Fears of Lifetime Reflux Risk in Band & Sleeve Patients with Minimal Symptoms Risk of Esophageal Cancer

Esophageal Cancer Risk Higher in GERD Patients with Fewest Symptoms

Medically treated patients with mild or no symptoms of gastroesophageal reflux disease (GERD) are at higher risk for developing esophageal cancer than those with severe GERD symptoms.

Many patients who develop adenocarcinoma, a common form of esophageal cancer, are unaware that they have Barrett’s esophagus – a change in the cells lining the esophagus often due to repeated stomach acid exposure. In some cases, Barrett’s esophagus develops into esophageal cancer.

“Typically, patients with severe GERD symptoms are screened for Barrett’s esophagus, but those with mild or absent symptoms are not. Unfortunately, many patients who develop adenocarcinoma don’t know that they have Barrett’s esophagus until it has transformed into cancer and become advanced, leading to obstruction,”

The study included 769 GERD patients who presented for their first upper endoscopy, in which a flexible endoscopic camera is guided through the esophagus and stomach to look for tissue changes. Participants were separated into three groups:

  • patients who were referred for upper endoscopy for any clinical indication regardless of symptoms;
  • patients with typical GERD symptoms, such as heartburn, regurgitation, and difficulty swallowing; and
  • patients with atypical GERD symptoms, such as hoarseness, throat-clearing, mucus, coughing, and a lump sensation in the throat.

All study participants underwent endoscopy and completed questionnaires and a detailed medication history. Endoscopy revealed that 122 of these patients, or 15.9 percent, had Barrett’s esophagus or adenocarcinoma. Patients who were adequately managing their GERD symptoms with proton pump inhibitors (PPIs) were 61 percent more likely to have Barrett’s esophagus or adenocarcinoma if they reported no severe GERD symptoms, compared to patients taking PPIs who reported severe symptoms. Patients with severe GERD symptoms often experienced irritation or swelling of the esophagus, but that was associated with decreased odds of having esophageal cancer.

“Our research indicates that even patients without severe symptoms may benefit from Barrett’s esophagus screening,” Dr. Jobe noted. “If GERD patients are screened early enough, there is a better chance that Barrett’s esophagus can be identified before it becomes cancerous,” he stated. “We are learning that the chronic and long-term use of PPIs may not be entirely without consequences and may lead to more insidious problems such as calcium malabsorption or cause one to be asymptomatic in the face of continued esophageal injury from GERD.”

Dr. Jobe and his Pitt colleagues have established the Barrett’s Esophagus Risk Consortium (BERC), in which primary care patients are being screened with in-office, small-caliber, unsedated endoscopy in an attempt to better understand risk factors for the condition as well as lower the threshold for screening. The multicenter effort is funded by the National Institutes of Health.


Sleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight Regain


Sleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight Regain

Obes Surg. 2012 Sep 23. [Epub ahead of print] Indications and Mid-Term Results of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Gautier T, Sarcher T, Contival N, Le Roux Y, Alves A. Source Département de Chirurgie Digestive, Caen University Hospital, Avenue de la Côte de Nacre, 14033, Caen Cedex, France, gautier.tho@gmail.com.

Abstract Sleeve gastrectomy (SG) is currently considered as a primary bariatric surgery. This is because of its relative simplicity and satisfactory results. As observed with other bariatric procedures, surgeons are confronted with insufficient weight loss or weight regain, insufficient resolution of metabolic disorders, and intractable severe reflux. A retrospective analysis of conversion from SG to Roux-en-Y gastric bypass (RYGBP) was performed to assess weight loss, diabetes resolution, and relief of reflux symptoms.

*** In ONLY 2 yrs!! The mean interval between the two procedures was

almost 24 months.

*** Eighteen patients underwent conversion from SG to RYGBP for

insufficient weight loss (n = 9),

severe reflux (n = 6), and persistence of type 2 diabetes mellitus

(T2DM) (n = 3).


Imagine the results in 10 years!


The median follow-up was 15.5 months. Weight loss was significantly improved with a mean percentage of excess of body mass index loss at 64.6 % after conversion versus 47.1 % before conversion. All reflux symptoms were immediately relieved without any medication at the end of the follow-up. The three patients who had an operation for persistence of T2DM are now free of medication. Only one postoperative complication was observed as a small bowel injury, which was treated surgically. Conversion from SG to RYGBP is safe. Severe reflux is definitely treated and is an incontestable indication with this procedure. Additionally, weight loss and diabetes are clinically improved. Our results appear to be similar to those with a primary RYGBP.

Obes Surg. 2012 Sep 23. [Epub ahead of print]
Indications and Mid-Term Results of Conversion from SleeveGastrectomy to Roux-en-Y Gastric Bypass.
Gautier TSarcher TContival NLe Roux YAlves A.
Département de Chirurgie Digestive, Caen University Hospital, Avenue de la Côte de Nacre, 14033, Caen Cedex, France, gautier.tho@gmail.com.
Sleeve gastrectomy (SG) is currently considered as a primary bariatric surgery. This is because of its relative simplicity and satisfactory results. As observed with other bariatric procedures, surgeons are confronted
with insufficient weight loss or weight regain, insufficient resolution of metabolic disorders,
and ** intractable severe reflux.***
A retrospective analysis of conversion from SG to Roux-en-Y gastric bypass (RYGBP) was performed to assess weight loss, diabetes resolution,
and relief of reflux symptoms.
*** The mean interval between the Sleeve and Failure was less than 24 months.
Eighteen patients underwent conversion from SG to RYGBP for insufficient weight loss (n = 9),
severe reflux (n = 6), and
persistence of type 2 diabetes mellitus (T2DM) (n = 3).
The median follow-up was 15.5 months. Weight loss was significantly improved with a mean percentage of excess of body mass index loss at 64.6 % after conversion versus 47.1 % before conversion. All refluxsymptoms were immediately relieved without any medication at the end of the follow-up. The three patients who had an operation for persistence of T2DM are now free of medication. Only one postoperative complication was observed as a small bowel injury, which was treated surgically. Conversion from SG to RYGBP is safe.
Severe reflux is definitely treated and is an incontestable indication with this procedure.
Additionally, weight loss and diabetes are clinically improved. Our results appear to be similar to those with a primary RYGBP.

Obes Surg. 2012 Sep 22. [Epub ahead of print]
Indications and Short-Term Outcomes of Revisional Surgery After Failed or Complicated Sleeve Gastrectomy.
van Rutte PWSmulders JFde Zoete JPNienhuijs SW.
Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
Sleeve gastrectomy (SG) is an upcoming primary treatment modality for morbid obesity. The aim of this study was to report the indications for and the outcomes of revisional surgery after SG.
Four hundred sixteen individuals underwent a SG between August 2006 and July 2010 with a minimum
follow-up of 12 months. The patients that needed revision were identified from our prospective registry. Patients were subdivided in a first group undergoing revision as part of a two-step procedure,
a second group with failure of a secondary SG, and a third group with failure of a primary SG.
Twenty-three patients (5.5 %) had an unplanned revision.
Fourteen (3.4 %) had a two-step procedure because of super obesity.
A significant additional weight loss was achieved after revision; no complications occurred in this group.
Five patients with failure of a secondary SG had no significant additional weight loss after revision.
Reflux disease was cured. Eighteen patients in the third group showed significant additional weight loss and remission of diabetes and hypertension.
Both reflux disease and dysphagia did not heal in all affected patients after revision.
The early complication rate in the whole cohort was 23.4 %;
staple line leakage was 5.4 %, and bleeding was 8.1 %. Revision-related mortality was 0 %.
In a large series of sleeve gastrectomies, the unplanned revision rate was 5.5 %. Revision of asleeve gastrectomy is feasible in patients that do not achieve sufficient weight loss and in those patients developing complications after the initial sleeve gastrectomy.

Obes Surg. 2012 Aug 23. [Epub ahead of print]
Laparoscopic Sleeve Gastrectomy: Symptoms of Gastroesophageal Reflux can be Reduced by Changes in Surgical Technique.
Daes JJimenez MESaid NDaza JCDennis R.
Minimally Invasive Surgery Department, Clinica Bautista, Carrera 38 calle 71 esquina, Barranquilla, Colombia, jorgedaez@gmail.com.
Bariatric surgery is the most effective treatment for gastro-esophageal reflux disease (GERD) in obese patients, with the Roux-en-Y gastric bypass being the technique preferred by many surgeons. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. In a previous observational study, we found that
*** relative narrowing of the distal sleeve, hiatal hernia (HH), and dilation of the fundus predispose to GERD after LSG.***
In this study, we evaluated the effects of standardization of our LSG technique on the incidence of postoperative symptoms of GERD.
This was a concurrent cohort study. Patients who underwent bariatric surgery at our center were followed prospectively. LSG was performed in all patients in this series.
A total of 234 patients underwent surgery. There were no cases of death, fistula, or conversion to open surgery. All 134 patients who completed 6-12 months of postoperative follow-up were evaluated. Excess weight loss at 1 year was 73.5 %. In the study group, 66 patients (49.2 %) were diagnosed with GERD preoperatively, and HH was detected in 34 patients (25.3 %) intraoperatively. HH was treated by reduction in three patients, anterior repair in 28, and posterior repair in three. Only two patients (1.5 %) had symptoms of GERD at
*** 6-12 months postoperatively. VERY SHORT FOLLOW UP ***
Our results confirm that careful attention to surgical technique can result in significantly reduced occurrence of symptoms of GERD up to 12 months postoperatively, compared with previous reports of LSG in the literature.

Surg Obes Relat Dis. 2012 Jun 19. [Epub ahead of print]
SHORT FOLLOW UP:  Sleeve gastrectomy and crural repair in obese patients withgastroesophageal reflux disease and/or hiatal hernia.
Soricelli EIossa ACasella GAbbatini FCalì BBasso N.
Gastroesophageal reflux disease (GERD) with or without hiatal hernia (HH) is now recognized as an obesity-related co-morbidity. Roux-en-Y gastric bypass has been proved to be the most effective bariatric procedure for the treatment of morbidly obese patients with GERD and/or HH. In contrast, the indication for laparoscopic sleeve gastrectomy (SG) in these patients is still debated. Our objective was to report our experience with 97 patients who underwent SG and HH repair (HHR). The setting was a university hospital in Italy.
From July 2009 to December 2011, 378 patients underwent a preoperative workup for SG. In 97 patients, SG was performed with HHR. The clinical outcome was evaluated considering GERD symptom resolution or improvement, interruption of antireflux medications, and radiographic evidence of HH recurrence.
Before surgery, symptomatic GERD was present in 60 patients (15.8%), and HH was diagnosed in 42 patients (11.1%). In 55 patients (14.5%), HH was diagnosed intraoperatively. The mean follow-up was 18 months. GERD remission occurred in 44 patients (73.3%). In the remaining 16 patients, antireflux medications were diminished, with complete control of symptoms in 5 patients. No HH recurrences developed. “De novo” GERD symptoms developed in 22.9% of the patients undergoing SG alone compared with 0% of patients undergoing SG plus HHR.
SG with HHR is feasible and safe, providing good management of GERD in obese patients with reflux symptoms. Small hiatal defects could be underdiagnosed at preoperative endoscopy and/or upper gastrointestinal contrast study. Thus, a careful examination of the crura is always recommended intraoperatively.
Copyright © 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Obes Facts. 2011;4 Suppl 1:42-6. Epub 2011 Apr 4.
Failure of laparoscopic sleeve gastrectomy–further procedure?
Weiner RATheodoridou SWeiner S.
Department of Surgery, Krankenhaus Sachsenhausen, Frankfurt/M, Germany. rweiner@khs-ffm.de
Worldwide, the incidence of morbid obesity is increasing, and surgery is the only effective longterm treatment. Laparoscopic sleeve gastrectomy (LSG) is associated with acceptable weight loss and reduced comorbidities. It is considered a safe procedure with sporadic complications. This publication aims to describe failures of LSG in terms of ineffective weight loss or early weight regain, and analyze secondary treatment options.
From October 2001 to December 2010, 937 patients underwent LSG in our department. Initially, all procedures were scheduled as a two-stage procedure (LSG followed by biliopancreatic diversion with duodenal switch). However, the second procedure was not performed in 64 patients (body mass index > 60 kg/m(2)). Since 2005, the frequency of second stage procedures after weight regain has been increasing; their outcome is analyzed.
Of the 937 patients, 17 (1.8%) experienced staple line leakage. Mean time to first reintervention or endoscopic stent placement was 15.6 ± 22 days (range 2-78). From 2005 to 2010, 106 secondary procedures were performed. Insufficient weight loss or weight regain were the indications in 88 cases.
*** Sixteen (15%) patients had severe gastroesophageal reflux which was resolved by Roux-en-Y gastric bypass (RYGB).
Stenosis was observed in 2 (2.6%) patients, which required endoscopic dilatation and stent placement in one case and gastric bypass in the other.
LSG is a feasible and popular bariatric procedure. Mortality (0.4%) was much higher than after gastric bypass (0.03%) and gastric banding (0%) The knowledge of potential complications and their management is crucial. All restrictive procedures require patient compliance, but increased food uptake after RYGB and LSG is common. Malabsorptive procedures are more effective for long-term weight loss. Duodenal switch and omega-loop gastric bypass are more efficient second stage procedures than re-sleeve or RYGB.

Surg Obes Relat Dis. 2011 Nov-Dec;7(6):709-13. Epub 2011 Aug 16.
Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients.
Howard DDCaban AMCendan JCBen-David K.
Department of Surgery, Minimally Invasive, Gastroesophageal and Bariatric Surgery Service, University of Florida, Gainesville, Florida 32610, USA.
Gastroesophageal reflux disease (GERD) is highly prevalent in morbidly obese patients and a high body mass index is a risk factor for the development of this co-morbidity. The effect of laparoscopicsleeve gastrectomy (LSG) on GERD is poorly known.
We studied the effect of LSG on GERD in patients with morbid obesity. A retrospective review of 28 consecutive patients undergoing LSG for morbid obesity from September 2008 to September 2010 was performed.
A total of 28 patients, 18 women and 10 men, were identified, with a mean age of 42 years (range 18-60). The mean weight and body mass index was 166 kg and 55.5 kg/m2, respectively. The mean percentage of excess weight loss was 40% (range 17-83), with a mean follow-up time of 32 weeks (range 8-92). All patients had a pre- and postoperative upper gastrointestinal radiographic swallow study as a part of their routine care. Of these
*** patients, 18% were noted to have new-onset GERD on their postoperative upper gastrointestinal swallow test after their LSG procedure.
Using the GERD score questionnaire, all patients were interviewed to evaluate their reflux symptoms. We had a 64% response rate, with
*** 22% of patients indicating new-onset GERD symptoms despite receiving daily antireflux therapy.
*** LSG might increase the prevalence of GERD despite satisfactory weight loss.
Additional studies evaluating esophageal manometry and ambulatory 24-hours pH-metry are needed to better evaluate the effect of LSG on gastroesophageal reflux symptoms.
Copyright © 2011 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Surg Obes Relat Dis. 2011 Nov-Dec;7(6):749-59. Epub 2011 Aug 10.
Third International Summit: Current status of sleeve gastrectomy.
Deitel MGagner MErickson ALCrosby RD.
Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.
The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1-8) of experience with LSG.
The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28-60F (mean 36F, 70% blunt tip). Resection began 1.5-7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0-10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.
According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic.

Surg Obes Relat Dis. 2012 Sep;8(5):654. doi: 10.1016/j.soard.2011.06.004. Epub 2011 Jun 17.
Laparoscopic conversion of laparoscopic sleeve gastrectomy to gastric bypass for intractable gastroesophageal reflux disease.
Abdemur AFendrich IRosenthal R.
Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic, Weston, Florida.

Surg Obes Relat Dis. 2011 Sep-Oct;7(5):569-72. Epub 2011 Mar 22.
Association between gastroesophageal reflux disease and laparoscopicsleeve gastrectomy.
Carter PRLeBlanc KAHausmann MGKleinpeter KPdeBarros SNJones SM.

Midwest Surgical Associates, 5201 South Willow Springs Road, Suite 180, LaGrange, IL 60304, USA. doctorpcarter@yahoo.com
Gastroesophageal reflux disease (GERD) is a common co-morbidity identified in obese patients. It is well established that patients with GERD and morbid obesity experience a marked improvement in their GERD symptoms after Roux-en-Y gastric bypass. Conflicting data exist for adjustable laparoscopic gastric banding and GERD. Laparoscopic sleeve gastrectomy (LSG) has become a popular adjunct to bariatric surgery in recent years. However, very little data exist concerning LSG and its effect on GERD.
A retrospective chart review was performed of 176 LSG patients from January 2006 to August of 2009. The preoperative and postoperative GERD symptoms were evaluated using follow-up surveys and chart review.
Of the 176 patients, 85.7% of patients were women, with an average age of 45 years (range 22-65). The average preoperative body mass index was 46.6 kg/m(2) (range 33.2-79.6). The average excess body weight lost at approximately 6, 12, 24 months was calculated as 54.2%, 60.7%, and 60.3%, respectively.
Of the LSG patients, 34.6% had preoperative GERD complaints.
*** Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms,
*** 47.2% had persistent GERD symptoms that lasted >1 month after LSG, and
*** 33.8% of patients were taking medication specifically for GERD after LSG.
*** The most common symptoms were heartburn (46%),
*** followed by heartburn associated with regurgitation (29.2%).
In the present study,
*** LSG correlated with the persistence of GERD symptoms in patients with GERD preoperatively. Also,
*** patients who did not have GERD preoperatively had an increased risk of postoperative GERD symptoms.
Comment in
Comment on: Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy.[Surg Obes Relat Dis. 2011]

Curr Gastroenterol Rep. 2011 Jun;13(3):205-12.
Obesity and GERD: pathophysiology and effect of bariatric surgery.
Tutuian R.
Division of Gastroenterology, University Clinics of Visceral Surgery and Medicine, Bern University Hospital, Inselspital Bern, Bern, Switzerland. radu.tutuian@insel.ch
Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD).
Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity.
*** Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting.
Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date,
Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.

Surg Endosc. 2011 Jul;25(7):2323-9. Epub 2011 Feb 7.
Three-dimensional stomach analysis with computed tomography after laparoscopic sleeve gastrectomy: sleeve dilation and thoracic migration.
Baumann TGrueneberger JPache GKuesters SMarjanovic GKulemann BHolzner PKarcz-Socha ISuesslin D,Hopt UTLanger MKarcz WK.

Department of Diagnostic Radiology, University Hospital Freiburg, Albert-Ludwigs-University, Hugstetter Straße 55, 79106, Freiburg, Germany. tobias.baumann@uniklinik-freiburg.de
Laparoscopic sleeve gastrectomy (LSG) is frequently performed as a definitive bariatric procedure today. Quantitative data on the detailed anatomy of the stomach after LSG are yet sparse.
Thirty-two multislice computed tomography (MSCT) data sets acquired in 27 LSG patients (22 female, 5 male) with a dedicated examination protocol and post-processing were evaluated for gastric volume, stomach length, sleeve length, antrum length, staple line length, and maximum cross-sectional sleeve area. Obtained parameters were compared to time after surgery, weight loss, and the occurrence of postsurgical regurgitation.
Mean gastric volume was 186.5±88.4 ml. Gastric volume correlated significantly with the time interval after surgery. Sleeve sizes of 105.3±30.2 ml during early follow-up confirmed correct primary sizing of the sleeve,
*** whereas marked dilation to 196.8±84.3 ml was found in patients with a follow-up of 6 months and longer (p=0.038).
*** Sleeve area and staple line length were also positively correlated with time after surgery.
*** No correlation was found between gastric volume and excess weight loss.
*** In ten patients an intrathoracic migration of the staple line could be noted, with
*** four of these patients developing persistent regurgitation after LSG.
Regurgitation was present in only 2 of 17 patients without sleeve herniation.
Multislice computed tomography allows for a comprehensive and quantitative evaluation of the anatomy after LSG and thus provides new insights in the process of sleeve dilation. Intrathoracic migration of the staple line could be identified as a possible cause of persistent regurgitation.

Obes Surg. 2011 Feb;21(2):167-72.
Erosive esophagitis after bariatric surgery: banded vertical gastrectomy versus banded Roux-en-Y gastric bypass.
Miguel GPAzevedo JLde Souza PHde Siqueira Neto JMustafa FZambrana ESde Carvalho PS.
Federal University of Espírito Santo-UFES, Vitória, ES, Brazil. gsoaresp@terra.com.br
Erratum in
Obes Surg. 2011 Mar;21(3):412.
Obesity is associated with gastroesophageal reflux disease. Roux-en-Y gastric bypass is the most performed bariatric procedure in the world, whereas sleeve gastrectomy is an emerging procedure. Both can be combined with the use of a Silastic® ring. The aim of this study was to compare the evolution of erosive esophagitis (EE) in patients who underwent Silastic® ring gastric bypass (SRGB) and Silastic® ring sleeve gastrectomy (SRSG) after a 1-year postoperative period.
We carried out a non-randomized, prospective, controlled clinical study. Sixty-five patients were enrolled based on the following inclusion criteria: female gender, age 20-60 years old, BMI 40-45 and written informed consent. The exclusion criteria were secondary obesity, alcohol or drug use, severe psychiatric disorder, binge-eating of sweets, and previous stomach or bowel surgery. The patients were divided into two groups-33 (51%) underwent SRSG and 32 (49%) patients underwent SRGB. All patients underwent an esophago-gastro-duodenoscopy during the preoperative period and at 12-14 months after the surgery.
Preoperatively, 15 patients (23.8%) were found to have erosive esophagitis, six (19.4%) in the SRSG group and nine patients (28.1%) in the SRGB group (p = 0.7795).
** Postoperatively, there was an increase in the number of patients with erosive esophagitis in the SRSG group to 14 (45.2%)
and a decrease in the SRGB group to two (6.3%), giving a total of 16 patients with EE (25.4%; p = 0.0007).
After 1 year of follow-up, we observed a worsening evolution of EE in the SRSG group, but improvement in the SRGB group.

Obes Surg. 2011 Mar;21(3):288-94.
Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection–comparative study.
Mohos ESchmaldienst EPrager M.
Department of General Surgery, Territory Hospital Oberwart, Dornburggasse 80, Oberwart, 7400, Austria. mohose@freemail.hu
The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead-Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1 kg/m(2) (mean follow-up: 15.7 months) and in gastric sleeve group 50.3 and 33.5 kg/m(2) (mean follow-up: 38.3 months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead-Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastricsleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeveresection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection.
*** Ninety-two percent of the gastro-oesophagealreflux were resolved in the bypass group and
*** 25% in the sleeve (*** with 33% progression) group.
Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.

Ann Surg. 2010 Aug;252(2):319-24.
Long-term results of laparoscopic sleeve gastrectomy for obesity.
Himpens JDobbeleir JPeeters G.
Division of Bariatric Surgery, AZ St-Blasius, Kroonveldlaan, Dendermonde, Belgium.
To determine the mid- and long-term efficacy and possible side effects of laparoscopic sleevegastrectomy as treatment for morbid obesity.
Laparoscopic sleeve gastrectomy is still controversial as single and final treatment for morbid obesity. Some favorable short-term results have been published, however long-term results are still lacking.
In the period between November 2001 and October 2002, 53 consecutive morbidly obese patients who, according to our personal algorithm, were qualified for restrictive surgery were selected for laparoscopicsleeve gastrectomy. Of the 53 patients, 11 received an additional malabsorptive procedure at a later stage because of weight regain. The percentage of excess weight loss (EWL) was assessed at 3 and 6 years postoperatively. A retrospective review of a prospectively collected database was performed for evaluation after 3 years. Recently, after the sixth postoperative year, patients were again contacted and invited to fill out a questionnaire.
Full cooperation was obtained in 41 patients, a response rate of 78%. Although after 3 years a mean EWL of 72.8% was documented, after 6 years EWL had dropped to 57.3%, which according to the Reinhold criteria is still satisfactory. These results included 11 patients who had benefited from an additional malabsorptive procedure (duodenal switch) and 2 patients who underwent a “resleeve” between the third and sixth postoperative year. Analyzing the results of the subgroup of 30 patients receiving only sleeve gastrectomy, we found a 3-year %EWL of 77.5% and 6+ year %EWL of 53.3%. The differences between the third and sixth postoperative year were statistically significant in both groups. Concerning long-term quality of life patient acceptance stayed good after 6 + years despite the fact that late,
*** new gastro-esophageal reflux complaints appeared in 21% of patients.
In this long-term report of laparoscopic sleeve gastrectomy, it appears that after 6+ years the mean excess weight loss exceeds 50%.
*** However, weight regain and
*** de novo gastroesophageal reflux symptoms appear between the third and the sixth postoperative year.
This unfavorable evolution might have been prevented in some patients by continued follow-up office visits beyond the third year. Patient acceptance remains good after 6+ years.
Comment in
Surgery: Laparoscopic sleeve gastrectomy as the first-line surgical option for morbid obesity. [Nat Rev Endocrinol. 2010]

Obes Surg. 2010 Dec;20(12):1627-32.
Revisional vs. primary Roux-en-Y gastric bypass–a case-matched analysis: less weight loss in revisions.
Zingg UMcQuinn ADiValentino DKinsey-Trotman SGame PWatson D.
Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, SA, Australia. uzingg@uhbs.ch
With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of 61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and refluxin 6. Intraoperative and surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%, p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up.

Surg Laparosc Endosc Percutan Tech. 2010 Jun;20(3):148-53.
Gastroesophageal reflux disease after sleeve gastrectomy.
Braghetto ICsendes AKorn OValladares HGonzalez PHenríquez A.

Obes Surg. 2010 Jul;20(7):835-40.
Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass–indications and outcome.
Langer FBBohdjalian AShakeri-Leidenmühler SSchoppmann SFZacherl JPrager G.
Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
Due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy (SG) has gained popularity as sole and definitive bariatric procedure. In the long-term follow-up, weight loss failure and intractable severe reflux can necessitate further surgical intervention.
A retrospective analysis of laparoscopic conversions from SG to Roux-en-Y gastric bypass (RYGB) was performed to assess the efficacy for reflux relief and weight loss success.
*** A total of eight out of 73 patients (11%) underwent conversion to RYGB for severe reflux (n=3) or weight regain (n=5) after a median interval of 33 months following laparoscopic sleeve gastrectomy.
In one of the patients, a banded gastric bypass was performed. In both groups, conversion to RYGB was successful, as proton pump inhibitor medication could be discontinued in all patients presenting with severe reflux, and a significant weight loss could be achieved in the patients with weight regain within a median follow-up of 33 months. Postoperative complications were observed in only one patient as leakage at the gastrojejunostomy was successfully treated by temporary stent placement.
Conversion to RYGB is an effective treatment for weight regain or intractable reflux symptoms following SG. Thus, SG can be performed, intended as sole and definitive bariatric intervention, with conversion from SG to RYGB as an exit strategy for these complications.

Obes Surg. 2010 May;20(5):535-40. Epub 2010 Jan 22.
Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin.
Bohdjalian ALanger FBShakeri-Leidenmühler SGfrerer LLudvik BZacherl JPrager G.
Department of Surgery, Division of General Surgery, Medical University of Vienna, General Hospital Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
Due to excellent efficacy for weight loss in the short-term follow-up, sleeve gastrectomy (SG) has gained enormous popularity as bariatric procedure, not only as first step in high-risk or super-obese patients but mainly as a sole and definitive operation in morbidly obese. In contrast to a large number of short and intermediate-term results, no series of SG with a follow-up of 5 years or more has been published so far.
We report on the weight loss results of our first consecutive 26 patients with a complete follow-up of 5 years. Furthermore in a subgroup of 12 patients, plasma ghrelin levels were measured preoperatively, and up to 5 years following SG.
Weight loss defined as mean percent excess weight loss (%EWL) was found as 57.5 +/- 4.5, 60.3 +/- 5.0, 60.0 +/- 5.7, 58.4 +/- 5.4, and 55.0 +/- 6.8 (not converted, n = 21) for the first 5 years. Weight regain of more than 10 kg from nadir was observed in five (19.2%) of the 26 patients.
** Four of the patients (15.4%) were converted to gastric bypass due to severe reflux (n = 1, 3.8%) and weight loss failure (n = 3, 11.5%).
** A total of eight patients (30.8%) were at chronic need for proton pump inhibitor medication due to severe reflux.
Plasma ghrelin levels were reduced from 593 +/- 52 to 219 +/- 23 pg/ml 12 months postoperatively, with a slightly, non-significant increase toward the 5-years values of mean 257 +/- 23 pg/ml.
At 5-year follow-up, a mean EWL of 55.0 +/- 6.8% was achieved, indicating that SG leads to stable weight loss.
** Beside significant weight regain, severe reflux might necessitate conversion to gastric bypass or duodenal switch.
After an immediate reduction postoperatively, plasma ghrelin levels remained low for the first 5 years postoperatively.

Obes Surg. 2010 Mar;20(3):357-62. Epub 2009 Dec 15.
Manometric changes of the lower esophageal sphincter after sleevegastrectomy in obese patients.
Braghetto ILanzarini EKorn OValladares HMolina JCHenriquez A.
Department of Surgery, Faculty of Medicine, University of Chile, Santos Dumont 999, Santiago, Chile. ibraghet@redclinicauchile.cl
Laparoscopic sleeve gastrectomy has been accepted as an option for surgical treatment of obesity. After surgery, some patients present reflux symptoms associated with endoscopic esophagitis, therefore PPI’s treatment must be indicated.
This study aims to evaluate the
** manometric characteristic of the lower esophageal sphincter (LES) before and after sleeve gastrectomy
This prospective study includes 20 patients submitted to esophageal manometry in order to determine the resting pressure, and total and abdominal LES length before and after the sleeve gastrectomy. Statistical variations on the LESP were validated according to Student’s “t” test.
Seventeen female and three male patients were included, with a mean age of 37.6 +/- 12.6 years. All patients reduced their body weight, from an initial BMI of 38.3 kg/m(2) to 28.2 kg/m(2) 6 months after surgery. No postoperative complications were observed in these patients. Preoperative mean LESP was 14.2 +/- 5.8 mmHg.
** Postoperative manometry decreased in 17/20 (85%), with a mean value of 11.2 +/- 5.7 mmHg (p = 0.01). Seven of them presented LESP <12 mmHg and ten patients <6 mmHg after the operation. Furthermore, the abdominal length and total length of the high pressure zone at the esophagogastric junction were affected.
** A sleeve gastrectomy produces an important decrease in LES pressure,
** which can in turn cause the appearance of reflux symptoms and esophagitis after the operation due to a partial resection of the sling fibers during the gastrectomy.

Obes Surg. 2010 Feb;20(2):140-7. Epub 2009 Dec 1.
Dilated upper sleeve can be associated with severe postoperativegastroesophageal dysmotility and reflux.
Keidar AAppelbaum LSchweiger CElazary RBaltasar A.
Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. andreik@hadassah.org.il
Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, and it can be done as an isolated LSG or in conjunction with biliopancreatic diversion bypass/duodenal switch (laparoscopic duodenal switch; LDS). Gastroesophageal reflux after LSG has been described, but the mechanism is unknown and the treatment in the severest cases has not been discussed. We describe a cohort of patients who have underwent an LSG or LDS, and have suffered from a severe postoperative gastroesophagealmotility disorder and/or reflux, report on their treatment, and discuss possible underlying mechanisms.
Seven hundred and six patients underwent an LSG by two of the authors (AK, AB). Sixty nine patients underwent laparoscopic sleeve gastrectomy in Hadassah Medical Center, Jerusalem, Israel (January, 2006 and December 2008; 55 isolated LSG, 14 with LDS), and 637 (212 isolated LSG, 425 LDS) in Clinica San Jorge and Alcoy Hospital in Alcoy, Spain, (January 2002 and November 2008).
Of them, eight patients who has suffered from a gastroesophageal dysmotility and reflux disease postoperatively and needed a specific treatment besides regular proton pump inhibitors (PPIs) were identified (1.1%).
A combination of
dilated upper part of the sleeve with a relative narrowing of the midstomach, without complete obstruction, was common to all eight patients who suffered from a severe gastroesophageal dysmotility and reflux.
The sleeve volume, the bougie size, and the starting point of the antral resection do not seem to have an effect in this complication.
Operative treatment was needed in only one case out of eight; in the rest of the patients, medical modalities were successful. More knowledge is required to understand the underlying mechanisms.

Obes Surg. 2010 Jan;20(1):1-6. Epub 2009 Oct 3.
Comparison between the results of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass in the Indian population: a retrospective 1 year study.
Lakdawala MABhasker AMulchandani DGoel SJain S.
Center for Obesity and Diabetes Support and Department of Minimally Invasive Surgery, Saifee Hospital, Mumbai, India.
Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a procedure for the treatment of morbid obesity. Its indications and long-term results are currently under evaluation. Initially started as a first-stage procedure for superobese patients, it is now emerging as a standalone procedure in Asia and other parts of the world. Early results suggest that, at the end of 1 year, weight loss and resolution of comorbidities with LSG is comparable to laparoscopic Roux-en-Y gastric bypass (LRYGB). Whether LSG alone can replace LRYGB as a standard bariatric procedure is questionable. The aim of this study is to compare the results, resolution of comorbidities, and complications between LSG and LRYGB.
A retrospective comparative analysis was done of 50 patients in each arm who underwent LSG and LRYGB from October 2007 to March 2008. Both groups were matched for age, sex, and body mass index. The resolution of comorbidities, percentage of excess weight loss (EWL), and complications were studied at 6 months and 1 year in our study.
It was seen that resolution of most comorbidities such as type 2 diabetes, hypertension, dyslipidemia, sleep apnea, joint pains, and percentage of EWL in both groups was comparable at the end of 6 months and 1 year. Though early resolution of type 2 diabetes was seen to be better in the LRYGB group, the results matched up at 1 year.
** There was increased incidence of gastroesophageal reflux disease in LSG patients.
On comparison, it was also observed that the Asian studies have shown better results with LSG when compared to studies done in a largely Caucasian population.
Long-term studies are needed to evaluate the efficacy of LSG alone as a procedure for the treatment of morbid obesity and its comorbidities.

Obes Surg. 2009 Dec;19(12):1612-6.
Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity.
Acholonu EMcBean ECourt IBellorin OSzomstein SRosenthal RJ.
The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Department of General & Vascular Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
Laparoscopic sleeve gastrectomy (LSG) has been used as a first step of a two-stage approach in bariatric surgery for high-risk patients. Recently, LSG is being utilized as a primary and final procedure for morbid obesity with acceptable short-term results. The aim of this study is to investigate the effectiveness of LSG as a revisional procedure for patients with unsatisfactory outcomes after laparoscopic adjustable gastric band (LAGB). A retrospective review of a prospectively maintained database was performed. Data were reviewed for all patients undergoing revision from LAGB to LSG during the period May 2005 and May 2009. Data collected included demographics, indication for revision, operative time, length of stay, postoperative complications, and degree of weight reduction. Fifteen patients (three males and 12 females) had revisional surgery converting a LAGB to a LSG. The indication in four patients (26.66%) was weight regains and in five patients (33.33%) was poor weight loss;
four patients (26.66%) had a band slippage and symptoms of gastroesophageal reflux, and one patient (6.66%) had poor weight loss, band slippage, and reflux.
In one patient (6.66%), the indication was slippage and duodenal fistula. One-step revision procedure was done in 13 patients (86.66%), while two-step procedure was done in two patients (13.33%). Mean preoperative weight and BMI were 233.02 (181.4-300) lb and 38.66 (29.7-49.3) kg/m2, respectively. Mean weight loss at 2, 6, 12, 18, and 24 months postoperatively was 20.7, 48.3, 57.2, 60.1, and 13.5 lb, respectively. Mean % excess BMI loss was 28.9%, 64.2%, 65.3%, 65.7%, and 22.25% at 2, 6, 12, 18, and 24 months, respectively. There was one major complication (staple line leak) and one postoperative acute gastric outlet obstruction. We had no mortality. Thirteen patients were followed up postoperatively. The number decreased as follow-up time progressed. LSG could provide short-term weight loss after previously failed LABG, but prone to more complications compared to an initial LSG without a prior bariatric procedure.

Surg Obes Relat Dis. 2009 Jul-Aug;5(4):476-85. Epub 2009 Jun 13.
The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009.
Gagner MDeitel MKalberer TLErickson ALCrosby RD.
Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida 33140, USA. gagner.michel@gmail.com
Sleeve gastrectomy (SG) is a rapid and comparatively simple bariatric operation, which thus far shows good resolution of co-morbidities and good weight loss. The potential peri-operative complications must be recognized and treated promptly. Like other bariatric operations, there are variations in technique. Laparoscopic SG was initially performed for high-risk patients to increase the safety of a second operation. However, indications for SG have been increasing. Interaction among those performing this procedure is necessary, and the Second International Consensus Summit for SG (ICSSG) was held to evaluate techniques and results.
A questionnaire was filled out by attendees at the Second ICSSG, held March 19-22, 2009, in Miami Beach, and rapid responses were recorded during the consensus part.
Findings are based on 106 questionnaires representing a total of 14,776 SGs. In 86.3%, SG was intended as the sole operation. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. Mean +/- SD percent excess weight loss was as follows: 1 year, 60.7 +/- 15.6; 2 years, 64.7 +/- 12.9; 3 years, 61.7 +/- 11.4; 4 years 64.6 +/- 10.5; >4 years, 48.5 +/- 8.7. Bougie size was 35.6F +/- 4.9F (median 34.0F, range 16F-60F). The dissection commenced 5.0 +/- 1.4 cm (median 5.0 cm, range 1-10 cm) proximal to the pylorus. Staple-line was reinforced by 65.1% of the responders; of these, 50.9% over-sew, 42.1% buttress, and 7% do both. Estimated percent of fundus removed was 95.8 +/- 12%; many expressed caution to avoid involving the esophagus. Post-operatively, a high leak occurred in 1.5%, a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%, and later stenosis in 0.9%.
*** Post-operative gastroesophageal reflux ( approximately 3 mo) was reported in 6.5% (range 0-83%).
Mortality was 0.2 +/- 0.9% (total 30 deaths in 14,776 patients). During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.
SG for morbid obesity is very promising as a primary operation.

Obes Surg. 2009 Aug;19(8):1143-9. Epub 2009 Jun 10.
Dysfunction of the lower esophageal sphincter and dysmotility of the tubular esophagus in morbidly obese patients.
Küper MAKramer KMKirschniak AZdichavsky MSchneider JHStüker DKratt TKönigsrainer AGranderath FA.
Department of General, Visceral, and Transplant Surgery, University of Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany. Markus.kueper@med.uni-tuebingen.de
Erratum in
Obes Surg. 2010 Jun;20(6):830. Kischniak, A [corrected to Kirschniak, A].
Morbid obesity is associated with gastroesophageal reflux (GERD). The aim of this prospective study was to determine esophageal motility in asymptomatic morbidly obese patients and compare it to non-obese individuals.
Forty-seven morbidly obese patients without GERD symptoms and 15 normal weight individuals were divided into four groups according to their body mass index (BMI; group I, <30 kg/m2; group II, 35-39.9 kg/m2; group III, 40-49.9 kg/m2; group IV, >or=50 kg/m2). Standard stationary water-perfused manometry was performed for the assessment of anatomy and function of the lower esophageal sphincter (LES). Twenty-four-hour ambulatory pH-metry and measurement of esophageal motility were performed with a microtransducer sleeve catheter. Data are given as mean+/-SD, and the results of groups II-IV were compared to the non-obese individuals from group I.
Patients with morbid obesity had significantly lower LES pressures than non-obese individuals (I, 15.1+/-4.9; II-IV, 10.5+/-5.4, mmHg, p<0.05 vs. I) and showed an altered esophageal motility with respect to contraction frequency (I, 1.8+/-0.7/min; II-IV, 3.6+/-2.5/min; p<0.05 vs. I) and contraction amplitude (I, 38+/-12 mmHg; II-IV, 33+/-17 mmHg; p<0.05 vs. I). Furthermore, these patients had significantly higher DeMeester scores than non-obese individuals. Length and relaxation of the LES as well as propulsion velocity of the tubular esophagus did not differ.
*** Patients with morbid obesity (=BMI>40 kg/m2) have a dysfunction of the LES and an altered esophageal motility, even when they are asymptomatic for GERD symptoms.

Obes Surg. 2009 May;19(5):544-8. Epub 2009 Mar 12.
Mid-term follow-up after sleeve gastrectomy as a final approach for morbid obesity.
Arias EMartínez PRKa Ming Li VSzomstein SRosenthal RJ.
The Bariatric and Metabolic Institute, Section of Minimally Invasive and Endoscopic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
In previous publications, we demonstrated the safety and short-term efficacy of laparoscopicsleeve gastrectomy (LSG) as a final step in the treatment of morbid obesity (MO). This study aimed to assess the mid-term efficacy of LSG.
We performed a retrospective review of a prospectively collected database. Between November 2004 and January 2007, 130 consecutive patients underwent LSG as a final procedure to MO. Data including patient demographics, operative time, length of hospital stay, complications, preoperative body mass index (BMI), complications, and weight loss at 3, 6, 12, 18, and 24 months were recorded and analyzed.
The mean age was 45.6 (range: 12-79) years while the mean BMI was 43.2 (range: 30.2-75.4) kg/m(2). The mean operative time was 97 (range, 58-180) min and all operations were completed laparoscopically. The mean hospital stay was 3.2 (range, 1-19) days with zero mortality in this series. One patient (0.7%) had leakage at the stapler line, while four patients (2.8%) developed trocar site infection.
*** Three patients (2.1%) complained of symptoms of gastroesophageal reflux disease (GERD),
three patients (2.1 %) developed symptomatic gallstones, and trocar site hernia was present in one (0.7%) patient. The mean weight loss was 21, 31.2, 37.4, 39.5, and 41.7 kg at 3, 6, 12, 18, and 24 months, respectively, while the mean BMI decreased to 36.9, 32.8, 29.5, 28, and 27.1 at 3, 6, 12 18, and 24 months, respectively. Percent of excess weight loss (%EWL) was 33.1, 50.8, 62.2, 64.4, and 67.9 at 3, 6, 12, 18, and 24 months, respectively.
LSG is a safe and effective surgical procedure for the morbidly obese up to 2 years. Excess body weight loss seems to be acceptable at 2 years postoperatively.

Obes Surg. 2008 Oct;18(10):1323-9. Epub 2008 Jun 6.
Deciphering the sleeve: technique, indications, efficacy, and safety ofsleeve gastrectomy.
Akkary EDuffy ABell R.
Department of Gastrointestinal Surgery, Yale University School of Medicine, 40 Temple St, Suite 7B, New Haven, CT, 06510, USA.
Some institutions perform sleeve gastrectomy (SG) as the initial operation for high-risk, high body mass index patients planning a definitive weight loss operation in 12-18 months. Other institutions consider SG a viable alternative to other bariatric operations. SG is frequently debated among the bariatric surgeons. Many questions remain about the current state of SG. Should it be performed as a definitive weight loss procedure or as a bridge for another bariatric procedure? Is there a specific BMI at which point SG should be encouraged? Is the weight loss comparable to other bariatric procedures? Is there a higher risk of gastric leak? What is the appropriate sleeve size? What are the hormonal benefits?
*** Does SG predispose to gastroesophageal reflux disease?
What is the mechanism of weight loss? Are long-term results available? And what are the complications? We conducted an extensive literature review aiming to resolve these commonly asked questions.

Obes Surg. 2008 Aug;18(8):1039-42. Epub 2008 Apr 2.
Is preoperative manometry in restrictive bariatric procedures necessary?
Klaus AWeiss H.
Department of General and Transplant Surgery, Medical University Innsbruck, Anichstrasse 35, Innsbruck, Austria. alexander.klaus@i-med.ac.at
Restrictive bariatric procedures are frequently considered for patients with morbid obesity, because the weight loss and reduction of comorbidities are good.
*** An impact on gastroesophageal refluxdisease (GERD), which is common in this population, may be anticipated.
Converse results of GERD symptoms are reported for patients after adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGBP).
A literature search was performed and, with our personal experience, are summarized.
Esophageal manometry is a practical tool to identify functional disorders of the esophageal body and the lower esophageal sphincter (LES).
*** For patients with weak esophageal body motility, AGB should not be considered as a therapeutic option because esophageal dilation, esophageal stasis, and consequent esophagitis often occur during long-term follow-up, and band deflation is inevitable.
Stable body weight can therefore not be achieved in these patients.
*** Low resting pressure of the LES may be a contraindication for SG, because taking away the angle of His further impairs the antireflux mechanism at the cardia.
So far, RYGBP is an option for all morbidly obese patients regardless of the results of esophageal manometry.
*** Preoperative esophageal manometry is advised for restrictive procedures such as AGB and SG.

Obes Surg. 2008 May;18(5):560-5.
A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years.
Nocca DKrawczykowsky DBomans BNoël PPicot MCBlanc PMde Seguin de Hons CMillat BGagner M,Monnier LFabre JM.
CHU Montpellier, Montpellier, France. d.nocca@wanadoo.fr
Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure.
From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI)>40 kg/m2] or severe obese patients (BMI>35 kg/m2) with severe comorbidities (diabetes, sleep apnea, hypertension…) with high-volume eating disorders and superobese patients (BMI>50 kg/m2).
The average BMI was 45.9 kg/m2. Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding.
*** Long-term morbidity was caused by esophageal reflux symptoms (11.80%).
The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients.
The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution ofmorbidities due to obesity need to be evaluated in a long-term follow up.

Gastroenterology. 1985 Oct;89(4):779-84.
Gastric distention: a mechanism for postprandial gastroesophageal reflux.
Holloway RHHongo MBerger KMcCallum RW.
The occurrence of gastroesophageal reflux after meals may be related to an increase in the rate of transient lower esophageal sphincter (LES) relaxations, the mechanisms of which are not understood. We investigated the effects of gastric distention on LES pressure in 16 normal subjects and 17 patients with gastroesophageal reflux disease. Intraluminal pressure was measured in the gastric fundus, LES, and esophageal body with a manometric catheter incorporating a sleeve device. Gastric distention was performed by injecting 0, 250, 500, or 750 ml of air in randomized order into a balloon and maintaining each stimulus for 15 min. Gastric distention did not significantly alter resting LES pressure in either group. During the basal period the rate of transient LES relaxation in the reflux patients (1.1 +/- 0.4 per 15 min) was greater than that in the normal subjects (0.6 +/- 0.1 per 15 min). Gastric distention resulted in a significant threefold to fourfold increase in the rate of transient LES relaxations in both groups. The reflux patients had a significantly greater proportion of complete relaxations (87%) than did the normal subjects (73%). We conclude that gastric distention, by significantly increasing the rate of transient LES relaxations in both normal subjects and patients with gastroesophageal reflux disease, may contribute to the postprandial increase in gastroesophageal reflux.


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Namaste, G’day, Guten tag, Konichiwa, Ciao, Olá e bem-vindos, Ni Xao, Sawadeeka, Bonjour, Buenos dias, Ciao, Howdy


Paris Oct18-20 2012
Thursday, October 18, 2012 at 8:00 AM
Friday, October 19, 2012 at 12:00 PM (PDT)
Paris Paris Charles de Gaulle Airport Marriott Hotel
Allée du Verger,  95700 Roissy-en-France, France

In addition Live Surgery Demonstration on Saturday Oct 20
Clinique Geoffroy Saint Hilaire – Paris , 59 Rue Geoffroy-Saint-Hilaire  75005 Paris, France, 01 44 08 40 00
Dr Rutledge & Dr Chiche, Two Operating Rooms 6 – 8 MGB,3 Visitors in OR,
Video Transmission Conference Room  25 Surgeons, (Contact DrR@clos.net for special invitation)

Brought to you by:

International Society of
Minimmally Invasive Metabolic Surgery

MGB: Take the Plunge



Latest Update 5/23/10

Sheba Raviv
Dr. P 10/01/09
Highest/Pre Op/Post Op/Now/Goal

Dear Contact:

I am a 55 and 9/12 year old female, 5’7” tall, and at my height weighed 266 pounds. I have been married twice, have two children from first marriage, 3 grandchildren and have had a weight problem my whole life.

I was never thin enough. Yet, when I look at my photos of myself in my youth, my oh my, I looked good. BUT, I don’t think I ever met anyone who thought I was thin enough. “If only you would lose a little weight, you would look amazing!! You have such a pretty face, but…”

I went to fat farms where I fasted

I gained 60 pounds with each pregnancy (9 months apart), and my body started disintegrating since then.  I lost and gained and lost and gained and lost and gained…..Until I got up to 180 pounds, and thought that I was going die from embarrassment. My husband was not a happy camper. I went to a diet doctor where I would get pills and injections. We would be given injections to take home and administer ourselves subcutaneously 3 times a week. My girlfriend would steal them, give some to me,  and I would do it even more. (Don’t tell anyone!!!) I lost a lot of weight and was my thinnest ever. BUT, it was short lived. I started gaining again and my husband was disgusted and would call me names. I went to live in Georgia where I gained more weight and reached 260 pounds. Then when he asked for a divorce, I didn’t eat for 40 days from anxiety, exercised 3 hours a day from the adrenaline and lost 45 pounds.

Then back to Florida, got divorced. And then met my second husband when I was 220 pounds. He thought he could fix me. But he couldn’t. I would lose weight but it was too hard. I went to Overeaters Anonymous and for two years I was “abstinent from sugar and flour” and weighed and measured all of my meals. My husband did all the shopping, all the cooking, all the weighing and measuring and I lost 50 pounds in two years. I was 173 pounds and my husband had promised me a tummy tuck if I reached 170 pounds. I couldn’t get past the 173 for 5 months and he did not relent. I did not get the tummy tuck, and I started to be resentful and gained back plus 30 pounds.

He became resentful and said bye bye. He said I didn’t love him enough or that he wasn’t able to give me what I needed to lose weight.

The only time I find I can’t eat a morsel of food is when I am anxious or fearful. Otherwise, there’s no stopping me. I eat when I am happy, when I am excited, when I am sad, when I am bored, when I am lonely…BASICALLY WHEN I AM AWAKE.  I did ALL THE DIETS!! ALL OF THEM!!!! Nothing left for me to do.

So, my husband left me at 230 pounds. I lived alone and little by little, within two years, I got up to 266 pounds. I kept going to meetings hoping it will “hit me again” until I got to 266 pounds. What, am I going to wait until I’m 500 to “Get it”???  I hit bottom when I had to get on the floor to play with my grandchildren and I couldn’t get up, couldn’t climb up the stairs in my son’s home, couldn’t bend down to buckle my shoes, couldn’t manipulate (with ease) basic hygiene …I was able to be clean but it was extremely difficulty, twisting with the aid of holding on to my shower door bar.  What the heck was I going to do?  When will I do something?
I couldn’t sit in the movie theater, I got stuck on a Disney ride…., mortified to ask for belt extension on the airplane…No, we can’t eat at this restaurant, there are arm rests on the seats…No darling, I can’t do that position…..

I work in a condo office. A resident came downstairs and said her niece is coming for lunch from Costa Rica. She went to a doctor in Las Vegas who did this amazing surgery and she had virtually no pain and was in the malls the next day!! (a little about that later on in this letter…) She came downstairs, and she was a size 4, from a size 24.  THAT’S WHAT I WANT!!!  NO PAIN!!! NO HASSLE.

Researched the information on line. What the hell am I doing?  I spent many many hours reading, watching youtube, etc. I even googled “complaints of mini gastric bypass” and nothing came up, versus all the problems that came up when I googled lap band and gastric bypass. So that was reassuring.

I downloaded all the forms I needed to . I spoke with Flo many, many, many times, to the point where I was afraid she would tell me, “Sorry, you are not a candidate.” But she didn’t.  : ) No matter what time of the day or night, she was always there.  I scheduled the surgery a couple of months away from the time I started the packet, but I finished it so fast because everyone was cooperative. And so I was able to change it to 10/1/09.

Well, let me tell you, I was crazy with questions.  I couldn’t sleep at all until the day of the surgery. I was up all night thinking… hmmm, are all these testimonies paid for??? Are these real people?

I got my contacts, Rose Wolf, Edie Elting, Shari Millette, Maggie Raia, Elinor Reynolds, Cindy Mielke, Holly Christensen, Toni Meares, Meg Parke, Marvin Jarrett, and Laura Harris.  They were with me all the way.

Three days before my trip, I began a quasi- liquid diet to make the surgery easier.
So, 9/29/09, I was on my way to Orlando and my first meeting with the psychiatrist in Orlando the next day.. then to meet Flo and Dr. Peraglie. My parents were my caretakers and they were so impressed with the doctor and never felt as confident about a doctor as they were about him. He explained everything and he showed me so many photos of before and after and was patient and caring…and cute.  Then I went to the hospital and filled out a lot of paperwork and met Barbara, a nurse there who also had the mini gastric bypass and she was so nice.

OK…surgery scheduled for 9:30 am 10/01/09.  Got up at 6:30 to be at the hospital at 7:30.  On the way they called to say they were going to schedule it for 7:30 because they had a cancellation.  Oh Oh…(Oh, by the way, I was going to be the only one and at first I was totally disappointed…but it was ok. I had Dr. P all to myself.)

So I got there, they admitted me, mom came into the admission area with me where I was prepped for surgery. The nurse, Louise, was another one who had the same surgery with Dr. P.  She administered the IV with antibiotics (they were trying to rush it because of the vacancy..) and fluids and I kept having to pee. The gowns were nice and big.  I was in a cubicle with a curtain as were all the other patients waiting for their turn for surgery for one thing or another. Dr. P came by and kibbutzed a little and left. Said something about how I would have to get off this bed and get on to the surgery bed by myself…

THEN….the assistant anesthesiologist came to explain what will happen….oh oh!!! ANXIETY SET IN AND I GRABBED MY MOM AND BEGGED HER TO TAKE ME HOME. “Mommy, I change my  mind, I ‘m afraid, please, please take me home!” I was practically climbing up her body.  “Give her something,” she muttered under her breath. The nurse came back and administered Verced. Whew! I felt better already and then Dr P said he’s ready and mom kissed me and dad kissed me (I remember his looming face, white beard, kiss me..) and then I woke up from surgery!!!!! (When did I get off this bed and on to the surgery bed????)

Ok.  So, I must say my memory may be a bit faulty..but I remember someone saying, “Sheba wake up.”  I opened my right eye a crack and saw bright light and couldn’t move or say anything except…p a  I n .  P a I n.  P a I n. I was too weak to speak but I was able to blurt it out in a very hoarse voice.  I felt a deep pain in my viscera… and then it was gone.

NO MORE PAIN until I left. The next thing I remember is going for a walk to the washroom and feeling so happy. I experienced very little pain due to the meds, which they gave so generously and they were at my beck and call. I sipped, sipped, sipped, nibbled on crackers, you know, the whole protocol….Peed A LOT!!! Relaxed, relaxed, relaxed… walked, walked, walked. Mom was with me in the hospital and slept over. They even brought her meals.

Time to go back to the hotel. (the hotel was ok.) I met the general manager there, who also had the surgery with Dr. P in Texas.  He lost a few hundred pounds!!!!

That evening, I started to feel like everything I swallowed was backing up and it was uncomfortable, and I got scared and called Dr. P.  I tried to take the liquid Tylenol, but I threw it up immediately. Mom didn’t want me to go back but I was insistent. I didn’t want to take any chances. So during the 25-minute drive to the hospital I started to feel better. Still, I wanted to go back.. and Dr. P ordered the cocktail, whatever that is.  And I slept like a baby until the next day and was all better.

Went back to the hotel and took care of myself (actually, mom and dad were my slaves) We went to Wal Mart, K Mart, a couple of malls.  I did get tired quickly and we would return back to the hotel and I would rest and sip sip sip, yogurt, nibble, sip sip, etc.

Luckily, the room had a 50-feet balcony and I walked 10 minutes three times a day on the balcony. It was a lifesaver. I experienced just tenderness, especially when sitting. But walking was the best. And when I couldn’t sleep took a Benedryl pill. (Per Dr. P.) Oh, and I succumbed to putting on the estrogen patch.

I ate yogurt, probiotic yogurt drinks (in those cute little bottles, the first one took me 1.5 hours to get down), G2, G2, G2, G2, G2, G2….did I drink  (sip sip sip) a lot of G2 ya’ think?)

And saltines, goldfish and pretzels. Mmmmmm.

Last day… have to get staples out. Went to Dr. P and he took out the staples, I lost 6 pounds, and he said, Bye Bye. Of course, I had THOUSANDS of questions, and he answered all of them.  I wanted to ask them again, but…

Driving home was wonderful. We got lost and took the scenic route.  A 3.5 hour trip took 5 hours. All the while I sipped, sipped, sipped and cracker, cracker, cracker.. I myself could not tolerate licking straight salt, I tried it once and I gagged.  I have an extremely sensitive gag reflex.

At home I continued my stage I diet. And tried to go to work the next day, but I overdid it and stayed home until the next Monday. It was easier, but sitting too long really does me in. I start to feel tenderness. So I get up and walk, walk, walk. I told everyone at work, everyone in my building, everyone in the supermarket…..about my surgery.

So now I am ready for stage II, and going on line with all my MGB friends. They are all supportive and helpful and I couldn’t continue without them, I really could not.

So, with all that said, hope I didn’t bore you too much. I am just about to start the supplements and do not know how that will go yet (considering my gag reflex).  But I’m sure it will be fine.

I am not a typical contact because I have no more experience past this. I don’t know how I will lose, how I will be, but at least you know how my experience was until now. Everyone is different.

I still can’t believe I did it.  As I said once before, desperation is the best motivation. I am so proud of myself as is everyone else. I am such a chicken and drama queen, no one believed I would do it. BUT I DID, and so will you!!!!!

I am sure I left out a few things, but I guess it wasn’t important.

Good Luck. And please keep in touch!

Love always,


Sheba Raviv
Dr. P 10/01/09
Highest/Pre Op/Post Op/Now/Goal

6 months have passed. WOW. What a journey.

Stage II was great!  I couldn’t swallow all the supplements, just as I thought. I tried Flintstone vitamins and gagged on those, couldn’t believe it. Thought I would die of malnutrition. But finally found gummy bear vitamins for kids and took 10 a day, and lo and behold, my blood work came out great!!!! I took extra D and the calcitrate and the actigal and the prilosec, etc. Hard but do-able.

Eating became so nice again. I ate mashed potatoes, cottage cheese , avocados, apple sauce, soups, etc. No problem And yogurt.

I went to work a day after my return home, and found that sitting for long periods of time was uncomfortable. The remedy for that was walking walking walking. I walked A LOT!! Also, I was not able to sleep on my side or stomach for the longest time. I would use a pillow between my legs to sleep on my side, but it was still uncomfortable. But sleeping on my back was hard for me. I propped myself up on pillows to help me out. My recliner was a lifesaver!!!!

(for more information please go to minigastricbypassrus.ning.com

and look me up)

Then Stage III. YUMMY!!! I tried everything slowly but surely. All the while my weight loss was getting pretty slow. I lost 17 pounds in one month and 5 days when everyone else was like at 30 pounds down!!! I was frustrated!!! What, 17,000 dollars…. Thousand dollars per pound!!!!  I kept whining and emailing complaints of failure. Everyone was supportive and told me to hold on!!! It will come off!!!! I’m not going anywhere and time will pass and that’s all I have to do, is wait.  I called Dr. P. and he said, “Sheba, please, you have 23 months more to lose weight!” I felt like a dum dum!!!

Today, I am down 63 pounds and 10 inches off my hips. Lost some hair, (to me a lot, and I bought a wig but I hate wearing it so I’m in acceptance with the loss) but heard it should grow back. My hair was thinning before surgery as well. I can sit in any restaurant seat, go on any Disney ride. As far as “not that position darling” I don’t know about that now, got rid of loser boyfriend. (Oh, that’s another 200 pounds I lost!!)

Everyone who knows me is in shock at the drastic difference.

This is only 3 months post op. My face looks pretty much the same at 6 months.

I am so happy now. The weight loss is virtually effortless. Eating is not an issue. I eat slowly (I try to ) and every day I am able to eat a little faster. I’m eating more at a sitting than I had hoped I could, but it still comes out and doesn’t stay in my body. I only drink water.  If you go into my blogs on the website I gave you above, you will see my fridge full to the brim with G2 and yogurts, but I don’t drink that anymore, although I didn’t have problems with cold Fruit punch.

My life is great. A guy asked for my phone number at this event I went to last week. He called too!!!!  (Nothing came about from it, but it’s a beginning).

I can’t tell you enough how happy I am that I did this surgery. HAPPY!!!!
I can’t tell you enough how happy I am that I did this surgery. HAPPY!!!!

So, with that said,


Love, Sheba

MGB Almost Twice as Powerful as Lapband

MGB Twice as Powerful as Lapband:
Five hundred and twenty severely obese patients with body mass index (BMI) ≥35 were recruited. Among them, 149 and 371 subjects received laparoscopic adjustable gastric banding (LAGB) and laparoscopic * mini-gastric bypass* (LMGB), respectively.

Obese patients had LESS decrease in BMI after LAGB (-7.5 vs. -6) compared to patients after LMGB, (-12.5 vs. -10.0)

Amplify’d from www.ncbi.nlm.nih.gov
Obes Surg. 2011 Jul 1. [Epub ahead of print]

ESR1, FTO, and UCP2 Genes Interact with Bariatric Surgery Affecting Weight Loss and Glycemic Control in Severely Obese Patients.


Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.



Significant variability in weight loss and glycemic control has been observed in obese patients receiving bariatric surgery. Genetic factors may play a role in the different outcomes.


Five hundred and twenty severely obese patients with body mass index (BMI) ≥35 were recruited. Among them, 149 and 371 subjects received laparoscopic adjustable gastric banding (LAGB) and laparoscopic mini-gastric bypass (LMGB), respectively. All individuals were genotyped for five obesity-related single nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genes to explore how these genes affect weight loss and glycemic control after bariatric surgery at the 6th month.


Obese patients with risk genotypes on rs660339-UCP2 had greater decrease in BMI after LAGB compared to patients with non-risk genotypes (-7.5 vs. -6 U, p = 0.02). In contrast, after LMGB, obese patients with risk genotypes on either rs712221-ESR1 or rs9939609-FTO had significant decreases in BMI (risk vs. non-risk genotype, -12.5 vs. -10.0 U on rs712221, p = 0.02 and -12.1 vs. -10.6 U on rs9939609, p = 0.04) and a significant amelioration in HbA1c levels (p = 0.038 for rs712221 and p < 0.0001 for rs9939609). The synergic effect of ESR1 and FTO genes on HbA1c amelioration was greater (-1.54%, p for trend <0.001) than any of these genes alone in obese patients receiving LMGB.


The genetic variants in the ESR, FTO, and UCP2 genes may be considered as a screening tool prior to bariatric surgery to help clinicians predict weight loss or glycemic control outcomes for severely obese patients.

Read more at www.ncbi.nlm.nih.gov