diabetes mellitus. 91% of patients had at least 1 major comorbidity (diabetes mellitus,
hypertension, dyslipidaemia, obstructive sleep apnoea) . 37 patients underwent laparoscopic sleeve
gastrectomy, 9 laparoscopic gastric bypass and 1 laparoscopic bilio-pancreatic diversion. 3 patientsrequired re-operation for haemorrhage (two) and anastomotic leak (one) on the 1st post-operative day,and then recovered uneventfully. 1 patient with post-operative haemorrhage was managed conservatively
with blood transfusion only. There were no mortalities. Median length of stay was 4 days (3-14). The
mean absolute weight loss at 6 months was 27% (12-34). CONCLUSION: A multi-disciplinary approach improves
patient selection and optimization, resulting in improved clinical outcomes after bariatric surgery.

Laparoscopic Sleeve Gastrectomy with a BIB in situ for 14 months

1

Al Taie center for laparoscopic and Obesity surgery,Dubai,UAE

Abdulsalam S. Al taie1

Introduction: Bioenteric Intragastric Balloon BIB is used to stay in the stomach for approximately 6months.its benefit as a sole procedure is questionable.It could be useful if used in a staged procedure
as a first step followed by a definitive bariatric surgery for high risk patients.patient and method:
In this video am presenting to you a 24 years old

gentleman 210 KG

with a BMI of 72 who had a BIB in

his stomach 14 months prior to our surgery.He had a trial of endoscopic removal of the balloon but

wasunsuccessful as the balloon was digested. We planned to remove the balloon in a novel technique,alongwith laparoscopic sleeve gastrectomy(LSG). we started by dividing the omentum on the greater
curvature,then dividing the stomach 3 cm from the doudenum along 36 Fr. calibration tube. Approaching
the mid stomach

after firing the 3rd 60 mm endo cartridge ,the balloon deflated and pulled into theresected stomach through a gastrostomy

made on that part,

part removed along with the BIB inside.results:

LSG completed as usual. then the resected

the aim is to show a novel technique of removal of BIB

that left for long time and was not possible to be taken out endoscopically.He did excellent

post

operative recovery and was dismissed home on the second post operative day . At the end of year one
following the surgery he lost a bout 75 KGs and his BMi dropped to 46 .conclusion: LSG
performed in patients with failed

can safely be

BIB , especially when they are left for longer than 6 months which

would be difficult to be removed endoscopically, it can be retrieved in such away that the resected stomachwould be used as a retrieval bag for that purpose.

Removal of stomach remnant after laparoscopic sleeve gastrectomy

1

Luton & Dunstable NHS Foundation Trust, Luton, UK

Kirsty R. Cattle1,Periyathambi S. Jambulingam1,Ravindra Date1

Removal of the remnant stomach after laparoscopic sleeve gastrectomy for obesity can be tricky without
enlarging the port site incision.

We therefore present a simple technique to facilitate the removalof the remnant stomach which does not involve additional equipment or expense.

Early Experience with Laparoscopic Roux-en-Y Gastric Bypass for Morbidly Obese patients

1

Department of General Surgery, Singapore General Hospital, Singapore 2Department of Endocrinology,

Singapore General Hospital, Singapore
CH Lim1,S Pasupathy1,KW Tham2,S Ganguly2,WK Wong1

Objective: To evaluate the early outcome for laparoscopic Roux-en-Y gastric bypass in a new bariatric
surgical program in SingaporeMethods: A prospective pilot study of 9 patients who underwent laparoscopic
Roux-en-Y gastric bypass for obesity by a single surgeon at Singapore General Hospital between September
2008 to October 2010. The study endpoint included operative time, complications and hospital length ofstay. At one month post surgery, weight loss and HbA1c levels were recorded.

Results: Five males and4 females with median age of 39 years (range 30 to 60) were included in the study. Mean pre-operative
weight was 125.5kg (range 74kg to 170.7kg) with a mean pre-operative BMI of 45.9 (range 35.4 to 70).
All our patients had diabetes. In addition to diabetes, 8 out of 9 patients had at least one othersignificant medical co-morbidity related to obesity. The median operative time was 325 minutes (meanof 438 minutes for first 4 cases and 246 minutes for last 4 cases). There was no conversion. One patient
required a re-operation for anastomotic leak. Median hospital stay was 4 days (range 1 to 13) and theaverage weight loss was 13.3% at one month. The median pre-operative HbA1c was 8.6% (range 6.5 to 12.3)
and at one month, HbA1c levels reduced to 6.1% (range 5.2 to 8).Conclusions: Laparoscopic Roux-en-Y
gastric bypass is a technically challenging procedure that can be safely integrated into a bariatrictreatment program with early weight loss and improved diabetic control. With more experience, operative
time and length of stay decreased.

Gastric Sleeve is a single restrictive procedure?

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Helena P. Proenca1,Carla M.
Melo1,Guilhermina C. Cantinho1,Henrique B. Castelo1

The authors present in their 221 gastric sleeve patients the criteria in which they consider gastricsleeve is both a metabolic and restrictive procedure.The improvement of the associated diseases, visceralfat, BMI and EWL, the levels of grelin, obstatin, grelin/obstatin ratio, PP-YY, the gastric emptying
before and after surgery, are evaluated in this series two years after surgery to demonstrate both
metabolic and restrictive features of this procedure.

GASTRIC SLEEVE AS TREATMENT FOR MORBID OBESITY: ANALYSIS OF 3 YEARS

1Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Dulce A. Antunes1,Mariana M.
Machado1,Filipa A. Andrade1,Helena P. Proenca1,Antonio F. Fernandes1,Henrique B. Castelo1

The authors analyze the results of their series of GASTRIC SLEEVES as treatment of patients with morbid
obesity.The study includes 221 patients evaluated at outpatient follow-up during two years of post-op,
according to the following protocol:Clinical Assessment, % of weight loss, decreased BMI and%
EWL;-Evolution of co-morbidities;Determination of ghrelin pre-and post-operative, as well as therelationship ghrelin / obestatin;Changes in gastric emptying, compared to pre-operative, 3, 6, 12 and24 months.The Authors also examine morbidity and mortality in the series.

Laparoscopic Adjustable Gastric Banding: 7-year results in Taiwan

1

Department of Surgery, Min-Sheng General Hospital

YEN HAO SU1,WEE JEI LEE1,KUANG HAN

SER1,JUNG CHIE CHEN1,SHU CHUN CHEN1,YI CHIH LEE1

Objectives: Laparoscopic adjustable gastric banding (LAGB) is a pure restrictive bariatric surgery. We
had reported our short-term results of LAGB in Taiwan. In this study, we report the long-term resultsof LAGB in Taiwan. Materials and Methods: From January 2002 to June 2010, 246 consecutive patients withmorbid obesity underwent LAGB in our department. Mean age was 32.1 years and mean BMI 39.8 Kg/m2.

The

demographic data and post-operative results were recorded . Results: All procedures were performed
laparoscopically with no conversion to open surgery.The major and minor complication-rate was 0% and
3% respectively. Mean BMI from 39.8 Kg/m2 to 35.4, 36.3, 34, 33 ,31 ,30.7 and 32.6 at 1, 2, 3, 4,5,6
and 7 years respectively, with 80% follow-up.

Revision rate was 13% (33/246). The most common causeof revision bariatric surgery was failed to lose adequate weight (20/32, 62.5%), poor quality of life
(5/32, 15.6%), and band slippage (3/32, 9.3%).Conclusion: LAGB is safe and effective in weight reduction
and improvement of quality of life. However, a late surgical re-intervention rate of 13% was observedwith conversion to another bariatric procedure was 8%.

The experience of laparoscopic mini-gastric bypass surgery in single institute of sunthern Taiwan.

1

Department of Surgery, National Cheng Kung University Hospita, Tainan, Taiwanl 2Min-Sheng General

Hospital
Kuo-Ting Lee1,Wei-Jei Lee2Introduction: Gastric bypass surgery is an effective treatment for morbidly obese patients. In Taiwan,
the incidence of morbid obesity increases. More obese patients would have bariatric surgery. We presented
the clinical results of laparoscopic mini-gastric bypass surgery in our hospital. Method and Material:
From 14,Jan,2009 to 17,Nov,2010, there were thirty patients underwent bariatric surgery in National Cheng
Kung University Hopital. Twenty-three patients (12 women,11 men) underwent mini-gastric bypass surgery.
Mean Body mass index (BMI) was 39.8 (30.7-55.7). All the procedures were completed laparoscopically .
No conversion procedure occured. We retrospectively analyze the patients' clinical data andoutcomes.Results: All patients had weight loss after surgery. Two patients had post-operativecomplications. One female patient had pituitary tumor hemorrhage 4 days after surgery. Later she had
craniotomy, and recovered. She had the hospitsal stay 25 days. Two months later, she totally recovered.
Another female patient had post-operative upper gastrointestinal hemorrhage imediately after surgery.
She had the conservative treatment. The bleeding stopped one day later. One female was dead 25 days after
surgery because of acute respiratory distress syndrome. The mean hospital stay was 6.4 days. All thepatients had regular follow-up visit in our hospital. Conclusion: The laparoscopic mini-gastric bypass
surgery could have an ideal body weight reduction, and it is a feasible surgery for morbidly obese patientsin southern Taiwan.

The introduction of laparoscopic sleeve gastrecotmy: initial three clinical experiences

1

The Department of Gastroenterological Surgery, University of Osaka, Osaka, Japan

Yasuhiro

Miyazaki1,Shuji

Takiguchi1,Kiyokazu

Nakajima1,Yukinori

Kurokawa1,Hiroshi

Miyata1,Makoto

Yamasaki1,Yoshiyuki Fujiwara1,Masaki Mori1,Yuichiro Doki1

Introduction: Recently, Sleeve gastrectomy(SG) has been proposed as potential single restrictive
baratric procedure. In fact, clinical outcome in terms of weight loss and resolution of comorbidities
encouraged and stimulated the diffusion of SG as a primary bariatric procedure. Based on the above,
laparoscopic sleeve gastrectomy (LSG) was introduced for primary procedure for morbid obesity in our
institution. The objective of this study was to evaluate the feasibility and safety of LSG at the timeof introduction for initial three cases. Objectives: LSG was introduced in our institution in March 2010
and performed in 3 patients (1 male, 2 females). Case 1: 26 year-old male, BMI48.1kg/m2, his comorbidities
with obesity were insulin dependent diabetes mellitus (DM), hyperlipemia, fatty liver, insomnia, andsleep apnea syndrome, Case2: 24 year-old woman, BMI44.1kg/m2, with slight mental retardation, and hercomorbidities were right cardiac failure and pulmonary hypertension, Case 3: 43 year-old woman, BMI44.3
kg/m2, with psychiatric disorder, and her comorbidities were the same as case 1.Results: LSG was completed
in 3 patients without conversion to laparotmy. Each operating time(minutes) was 150, 250, 176 andestimated blood loss(ml) was 20, 540,30, respectively. No major postoperative complications directly
related to LSG were noted. All patients showed uneventful postoperative recovery, with their oral intake
resumed in 2 days and median hospital stay of 15days. They showed expected effect on body weight loss,
and remarkable improvement of DM in case 1 and 3 resulted in no need for insulin injection. Conclusion:
LSG was safely introduced as primary procedure for morbid obesity in our institution.

Sleeve Gastrectomy in combination with Duodeno-Jejunal Bypass. Three year Period Results.

1

State Hospital, Ufa, Russia 2Bashkirian University of Medecine

Evgeny E Semenov1

Background: A new surgical procedure - Sleeve gastrectomy with Roux-en-Y Duodeno-Jejunal bypass (SG-DJBP)
is being performed in the world since 2007. They generally brought to successful results but some certain
indications to the operation might be developed.
Material and methods: We present results of four SG-DJBP procedures performed since July 2007 to September
2010. The mean age of patients was 38,1±7,3 (29-48) years, mean BMI-47.4±7,8kg/m2(38,9-59,8), initial
weight-130,6±22,6kg (111-159). A Roux-en-Y procedure was performed with a biliopancreatic loop 60 cm
and alimentary loop-100 or 150 cm depending on initial BMI (less or more 50 kg/m2 respectively) four
operations within a period of follow up control for 3 years and ±6 months. Two operation were performed
with alimentary loop-180 with the follow up control up to 1 year. A bandage was placed on the gastrictube intersurgically to two patients.
Results: All the patients tolerated the procedure well. During 6 months the percentage of %EWL was 45,7
±5,1%. Up to 1 year all the patients could lose more than 53,2 %EWL (47,0 - 64,4%). Up to 3 years 4
patients could lose more than 60,7% EWL (52,6 - 68,6%). The patient with a bandage had the best result- 68,6%. All the patients have a tendency to further weight gaining up to 3-8kg.
Conclusion: The positive influence on the carbohydrate and lipid metabolism is noticed, all the patients
have a slight weight gaining, but there is a less weight gaining with a bandage. It is connected withthe stomach extension and lesser malabsorption in contrast to BPD, a bandage gives additional restriction.
SG-DJBP is an effective and safe surgery with the slightest metabolic disturbances. It might be offeredto patients with BMI>50kg/m2. However, it is necessary to control a follow up period and compare it withthose of SG and BPD.

A case of migration of gastric band

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Andreia C. Barao1,Jose S. Girao1,Fatima M. Carepa1,Ines L. Leite1,Graciela M.
Matias1,Antonio F. Fernandes1,Antonio S. Ruivo1,Henrique B.

Castelo1

Bariatric operations produce weight loss as a result of two factors. One is restriction of oral intake.
The other is malabsorption of ingested food. All bands work on the principle of restriction of oral intake
by limiting the volume of the proximal part of the stomach. Their major advantage is adjustability. Their
most common complications include acute obstruction of the stoma, infection, prolapse of the band,
attached to the trocar ports and erosion / migration of the band, which is a rare complication (3%).TheAA present a case of migration of gastric band, four years after his placement in a patient with morbid
obesity, which starts with dyspepsia, nausea and fever and whose imaging and endoscopic study revealed
migration of the band with gastric fistula.

Endoluminal Surgery (StomaphyX device). An alternative to the revision surgery?

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Jose S. Girao1,Fatima M. Carepa1,Adreia C. Barao1,Elisabete S. Ferreira1,Carlos S.
Silva1,Graciela M. Matias1,Antonio S. Fernandes1,Henrique B.

Castelo1

The Authors analyze the results of Endoluminal Gastroplasty "StomaphyX" obese patients already receiving
prior to bariatric surgery.The 15 patients in whom technique was used, 4 had previously undergone gastricSleeve, 10 gastric bypass and 1 placement of a gastric band. All patients remained liquid diet / paste
for 3 months postoperatively and were evaluated by Esophagogastroduodenoscopy at 6 months, confirming
the maintenance of fasteners. We evaluated the weight loss at 1, 3 and 6 months of surgery as well as
the improvement the feeling of satiety reported by all patients pre-application of the technique.The
Authors conclude the benefits of endoluminal gastroplasty and advantages of this technique which canbe used repeatedly in the same patient.

A successful case of safety weight loss using formula diet in alcoholic cardiomyopathy with obesity

1

Internal medicine, Toho University Sakura Medical Center, Chiba, Japan

HiroshiMikamo1,Kazuhiro

Shimizu1,Keiichi

Hirano1,Kakahiro

Nakagami1,Masayo

Suzuki1,Mao

Takahashi1,Takuo Iiduka1,Yuukou Sugiyama1,Hirohumi Noike1,Kouji Shirai1

Introduction: We often experiences weight loss improve cardiac function in obesity with heart failure(HF). Recent study shows obesity may lead to left ventricular hypertrophy and systolic dysfunction. On
the other hand, alcoholic cardiomyopathy is a common cause of DCM-like change. Alcohol effect on cardiac
function can usually be reversible by abstinence from alcohol. Since alcohol addict often are complicatedwith metabolic syndrome, they should be treated comprehensively. Therefore, it is important to reduceweight of these patients. So, modern formula diet has been recommended as dietotherapy. However there
are few reports on the use of formula diet for them. Previous report showed healthy obese patients diedsuddenly during use of the liquid-protein-modified-fast diet 30years ago. The cardiac accident appears
to depend on diet duration and on whether protein and mineral nutritional status are maintained.
Pronounced weight loss causing lack of these nutrients has been thought to produce a decrease in myocardial
fiber size. However, the moderate caloric restriction could be performed enough safely by the modern
formula diet including protein, vitamins, a mineral. We report a case of weight loss using formula dietafter acute heart failure (AHF) treatment. Case report: 36-year-old obese male was hospitalized withdyspnea. On admission, his weight was 103.3kg, BMI 32.6kg/m2. Blood pressure was extremely high.
Examinations revealed severe cardiac dysfunction, enlarged heart and pulmonary congestion. He had aten-year history of alcohol abuse. As above, AHF due to alcoholic cardiomyopathy with obesity andhypertension was diagnosed according to the absence of coronary disease. After AHF therapy, weight loss
using formula diet and cardiac rehabilitation were started. After these therapies, weight was reduced
to 82kg. The cardiac function was improved without any cardiac accident during the hospital days.
Conclusion: Weight loss using the formula diet for obese patient with HF was safe and useful.

Gastric Sleeve and Metabolic Syndrome1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Helena C. Pinto1,Henrique B.
Castelo1

The Metabolic Syndrome (MS) is a complex disease, associated with an increased cardiovascular risk, due
to central fat distribution and insulin resistance. Today there are several treatments for MS, including
bariatric surgery, that improve that cardiovascular risk.The authors present a group of 48 patients withMS, submitted to gastric sleeve procedure,and evaluate their BMI, body weight and MS at 6, 9 and 12

months after surgery. The MS improved with weight loss in all the patients, sometimes with fullremission.The authors conclude that gastric sleeve surgery is a good option for the treatment of MS inobese patients.

Our experience in treatment of metabolic syndrome

1

Faculty Surgery Clinic, State Medical University n.a. Pavlov, Saint-Petersburg , Russia

Michael B. Fishman1,Valery Sedov1

Methods. A total of 439 patients underwent various bariatric procedures for 9 years were investigated.
In 391 cases laparoscopic operations were done. LAGB was performed in 307 patients. Median age was 37.
There were 253 (82,4%) women and 54 (17,6%) men. Average preoperative BMI was 42 kg/m2 (35 to 54). Beginningfrom 2007 we had performed 45 patients underwent LSG, 11 - LDS, 28 - LRYGB. Median age for the patientswas 36 years, of them 63 (75%) were females and 21 (25%) males. BMI was in limits of 41-90 kg/m2. In
the cohort of patients who underwent LAGB 68 (22,4%) suffered from metabolic syndrome (MS), LSG - 12
(26,6%),LDS - 100%, LRYGB - 16 (57,1%) respectively.Results. At North-West Russia obesity was foundin 41,4%. After LAGB during first two years of follow up sugar level in blood became normal in 156 (52,3%)
patients. Blood pressure became normal in 103 (34,5%). BMI was in limits of 26 - 38 kg/m2 with the sametendency in the following years. We managed best weight reduction mainly in women younger then 39 y.
o., with BMI lower then 45 kg/m2. In 46 (15,4%) patients there were complications, among them 38 (12,7%)
cases of bandage slippage. 17% of the patients were reoperated. Symptom-complex, that different MS was
lost after LDS in 100 % and in 75% after LRYGB. No complications were identified after LSG, LDS and LRYGB.
Conclusion. LAGB is an effective method of treatment for the patients with BMI lower then 45 kg/m2 inyounger age cohort. LSG can be an alternative for LAGB.LDS and LRYGB are most effective operations intreatment of MS.

Irregular CPAP use induced visceral fat accumulation in obstructive sleep apnea regardless of daily
sleepiness

1

Department of Cardiovascular Center, Sakura Hospital, Medical Center, Toho University, Chiba, Japan2

Department of internal medicine, Sakura Hospital, Medical Center, Toho University Chiba, Japan3

Department of ophthalmology, Sakura Hospital, Medical Center, Toho University Chiba

mao takahashi1,takashi hitsumoto2,tomoaki shiba3,kohji shirai2

Background: Obstructive sleep apnea syndrome (OSAS) is a common disorder in obese subjects. Occasionally
OSAS causes excessive daily sleepiness (EDS) and resulted in adipose tissue accumulation. The other hand,
there were many people who do not have daily sleepiness despite of sever OSAS. But the effect of continuous
positive airway pressure (CPAP) treatment on visceral fat accumulation (VFA) in OSAS without sleepinesshas not been known.

Material and Methods:VFA and subcutaneous fat accumulation (SFA) were assessed by CT before and 1 year
after CPAP treatment in 47 OSAS patients(mean apnea and hypopnea index/Epworth sleepiness scale;40.7
times/h/5.4±4.5).The sample was divided according to CPAP therapy, with regular users defined as aminimum nightly use of(≥4 h /day≥75%/month);27 subjects were regular and 20 were irregular CPAP users.

Results: Neither the regular CPAP use group nor irregular CPAP use group showed any change in body massindex or subcutaneous fat area levels.VFA increased significantly after 1year of CPAP treatment in
irregular user(171.3±68.5 to 161.2±72.4cm2 (-3.4±5.1%) vs 170.0±75.3 to 192.5±66.7cm2 (+13.4±
14.6%), P<0.0061)

ConclusionsThese data suggested that irregular CPAP use induce visceral fat accumulation in patientswith severe OSAS regardless of EDS. OSAS may have significant effects on the visceral fat accumulation
without EDS.

Individualized intervention with Metabolic Stem Cell system after bariatric surgery

1

Department of Complementary & Alternative Medicine, Osaka University Graduate School of Medicine

2

Department of Metabolic Medicine, Osaka University Graduate School of Medicine

3

Department of

Gastroenterological Surgery, Osaka University Graduate School of Medicine
Miki Sakaue1,Kazuhisa Maeda1,2,Kei Hirai1,Yasuhiro Miyazaki3,Shuji Takiguchi3,Yuichiro Doki3,Toshinori
Ito1,3(Background) In addition to reducing body weight, ameliorating fat dysfunction by improving
hypoadiponectinemia is crucial in protection against the development of metabolic syndrome. We recently
started a Weight Management Clinic in order to perform integrated and individualized intervention forobese patients. Here we report 3 cases whose metabolic stem (MSC) cell as adipocyte precursors wereobtained during bariatric surgery that can be used as a novel screening system for selecting
patient-suitable drugs or supplements to enhance adiponectin secretion. (Method) MSC were prepared fromfat tissues collected from 3 patients during bariatric surgery. Case1: 24yo male BMI 52 adiponectin
3.5ug/ml Case2: 24yo female BMI 46 adiponectin 5.3ug/mlCase3: 40yo female BMI 40 adiponectin 1.7ug/mlMSCs
were differentiated in cultures into mature adipocytes and treated with drug or supplementation medium
every 48 hours. Levels of adiponectin were measured in the culture medium. Dividing the adiponectin
secretion on day 12 by that on day 10 provided an estimate of adiponectin-producing activity in culture.
(Result) Using this score, we assessed 80 candidate agents in a 96-well plate. Moreover, we identified
some novel adiponectin up-regulatory effects for several substances, including Turmeric and Ryukyu herb.
Even after weight reduction achieved by surgery, additional enhancement of adiponectin was observed in
all cases with suitable supplementation. (Case1: adiponectin 7.4 ug/ml, Case2: adiponectin 10.1 ug/ml,
Case3: adiponectin 2.1ug/ml)(Conclusion) MSC system is able to identify potential responders to specificagents. This can be applied to post-operative individualized intervention for morbid obese patients.

Diabetic complications stratified by past maximum body mass index

1Center of Diabetes, Endocrine and Metabolism, Toho University Sakura Medical Center 2Department ofInternal Medicine, Toho University Sakura Medical Center
Takashi Yamaguchi1,Atsuhito Saiki1,Noriko Ban1,Hidetoshi Kawana1,Daiji Nagayama1,Ayako Nagumo1,Masahiro
Ohira1,Kei Endo1,Tomokazu Oyama1,Yoh Miyashita1,Kohji Shirai2

Background: In Japan, prevalence of obesity (especially high degree obesity values 35<BMI) is relatively
low. Therefore, relationship between degree of obesity and development of diabetic complications has
not been fully understood.Objective: To investigate the impact of past maximum BMI on the subsequentdevelopment of diabetic complications.Methods: One hundred inpatients with type 2 diabetes were divided
into 3 groups according to each patient's past maximum BMI; Group A: 25<BMI<30, Group B: 30<BMI<35 andGroup C: 35<BMI. There were no significant differences in mean age, duration of diabetes and HbA1C among
all groups. And we compared the prevalence of diabetic complications as well as other obesity-related
complications among groups retrospectively.Results: Mean past maximum BMI of each group (Group A, B andC) were 28.4, 32.1 and 37.3 respectively. In group C, the difference between past maximum BMI and meancurrent BMI (30.2) was greater than in other groups. A rate of Insulin use was significantly higher inGroup C than in Group A (Odd ratio: 6.3). With increase in past maximum BMI, the prevalence of diabetic
retinopathy, nephropathy and neuropathy became higher (Odd ratio; retinopathy: 3.4, 7.6, nephropathy:
3.9, 12.3 and neuropathy: 6.9, 14.8). The prevalence of diabetic macro angiopathy (includes coronary
artery disease, cerebral infarction and peripheral artery disease) also tended to be higher in GroupC than in other groups (Odd ratio: 2.1, 2.7). Arterial stiffness (evaluated by cardio-ankle vascularindex) was significantly higher in Group C than in Group A (7.7vs9.8). The prevalence of the otherobesity-related complications (sleep apnea syndrome, osteoarthritis, liver dysfunction) showed similar
results.Conclusion: Degree of obesity may associate with future development of obesity-related
complications, especially with diabetic complications.

Background: The impact of a degree of obesity on the development of diabetic and other obesity-related
complications is not fully understood.Objective: To investigate the impact of a maximum BMI in the pasthistory on the development of diabetic and other obesity-related complications.Methods: One hundred
inpatients with type 2 diabetes were divided into 3 groups according to each patients maximum BMI in
the past history (max BMI); Group A: 25<BMI<30, Group B: 30<BMI<35 and Group C: 35<BMI. And we compared
the prevalence of diabetic complications as well as other obesity-related complications amonggroups.Results: Mean max BMI (Group A, B and C) were 28.4, 32.1 and 37.3 respectively. In all groups,
mean present BMI (25.8, 27.4 and 30.2) were significantly lower than those of max BMI. There were no
significant differences in mean age, duration of diabetes and HbA1C among all groups. A rate of Insulin
use was significantly higher in Group C than Group A (Odd ratio: 6.3). The prevalence of diabetic
retinopathy, nephropathy and neuropathy became higher accompanied with increased max BMI (Odd ratio;
retinopathy: 3.4, 7.6, nephropathy: 3.9, 12.3 and neuropathy: 6.9, 14.8). The prevalence of diabetic
macro angiopathy (includes coronary artery disease, cerebral infarction and peripheral artery disease)tended to be higher in Group C than the other groups (Odd ratio: 2.1, 2.7). Arterial stiffness (evaluatedby cardio-ankle vascular index) was significantly higher in Group C than Group A (7.7 vs 9.8). The
prevalence of the other obesity-related complications (sleep apnea syndrome, osteoarthritis, liver
dysfunction) showed similar results.Conclusion: A degree of obesity in the past history might beassociatedwithcomplications.

thedevelopmentofobesity-related

complications,especiallywithdiabeticPsychosocial Assessments of Japanese Severe Obese Patients before Intragastric Balloon Placement
Therapy.

1

Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The Universityof Tokyo, Tokyo, Japan 2Depertment of Gastrointestinal Surgery, Graduate School of Medicine, The
University of Tokyo, Tokyo, Japan 3Department of Diabetes and Metabolic Diseases, Graduate School of
Medicine, The University of Tokyo, Tokyo, Japan
Shuji

Inada1,Yoshiyuki

Takimoto1,Kazuhiro

Yoshiuchi1,FumihikoHatao2,Yusuke

Hada3,Sumie

Okahata3,Toshimasa Yamauchi3,Takashi Kadowaki3,Akira Akabayashi1

Bariatric surgery was not so popular in Japan as in other countries. Instead, intragastric balloon
placement therapy has been performed in our hospital since 2007. The results of bariatric surgery andintragastric balloon placement therapy could be influenced by patient's psychosocial factors, and viceversa. Therefore it is important to assess psychosocial factors before procedures. The purpose of thepresent preliminary study is to explore characteristics of psychosocial factors of Japanese obese
candidates for intragastric balloon placement therapy. Eligible patients for this study were adult obese
ones classified to class II or higher (body mass index [BMI] was over 35kg/m2) who applied to receive
intragastric balloon placement therapy. Thirteen male (44.8±8.7 years) and 14 female patients (51.4±9.6 years) were candidates for the therapy and received an initial psychosocial assessment between
2007 and 2010. Mean BMI was 42.6kg/m2 in the male patients and 43.2kg/m2 in the females. Five patients
had psychiatric comorbidity. The psychosocial assessment included an interview about weight history,
lifestyle, and psychiatric history, and questionnaires about mood states, coping skills, self-esteem,
and social support. We evaluated correlations between initial BMI and the psychosocial factors. There
was a significant negative correlation between initial BMI and problem-focused coping (r = -0.485, p= 0.012). In the subscales of the problem-focused coping, planful problem solving (r = -0.393, p = 0.047)
and confrontive coping (r = -0.473, p = 0.015) had negative correlations with BMI. In conclusion, heavier
patients might have poorer ability to solve their own problems including their weight and diet. Because
this study was cross-sectional, it is necessary to assess prospectively the influence of preoperative
psychosocial factors on outcomes of intragastric balloon placement therapy and vice versa.

First experience of laparoscopic sleeve gastrectomy for morbid obesity in our OR

1

Chiba University Hospital, Nursing 2Research Center for Frontier Medical Engineering, Chiba University

3

Department of Frontier Surgery, Graduate School of Medicine, Chiba University

Megumi Kanoh1,Norihiro Kameda1,Yuki Miyake1,Mami Yoshida1,Sizue Komoda1,Hiroshi Kawahira2,Toshiyuki
Natsume3,Hideki Hayashi2,Hisahiro Matsubara3

Introduction: Laparoscopic approach to bariatric surgeries has been penetrating into our country andfirst case of laparoscopic restrictive surgery for morbid obesity has been performed until 2010 in our
hospital. Perioperative nursing experience of the case will be reported.Patient and Methods: A
39-year-old, 132 kg man (height 170cm, BMI 45.7) was planned to undergo laparoscopic sleeve gastrectomy
for weight reduction under general anesthesia. His medical background included hypertension, sleep apnea
and gall stone. Setting in operating theatre was designed on the basis of that for laparoscopic gastrectomy
for gastric cancer in our OR. The patient was positioned supine with thighs abducted and 30 degrees reverse
Trendelenburg. Lithotomy positioning device (LevitatorTM), which was routinely used for the operating
position of laparoscopic gastrectomy, were revealed to be too small for the patient, thus, leg sectionof electric operating table was switched between right and left part to obtain wide area for abductedthighs. Intermittent pneumatic compression devices were also equipped during surgery.Results: Operative
procedures were completed within 3 hours with little blood loss. However, the patient noted numbness
and mild foot drop of right leg right after surgery. Examination by a neurologist on the second
postoperative day revealed right peroneal palsy. Slow, but complete recovery occurred over three month.

Discussions: Photographical review of the OR setting could not reveal any mechanical compression of thesite. However, repeated checkup of the whole body of patient during operation was suggested to be importantto this type of surgery.

The effects of regular advice-messages via to internet with cell phone on diet using formula dietsupplements.

1

Graduate School of Medicine, Study of Medical System Management, Nagoya University 2Clinical Pharmacy,

Department of Pharmacy, Kinjo Gakuin University 3Information Culture, Kinjo Gakuin University
Hiroshi

Gohma1,Mika

Asano2,Yuko

Aoyama1,Rina

Fujii2,Konatsu

Hayashi2,Chihiro

inoue2,Tomomi

Kawanishi2,Katsuo Amioka2,Makoto Nakao2,Sin-ichi Sugiura1

Since WHO has proposed the criteria of metabolic syndrome in 1998, obesity is focused as a risk factorof life-style related diseases.

In the result, many formula diet supplements which aimed weight loss

have been market in the world.

Although the formula diet supplements have nutritional availability,

some users fail to loss their weight due to their lack of knowledge, or gain weight due to the reboundphenomenon.

Therefore it is thought that the formula diet supplements are not effective to weight loss,

despite their price.

However we propose that the users might be able to be loss their weight by giving

advice-messages regularly.

In this study, we evaluated whether the regular advice-messages via tointernet with cell phone were effective to the subjects who intake formula diet supplements. A total
20 subjects with BMI more than 23 were recruited. They were divided into two groups by an advice groupor no advice group.

Each group received formula diet supplements for 12weeks, and was provided

consecutive 12 weeks as follow up.

The advice group was provided an advice-messages everyday during

trial, while the no advice group was provided nothing during same period. We evaluated weight and BMI
as parameter in this study.Each group lost their weight compared to their initial value.
difference was indicated between both groups in their weight and BMI.
that each group intake the formula diet supplements.

No significant

This study was finished the period

Follow up for 12 weeks is performed at present.

We hypothesize that the deference is indicated between both group in their weight and BMI during follow
up period.

We will report the effect of advice-messages during follow up period in the congress.

Hours of nightly nasal continuous positive airway pressure use is associated with weight change inpatients with obstructive sleep apnea-hypopnea syndrome1

Department of Laboratory Medicine, Iwate Medical University School of Medicine, Devision of Behavioral

Sleep Medicine 2Department of Laboratory Sleep Medicine, Iwate Medical University School of Medicine
3

Department of Respirology, Hachinohe Red Cross Hospital

TsuguoNishijima1,Keisuke

Hosokawa1,Sayaka

Ishidoya3,Susumu

Takahashi1,Hiroshi

Kagami3,Keijiro

Suzuki1,Akira Suwabe1,Shigeru Sakurai2

Nasal continuous positive airway pressure (nCPAP) is known to alleviate sleep-related disturbances andmay reduce the risk of hypertension and cardiovascular disease. Using an electronic database of numberof hours of nightly CPAP use, we estimated the habitual sleep time of patients during nCPAP and examined
its relationship to association with changes in body weight. In obese patients with obstructive sleep
apnea-hypopnea syndrome (OSAHS), percent weight gain over 9 years displayed a U-shaped relationship withthe minimal weight gain in patients with 5 to 6 hours of habitual sleep. In contrast, weight gain was
the largest in patients with sleep time of less than 4 hours per night or more than 8 hours per night.
These results suggest that changes in body weight in patients with OSAHS are associated more with habitual
sleep time.

Title:Successful application of a new stapler with reinforcement installed to sleeve gastrectomy inbariatric surgery

Hiroko TORII MD*, Yuhki OZAMOTO MD*#, Takeshi TOGAWA MD, PhD*#, Isao KAWAMURA MD, PhD+, Akeo HAGIWARA
MD, PhD#*Kusatu General Hospital, #Doshisha University, +Kamagaya General HospitalIn patients undergoing sleeve gastrectomy, the gastric wall is often thick and readily breakable due
to adipose tissue accumulating in the submucosa and the musclularis. When sleeve gastrectomy is performedon such patients, conventional staplers often break or fail to suture the thick and fragile gastric wall,
sometimes resulting in serious post-operative complications such as bleeding and/or anastomotic leakage.
As a countermeasure for this problem, we have used a newly available type of stapler, which sandwiches
a strip of reinforcement between the staples and the tissue. By stapling the gastric wall from thereinforcement layered atop, the stapler prevents breaking of the tissue and ineffective stapling. The
layer of the reinforcement and the gastric wall seems to have a proper physical strength for stapling.
Since the introduction of the device, we have experienced no post-operative complications stemming fromsuture errors. This new stapler can be useful in sleeve gastrectomy.

Enhanced glucagon-like peptide (GLP-1) secretion leads to rapid improvement of glucose tolerance andinsulin secretion after laparoscopic sleeve gastrectomy (LSG)

Satoshi Ugi1, Hiroshi Yamamoto2, Chisato Kusunoki1, Azusa Kamo1, Tetsuya Hashimoto1, Yoshihiko Nishio1,
Kazunori Kasama3, Toru Tani2, Atsunori Kashiwagi1, and Hiroshi Maegawa1
Departments of 1Medicine and 2Surgery, Shiga University of Medical Science, and 3Yotsuya Medicalcube
Hospital【Objective】 Bariatric surgery, especially Roux-en-Y gastric bypass (RYGP), has been shown to resolve
T2DM. Although the mechanism by which RYGP improves T2DM have yet to be fully determined, the most possible
mechanism of this is assumed to be increment of GLP-1 secretion. LSG has been designed as the first of
a two-stage procedure for the high-risk, super-obese patient. Recently LSG has been studied as asingle-stage procedure because of excellent weight loss and low incidence of complications. However,
little is known about the impact of LSG on glucose homeostasis. We performed LSG in two diabetic patientsand both showed rapid and profound improvement of glucose tolerance after LSG.
【Methods】 We performed glucose tolerance test (GTT) before and twenty days after surgery and analyzed
area under the curve of plasma glucose, insulin and GLP-1 ; AUCglucose (mg/dl‧hr), AUCinsulin (U/ml‧hr),
AUCGLP-1 (pmol/l‧hr), and fasting ghrelin levels.
【Results】The first case had received metoformin 750mg/day for three years. HbA1c was 6.3%. Twenty days
after surgery, BMI decreased from 38.0 to 36.4 (-4.1kg). Although AUCglucose slightly decreased (510 to457), both AUCinsulin and AUCGLP-1 dramatically increased (122 to 216 and 6.4 to 68.5, respectively). Threemonths after surgery, HbA1c was 5.5% without medication. Second case also showed great improvement of
glucose tolerance with enhancement of insulin and GLP-1 secretion. Ghrelin levels were significantly
decreased in both cases.

Enhanced GLP-1 secretion is specific to bariatric surgery, because weight

reduction by diet therapy did not enhance GLP-1 secretion.
【Conclusion】 These results suggest that LSG can lead to rapid improvement of glucose tolerance andinsulin secretion along with GLP-1 secretion. Reduction in ghrelin levels may also contribute toimprovement of glucose tolerance. Thus, LSG will be ideal procedure for obesity with T2DM.

Duodenal switch for failed gastric banding

Dr Daniel KRAWCZYKOWSKI, Dr Youssef El SOUKI
Centre Hospitalier Regional de Metz FRANCE

Background
Biliopancreatic duodenal switch (BPD/DS) has 2 components: a restrictive one the sleeve
gastrectomy (SG) and a malabsorptive one the duodenal switch (DS). Each of the twocomponents can be performed separately.
MethodBetween May 2003 and July 2008, 38 patients with an uncomplicated and well tolerated
adjustable gastric banding (AGB) sustained an additional DS for an inadequate initialexcess BMI loss (IEBMIL) (BMI >30) or for persisting curable co-morbid condition. Most of
the bands were kept deflated.
Results
So far, 16 patients remained with the band associated to the DS while 22 patients had alater band removal for convenience, intolerance or IEWL (6 patients had a conversion to SG
and 16 patients are free of any restriction). All glycemic and high cholesterol problems
were resolved.

BMI before BMI before Type ofAGB
DSrestriction

46.9 (35.4– 61.7)40.9 ±
6.9

Differential evolution of
BMI% IEBMILAt 1 YAt 2 YAt 1 YAt 2 YAGB

32.3±530.6±4.5

67.5±22.8

65.9±18.9SG

29.9±7.6

28.6±3.877.2±16.2

81.9±11.9

Without33.7±5.5
restriction

32.9±6.0

61.8±24.8

64.9±29.5

Conclusion:
Additional DS is feasible. With or without any restriction, it contributes to patientsweight loss and to resolve curable co-morbid condition. Although AGB + DS, isolated DS or
debanding and SG and are options for failure AGB further studies are needed.