OBES SURG (2012) 22:1315–1419 DOI 10.1007/s11695-012-0713-1

ABSTRACTS

Abstracts from the XVII World Congress of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), New Delhi 11–15 September, 2012 Published online: 15 August 2012 O001 Incidence of Marginal Ulcer After Laparoscopic Roux-en-Y Gastric Bypass and Roux Limb Course Presenter: Lara Ribeiro Parenti Co-author: Denis Chosidow Konstantinos Arapis Pierre Fournier Jean Pierre Marmuse Hopital Bichat Claude Bernard, France Background Marginal ulcer can be a serious complication after laparoscopic gastric bypass surgery. The aim of this study was to determine the rate of anastomotic ulcer in a large cohort of patients and to identify patient or technique factors predisposing to such complication. Methods Over a near 10-year period, 1142 patients underwent laparoscopic gastric bypass surgery. The antecolic and the retrocolic technique wasused in 572 and 570 consecutive patients respectively. All procedures were performed using a circular stapled gastrojejunostomy. Results Patients were followed for 18 to 99 months (mean 48.8 months). During follow-up, 46 patients developed a marginal ulcer (4 %), 32 in the antecolic group (5.6 %) and 14 in the retrocolic group (2.5 %). Nineteen patients (3.3 %) in the antecolic group and 8 patients in the retrocolic group (1.4 %) developed early marginal ulcer (i.e. within 3 months after surgery). The mean time to onset of anastomotic ulcer symptoms after surgery was 11 months (range 0.25 -72). Forty-four patients were submitted to medical treatment and 34 patients (77.3 %) had complete resolution of their symptoms. On multivariate analysis, the antecolic technique was identified as a risk factor of marginal ulcer (p 00.007) and early marginal ulcer (p 00.033). Conclusion A significant lower incidence of marginal ulcer was observed in the retrocolic group. The antecolic technique is a risk factor for appearance of marginal ulcer. Keywords: stomal ulcer, marginal ulcer, gastric bypass, complications, bariatric surgery. O002 Comparative Single Centre Analysis of Outcome Following Different Modalities of Bariatric Surgery for Obesity Presenter: Vittal Rao Co-author: Rupa Sarkar, Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castel Hill Hospital, Cottingham, Hull, United Kingdom Introduction Bariatric surgery is associated with long-term weight loss. We report a large single centre experience of different modalities of bariatric surgery over a 12 year period. Methods A retrospective database review of patients who underwent bariatric surgery between 1998 – 2009 was undertaken. Type of surgery and outcome (percentage excess body weight loss:%EBWL) was analysed. Statsitical analysis was performed using likelihood ratio chi square test.

Results 951 patients underwent gastric band (LAGB; n 0211), gastric bypass (LRYGB; n0700) and sleeve gastrectomy (LSG; n040) laparoscopically. Patient groups were comparable for demographic profile. Pre-op mean BMI (LAGB:49; LRYGB:48; LSG:58) and mean excess body weight (EBW in Kg; LAGB: 73; LRYGB:72; LSG:101) was recorded. Mean %EBWL at mean follow up (LAGB: 40 % at 47 months; LRYGB: 60 % at 23 months; LSG: 47 % at 19 months) was analysed. Older people had significantly lower %EBWL at all times (p00.034). People with higher EBW had significantly lower predicted % EBWL at 12 months but the gap narrowed with time (p<0.001). % EBWL and changes in % EBWL were significantly different between the three modalities (p < 0.001). After 12 months, predicted % EBWL was considerably lower for the band group than the other two groups. After 60 months, %EBWL is predicted to increase slightly for the band group and decrease for the bypass group, thus narrowing the gap. Conclusion The results corroborate the findings of recent studies that the medium and long term weight loss for LRYGB and LAGB tend to become similar with long term follow up. 0003 Two Years Experience with 470 Gastric Plication Surgeries Presenter: Ariel Ortiz-Lagardere MD, FACS. Co-author: Arturo Martinez-Gamboa MD, Marco Viramontes MD, Gabriela Miranda MD, Lose A. Jimenez MD. Obesity Control Center Hospital, Mexico Background Total vertical gastric plication (TVGP) is a new surgical technique that falls into the restrictive procedure category. TVGP surgery involves shape modification of the stomach to achieve restriction by folding the greater curvature of the stomach inward with suture materials thus reducing gastric capacity. Methods A total of 470 gastric plication surgeries by the same surgical team in a single bariatric center have been performed from July 2010 to January 2012. The surgical technique involves a 2 layered complete plication of the greater gastric curvature including anterior and posterior gastric surface. The technique has been modified at our facility as experience increased. Results Of the 470 patients (Mean BMI 40.34 kg/m), 444 Initial surgery and 26 revisions from LAGB surgery. Of the 444 patient group the mean surgery time was 41 Minutes ranging from 26 to 145 minutes. Mortality rate is 0 %. Early surgical complications occurred in 12 patients(2.6 %) and delayed surgery complications in 8 patients (1.7 %). Follow up 6 months to 2 years (mean follow-up time 10.5 months), 86 % followup rate at 1 year. 58 % EWL at 1 year after surgery . 35 patients where re-operated because of loss of restriction. No complications from reoperations. 1 conversion to sleeve gastrectomy. Persistent heartburn of varying degrees is the most common postoperative symptom after TVGP (11 %). Conclusion Although long term data on gastric plication surgery is still not available, our initial experience with this procedure surgery has offered positive results.

1316 0004 Single-Incision Transumbilical Laparoscopic Sleeve Gastrectomy: First Results of a Novel Surgical Technique Presenter: Reinhard Mittermair Co-authors: Robert Sucher, Thomas Resch, Fergu¨l Cakar-Beck, Johann Pratschke Department of Visceral-, Transplant- and Thoracic Surgery, Innsbruck Medical University. 6020 Innsbruck, Austria Background Laparoscopic sleeve gastrectomy is an emerging bariatric procedure. Since a minimal invasive single incision approach would be even superior we pioneered a novel surgical technique and thereby realizedsingle incision transumbilical laparoscpic sleeve gastrectomy. Methods In 2011, a number of 23 morbidly-obese patients, who qualified for restrictive surgery, were selected for transumbilical-single-incision-laparoscopic-sleeve-gastrectomy. All operations were performed by the same lead surgeon. The percentage of excess weight loss(EWL) was assessed at a median follow up of 4±4.38 month. A retrospective review of a prospectively collected database was performed for all patients. Resuts All patients were female with a median age of 40±12 yeas. The preoperative body mass index was 40.15 ± 2.82 kg/m2. Co-morbidities comprised arterial hypertension(70 %), IDDM(4 %), NIDDM(9 %) and metabolic syndrome(13 %). Total operative time was 88.64 ± 20.68 minutes and mean hospital stay was 5±1 days, respectively. A median EWL of 23 % was documented after 4.4 ± 4.4 month. Postoperative hemorrhage occurred in one case (complication rate:4.4 %) and was resolved by re-single incision laparoscopic surgery at POD one. All patients admired the cosmetic outcome. Conclusion Single incision transumbilical laparoscopic sleeve gastrectomy is feasible and save and should therefore be considered as a novel, viable minimal invasive procedure in bariatric surgery. O005 Lessons Learned from 108 Consecutive Laparoscopic Adjustable Gastric Banded Plications Presenter: Chang Po-Chih, Co-Author: Chin-Kun Huang, Sanoop K Zachariah, Rajat Goel, Satish Pattanshetti, Ming-Che Hsin, Andrea Ooi Se, Alvin Eng Kim Hock Bariatric & Metabolic international Surgery Center, E-Da Hospital, Taiwan Background Laparoscopic adjustable gastric banded plication (LAGBP) has been recently reported to be a novel bariatric procedure and very less is known about its potential complications. Here wereport 108 consecutive procedures of LAGBP, with special focus on the surgical complications and re-operative techniques. Methods Prospectively collected data of 108 morbidly obese patients, who underwent LAGBP between August 2009 and March 2012, was retrospectively analyzed. Results 34 men and 74 women received LAGBP during this period. The mean BMI and age were 38.95±5.23 kg/m2 and 31.3 (range 18-60) years respectively. No surgical mortality was observed, but 8 (7.4 %) patients encountered complications, including 1 trocar site hernia, 1 band leak, and 6 gastric fundus herniations. Gastric fundus herniations, occurred more frequently in the first postoperative month and the treatment approaches included gastric band removal (4 patients), re-plication (2 patients) and resection of fundus for cases of perforation/necrosis (4 patients), all of which were successfully managed laparoscopically. The percentage of excess weight loss at 12 and 24 months following surgery was 52.1 % and 62.6 % respectively. Conclusions LAGBP is a new bariatric procedure achieving effective weight loss at 2 years, with anacceptable complication rate. Gastric fundus herniation is a complication that needs to be emphasized and early surgical intervention is the key to successful management in these cases. O006 A New Bariatric Surgery Training: Hands-On Workshop in Human Soft Cadaver Presenter: Suthep Udomsawaengsup,MD Chulalongkorn Surgical Training Center,Chulalongkorn Minimally Invasive Surgery Center,Chulalongkorn University, Bangkok, Thailand 10330 Multi-disciplinary approach is required in bariatric care. Bariatric surgery is relatively complicated. It requires numbers of cases to obtain

OBES SURG (2012) 22:1315–1419 expertise. Aiming to reduce this particular long learning curve and importantly to ensure patient safety, we have been introducing the hands-on workshop training in the well-preserved human cadaver. The workshop gives the participants opportunity to review surgical anatomy and to earn their laparoscopic skill in performing bariatric procedure in steps. Complimentary with the appropriate proctorship in the initial clinical experience, it would cut short the learning curve and optimize the patient benefit. O007 BMI-EWL Trends, Short and Long-Term Slippages in Patients Operated with the New-HAGA LAGB (Heliogast System) for Morbid Obesity, According to Four Different Techniques. Definitive Results in a Pilot Prospective Randomized Study Presenter: Pizzi Pietri Co-authors: Alberti Alessandro, , Pizzi Mattia, Gianfranco De Lorenzis Policlinico Di Monza, Italy Background LAGB is a safe and effective procedure for the management of morbid obesity. A standardization of the surgical technique could be important in order to reduce the incidence of surgical related complications. Methods We included in our study 154 consecutive patients operated with the new-HAGA (Heliogast System) LAGB for morbid obesity between September 2008 and Mars 2009. Patients enrolled were randomly assigned to four groups according to the different surgical technique. The groups were homogenous for age and BMI. Four groups were: 1"pars flacida technique" with anterior fixation; 2-"pars flacida technique" without anterior fixation; 3-"two-step perigastric technique" with anterior fixation; 4-"two-step perigastric technique" without anterior fixation. We evaluated for each group the intra and peri-operative complications, the short-term complications and the BMI and EWL trends. The patients rested in follow-up at December 2011 are 128 and the parameters checked in all the four groups were: BMI and EWL trends, intraoperative complications, short and long term complications. Statistical analysis has been done with the T Student test. Results Mean age of the 154 operated patients (27:1270M:F) was 38.7 M (18-53) and 40.3 F (16-66), (International HAGA results (1): 39.3 M (1668) and 41.2 F (16-66)). Mean BMI was 44.6 M and 42.1 F (international results (1): 43.2 M and 42.9 F). Mean BMI evaluation at 12 months for 147 pts. (out of 154 operated pts) was 34.3 M and 31.3 F (International HAGA results (1): 33.8 M and 32.6 F). Mean BMI evaluation at 18 months for 147 out of 154 operated patients was 31.6 M and 29.7 F (International HAGA results (1): 34.6 M and 30.5 F). Mean BMI evaluation at 24 months for 132 out of 154 operated patients was 30.7 M and 29.2 F (International HAGA results (1): 32.5 M and 29.8 F). Mean BMI evaluation at 36 months for 128 out of 154 operated patients was 30.6 M and 28.8 F (International HAGA results (1): 32.4 M and 29.6 F). Mean EWL evaluation at 12 months for 147 out of 154 operated patients was 41.6 M and 46.9 F (International HAGA results (1): 42.1 M and 45.6 F). Mean EWL evaluation at 24 months for 132 out of 154 operated patients was 49.8 M and 54.7 F (International HAGA results (1): 49.1 M and 53.9 F). Mean EWL evaluation at 36 months for 128 out of 154 operated patients was 49.7 M and 54.9 F (International HAGA results (1): 49.1 M and 53.9 F). Among the 154 patients we analyzed neither intraoperative nor short-term complications happened. In the group of patients examinated at 24 months (December 2010) we found four slippages in 3 wimen and 1 man. 1). Woman, 8 months post-LAGB, pars-flaccida technique without anterior fixation. 2). Woman, 9 months post-LAGB, with two-step perigastric technique without anterior fixation.3). Man, 15 months after two-step perigastric technique without anterior fixation 4). Woman, 20 months after pars-flaccida LAGB without anterior fixation. At 36 months we found other 3 slippages, without anterior fixation and 1 slippage with anterior fixation. Conclusion In our study the new-HAGA LAGB for morbid obesity is a safe a well reproducible procedure for all the four different techniques we used. In all groups we found an efficacy in the BMI and EWL trends at 36 months. Our results were similar or even better than the international HAGA results. Total number of slippages at 36 months is 8: 7 slippages without anterior fixation. We performed 7 re-bandig and 1 removal. A longer follow-up will give us the chance to evaluate an eventual increase of the incidence of complications in one or more of

OBES SURG (2012) 22:1315–1419 the studied groups. An implementation of the sample of course is necessary to appreciate statistically significant differences among the four groups. From March 2009 to December 2011 we performed 858 newHAGA LAGB: pars-flaccida technique with anterior fixation in 828 patients and two-steps perigastric technique with anterior fixation in 29 pts. We observed 3 slippages (2 pars-flaccida technique). We think better the anterior fixation of the new-HAGA LAGB. O008 Bariatric Surgery in the Prevention of Diabetes. Experiences from the SOS Study Presenter: Lars Sjostrom Institute of Medicine, University of Gothenburg, Sweden Background Weight loss protects against type 2 diabetes (T2D) but is hard to maintain by behavioral modifications. The effects of bariatric surgery on T2D prevention were examined in the non-randomized prospective controlled Swedish Obese Subjects (SOS) study. Method For the current calculations, 1658 surgery patients and 1771 obese controls without diabetes at baseline were available. The surgery patients underwent banding (19 %), vertical banded gastroplasty (69 %) or gastric bypass (12 %). The non-randomized matched prospective controls received usual care. Age was 37-60 years and BMI was 34 kg/m2 in men and 38 kg/m2 in women. T2D was a predefined secondary endpoint in SOS. Date of analysis was Jan. 1 , 2012. Follow-up-time was up to 15 years. Results In spite of matching, body weight was higher and risk factors more pronounced in the surgery group at baseline. Patients lost to follow up were 31.2 % at 10 years and 36.2 at 15 years. In addition, 30.9 % of original participants were non-eligible due to accrual at 15 years. During follow up, 392 controls and 110 surgery patients developed T2D (adjusted hazard ratio 0.18, 95 % confidence interval: 0.14 to 0.22, p< 0.001) Impaired fasting glucose (yes/no) predicted the surgical treatment effect (interaction p-value00.010) while BMI did not (p 00.443). Sensitivity analyses including imputations did not change our overall conclusions. Conclusions Bariatric surgery is markedly more efficient than usual care in the prevention of T2D. It seems warranted to give priority to patients with IFG in the prevention of diabetes by means of bariatric surgery. O009 Long Term Results of Laparoscopic Sleeve Gastrectomy in a University Hospital Presenter: J. Melissas Co-authors: V. Charalampakis, N. Galanakis, A. Laliotis, A. Leventi, I. Askoxylakis, M. Abukhater Bariatric Unit, Department of Surgical Oncology, Heraklion University Hospital, University of Crete Medical School, Greece Introduction The aim of this study was to present results of LSG in patients with follow-up up to 6 years. Materials & Methods From January 2005 to December 2010, 201 patients (69 males, 132 females) underwent LSG, using a 34 F bougie and sparing 5 cm of antrum. Their median age was 35 years (13-65), weight 130 kg (87-210) and BMI 46 kg/m2 (35-69). Co-morbidities were diabetes 19 %, dyslipidemia 30 %, hypertension 32 %, sleep apnoea 53 % and osteoarticular problems 30 %. 171 patients with at least 12 and up to 72 months postoperative follow up were analyzed. Results There was no mortality. Early serious complications were noted in 10 patients (4.9 %) including 9 cases (4.4 %) of haemorrhage (1 operated) and 1 leak (0.49 %). Long term follow up was achieved in 85 %. Median %EWL was 66.06(15.65-105.7), 68.58 (13.48-97.48), 64.6 (11.2494.29), 63.08 (5.35-98.57), 61.68 (25-93.87), 59.07 (32.58-93.87), 1, 2, 3, 4, 5 and 6 years post LSG. No patient developed hernia, dumping, peptic ulcer, DVT or PE. Seven patients developed diarrhoea, 24 occasional vomiting, 13 cholelithiasis and 5 anaemia. Postoperatively type 2 diabetes resolved in 66 % and improved in 22 % of patients, dyslipidemia in 73 % and 27 %, hypertension in 58 % and 29 %, apnoea in 81 % and 14 %, respectively. Osteoarticular problems improved in 100 % of cases. Ninety-one percent of patients were satisfied by end result.

1317 Conclusion LSG is a safe and effective procedure with acceptable early and late morbidity, satisfactory and sustained weight loss. O010 Outcomes of Laparoscopic Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass: A case matched controlled study Presenter: Menon A, Co-authors: Al-Rashedy M, Thawdar P, Knight B, Akhtar K, Senapati PS, Ammori BJ Department of Oesophagogastric Surgery, Salford Royal Hospital, Salford, UK Introduction Published evidence comparing laparoscopic sleeve gastrectomy (LSG) to Roux-en-Y gastric bypass (LRYGB) has shown comparable short and medium term weight loss. However, potentially confounding factors such as diabetes and preoperative body mass index (BMI) have previously not been controlled. This study compares LSG and LRYGB in terms of complications, weight loss, and diabetes resolution. Methods A retrospective, case-controlled analysis was performed on 44 patients who underwent either LSG or LRYGB in a single institution between October 2008 and January 2012. The patients in each group were matched for age, gender, diabetic status and BMI. Outcome measures were postoperative morbidity and mortality, percentage excess weight loss (%EWL), and resolution of diabetes. Results The median operating time was significantly longer in the LRYGB group (90 vs. 43 min, p 00.03). There were no leaks, conversions or mortality. There were no significant differences between LSG and LRYGB in readmission within 30 days (4.5 % vs. 0 %, p 00.31), postoperative hospital stay (27 vs.25 hours, p 00.32), and %EWL at 3 months (28 % vs. 26 %, p 00.94), 6 months (50 % vs. 49 %, p 00.88), and 12 months (63 % vs. 64 %, p 00.62). Two out of five LSG diabetic patients (40 %) had normal glycosylated haemoglobin (HbA1c) at 6 months, compared to all of the LRYGB diabetic patients (100 %). Discussion Both LSG and LRYGB result in comparable successful weight loss at 1 year (%EWL >50 %), with low postoperative morbidity. Further information is required to compare diabetic resolution and long-term weight loss. O011 Early Results of Laparoscopic Greater Curvature Gastric Plication Presenter: Ludo Van Krunckelsven Co-authors: Jan Yperman Hospital Jan Yperman Hospital, Belgium Background We evaluated safety and efficiency of gastric plication in a series of 100 patients(35 % male,65 % female) with mean age 32 (15-65)y ,mean BMI 35 (30-42) and mean IEW 65 (40-110)%. Methods A laparoscopic gastric plication was performed with greater curvature liberation from 7 cm prepyloric up to the cardia and two layer plication ( interrupted 2/0 silk, running suture 2/0 prolene) calibrated on a 36 F gastric tube. We include cholecystectomy and for reflux disease hiatal closure was performed. Results Mean operating time was 60 minutes without blood loss or conversion.Mean hospital stay was 48 hours.There were no pulmonary,urinary, wound or thromboembolic complications,no perioperative mortality. 1 relaparoscopy was needed for closure of a small perforation near the cardia (ripped out suture after excessive drinking on postop day 1). In 3 patients a gastric outlet problem due to swelling was treated conservatively with resolution within 3 days. Follow up of weight loss in this series now ranges from 3 to 9 months: mean %loss of the IEW was 40 % at 2 months,70 % at 4 months,88 % at 6 months and 92 % at 9 months.Up to now no long term side effects or gastric ulcerations were noted,no malnutrition or vitaminary deficiency. Conclusion In this series gastric plication appears to be a very safe and effective weight loss operation. Longer follow up and larger series are of course necessary.Currently we are also expanding our indications to higher BMI ranges and reoperations (resleeve,failed gastric band).

1318 O012 Laparoscopic Duodenojejunal Bypass with Sleeve Gastrectomy – A Novel Procedure for Resolution of Metabolic Syndrome in Patients with BMI <32.5:A Retrospective Study Presenter: Praveen Raj Co-authors: P Senthilnathan, B.Vijay, Parimala, Roja Ramani, Palanivelu C Gem Obesity&Diabetes Surgery Centre,Gem Hospital&Research Centre, India Background Type II DM resolution in morbidly obese patients following Bariatric Surgery suggests these may be of benefit even in non-morbidly obese too literature favoring combined restrictive/malabsorptive procedures. In India,the incidence of gastric cancer is high.Hence we need a procedure like a Duodenojejunal bypass with Sleeve gastrectomy that leaves behind an accessible gastric remnant. Methods A retrospective study of all patients who underwent a Laparoscopic Duodenojejunal bypass with Sleeve gastrectomy at our institute were analysed.It included patients with with less than32.5BMI, confirmed to be Type IIDM and with HbA1C>7.5.Laparoscopic Duodenojejunal bypass was done in a retro colic fashion, anastomosis being done by end-end with a 60 F Sleeve, 75 cm for the biliopancreatic limb and 125 cm for Roux limb. Results A total of 18 patients (10 women, 8men) were retrospectively studied. The mean age was 40.5 yrs.The mean pre-operative BMI, (Fasting Blood Glucose) FBG and HbA1C was29.5,200.8 mg/dl and 8.3 %.The postoperative BMI,FBG and HbA1C at the end of 6mts and 1 year was 26.4,113.2,6.6 %,and 24.6,108.4,6.3 % respectively. 16out of 18 patients with diabetes had complete remission.5 out of 7 patients with hypertension had complete remission.9 patients had dyslipidemias and all had complete normalization of all parameters Conclusion Laparoscopic Duodenojejunal bypass with Sleeve, which combines the principles of sleeve gastrectomy and foregut hypothesis, is an effective procedure for resolution of diabetes and other co-morbidities in lower BMI population. With its additional advantages of presence of a remnant stomach that’s amenable to endoscopic surveillance the procedure is best suited for a country like India. O013 Single-incision Laparoscopic Gastric Bypass vs Conventional Technique: A Retrospective Analysis Presenter: Praveen Raj Co-authors: P Senthilnathan,B.Vijay,Parimala,Roja Ramani,Palanivelu C Gem Obesity&Diabetes Surgery Centre,Gem Hospital&Research Centre, India (for oral) Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. Recently, the concept single-incision laparoscopic surgery has been used for bariatric procedures, and this surgery may be the next step in minimally invasive surgery. Methods All patients who underwent Roux en Y gastric bypass between May 2010-May 2011 were retrospectively studied from the hospital database Results It included 16 patients who underwent the Single incision technique (Group I) and 67 patients who underwent the conventional technique (Group II).The mean age for Group I patients was 32.5 and that for Group II was 44.8 yrs.The mean operating times were 88 min in Group I and 131 min in Group II.There was no difference in the duration of hospital stay,post operative pain score or analgesic usage in both the group of patients. The mean weight loss was also similar. Conclusion Single Incision laparoscopic surgeries are gaining popularity around the world and the same applies to gastric bypass as well. Based on the above results it can be concluded that except for the cosmetic advantage, there is no added benefit in terms of the post operative outcome variables.The added technical difficulty needs no mention.

OBES SURG (2012) 22:1315–1419 An analysis of the latest results of laparoscopic greater curvature plication. laparoscopic plicated gastric band and laparoscopic ileal interposition will be discussed. Advances in laparoscopic gastric pacing technology through the Introduction of the Abiliti pacing system will be described in detail. A summary of the results of percutaneous placed extra-gastric implants to induce early satiety, currently being trialled in Australia, will be made. An overview of advances in endoluminal suturing technology by way of the Apollo Overstitch in the treatment of weight regain post-gastric bypass by way of stoma size reduction, closure of gastro-gastric fistulae and treatment of sleeve leaks at the Angle of His will be made. Novel endoluminal implants such as the Transpyloric Shuttle and endosphere speed bumps will be described as well as an update on Endobarrier technology, by way of the Gastrointestinal Liner and Valentx systems. The concept of the ‘smart band’ with an in-built intra-band pressure stabiliser will be introduced and its’ rationale for clinical use. O015 Effect of Laparoscopic Roux-en-Y Gastric Bypass on Metabolic Syndrome and glp-1 Hormone in a Group of Egyptian Patients Presenter: Alaa Abbass Moustafa* Co-authors: Reda AbdelTawab*, Mohamed ElSayed*, Islam Hossamel Din*, Essam Abd El Galil***, Islam Hossam *Randa Reda,** Nesrine Ali,**Rania el Kabrity** General Surgery Department* and Immunology & Clniical Pathology Department**Surgery Unit Ahmed Maher Teaching Hospital***, Faculty of Medicine – Ain Shams University, Egypt Introduction An enlarged incretin response after Roux-en-Y gastric bypass (RYGBP) has been proposed to promote profound weight loss and obesityrelated comorbid condition same lioration especially type 2 diabetes mellitus (T2DM). This aimed to prove that a truemetabolic surgery should be able to resolve one or more of the metabolic syndrome parameters independently of the body weight. Material & Methods The study included 30 patients with BMI of 30-36 Kg/m2. The study intended to evaluate the effect of laparoscopic Roux-en-Y gastric bypass as a metabolic surgery on metabolic syndrome parameters and on fasting serum GLP-1 after one year in metabolic syndrome patients. Results The selected group of patients had different degrees of glucose tolerance: normal glucose tolerance (NGT, n09), impaired glucose tolerance (IGT, n09), and type 2 diabetes(n012). This study was done to determine the changes of GLP-1, BMI, insulin resistance before and 1 year after Lonroth’s laparoscopic RYGBP. There was a high significant increase in serum GLP-1, postoperatively from 63.67(31) to123(32.7) ng/ml, in all these three groups, postoperatively .There was high significant decrease in fasting glucose from 145.3(66.8) to 99.2 (13.9) mg/dl, and significant decrease in fasting insulin from16.1(5.5)to11.3(4.4) Iu/liter, in all these three groups ,postoperatively, along with a high significant decrease in HOMA-IR from 5.45 (+\-2.35) to 2.78 (+\-1.1). Discussion & Conclusion Metabolic Syndrome improved significantly postoperatively, including dyslipidemia, hypertension, and obesity. These findings indicate that RYGBP is associated with alterationsin glucose kinetics and glucoregulatory hormone secretion, leading to improvement of type IIDM. O016 Adjustable Gastric Banding Improves Obesity and Weight-Loss Quality of Life (owlqol) Measures Over 3 Years: Interim Results: of the Apex Study Presenter: Ted Okerson MD FACP Co-authors: Jaime Ponce MD, Helmuth Billy MD, Adam Smith DO, Trace Curry MD, Christopher Cornell PhD, Ted Okerson MD FACP and the APEX study group

O014 Latest Developments in Metabolic and Bariatric Surgery

Allergan, United States of America

Presenter: HA Khwaja Co-authors: SM Javed, CJ Magee, DD Kerrigan

Introduction Laparoscopic Adjustable Gastric Banding has been established as a safe, effective treatment to reduce weight in obese patients. This summarizes the 3-year prospective outcomes of the Obesity and Weight-Loss Quality of Life (OWLQOL) instrument after surgical placement of the LAPBAND AP® (LBAP) device. Methods The APEX trial is an ongoing 5-year open-label study to assess the progressive weight reduction, change in comorbidities and OWLQOL results

Gravitas, United Kingdom The evolution of metabolic/bariatric surgery has proceeded at a phenomenal pace over the last 10 years.

OBES SURG (2012) 22:1315–1419 after implantation of the LBAP (NCT00501085). The well-validated OWLQOL was prospectively provided pre-implantation and at 6 month intervals post-operatively. This represents an interim analysis of the 159 evaluable subjects (159/359) who have exited or completed the 30-month postoperative visit. Results Significant improvements in all questions of the OWLQQOL were observed within 6 months after implantation and continued to improve over 3 years. Mean change in score from baseline was -2.2 (range -0.9 (Q16 fear of weight regain) to -3 (Q7 ability to do what I want)). Total score improved from 70.4 at baseline to 33.3 at 3 years, (mean total improvement of 53 % from baseline (range 24 % (Q16) to 65 % (Q7)). These improvements correlated with the mean 52 % excess weight loss (%EWL) and with remission /improvement of many comorbidities of obesity: type 2 diabetes (96 %), hypertension (91 %), hyperlipidemia (77 %), GERD (91 %), sleep apnea (86 %), arthritis (75 %) and depression (93 %). Conclusion Weight loss facilitated by LBAP placement offers meaningful improvement in all 17 OWLQOL measures, and correlates with significant %EWL and comorbidity changes. Durability of these improvements will be followed and reported over 5 years. O017 Biliopancreatic Diversion/Duodenal Switch – Revisional Cases Presenter: Yury Yashkov Institution: Center of Endosurgery and Lithotripsy, Moscow, Russia Background Every bariatric operation may lead to the necessity of revisions in the late postoperative period. Malabsorptive procedures may be indicated in case of poor result after simple restrictions, but may themselves demand conversions or revisions by different reasons. The aim of this study is to evaluate the results of Biliopancreatic Diversion/Duodenal Switch (BPD/DS) as a revisional operation and to evaluate the outcomes of revisional surgery after BPD/DS. Methods Series of 360 BPD/DS done since 2003 is studied with a special attention to: 1) BPD/DS done as a revisional surgery, 2) revisions done after BPD/DS. Operative outcomes and late results are presented. Results 16 of 360 patients (4,4 %) had DS as a revisional procedure after: vertical banded gastroplasty (VBG) - 9, gastric banding - 4, sleeve gastrectomy (SG) -2, horizontal gastroplasty-1. 7,7 % patients underwent revisional operations after BPD/DS: bowel shortening -15 (4,2 %), re-resections or sleeve-plication – 5 (1,4 %), lengthening of bowels for protein malnutrition 8 (2,2 %), gastric banding-1 (0,28 %). There was no mortality. Revisions from VBG to BPD/DS were technically more demanding operations with potential risk of complications. Additional gastric restrictions provided better weight loss than bowel shortening alone in case of insufficient weight loss after BPD/DS. Conclusions BPD/DS is a very effective solution after failed restrictive operations. Further revision of insufficient weight loss after BPD/DS should include not only bowel shortening but also further gastric restriction. O018 Laparoscopic Adjustable Gastric Banded Plication: 2 Year Results and Evolution of Procedure Presenter: Dr. Satish Pattanshetti Co-authors: Dr. C.K Huang, Dr. Rajat Goel E-Da Hospital, Kaohsiung, Taiwan Background Laparoscopic adjustable gastric banded plication (LAGBP) is a new restrictive bariatric procedure combining adjustable banding and greater curvature plication of the stomach. This study aimed to report the evolution of this surgical technique and analyze the surgical results. Methods Eighty patients receiving LAGBP were enrolled in this study. The band-first technique was used for 50 patients from May 2009 to June 2011 and was then changed to the plication-first technique from July 2011 to October 2011. Patients’ demographics and pre- and postoperative data, including complications and weight loss, were collected and analyzed. Results Eighty patients (26 men and 54 women) with a mean age of 30.75± 8.68 years and a mean BMI of 38.05±4.73 kg/m2 were evaluated with a mean follow-up for 10.52 (1–24) months. Average operation and hospitalization times were 92.85±35.86 minutes and 1.73±1.04 days, respectively, when there were no intraoperative complications or surgical mortality. There were

1319 4 (8 %) postoperative complications with the band-first technique and 1 (3 %) with the plication-first technique. Mean percentage excess weight loss at 3, 6, 12, 18, and 24 months was 34.73±10.42, 42.59±13.67, 56.38±19.89, 57.59± 19.88, and 65.84±17.36, respectively. Band adjustment frequency was 2.44± 2.21 times in 2 years. Conclusion LAGBP is a new bariatric procedure with few complications and superior weight loss at the end of 2 years. We suggest that the plication-first technique be standardized to decrease postoperative complications. Long-term follow-up is necessary for standalone acceptance of this bariatric procedure. O019 Bariatric Evaluation and Surgical Follow Up: the Need to Incorporate Additional Mental Health Components Presenter: Connie Stapleton, Ph.D. An exemplary pre-surgical bariatric evaluation would be a comprehensive, multidisciplinary effort requiring consensus by all disciplines on the readiness of each patient for WLS. Of equal importance, is the need for the evaluation to point toward specific multi-disciplinary post-operative follow-up. The NIH Consensus Panel recommended careful selection of surgical candidates by a multidisciplinary team with access to psychiatric expertise. (NIH conference. Ann Intern Med1991). In 2005, a panel concluded that psychiatric evaluation was not needed routinely but should be available if indicated (Buchwald H. J Am Coll Surg 2005).“Although a comprehensive presurgical evaluation provides an opportunity to identify the small number of patients for whom surgery is contraindicated, for most individuals careful presurgicalevaluation should serve a planning and education function rather than a gatekeeping function.”(Kalarchian MA, Marcus MD. Cogn Behav Pract 2003)“The consultation provides an opportunity to review motivations for and expectations of surgery and to provide education. Individuals with psychiatric problems may benefit from treatment prior to surgery and from establishment of a plan for postsurgical monitoring and intervention.”(Marcus, MD, Kalarchain, MA, & Courcoulas, AP. Am J Psychiatry 2009; 166:285-291) “Postsurgical monitoring and intervention”… those are the key words. The pre-surgicalevaluation is a place to start helping patients prepare for the issues they will need toaddress throughout the WLS process, but more importantly, for a good deal of time following the actual surgery. A specific aftercare plan needs to be established at the time of a multidisciplinary team evaluation. O020 redicting the Glycemic Response to Gastric Bypass Surgery in Patients with type 2 Diabetes Presenter: John B. Dixon (MBBS PhD FRACGP)1 Co-authors: Lee-Ming Chuang (MD)2,3, Keong Chong (MD)4, Shu-Chun Chen (RN)5, Gavin Lambert (PhD)1, Nora Straznicky (PhD)1, Wei-Jei Lee (MD PhD)5. Baker IDI Heart & Diabetes Institute1, Melbourne, Victoria, Australia Objective To find clinically meaningful preoperative predictors of diabetes remission, and inadequate glycemic control or improvement following gastric bypass surgery. Predicting the improvement in glycemic control in those with type 2 diabetes following bariatric surgery may help in patient selection and counseling. Research design, Methods Preoperative details of 154 ethnic Chinese subjects with type 2 diabetes were examined for their influence on glycemic outcomes at 1-year. Remission was defined as HbA1c 6 %. Analysis involved binary logistic regression to identify predictors and receiver operator characteristics to determine clinically useful cut-off values. Results Remission was achieved in 107 (69.5 %) patients at 12 months. Diabetes duration of <4 years, body mass index >35 kg/m2 and fasting Cpeptide concentration >2.9 ng/ml provided three independent preoperative predictors and three clinically useful cut-points. A combination of 2 or 3 of these predictors allows a sensitivity of 82 % and specificity of 87 % for remission. Duration of diabetes (with different cut-points) and C-peptide also predicted those not achieving HBa1c 7 % and a fall in HbA1c of<1.5 %. Percentage weight loss following surgery was also predictive of remission and less satisfactory outcomes. Conclusion In those with type 2 diabetes, the glycemic response togastric bypass is related to BMI, duration of diabetes, fasting C-peptide (an indicator of insulin resistance and residual beta-cell function) and weight loss. These data support and refine the findings in largely Caucasian populations and for

1320 other bariatric procedures. Specific ethnic and procedural cut-points may vary and require further investigation. O021 Laparoscopic Mini-Gastric Bypass Versus Rroux-en-YGastric Bypass for the Treatment of Type 2 Diabetes Mellitus Presenter: Wei-Jei Lee MD&PhD Co-authors: Jung-Chien Chen MD; Kong-Han Ser MD Dep. Surg. Min-Sheng General Hospital, National Taiwan University, Taiwan Background Gastric bypass is now the treatment option for T2DM. This study is to evaluate the efficacy of laparoscopic mini-gastric bypass (LMGBP) versus laparoscopic Roux-en-Y gastric bypass (LRYGBP) for the treatment of T2DM. Methods T2DM patients receiving gastric bypass at our department with 12 months follow-up data were included. The end point is T2DM remission, defined by fasting plasma glucose<110 mg/dl and HbA1C<6.0 %. Results Of the 159 patients, 100 patients received LMGBP and 59 received LRYGBP. Gender (66.5 % female), age (mean 45.0 + 10.8) and HbA1C (mean 9.3 + 1.9 %) did not different between procedure groups. One year after surgery, remission of T2DM was achieved in 69 % of the patients. Patients with their BMI>35 kg/m2 had a higher remission rate than those with BMI<35 kg/m2 (90 % vs. 40 %; p< 0.001). LMGB had a higher rate of remission (85 %) compared with LRYGB (44 %). LMCB also produces a higher excess weight loss than LRYGBP (60.1 % vs. 72.1 %, p 00.032). Multivariate analysis confirmed that weight loss is the deciding factor for the influence on remission between LMGB and LRYGB. Conclusion This study demonstrates that LMGBP is a more effective treatment for T2DM than LRYGBP. The superiority is attributed to a greater weight loss in LMGBP than LRYGBP. O022 Laparoscopic Revisional Bariatric Surgery: ADecade Spectrum at an Asian Bariatric Center Presenter: Wei-Jei Lee MD&PhD Co-authors: Jung-Chien Chen MD; Kong-Han Ser MD Dep. Surg. Min-Sheng General Hospital, National Taiwan University, Taiwan Background A rapid increase of bariatric surgery has lead to a significant increase of patients that necessitate revision procedures. Methods A total of 143 patients (5.8 %) out of 2485 bariatric patients enrolled in a Asian bariatric center were included. The reasons and type of surgery for revision surgery were identified and analyzed. Patients who underwent laparoscopic revision surgery for early surgical complications at post-operative period were not included. Results Of the 143 patients, 38(27.1 %) underwent revision surgery for complication and 105(72.9 %) for weight regain or inadequate weight loss. The revision rate was 12.8 % (81/653) in LVBG, 13.0 % (32/246) in LAGB, 5 % (5/ 198) in laparoscopic sleeve gastrectomy (LSG), 2.1 %(27/1299) in laparoscopic mini-gastric bypass (LMGB), and 1.4 %(4/287) in LRYGB. All procedures were completed by laparoscopic approach, including conversion to LMGB (72), LRYGB (51), LSG (n 017), reduction of slippage (4), biliopancreatic diversion (2) and conversion to normal anatomy (17). The operative time was 155 min and postoperative hospital stay was 4.0 days. The major complication and mortality rates were 4.8 % and1 % respectively. At a follow-up of 12.9 months, the BMI decreased significantly from 40.9 (7.4) to 31.7 (6.6) kg/m2. Conclusions The laparoscopic approach to revision surgery is safe and effective in patients with previous bariatric surgery and is associated with rapid recovery and short hospital stay. O023 Patients Satisfaction After Bariatric Surgery Presenter: Wei-Jei Lee MD&PhD Co-author: Jung-Chien Chen MD; Kong-Han Ser MD Dep. Surg. Min-Sheng General Hospital, National Taiwan University, Taiwan Background At present, obesity surgery outcomes are predominately measured by the degree of weight loss and nature of complications after surgery. A

OBES SURG (2012) 22:1315–1419 satisfaction outcome measured by patient itself is relative lacking in the field of obesity surgery. Methods From Jan 2000 to December 2010, 1361 patients affected from morbid obesity and receiving laparoscopic bariatric surgery at our department with at least 24 months follow-up data were included. All patients received a satisfaction evaluation at postoperative visit. Satisfaction was measured by a scoring question and is quoted from 1 to 5 (1 being the worst and 5 the best option). Results Of the patients, 409 received laparoscopic vertical banded gastroplasty (LVBG), 128 laparoscopic adjustable banding (LAGB), 63 laparoscopic sleeve gastrectomy (LSG), 677 laparoscopic mini-gastric bypass (LMGB), 34 laparoscopic Roux-en-Y bypass (LRYGB) and 50 laparoscopic revision surgery (LRS). The mean patient satisfaction score at 2 years is 4.46. The highest score is at LMGB (4.57) and LSG (4.57), followed by LVBG (4.41), LRYGB(4.32) and LRS(4.30). The lowest score is at LAGB (4.09). LAGB had the lowest patient’s satisfaction followed by LVBG at longer follow-up. LMGB, LRYGB, LSG and LRSG had similar high patient satisfaction rate. Conclusions Patient’s satisfaction is high in modern laparoscopic bariatric surgery but LAGB has a significant lower score. O024 Gall Bladder Stone and Bariatric Surgery Presenter: Wei-Jei Lee MD&PhD Co-authors: Yi-Chih Lee MHA; Jung-Chien Chen MD; Kong-Han Ser MD; Weu Wang MD. Institution: Dep. Surg. Min-Sheng General Hospital, National Taiwan University, Taiwan Background Gall bladder stone is a common co-morbidity of morbid obesity before and after bariatric surgery. This study investigate the incidence of accompanied cholecystectomy before and after bariatric surgery.. Methods From 1998 to 2011, 3439 patients received bariatric surgery enrolled in a Asian bariatric center were included. The accompanied cholecystectomy before and after bariatric surgery were identified and analyzed. Results Concomitant cholecystectomy was performed in 309 (9.0 %) patients. However, only 52 (1.5 %) patients were symptomatic. At follow-up, 29 (2.1 %) patients out of 1361 received laparoscopic cholecystectomy for symptomatic gall stones. The duration from bariatric surgery to the development of symptomatic gall stone varied from 6 months to 12 years. The accumulative incidence increased from 0.2 % at the 1st post-operative year to 3.75 % at the 13th post-operative year. There was no any complication in laparoscopic cholecystectomy after bariatric surgery in this study. The development of symptomatic gall stone is related to weight loss rather than the influence of duodenum exclusion. Conclusions Symptomatic gall bladder stone may be found during or after bariatric surgery at a relative low incidence. Laparoscopic chocystectomy can be safely performed in these patients. O025 The Failed Bilio-pancreatic Diversion/Duodenal Switch – What next? Presenter: Haris A. Khwaja Co-authors: Shafiq M. Javed, Conor J. Magee, David D. Kerrigan Gravitas, United Kingdom Bilio-pancreatic diversion and duodenal switch is regarded as the most effective bariatric operation in terms of weight loss and resolution of obesity-related co-morbidities. The failed BPD-DS is an uncommon scenario and thus there is a paucity of literature on the management of such failures. BPD-DS failures may be defined in terms of a) Excessive weight loss with or without protein calorie malnutrition b) Severe vitamin/mineral deficiencies c) Poor quality of life as a consequence of severe diarrhoea, steatorrhea or malodorous stool d) Poor weight loss post BPD-DS. Surgical strategies for BPD-DS failures will be described in detail. The rationale for managing excessive weight loss by way of lengthening of the common channel or restoration of intestinal continuity will be described including the technique of duodenal sparing and complete reversal of the BPD-DS. The significance of the torted gastric sleeve and the significance of the Petersen internal hernia in duodenal switch patients will also be described.

OBES SURG (2012) 22:1315–1419 Management of poor weight loss post-BPD-DS will be discussed. Modifications of the gastric sleeve by way of re-sleeving, plication and adjustable gastric banding of the sleeve for patients with poor weight loss as well as common channel modifications will also be reviewed. O026 Single Incision Laparoscopic Gastric Bypass Surgery: A Study of 75 Cases Performed By A Single Surgeon Presenter: Keyur Chavda MD Co-authors: Sunil Sharma MD

1321 All but four had DM+MX. Two patients had a HbA1c <7 % and the rest from 7,1 to13,2 %. Sixteen patients do not need DM treatment since surgery, 10 one month after, 6 three months after and the 8 patients with peptide C levels 0,0 ng/ml improved their DM treatment (4/8 do not need insulin). All the patients abandon all preoperative treatment except those anti-coagulated (n 03) and one case off ibromyalgia. No difference were found related to preoperative BMI. In conclusion, BMI do not appear "per se" being a parameter for deciding gastrointestinal surgery for DM. However, high and/or combination necessity of oral anti-diabetic drug or insulin requirements, could suggest a minimal beta cell mass and lower remission chance by surgery, especially in lower BMI.

University of Florida – Jacksonville, Florida, USA Introduction Laparoscopic Roux en Y gastric bypass is one of the most commonly performed weight loss surgery in United States. This complex reconstructive surgery requires high level of expertise with little room for error. Single Incision Laparoscopic Surgery (SILS) is a new approach where by the whole surgery is performed using a small incision and inserting multiple ports through it. Better cosmetics, less pain and faster recovery are potential advantages of this approach. Inadequate visualization, lack of space, expensive equipments, long operative time and being potentially unsafe are often criticism. SILS has been successfully performed and reported for cholecystectomy, sleeve gastrectomy and lap band surgery. For the first time we are reporting our successful technique for performing Single Incision Laparoscopic Surgery for Roux en Y Gastric Bypass using end-to-end anastomosis (EEA) stapler technique and extracorporeal small bowel anastomosis. Material and Method retrospective analysis of first 75 patients who underwent SILS LGBP over a period of 18 months. Selection criteria included body mass index (BMI) of 33-60, no prior major abdominal surgery and patient consenting for this approach. Results Attempted in 75 patients. 7 patients required additional single 5 mm port. Average operative time was 110 minutes with minimal blood loss. No major complication. One patient had anastomotic leak secondary to EEA stapler malfunction. Average hospital stay was between 24 to 36 hours. 4 patients developed small seroma which required drainage but no hospitalization. Conclusion SILS LGBP is a reasonable option for selected patients. The procedure is safe, technically feasible and can be performed in a reasonable time with a potential of faster recovery. O027 Diabetes Mellitus with Metabolic Syndrome in BMI 24-29 vs 30-34 treated by One Anastomosis Gastric Bypass: is there differences in the results? Presenter: Garciacaballero M Co-authors: Martı´nez-Moreno JM, Toval JA, Miralles F*, Mata JM,Osorio D, Mı´nguez A. Department of Surgery. Facultad de Medicina. University Malaga. 29080Malaga/Spain. *Internal Medicine Department. Associate University HospitalParque San Antonio. 29017-Malaga/Spain The current and longer term evolution evidence on the effect of gastrointestinalsurgery on remission, control or improvement of Diabetes Mellitus (DM) comefrom partial gastrectomy in normal weight patients (195581) and GreenvilleGastric Bypass in obese (1982). The DSS recommended surgery only in simpleobesity (BMI30-34). However the resolution of diabetes after surgery occur inthe first days, before weight loss happen. On the other hand, few information isavailable on prognostic factors of remission such as: years of DM, intensity of necessary treatment, years of insulin, dose of insulin (iu/kg), peptide C levelrelated to HbA1c, HbA1c level related to treatment and autoimmunity markers? We compared the results of 40 patients (age range 17 to 80 years) operated by One Anastomosis Gastric Bypass (BAGUA) for DM and Metabolic Syndrome (MX): 24 had a BMI24-29 and 16 BMI30-34. We evaluated them preoperatively and from 1 to 48 months after surgery for: years of DM, intensity of treatment, years and dose of insulin (iu/kg), peptide C level related to HbA1c, HbA1c level related to treatment, body weight and composition, Fasting Plasma Glucose, blood pressure and serum lipids levels, as well as necessity of postoperative treatment. Eight patients had a peptide C level of 0,0 ng/ml and the rest between 0,24 and4,21 ng/ml, although its meaning is different depending of HbA1c levels.

O028 Cognitive Biases in Bariatric Surgery: The Strange case of the Mini-Gastric Bypass Presenter: Robert Rutledge Center for Laparoscopic Obesity Surgery, United States of America Cognitive errors are thought-process errors, or thinking mistakes, which lead to clinical decision making errors.

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Anchoring – "anchoring" decision on a unrelated piece of information Availability Bias – decision based upon what is more available in memory Groupthink & Herd behavior – decisions based on other peoples decision Choice-supportive bias – remembering prior choices as better than reality Confirmation bias – interpreting information in a way that confirms preconceptions Irrational escalation – increased belief in a decision, because of prior investment Knowledge bias – choosing the option one knows best Loss aversion – refusal to give up a belief once acquired Overconfidence effect – excessive confidence in one’s beliefs Selective perception – prior expectations to affect beliefs Semmelweis reflex – rejecting new evidence that contradicts a personal belief Status quo bias – refusal to make new decisions Subjective validation – Deciding based upon one’s beliefs not evidence

The state of bariatric surgery is complicated by many old and new procedures and biases for and against different procedures. The Mini-Gastric Bypass is used as a model to explore surgeons cognitive decision making errors in the selection of bariatric surgery procedure. The Mini-Gastric Bypass has been the subject of numerous controlled prospective randomised trials as well as other positive reports all positive. It is time to reevaluate the MGB on a rational basis avoiding these biases. O029 The Role of Bariatric Surgery in the Management of Patients with Type IDiabetes Presenter: Robert Dorman Co-authors: Nikolaus F. Rasmus, Federico J. Serrot, Nikki Voulgaropoulos, Loren Bach, Bridget M. Slusarek, Barbara K. Sampson, Henry Buchwald, Daniel B. Leslie, and Sayeed Ikramuddin University of Minnesota, University of America Introduction The benefits of bariatric surgery in patients with type I diabetes are not well-known. Here, we report outcomes on the largest case series of patients with type I diabetes following bariatric surgery. Materials and Methods Demographic data as well as hemoglobin A1c (HbA1c,%) and body mass index (BMI, kg/m2) were collected in patients following laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB) and duodenal switch (DS). Results Two patients each underwent LAGB, RYGB and DS. Average followup was 23-months (range 18-30 months). Average age was 44 years (range 29-59 years) at time of surgery. There was an average percent excess weight loss (EWL) was 56.4 % with 22 %, 68 % and 80 % EWL following LAGB, RYGB and DS, respectively. Average HbA1c values went from 8.6 % to 8.5 % with changes from 7.9 to 8.3 %, 7.9 to 8.7 %, and 9.8 to 8.4 % in the LAGB, RYGB and DS groups, respectively. Average daily insulin requirements did not significantly change. One patient in the DS group required several months of parenteral nutrition due to inadequate oral intake.

1322 Discussion These data represent the largest case series of patients with type 1 diabetes who have undergone bariatric surgery. The malabsorptive nature of the DS may provide some additional benefit in this patient population likely through its effect on peripheral insulin resistance. Conclusion These procedures are efficacious with regards to weight loss but do not have significant impact on overall glycemic control in this patient population. O030 Systematic Review of Rhabdomyolysis in Bariatric Surgery Presenter: Saurav Chakravartty, Diwakar R Sarma, Ameet G Patel King’s College Hospital NHS Foundation Trust, United Kingdom Background Rhabdomyolysis (RML) is a rare but known complication of bariatric surgery. However the clinical spectrum, risk factors, prevention and optimal management of RML in bariatric surgery still remain to be evaluated systematically. Methods and Materials A systematic search was performed between January 1990 and March 2012 using relevant MeSH terms. All abstracts, articles and relevant references were analysed. Studies were chosen based on well defined inclusion criteria. The parameters assessed included characteristics of the RML population, type of bariatric surgery performed, operating time, presentation, diagnosis, complications and treatment of rhabdomyolysis. Results Twenty two studies were analysed. Of these, nine comparative studies compared 125 RML patients to 777 non RML patients. Both groups had a similar age (39.26 vs 39.8 years) and sex distribution (male: female; 49:54 vs 140:147). The RML patients had a greater mean body mass index (52 vs 48 kg/m2, p<0.01) and a longer operation (250 vs 207 minutes, p<0.01) compared to non-RML patients. Most operations were open procedures (n091; 71 %). Acute renal failure was found in 20 patients (13.7 %) and was more likely to occur in patients with muscle pain (p<0.001). The overall mortality was 3.6 % (n05). Conclusion RML is more likely to occur in patients with a higher BMI and a longer operation. Patients with myalgia after bariatric surgery may develop RML leading to renal failure and should be identified and treated promptly. O031 The Ideal Way to Perform Gastric Band Presenter: Fabrizio Bellini Co-author: Pietro Pizzi Bariatric and Metabolic Surgery, Desenzano Hospital, Italy Introduction The ideal operation to control obesity has not yet been defined. The aim of bariatric surgery is to reduce comorbidities and mortality with the less invasive procedure. Gastric Band remains worldwide the less invasive surgical approach. We present our 9 years experience, procedures and results. Materials & Methods From 2002 to 2011, 3089 patients underwent LAGB placements (Heliogast ® System).Procedures were rigorously performed by two surgical teams:”two-step” perigastric technique, minimal dissection of the gastro-phrenic ligament, band fixation and the meticulous follow up. Results Data on patient demographics, operative variables and postoperative outcomes were collected prospectively and reviewed retrospectively. The results are analyzed according to EWL%, BMI, mortality, complications and percentage of follow up. Preoperative BMI was 42,2 for male and 41.4 for female respectively. No deaths. Conversion rate: 2(0,07 %), slippage 137 (4,43 %), band erosion 14 (0,45 %), trocar hernia 27 (0,87 %), port disconnection or leaking 41 (1,32 %), poor weight loss 193 (6,2 %), band removal for psychological intolerance 16 (0, 51 %). Follow up 89 % at 72 months. Mean EWL at 72 months was 55,7 % for female, 53.9 % for male. Discussion and Conclusion Patients who are not committed to making longterm lifestyle changes should not be recruited for gastric band. We assume that combining some simple technical artifices, we can achieve and maintain EWL>54 %, with a low rate of complications and therefore a clearly improvement of quality of life. The more procedures performed in a hospital, the lower the risk of serious complications, likewise moreO032 Childhood Obesity Presenter: Connie Stapleton, Ph.D. A 24-week childhood obesity program will be described, which can be an adjunct program at bariatric centers. Children will have been referred by their primary care doctor. Each child, as well as their parent(s), will be screened to determine

OBES SURG (2012) 22:1315–1419 their appropriateness for the group. The parent(s) a) agree to bring the child to be brought to each weekly group session, b) agree to attend, and actively participate in, each weekly group, and c) agree to bring the child to a minimum of one weekly children’s group exercise session. Each group session will include the following: 1) weighing and measuring 2) review of homework 3) didactic psycho educational material 4) interactive group therapy 5) parenting tip 6) presentation and practice of new exercise 7) healthy foods and recipes; eating tips 8) relaxation exercise 9) goals Each session will be two hours. Every family will meet with the therapist and the physician. The child’s medical status will be reviewed and weight loss goals will be reviewed. In addition, each group member will be expected to keep a personal journal throughout the course of the group. A variety of instruments will be used to obtain statistics for research purposes. Research will be conducted in order to determine results in terms of weight loss over time, levels of depression, anxiety, and anger in relation to weight, and family functioning in relation to weight. O033 Plastic surgery after Roux-en-Y gastric bypass Presenter: CUBAS R, e, Co-authors: Arruda slm, Watanabe a, Medeiros rs, Barbosa ps, Ugarte mfs, Melendez-Arau´jo ms, Neves cv, Milhomem pd, Quirino kp, Mensorio ms Background Patients submitted to Roux-en-Y Gastric Bypass (RYGB) are susceptible to high weight loss and consequently to body and psychosocial changes. Many patients will be submitted to plastic surgery after bariatric procedures based on their own objectives and expectations. Our aim is to evaluate the profile of patients submitted to plastic operation after RYGB. Methods Between Jan/2004 and May/2011, 785 patients submitted to Rouxen-Y Gastric Bypass were evaluated regarding mean age (MA), sex, mean pre-operative BMI (PreBMI), mean post-operative BMI (PostBMI) and Excess Weight Loss (%EWL). The patients were divided in two groups: submitted to post-operative cosmetic surgery (PLG) and patients who are not (NPLG), with respectively 55 and 729 patients. Statistical analysis was performed by GraphPad Instat® and Microsoft Excel®. Results From all patients (785), 665(84.7 %) were females. MA was of 37.2± 10.6(16.5–67.4) years. PreBMI was of: 41.8±4.9(33.1-75.1) kg/m. Mean follow-up was of: 14.4±11(0.2-68.1) months. PLG: Females: 49(89 %). Abdominal: 63 %. Breast: 47 %. Extremities: 20 %. Others: 18.1 %. PLG vs. NPLG: MA: 38.3±10.2(19-57.5) vs. 37.1±10.7(16.5-67.3). %EWL: 92.5±16.4 (59.6-133.7) vs. 75.1±25.5(2.8-147.9); p<0.0001. PostBMI: 26.7±3.1(21.135.5) vs. 29.5±4.8(18.6-57.7); p<0.0001. Conclusion In our sample, abdominal plastic surgery was the most commonly chosen by the sample. Patients submitted to plastic surgery after RYGB showed higher Excess Weight Loss and lower post-operative BMI when compared to patients that did not. O034 Weight Regain - Causes/Management: A Psychological Perspective Presenter: Connie Stapleton, Ph.D. Weight regain is a concern for many surgical weight loss patients, and a troublesome reality for a percentage of patients. Although many bariatric programs provide a degree of non-surgery related education prior to WLS, post-surgical support services focused on helping patients deal with the changes in all areas of their lives are often minimal in a bariatric center, if they exist at all. Monthly or twice monthly support groups are valuable, but lack the psychological support patients need in order to make long-term behavioral and cognitive changes in relation to their eating and exercise habits, along with the myriad of changes in their interpersonal relationships.“Data documenting variability in outcome among bariatric surgery patients over time highlight the importance of patient selection and education, as well as the potential importance of pre- and postsurgical intervention.” (Marcus, Marsha, D., Kalarchain, Melissa A., & Courcoulas, Anita, P. Psychiatric Evaluation and FollowUp of AGS Bariatric Surgery Patients. Am J Psychiatry2009; 166:285-291.) This presentation highlights postsurgical psychological care as part of patient follow-up in all bariatric centers to help prevent weight regain following WLS. In addition to offering patients individual and group therapy, behavioral and

OBES SURG (2012) 22:1315–1419 cognitive restructuring classes could be offered, allowing patients to have access to services to help them deal with non-physiological aspects of adjusting to WLS. Of equal importance, surgeons are then able to direct patients to professionals within the bariatric center who can help with the WLS issues that surgeons are not trained to, and should not have to, address. O035 The Role of a Bariatric Physician: What It Is and What It Is Not! Presenter: Connie Stapleton, Ph.D. The bariatric physician. Theoretically, that is their role. To be the surgeon. That’s what surgeons do – they perform surgery. However, to the patient, the surgeon is often viewed as having multiple roles in the process of weight loss surgery. In addition to being the person who performs the operation, the patients view the surgeon as their nutritional consultant, their cheerleader, their support team leader, and their advisor to all matters person (from marital issues to mental health problems).Surgeons are surgeons. They are not psychiatrists, psychologists or any other sort of mental health practitioner. Many patients presenting for weight loss surgery, however, suffer from mental health issues. Maintaining long term weight loss following weight loss surgery requires interventions that have nothing to do with surgery. Therefore, much of maintaining long term weight loss following weight loss surgery has nothing to do with the surgeon. Hence, the need for the multidisciplinary team including nutritionists, exercise physiologists, and mental health professionals. Implementing ongoing exercise and consistently making healthy food choices requires sustained motivation. Surgeons are not trained in assisting patients to explore their resistance to behavior change. Nor are they trained to treat depression, anxiety, bipolar disorder, or personality disorders, from which a percentage of weight loss patients suffer. These same mental health issues can interfere with long term success following weight loss surgery. The patient and the surgeon need a team of professionals to increase the likelihood of long-term weight loss success following weight loss surgery. O036 6,385 Consecutive Mini-Gastric Bypasses: 15 Years Later Presenter: Robert Rutledge Center for Laparoscopic Obesity Surgery, United States of America In spite of initial skepticism; there is growing evidence that mini-gastric bypass (MGB) is a safe and effective procedure with many of the features of an ideal bariatric surgery. Outcome and long-term follow-up of a consecutive cohort of patients who underwent MGB are reported. The data on 6,385 patients who underwent MGB from September 1997 to June 2011 were reviewed. Mean preoperative weight (+/- Standard Deviation) was 143 +/- 31 kg, BMI 47 +/- 7. & 83 % were female. Mean operative time 41 minutes and median length of stay 1 day. Three deaths occurred within 30 days of surgery, (0.05 %). Early complications occurred in 4.9 %. 44 (0.7 %) patients had anastomotic leaks. Three (0.05 %) patients presented with dypepsia/bile reflux not responsive to medical therapy and were successfully treated by Braun side-toside jejuno-jejunostomy. Gastritis/dyspepsia/marginal ulcer was the most serious long term complication; routinely treated medically. Excessive weight loss occurred in 1 % of patients; treated by take down of the bypass. Mean % excess weight loss (EWL) of 78 %. 10 year weight regain was mean 4.9 %. >50 % EWL was achieved for 95 % of patients at 18 months and for 92 % at 60 months. 6 % of patient had inadequate weight loss or significant weight regain were treated by revision, (addition of ~2 meters to the bypass). MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed. O037 Weight Loss and Weight Regain After Laparoscopic Sleeve Gastrectomy Presenter: Ismael Court Co-authors: Juan E. Contreras MD, Gustavo Czwiklitzer MD, Ismael Court MD, Juan P. Camacho MD, Jorge Bravo MD, Pablo Marin MD, Diva Villao MD. Bariatric Surgery Department. Clinica Santa Maria. Santiago Chile. Hospital Salvador. Universidad de Chile Background Laparoscopic Sleeve Gastrectomy (LSG) is a safe and effective alternative for obesity treatment.

1323 Aim Describe weight loss and weight regain at medium term in a group of patients underwent LSG. Methods Uncontrolled descriptive prospective study, between January 2006 and February 2009. 74 and 21 patients with 3 and 4 years follow up (FU), respectively. We calculate weight loss (Kg), BMI (Body Mass Index), %EWL (Excess Weight Loss) over the time. We define weight regain as the increase of BMI in more than 10 % over the minor BMI reached in the first year after surgery (%RBMI), excluding those who were still eutrophic. Results 74 patients. Female 75,68 %, male: 24,32 %. Mean age 39,7 years. Mean BMI 41,82. One year FU: mean BMI 28,16; mean %EWL 88,06 %. Two years FU: mean BMI 29,17; mean %EWL 88,06 %. Three years FU: mean BMI 29,76; mean %EWL 76,34 %; 22,97 % (17/74) patients regain weight, %RBMI 10-15 %; 15,1-20 % and >20 % was 41,2 %; 35,3 % and 23,5 %, respectively. Mean %RBMI was 16,4 %. Four years FU: mean BMI 29,82, mean %EWL 70,51 %; 28 % (6/21) patients regain weight, %RBMI 10-15 %; 15,1-20 % and >20 % was 33,3 %; 50 % and 16,7 %, respectively. Mean %RBMI regained was 16,1 %. Conclusion Sleeve Gastrectomy is an effective technique to weight loss. Patients can regain weight after surgery. Our data show weight regain in 23 % of patients at 3 years follow up, and 28 % at 4 years follow up. The average %RBMI at 3 and 4 years after surgery was 16,4 % and 16,1 % respectively. O038 Pregnancies After Sleeve Gastrectomy Presenter: Krawczykowski Centre Hospitalier Notre Dame de Bonsecours, France Background Obesity increases the rate of maternal and newborn complications. For many years, sleeve gastectomy (SG) has gained acceptance as a weight loss surgery but there is still a lack of information regarding subsequent pregnancies. The series based on the information gained at follow up consultation, among 472 SG (341 primary, 131 as a revision), there were 410 females and 39 recorded pregnancies in 34 women, but data are available for 27 patients and 32 pregnancies. For those 27 patients, before SG mean age was: 29 (19-46); mean BMI: 45.2 (36.5-61), 1 had type 2 diabetes, 3 hypertension, 3 SAS, 6 an obvious fertility problems. Results Mean time elapsed between SG and pregnancy was: 22 months (6 – 69), mean BMI before pregnancy was 28.1 (20.3-38.9). During the pregnancy mean weight fluctuation was+9.6 kg (-16 to+26). Only 2 patients were presenting vomiting after 3 months, 4 had a gestational T2D only one required insulin, 2 had hypertension, no preeclampsia, no SAS. Neonatal outcomes: premature delivery 5 (before 37 weeks), 5 after 42 weeks, the cesarean delivery encountered in 9, 2 low birth weight (<2.5 kg), no macrosomia, 1 late miscarriage (at 18 w) and 2 intra uterine deaths (1 at 26 w, 1 at 37 w). Conclusion Weight loss after SG seems to resolve fertility problems and to reduce the rate of maternal and new born complications. O039 CT Volumetry after Sleeve Gastrectomy and Relation to Weight Loss Presenter: Mohamed D Sarhan Co-authors: Mohamed Elmasry, Omar Abd Elaziz, Mohamed Ghobashy, Tamer Nabil ,Ali Elbassiony, Mostafa Elshazli , Faheem Elbassiony Cairo University Hospital, Egypt Introduction Sleeve Gastrectomy has gained wide popularity in the past few years; however there has been no accurate method for assessing the remnant gastric pouch. Methods Twenty morbidly obese patients in Cairo University with a mean BMI of 48.6 were included in the study. CT Volumetry was done 1 and 6 months postoperative to assess the gastric pouch volume changes. A plain multi-slice abdominal CT with 5 mm reconstruction software was used to calculate the volume in each section and finally summates them. Results The mean 1st month postoperative pouch Volume was 110 cm3 which increased to 146 cm3 after 6 months. The mean Pouch Volume increase after 6 months was 36 cm3(42 % volume increase). Six months postoperative, the mean BMI dropped from 48.6 to 34.6 with 60 % EBWL.

1324 58 % of patients with significant weight loss (>60 % EBWL), had a smaller initial pouch volume (<110 cm3), however there was no statistical correlation(p00.25). Also, 66 % of the patients with significant weight loss had a lower percentage of increased gastric pouch volume after 6 months(<42 % increase in the pouch volume), however there was no statistical correlation (p00.5). Conclusion CT Volumetry is a non invasive, feasible and relatively accurate method for the follow up of laparoscopic sleeve gastrectomy, yet more patients and longer periods of follow up are needed for wider use of this new technique. Restrictive factors such as initial pouch volume and rate of pouch volume increase are important but not the only factors determining weight loss following sleeve gastrectomy. O040 Vertical Gastric Bypass with Jejunal Interposition as a Treatment for Gastroesophageal Reflux and Hiatal Hernia Repair Presenter: Alberto Salinas Co-authors: Wilfredo Garcı´a, Maria Daniela Ramı´rez, Henry Garcı´a Hospital de Clı´nicas Caracas, Venezuela Background Gastroesophageal reflux disease (GERD) and Hiatus Hernia is present in 44.4 % of the obese population. Case Report A 37 year old obese female (BMI039 kg/m2) with symptoms of gastroesophageal reflux and hiatal hernia diagnosed by endoscopy, underwent a Silastic Ring Vertical Gastric Bypass. After preparation of the Roux limb, we performed a vertical gastric pouch transecting the stomach parallel to the lesser curvature. The Roux limb was brought up antecolic and antegastric to the hiatus defect. We closed the defect primarily and fixation of the jejunal loop to it. We placed a 6 cm circumference silastic ring above the gastrojejunal anastomosis as we routinely do. Results At the 6th post operative month, the patient is free of symptoms with a 70 % of excess weight loss. Conclusion Vertical Gastric Bypass with a jejunal interposition, closing the hiatus defect with fixation of the Roux limb guarantees the anatomical correction of the hiatus hernia. It is well known that the gastric bypass itself provides excellent control of gastroesophageal reflux.

OBES SURG (2012) 22:1315–1419 pronounced. It is a very valid alternative to other procedures especially in Class I obesity. O042 Overweight and Obesity in Children in a Hospital of Madrid Presenter: Vicente Silvestre1 Co-authors: Mario Ruano2, Elena Aguirregoicoa2, Laura Criado2, Yolanda ´ ngel Marco3, Gonzalo Garcı´a-Blanch1 Duque L2,A 1.

Department of General and Gastrointestinal Surgery; Biochemistry;3.Department of Endocrinology Hospital Universitary of Mo´stoles.Mo´stoles. Madrid (Spain)

2.

Department of

Introduction The prevalence of overweight and obesity in children is very high. In Spain, is estimated at 16 % (second highest in Europe surpassed by Great Britain). This is truly a public health problem. The objectives our study are: 1) evaluate the frequency of overweight and obesity found in children in our hospital over a period of two years; 2) analyze their anthropometric measures and plasma levels of the criteria defining the metabolic syndrome and risk of cardiovasculardisease (CVD). Material & Methods Retrospective analysis of data from 496 children with overweight and/or obesity treated in our hospital. The mean age was 6.0 years (range: 1 – 14). We collected anthropometric measures: age, weight, body mass index (BMI) and waist circumference (WC) and plasmatic levels of: glucose, insulin, lipids and triglycerides Results We classify children in three groups according to the rate of BMI: Group A (over weight grade I, BMI: 25.0 – 26.9) n0200 (40, 3 %); group B (overweight grade II, BMI: 27. - 29.9) n 0216 (43.5 %) and group C (obesity type I, BMI030.0 – 34.9) n080 (16.1 %).All children show elevated values: glucose, insulin and triglycerides and decreased HDL cholesterol. Higher values correspond to the children in group C. Discussion and conclusion The frequency of overweight and obesity detected in our study(16.1 %) corresponds to that described for Spain.The results obtained suggest that these children suffer metabolic syndrome and insulinresistance, at great risk for CVD or diabetes mellitus type I or II. O043 Staple Line Dehiscence After Laparoscopic Sleeve Gastrectomy for Morbid Obesity; Prevalence, Outcome and Management modalities

O041 Laparoscopic Greater Curve Plication in Asia: Initial Experience Presenter: Wilfred Mui Co-authors: Lee Wai Hung Danny, Lam Kar Yee Katherine

Presenter: Ayman M. Soliman, MD* Co-authors: Samuel Szomstein, MD, FACS*, Raul J.Rosenthal ,MD, FACS* Minimal Invasive Surgery Department, Cleveland Clinic, Florida, Saudi Arabia

Hong Kong Bariatric and Metabolic Institute, Hong Kong Objective To evaluate the effectiveness and safety of laparoscopic greater curve plication (LGCP) for the treatment of obesity in ethnic Chinese in Hong Kong. Material and Methods 27 consecutive Chinese patients (23 females; mean age 37.6±8.9 years) received LGCP for the treatment of obesity from Sept 2010 to Dec 2011. Mean baseline body weight (BW) and body mass index (BMI) were 84.6±17.5 kg and 31.4± 4.8 kg/m2 respectively. Outcome measures were collected and assessed in a prospective manner. Results All procedures were performed laparoscopically with conversion to open surgery in one patient due to bleeding intra-operatively. There was neither mortality nor any postoperative complications. One patient developed prolonged vomiting for three days after surgery and symptoms subsided with conservative management. Mean follow-up was 10.1 ±6.8 months. Mean procedure time was 117.9 ± 22.3 minutes and mean hospital stay was 2.6 ±0.7 days. Mean BMI loss was 4.4±1.5, 4.9±2.2 and 5.6±2.7 kg/m2 at 3-month, 6-month and 12month. Mean % EBWL was 68.6 ±41.4, 68.4±35.5 and 60.2± 25.5 % at 3-month, 6-month and 12-month. Mean % of BW loss was 13.6± 3.9, 15.1±4.8 and 15.7±6.2 at 3-month, 6-month and 12- month. Mean % EBWL in BMI >35 group (n 08) was 37.5 ±10.3, 47.1±10.9 and 48.1 ± 20.2 at 3-month, 6-month and 12-month. Mean % EBWL in BMI <35 group (n019) was 81.4±42.8, 78.3±38.8 and 68.2±26.5 at 3-month, 6-month and 12- month. Conclusion LGCP is safe and effective in achieving significant weight loss in obese ethnic Chinese patients. However, weight loss in BMI<35 is more

Introduction Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as “per se “bariatric procedure for the surgical treatment of patients with different degrees of obesity. With the increase in the number of laparoscopic sleeve gastrectomies (LSG) being performed, the incidence of complications is also bound to increase. The most feared and life threatening complication is a stapled line dehiscence (SLD). We discuss the prevalence, outcome and management options of this complication. Methods The records of patients that underwent LSG between 2004 and 2009 were retrospectively analyzed from a prospectively collected database. Results 4 cases with staple line dehiscence were recorded. Two of the patients with mean BMI (41 ±5), mean age (38 ±6) had their primary operations performed at our institution (0.47 %) and two with mean BMI (47± 5), mean age (48 ±3) were transferred from outside facilities. Three dehiscence were proximal and one was distal. In three cases a SLD occurred after a primary LSG and the other case was in a secondary LSG after removal of an LAGB. All patients required a laparoscopic reoperation. One case had to be converted to an open procedure. Of the proximal SLD, two were managed by laparoscopy and drainage and one was converted to a Roux en Y gastric bypass. The distal SLD was managed with a t- tube. Subsequent Complications included two intraabdominal abscesses that weremanaged with percutaneous drainage and one infected trocar site. There were no complications with the conversion to roux en y gastric bypass. Length of stay ranged between 9-21 days with the average being 17 days. There were no mortalities. Conclusion Staple line dehiscence after LSG is a feared complication that requires prompt intervention. Drainage, stenting, and conversion to RYGBP are possible treatment options that vary based on location of the dehiscence.

OBES SURG (2012) 22:1315–1419

1325

Successful management of these patients can be managed laparoscopically in the majority of the cases.

O046 Influence of the Great Omentum Section in the Appearance of Gastrojejunal Anastomotic Leaks.

O044 Laparoscopic Crural Repair with Simultaneous Sleeve Gastrectomy for the Treatment of Gastroesophageal Reflux Disease Associated with Morbid Obesity

Presenter: Carlos Ballesta-Lopez Co-authors: C. Ballesta Lopez, A.F. Fernandez Zulueta, A. Bordo`n, J. Ybarra, E. Yakusik, F.Sosa.

Presenter: Ayman M. Soliman, MD* Co-authors: Samuel Szomstein, MD, FACS*, Raul J.Rosenthal ,MD, FACS*

Centro Laparoscopico Dr. Ballesta, Spain

Minimal Invasive Surgery Department, Cleveland Clinic, Florida, Saudi Arabia Background Laparoscopic sleeve gastrectomy (LSG) has increased in popularity as both a definitive and a staged procedure for morbid obesity. Gastroesophageal reflux disease (GERD) is a common comorbid disease in bariatric patients. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal. Methods The study included 20 patients (of whom 14 were women) with a mean body mass index of 43.4±1.9 kg/m2 and mean age of 47 years. All were eligible for LSG and eight were found to have esophagitis at pre-operative endoscopy. Patients with Barrett’s esophageus were excluded. Pre-and postprocedure assessments included GERD symptom questionnaire, 24-hour esophageal pH-metry, and manometry. The mean follow-up period was 4 months. Clinical outcomes also have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence. Results Symptomatic HH was diagnosed preoperatively in eighteen patients. In two additional patients, HH was asymptomatic and it was diagnosed intra-operatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with a HH >5 cm. Mortality was nil and no complications occurred. After a mean follow-up of 4 months, GERD symptoms resolution occurred in nine patients, while the other patients reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m2. Conclusion A laparoscopic hiatal repair with or without commercially available onlay reinforcement biologic mesh and a sleeve gastrectomy performed at the same time was successful in controlling the reflux symptoms and reducing body weight. O045 A Discharge Protocol for Reduction of Hospital Readmissions Presenter: Sharon Krzyzanowski Co-authors: RN, Keith Kim, MD Cynthia K. Buffington, PhD Florida Hospital Celebration Health, United States of America Introduction Hospital readmissions following bariatric surgeries are costly. Some readmissions may be avoidable. We have developed a discharge protocol in an effort to reduce complications and associated readmissions postoperatively. Methods The discharge protocol includes: 1) a required discharge check list of specific criteria involving pain, nausea, liquid consumption, respiratory status, and 2) a telephone interview by the nurse coordinator following discharge for discussion of physical and mental issues, medications, and the postoperative regimen. Readmission rates (30-day) were examined prior to and following initiation of the protocol along with causes for readmissions categorized as ‘technical’ (leaks, bleeding, organ injury), ‘medical’ issues (infection, stenosis, ulcer, deep vein thrombosis, pulmonary emboli, strangulated hernia, more), or general ‘malaise’ (nausea, vomiting, dehydration, weakness, benign abdominal pain). Results Prior to our employment of the discharge protocol, our 30-day readmission rates for all bariatric procedures averaged 9.79 %. The 30day readmission rate was 0 % for ‘technical’ complications, 3.34 % for conditions categorized as ‘medical’, and 6.46 % for issues involving general malaise. Following initiation of the protocol, the overall 30-day readmission rate declined significantly (Chi square <0.01), i.e. 9.79 % pre-protocol to 3.70 % post-protocol. The greatest change in readmission rates with the protocol involved readmissions associated with malaise, i.e. a greater than 50 % decline. Conclusion Hospital readmission rates following bariatric surgeries, particularly readmissions involving general malaise, can be significantly improved through the routine use of a discharge protocol.

Introduction The aim of this communications is to report our experience with the introduction of the section of the greater omentum in reducing the incidence of anastomotic gastrojejunal leaks Materials and methods The period of time evaluated, was divided into three stages which included 1879 patients in a period between January 2002 and January 2012. In step 1, January 2002 to March 2007, included 1200 patients undergone section of the omentum. In step 2, from April to December 2007 were evaluated in a prospective, randomized 178 patients divided into 2 groups, A with section 92 and the B without section 86 patients. In step 3, from April 2007 to January 2012, 501 patients were included all with the section of the great omentum. Results Step 1: over 1200 surgical procedures in patients with a mean age of 43 years and a BMI of 44.6 were found 40 gastrojejunostomy leaks (3.33 %). In step 2, in group A included patients with a mean age of 46 years and a BMI of 44.6 being stated a leak (1.08 %) and group B in which we included 86 patients with mean age 34 years and a BMI of 44.5 was verified 3 leak (3.84 %). In step 3 on 501 patients with a mean age of 38.4 years and a BMI of 44.4 were found 10 AL(2 %). Conclusion The systematic section of the omentum in patients undergoing laparoscopic gastric bypass with jejunal loop pre-colic and ante-gastric, helps to reduce the incidence of AL. O047 Effectiveness of Adjustable Gastric Banding based on Baseline BMI Presenter: Ted Okerson MD FACP Co-authors: Jaime Ponce MD, Helmuth Billy MD, Adam Smith DO, Trace Curry MD, Christopher Cornell PhD, Brad Watkins MD, the APEX study Allergan, United States of America Introduction Adjustable gastric banding (AGB) has been established as an effective treatment to reduce weight in obese patients (> 40 kg/m2OR>30 kg/ m2 with>1 co-morbidity). Here we summarize the safety and efficacy of AGB based on baseline BMI at 2.5-year. Methods This ongoing 5-year, prospective, observational study will assess weight reduction, comorbidities and health related-quality of life after the LAPBAND AP® System insertion. This is an interim analysis of subjects (n0359) who have completed or exited at 2.5 years. Results At baseline, subject BMI (in kg/m2) distribution was as follows: <40: 27 %; 40 to 45: 34 %; 45 to 50: 22 %; >50: 17 %. Mean respective %WL values were -17.3, -20.2, -18.5 and -19.6 at 2.5 yrs. The overall population achieved a %WL of -18.9. The %EWL for these respective groups at 2.5 years was -52.4, -49.3, -39.3 and -36.9. An AE or SAE was experienced by 34 % and 16 % of subjects, respectively; 80 % of AEs and 49 % of SAEs were device-related. Explantation and revision rates were 4.2 % and 3.3 %. There were no statistically significant differences in AE/SAE rates between the baseline BMI categories (2; p0NS). Conclusion Baseline BMI does not appear to correlate with %WL; the variation observed between %EWL and baseline BMI likely reflects the fact that those with a higher starting BMI have more excess weight. The LAP-BAND® is safe and effective over a broad range of baseline BMIs. Hence, choice of which bariatric procedure to perform should be based on other clinical factors. O048 Sleeve Gastrectomy with one Layer of Buttressing Material Presenter: Drs. hector conoman Co-authors: Cristobal guixe, franz delgadillo. Cencolap, Chile Introduction Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (SG). In order to reduce these complications, the staple line can be reinforced with buttressing material.

1326 Objective The aim of this report is to present our experience in the realization SG in obese patients with one layer of buttressing material in relation to bleeding, leaks, operative time and mortality. Methods Prospective case series of 180 patients who went to SG with one layer of buttressing material in the stapled line between December 2009 to December 2011 and who were followed for specific protocols results. Results There where 180 patients. Male: 26 patients, Female: 154 patients. Mean Age 38 (range 15 to 70) years. Mean Preoperative Weight: 98.3±15 (68-170) kg. Mean Preoperative BMI: 36 ±4.1 (range 30 to 61) Kg/m2. Mean Excess Weight: 30.6±12.3 (range 12.7 to 95) kg. Mean OR Time 60.7±20.2 (45 to 150) min. %EBMIL mean was 70.1±24.2 (range 26.1 to 134.4)% at 6 months. Morbidity: 2 patients (3.8 %). No reoperations, No bleeding, No leaks, 1 conversions for splenic trauma, 2 portal vein thrombosis that did not required reoperation. No mortality Conclusions SG is a safe and effective treatment for obesity. The staple line reinforced with one layer of buttressing material may diminish the rate of bleeding and leaks and may be less time consuming. O049 Gastric and Intestinal Motility in Lean Individuals and Obese Patients Before and After Sleeve Gastrectomy Presenter: Leventi Aikaterini Co-authors: Leventi Aikaterni *,Perisynakis Kostas ***, Klinaki Ifigeneia **, Koukouraki Sofia**, Charalampakis Vasileios*, Karkavitsas Nikolaos **, Melissas John* *Bariatric Unit and Department of Surgical Oncology ** Departments of Nuclear Medicine and *** Medical Physics, Institution : University Hospital of Heraklion, Faculty of Medicine, University of Crete, Greece Objective To investigate differences in gastrointestinal motility among lean and obese subjects and study changes after bariatric surgery. Design 21 morbidly obese patients and 10 lean controls were examined after consumption of a semisolid radio labelled meal. The obese group was reanalysed 4 months post laparoscopic sleeve gastrectomy (LSG). Gastrointestinal motility parameters were recorded with a gamma camera and their differences compared among the groups. Results Gastric emptying is faster in obese compared to lean subjects (Tlag 15.5 vs 18.4 min) but there are no other statistically significant differences. Contrary significant alterations occurred postoperatively in the obese group compared to the preoperative state, with further acceleration of gastric emptying (8.4 vs 15.5 min), intestinal filling (110 vs 141.5 min) and small bowel transit time (62.6 vs 71.8 min), causing earlier meal arrival to terminal ileum. Simultaneously, significant delay in initiation of cecal filling (210 vs 182 min) and ileocecal valve transit (126 vs 102 min) were noted postoperatively. Conclusions Among motility parameters, only gastric emptying was found to be significantly faster in obese comparing to lean group. LSG led to substantial weight loss and simultaneously caused a contradictory altered motility profile: although the entry and passage from the small intestine was faster, a delay occurred in the area of the terminal ileum. This finding can account not only for the weight loss but also for the improved metabolic profile following the operation and can attribute to this area a key role for the understanding of obesity and the metabolic disorders associated with it. O050 Wernickes Encephalopathy Presentation After Laparoscopic Sleeve Gastrectomy Presenter: Lal Pawanindra Co-authors: Chander J, Hadke N S, Vindal A, Kiran S, Shrivastava N. Institution: Maulana Azad Medical Collge, New Delhi, India We report a case of wernickes encephalopathy in a morbidly obese patient after laparoscopic sleeve gastrectomy which was diagnosed in early stages without cognitive impairment and was a result of noncompliant diet practices and recurrent vomiting. In this patient thiamine deficiency became clinically evident 6 months after the procedure. After intense thiamine replacement therapy clinical improvement was noticed

OBES SURG (2012) 22:1315–1419 within hours of administration of thiamine. Wernickes syndrome should be kept in mind in every post operative patient undergoing laparoscopic sleeve gastrectomy particularly with recurrent vomiting and any neurological complaints. Early diagnosis and treatment remains the only way to prevent this permanent neurological damage. O051 Surgical Treatment of Chronic Gastric Fistulas after Sleeve Gastrectomy Presenter: Miguel F Herrera Co-authors: Hugo Sanchez, Guillermo Dominguez, Juan Pablo Pantoja, Maureen Mosti Institution: ABC Medical Center, Mexico, USA Background Sleeve gastrectomy (SG) is a bariatric procedure with increasing acceptance. Among the surgical complications of SG, gastric leaks represent a particular challenge. They may be refractory to conservative and endoscopic management and become a persistent problem. Aim To analyze the surgical management and outcome of patients with intractable fistulas after SG Methods From our prospectively collected database, demographics, presurgical management, surgical treatment and outcome of 5 patients who were referred to our center with chronic fistulas after SG were analyzed. Results There were 4 females and 1 male with a mean age of 42.4 years. All patients had been treated with several surgical and non-surgical maneuvers. In four patients open total gastrectomy with Roux-en-Y esophagojejunostomy was performed and in one patient a Roux-en-Y Gastric Bypass (RYGB) was performed laparoscopically. One patient required management in the ICU for 2 days. Two patients developed wound infection and 1 patient had a gastric leak in the remnant stomach that resolved spontaneously. All patients were able to tolerate soft diet at discharge with a main hospital stay of 9.8 days (5-21). In the long-term follow up 2 patients have developed small bowel obstruction due to surgical adhesions that have required surgery. Conclusion Total gastrectomy or conversion to a RYGB may be needed to treat chronic gastric fistulas after SG. They are challenging procedures. O052 Laparoscopic Sleeve Gastrectomy. Initial Single Centre Australian Experience Presenter: William Braun Co-authors: Maree Kekeff, Donna Tancheva, Candice Silverman and Laurent Layani John Flynn Private Hospital, Australia LSG has become popular as both definitive and revisional bariatric operation in morbidly obese. Our aim was to investigate safety and efficacy of LSG in both weight loss and remission of comorbidities We conducted retrospective and prospective analysis of LSG performed from 1 January 2008 to 1 April 2011. We also interviewed the patients in order to establish their overall satisfaction with the program 268 patients underwent LSG. Male to female distribution was 1:1.4. Median age and BMI were 48 (21-76), and 53 (35.5 – 89) respectively. 61 operations were staged procedures following failed LGB (58) and open stapled gastroplasty (3). Mean operative time was 81 min (38 142). There was no mortality. Postoperative complications included gastric leak (1), stricture (1), bleeding (1), wound infection (4) and prolonged nausea (1). Median LOS was 2 (1-61 days). Follow-up was achieved in 259 patients (97 %). Mean EWL were 77 % (23 - 100) for primary and 38 % (16-79) for revisional LSG. Relief of comorbidities was overwhelming. 252 (94 %) patients participated in phone interviews. 250 (99 %) were absolutely satisfied with their weight loss and service provided In competent hands, LSG is safe, simple and efficacious. It achieves excellent results in weight loss and sustainable mid-term improvement in patients’ health overall. Stand-alone LSG consistently produced good EWL in moderate term follow up. Revisional operation is less satisfactory. Serious complications are rare, but extremely difficult to manage both clinically and psychologically

OBES SURG (2012) 22:1315–1419 LSG laparoscopic sleeve gastrectomy, LGB laparoscopic gastric banding, LOS length of stay, EWL excess weight loss O053 Nutritional Experience in Bariatric Surgery Egyptian Patients Presenter: Randa Reda Mabrouk* Co-authors: Alaa Abbass Moustafa** Faculty of Medicine, Ain Shams University, Cairo, Egypt Introduction In Egypt, nutritional difficulties & malnutrition in bariatric surgery patients do not only depend on the selected procedures but also on other factors. In this study we aimed to assess the weight loss, nutritional deficiencies & difficulties in post bariatric surgery patients & to determine the affecting factors. Methods This retrospective study (1997-2012) included 3500 patients, 2500 underwent restrictive procedures & 1000 underwent bypass. Preoperative data of the patients included weight, BMI, age, sex, socioeconomic class, nutritional deficiencies & behavior. In each postoperative follow up visit, the EWL was measured & patients were interrogated for the incidence of food intolerance, vomiting & dumping. Malnutrition was also monitored according to the clinical symptoms & if needed, laboratory investigations were performed. Patients were advised to follow up for a period of not less than three years. Results The type of performed procedures depended on age, sex, & socioeconomic class. EWL, dumping & vomiting were more associated with socio- economic class & non adherence to nutritional guidelines. Yet vomiting, dumping, & nutritional intolerance are more affected by type of procedure. Reported nutritional deficiencies included thiamin, more with vomiting &increased carbohydrate intake. Iron deficiencies were more affected by age, sex &preoperative deficiency. Protein & Vitamin B12 malnutrition were correlated to the bypass &non adherence to the protein intake. Conclusion Nutritional difficulties & deficiencies can be minimized after bariatric surgery if the determining factors are put into consideration in the pre & postoperative care. A notable side O054 Laparoscopic Management of Acute Intestinal Obstruction Due to an Unusual Cause After Roux -En -Y Gastric Bypass Presenter: Sandeep Aggarwal Co-authors: Akshat Wahal, Santosh Anand, Mahesh C Misra, Richa Jaiswal, Lokesh Kashyap All India Institute of Medical Sciences (AIIMS), New Delhi, India Abstract text A 35-year-old female with BMI 48 and type II diabetes mellitus underwent an uneventful Laparoscopic Roux-En-Y Gastric Bypass (LRYGBP) in June 2011. Five months later she presented with pain abdomen, distension and vomitings of 4 days duration. At presentation she looked sick and dehydrated. She was hemodynamically stable. Abdominal examination revealed fullness in upper abdomen suggestive of dilated remnant stomach. A plain X-ray abdomen showed dilated remnant stomach and small bowel loops. A contrast-enhanced computed tomography (CECT) scan suggested small bowel obstruction (SBO) with hugely dilated stomach. There was no suggestion of internal herniation. After resuscitation with intravenous fluids, the patient was taken up for surgery. Access to the peritoneal cavity was obtained by using optical trocar using zero degree telescope in the supra-umbilical position. After initial adhesiolysis, a grossly dilated remnant stomach was found. A 5 mm long trocar was inserted into the dilated stomach to decompress it. More than a litre of bilious fluid was aspirated. Following this, both the alimentary and bilio-pancreatic limbs were traced to the site of jejuno-jejunostomy (JJ) which was found densely adhered to the anterior abdominal wall. Distal to the JJ, the small bowel appeared collapsed. Using careful sharp dissection, the JJ limb was brought down. There was no internal hernia. However, there was an acute angulation of small bowel due to an adhesive band between the proximal part of common limb and loop just distal to it. The division of band resulted in release of the kinked bowel and the obstruction was relieved. During this process, there was a minor enterotomy in the kinked distal bowel which was closed using sutures. A gastrostomy was done by using a Ryle’s tube through

1327 the 5 mm trocar inserted in remnant stomach. A drain was placed near the site of gastrostomy.Post-operatively patient recovered well and was discharged one week after surgery with the gastrostomy tube in situ. The gastrostomy was subsequently removed 3- weeks later. The patient is doing well at 4 months of follow-up. Incidence of SBO after LRYGBP is reported to be 1.5 %-5 %. It is a serious complication resulting in significant morbidity and mortality if not treated on time. The common causes include internal herniation, narrow anastomosis at JJ, kinking of bowel and adhesive bands. In the present case the adhesive band was possibly a result of a reaction due to a non-absorbable suture used at jejuno-jejunostomy. O055 Medium-Term Results of Laparoscopic Sleeve Gastrectomy: A Comparison with Laparoscopic Adjustable Gastric Banding and Laparoscopic Mini-gastric Bypass Presenter:Kong-Han Ser, M.D.1, Co-authors: Cheng-Chieh Chang, MD1, Wei-Jei Lee, M.D., PH.D.1, Shu-Chun Chen, RN2,Yi-Chih Lee, PH.D 3, Jung-Chien Chen, MD1 Institution : 1Department of Surgery, Min-Sheng General Hospital,Taiwan 2 Department of Nursing, Min-Sheng General Hospital,Taiwan 3 Department of International Business, Ching Yun University, Taiwan Purpose Laparoscopic sleeve gastrectomy (LSG) has recently become a feasible option in the management of morbid obesity. This retrospective study evaluated medium-term weight loss, resolution of comorbidities, and quality of life after LSG in Taiwanese cases of morbid obesity. Materials and Methods In the period between December 2005 and June 2008, 81 patients underwent LSG as bariatric operation in Min-Sheng General Hospital were reviewed. The demographics, resolution of comorbidities, percentage of excess weight loss (EWL), quality of life, and complications were collected prospectively for evaluation. To determine the efficacy of LSG, we compared the 3-year result of LSG , laparoscopic mini-gastric bypass (LMGB) , and laparoscopic adjustable gastric banding (LAGB) Results A total of 56 patients were eligible for 3-year follow-up evaluation, a follow-up rate of 69 %. Their mean initial body mass index (BMI) was 36.9± 7.5 kg/m2. The mean BMI decreased to 25.8±5.1 kg/m2(30 % reduction) 3 years after LSG. Resolution rates of comorbidities followed up for 3 years were 71.4 % for type 2 diabetes, 75 % for hypertension, 79.2 % for hyperlipidemia, and 95.5 % for hyperuremia. The major complication rate was 5.4 % (3 of 56), higher than LAGB (0 %) but similar to LMGB (4.5 %). LSG had significantly better excess weightloss than LABG (77.6 % versus37.3 % , p< 0.05) but there was no significantly different between LSG and LMGB group at 3 years (77.6 % versus 80.8 % , p : 0.778). Conclusion In this medium-term report, LSG can be an effective treatment to achieve significant weight loss and resolution of comorbidities in morbid obese Asian . Both LSG and LMGB have similar effective for morbid obesity with similar results for weight loss after 3 years follow-up. O056 Stapling and Section of Nasogastric Tube During Sleeve Gastrectomy Presenter:Dr.Shivaram HV, Dr.Arun Kumar, Dr Mahesh Channappa Columbia Asia Hospitals, Bangalore, India During laparoscopic sleeve gastrectomy most bariatric surgeons insert a nasogastric tube to decompress the stomach. Nasogastric /oral tube complications can occur during laparoscopic sleeve gastrectomy, but are seldom reported. Treatment options are dependent upon the situation. We report a case of 24 year old male patient of BMI 52 with diabetes mellitus whose nasogastric tube got stapled and transected in two areas during sleeve gastrectomy. The video presentation shows how it was detected during the surgery and managed. On table gastroscopy was performed to localize stapling; the tube was retrieved cutting the staple line and again the defect in stomach was re-stapled. Intra-op and post- op leak tests showed no leak. This patient had an uneventful recovery and is doing well 4 months since this procedure. Every bariatric surgeon should have strategies to prevent such complications. After this incident we have stopped using nasogastric tube to

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decompress the stomach. Gastric calibration tube is inserted early which serves both purposes of decompression and calibration. Constant communication and co-operation of the anesthesiologist is also of paramount importance.

Conclusion All three types of bariatric surgery are safe and effective. Though the long term excess weight loss and resolution of comorbities was maximum in the laparoscopic roux-en-y bypass group, the operating time, hospital stay and complications were slightly higher in this group.

O057 BPD with and Without DS Stops the Progressive Deterioration of Beta-Cells in Patients With Overt Type 2 Diabetes

O059 Esessophageal Bougie Perforation During Sleeve Gastrectomy Managed by Endoscopic Stenting and Subsequent Gastric Bypass

Presenter: Michael Frenken Co-authors: Cho Eun-Young, Kemmet Olga

Presenter: Dr. Davit Sargsyan Co-authors: Moataz Bashah, Mohammed Al Kuwari, Mohammed Rizwan

University of Heidelberg, Germany Background BPD/BPD-DS induce durable remission of T2DM. Is the evolution of progressive deterioration of -cells influenced by the operation? Methods We partitioned our patient population according to the mode of therapy and duration of insulin treatment and determined the complete remission rate for each group. Follow-up was up to 6 years (mean 3.3 years). All relapses of T2DM were detected. Follow-up time was added to the duration of therapy and remission rates were redetermined. Results n0105 patients with advanced T2DM underwent a BPD/BPD-DS. Mean age was 51 years, mean BMI 47 kg/m2. Complete remission rates for patients using oral antidiabetic drugs was 100 % (n 018), for patients using insulin for up to 3, 6, 9, 12, 15 or over 15 years were 92 % (n024), 95 % (n021), 64 % (n 011), 50 % (n016), 50 % (n 04) and 25 % (n04), respectively. Relapse of T2DM was found in 4 patients with slight increase of HbA1c (less than 7 %) without therapy. After adding the follow-up time to the duration of insulin therapy remission rates were recalculated. In patients with insulin treatment less or more than 9 years remission rates were 90 % and 46 % (true values) and 88 % and 55 % (calculated values) (n.s.). Conclusions Unlike after Roux-en-Y gastric bypass, where re-emergence rates of T2DM of 37 % to 43 % after 3 to 5 years have been published, we found only a 4 % relapse rate of T2DM after BPD/BPD-DS. Our analysis of remission rates as a function of mode and duration of diabetes treatment is consistent with the concept of unstressing -cells after surgery. O058 An Audit of 307 Patients Undergone Bariatric Surgery in A Rural Centre in India Presenter: Dr. Mohamed Ismail (1) Co-authors: Dr.Sreejth Nair (2) Dr.NM Mujeeb Rahman Rajagopal (4) Dr.Mohammed Shareef (5) Dr.Hafees Ansari (6)

(3)

Department of General Surgery, Hamad General Hospital, Doha, State of Qatar A 42 year old lady with BMI of 42 kg/m2 without co morbidities underwent laparoscopic sleeve gastrectomy in other facility during which she sustained incidental injury of lower thoracic esophagus by bougie insertion, which went undiagnosed. On postop day 5, she underwent left thoracotomy, esophageal perforation repair and drainage. She continued to show signs of esophageal leak and 3 days later underwent endoscopic esophageal clipping which also failed. She became septic and was transferred to our facility 20 days postop, with signs of mediastinitis and septic shock. A gastrografin study showed distal esophageal leak into the mediastinum and retroperitoneal space. She underwent coated stents insertion placed in distal esophagus and sleeved stomach covering a distal stenosis. A feeding jejunostomy was fashioned laparoscopically. Over subsequent weeks, she recovered from sepsis and resumed an oral diet, but later on developed persistent vomiting, even with fluids. She underwent barium swallow which showed distal stenosis of the sleeved stomach. So a decision was taken to convert the sleeve gastrectomy to a Rouxen-Y gastric bypass two months after stenting. Stents were removed and hand sewn conversion of gastric sleeve to Roux-en-Y gastric bypass was performed. Her postoperative course was uneventful. She resumed oral fluid diet on postop day 2 and was discharged on postop day 5. Educational points: Any type of esophageal repairs (surgical or endoscopic) should be attempted if perforation is detected within 24 hours, perforations detected later must be managed with coated stents. Conversion to RYGB is an effective solution for post sleeve distal stenosis.

Dr.Mahesh O060 Oesophago Bronchial Fistula – an Unusual Complication Following Sleeve Ressection

1

Chief Surgeon, Moulana Hospital Perinthalmanna, Kerala, Asst. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna,Kerala, India 2,4,5,6 Consultant Surgeons, Dept. of GI, Bariatric & metabolic Surgery, Moulana Hospital, Perinthalmanna, Kerala 3 Asso. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna, Kerala, India

Ojective To review our results of laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, and laparoscopic gastric bypass for the treatment of morbid obesity Materials and Methods It was a prospective cohort study in which the 307 patients who had undergone bariatric surgery (laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, and laparoscopic gastric bypass) during the period January 2006 to April 2012 were followed up at 1 month,6 months,1 year and 2 years interval. The various parameters studied included weight loss, excess weight loss, percentage excess weight loss, resolution of comorbidities like diabetes mellitus, hypertension, sleep apnoea etc. Also studied were the operating time, hospital stay, complications- perioperative and delayed and the mortality. Results The percentage excess weight loss was 74.6 % in the laparoscopic roux-en-y bypass group but was 62,9 % in the laparoscopic sleeve gastrectomy group. The resolution of diabetes mellitus was 72.7 % in the laparoscopic roux-en-y bypass group but 66.6 % in the laparoscopic sleeve gastrectomy group. However the LRGB group had perioperative complications like bleeding from the remnant stomach and anastomotic leak and delayed complication presenting as a case of intestinal obstruction. There were two delayed mortalities as a result of DVT.

Presenter: Dr Abhay Agrawal Co-author: Dr Jugal B Agrawal SevenHills Hospital, Asian Heart Institute, Mumbai, India A young morbidly obese female who underwent Sleeve Gastrectomy presented with an early leak. Management of leak resulted into an unusual complication in the form of Oesophago- Bronchial Fistula. The various techniques of demonstrating the fistula and management of fistula will be presented O061 Lap Band in Patients with bmi
OBES SURG (2012) 22:1315–1419 preoperative weight 91,5 Kg). 30 days mortality, intraoperative complications and laparoscopic conversion were absent. Follow up is completed in 95,4 % of the patients. Comorbidities were present in 40 % of the patients (mainly arterial hypertension 21,6 %, hiatal hernia with reflux 24,3 %, diabetes mellitus in 16 %), and were resolved in 64,8 %, improved in 20,6 % and unchanged in 14,6 %. Complications happen in 19.5 % of the patients (reflux in 6 patients solved with deflation of the band, 2 with pouch dilatation, two with band intolerance, five deconexion of the gastric tube from the port, one colelitiasis and one intragastric migration). Mean BMI was 30, 28.3, 27.5, 26.9, 26, 26.4, 26.2 at 3, 6, 9, 12, 24, 36, 48 and 60 months. At the same follow-up period the mean %EWL was 32, 48.5, 56.7, 61.6, 67.8, 65.7, 67.8 and 68.6 Conclusion LAGB with Lap Band® in patients with
1329 of SILS Gastric bypass is comparable with laparoscopic technique with cosmetic superiority, more but no significant increase in errors, and similar outcome for weight loss & metabolic resolution. However there is a significant increase in operating time. Conclusion SILS is all set to replace laparoscopis sleeve gastrectomy. With thepossibility of more instruments to come, gastric bypass can be safer than the presentscenario. However long term multi-centric studies are required to prove theiradvantages over conventional laparoscopy. O064 Ergonomic Modifications for Single Incision Bariatric Surgery Presenter: Dr. Rajkumar Palaniappan Department of Minimal Access & Bariatric Surgery, Apollo Hospitals, Chennai, India Abstract: Introduction Single Incision Laparoscopic Surgery (SILS), though has become apopular alternative to conventional laparoscopy, feasibility of various procedures aretried worldwide in multiple centers and the ergonomics are modified accordingly. Study With study on more than 71 successful bariatric surgeries , we devised apractical solution to this persistent issue to aid reduction in operating time & errors. Results Port placement-Dominamt hand port positioning at 2’0 clock and telescopic portat 7’0 clock gives the best azimuth angle of around 20o. Non-dominant hand port is positioned at 10’0 clock to give the best use for graspers. Low profile ports should be introduced at various depths. Use of long length conventional instruments & sealing devices in dominant hand and roticulating or pre-bent instrument in non-dominant hand gives the best ergonomic alternative to conventional laparoscopy. Traction techniques-Numerous innovative techniques are available for liver traction. However the novel “hiatal sling’ technique by the Co-Author is very promising with adequatetraction on liver in the least possible operating time. Bowel traction is best done by percutaneous needle loop technique. Suturing Gelpoint or multiport technique suits best for intracorporeal suturing technique where as endostitch serves best for other single incision port systems. Conclusion Poor ergonomic & traction devices makes SILS more challenging. The modifications proposed by the Co-Author aids in best ergonomic alteration to get the best of conventional laparoscopic port placement for optimal performance. However further instrument designs needs to be introduced to make this technique more reproducible. O065 The Effect of Laparoscopic Adjustable Gastric Banding and Impact of Initial Body Mass Index on Weight Loss Among Obese Adults at a Private Tertiary Hospital in the Philippines: a Retrospective Study Presenter: Teodora Amor Evora, MD*, Co-authors: Edward Oliveros, MD**, Hildegardes Dineros, MD**, Roberto Mirasol, MD* *Section of Endocrinology and Metabolism, Department of Internal Medicine; ** Department of Surgery, St. Luke’s Medical Center-Quezon City Institution: St. Luke’s Medical Center, Philippines

Apollo Hospitals, Chennai, India Introduction Single Incision Laparoscopic Surgery (SILS) tipped as the next generationof laparoscopic surgery and has gained immense popularity grabbing the attention of surgeons and patients alike all over the world. SILS has its limitations like ergonomic problems, poor traction possibilities, paucity of instruments making the procedure technically difficult and more time consuming and carries a learning curve. Study: We present our initial experience with 71 cases in our center since October 2009 following the same principles as in laparoscopic technique. A total of 60consecutive sleeve gastrectomies and 11 selective gastric bypass were done since October 2009. Results The early results in our center are very promising and proved feasible, safe andbeneficial in all cases. There is no increase in error, no visible scar, similar operating time, less pain and early recovery with similar outcome with weight loss seen in sleeve gastrectomy. Though more demanding, the results

Objective To determine the effect of laparoscopic adjustable gastric banding on weight loss and the association between initial body mass index (BMI) and successful weight loss among obese adults at a private tertiary hospital in the Philippines. Methods We retrospectively reviewed data for 97 patients who were at least 18 years old at the time of gastric banding and had at least one weight measurement during the follow-up period. We stratified the percentage of excess weight loss (%EWL) within one year and two years according to BMI and age groups. Analysis of variance and chi-square or Fischer’s exact test were used for analysis. Logistic regression was done to determine independent association between lower BMI and %EWL >50 % after gastric banding. Results Majority of the patients were female (61 %) and Filipino (77 %). Their ages ranged from 18 to 68 (mean 36.1 years±12.2). The mean BMI was 44.1±0.1 kg/m2 and mean excess weight was 61.4±26.5 kg. Follow-up data are available in 98 % (90/97) of patients at 3 ±3 months, 68 % (66/97) at

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1 year±6 months and 26 % (25/97) at 2 years±6 months. Greatest %EWL (43.84±25.09 %) and BMI reduction (21.54±13.39 %) were attained at two years. BMI <43.4 kg/m2 was independently associated with successful weight loss one year after gastric banding (p00.0238). Conclusion Patients attained 43.84 % EWL two years after gastric banding. Those with BMI <43.4 kg/m2 were more likely to achieve successful weight loss one year after gastric banding. Keywords: Laparoscopic adjustable gastric banding, bariatric surgery, obesity, weight loss, O066 To Assess the Effectiveness of Ileal interposition in the Management of Type II Diabetes Mellitus in Patients with BMI <35 Presenter: Dr. Mohamed Ismail (1) Co-authors: Dr.Sreejth Nair (2) Dr.NM Mujeeb Rahman Rajagopal (4) Dr.Mohammed Shareef (5) Dr.Hafees Ansari (6);

(3)

Dr.Mahesh

(1)

Chief Surgeon, Moulana Hospital Perinthalmanna, Kerala, Asst. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna,Kerala;(2,4,5,6) Consultant Surgeons, Dept. of GI, Bariatric & metabolic Surgery, Moulana Hospital, Perinthalmanna, Kerala;(3) Asso. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna, Kerala

Background Type 2 diabetes mellitus (T2DM) is a common disease with numerous complications. Bariatric surgery is an efficient procedure for controlling T2DM in morbidly obese patients. In T2DM, the incretin effect is either greatly impaired or absent. This study aimed to evaluate the preliminary results from interposing a segment of ileum into the proximal jejunum associated with a sleeve or diverted sleeve gastrectomy to control T2DM in patients with a body mass index (BMI) less than 35 kg/m2 Methods For this study, 16 patients (7 women and 9 men) underwent either of the two laparoscopic procedures-Laparoscopic Fundectomy with Standard ileal interposition or Laparoscopic Fundectomy with Diverted ileal interposition,The mean age of these patients was 44. 5 years (range, 26-63 years). The mean BMI was 28.68 kg/m2 (range, 22-34.9 kg/m2). All the patients had a diagnosis of T2DM that had persisted for at least 2 years and evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months. The mean duration of T2DM was 8.9 years (range, 221 years).The trial was registered at the national clinical trial registry of India (CTRI/2010/091/002938). The patients were selected for the surgery after preoperative special investigations like serum C-peptide, serum Insulin, Antiislet cell antibody, Anti GADA antibody, HbA1c.Only patients with BMI<35 were included in the study. Results The mean operative time was 270 min, and the median hospital stay was 6.5 days. The mean postoperative follow-up period was 7 months (range, 4-16 months), and the mean percentage of weight loss was 12 %. Eight patients (50 %) were off diabetic medications, four patients (25 %) were on decreased dose of insulin, three patients(18.75 %) were on oral hypoglycemic agents and in one patient (6.25 %) there was no response to treatment Conclusions The laparoscopic fundectomy with standard or diverted ileal interposition seems to be a promising procedure for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed. O067 Antecolic Versus Retrocolic Bypass Surgery in Obesity. A Systematic Review and Meta-Analysis of the Literature

reviewers. Comparative studies (randomised and non-randomised control trials) of antecolic and retrocolic gastric bypass surgery for obesity were included. Individual case series of antecolic and retrocolic techniques were also identified and assessed. Data Extraction Data was extracted by two independent investigators. Disagreements were resolved by a third Co-Author. Inclusion and exclusion criteria were clearly outlined in advance. Outcomes of interest included technical operative endpoints and post-operative complications. Results A total of 12 studies including one RCT were identified. Metaanalysis demonstrated a significant reduction in post-operative small bowel obstruction associated with the antecolic technique (RR 0.33, 95 % CI 0.23 – 0.47, fixed effects analysis). Incidence of internal herniation was also significantly reduced in the antecolic patient groups (RR 0.55, 95%CI 0.37 – 0.81, fixed effects analysis), as was overall operative time (WMD -16.39 minutes, 95%CI -22.25 to -10.53, fixed effects analysis). Conclusion This study suggests that antecolic bypass surgery is associated with a reduction in postoperative small bowel obstruction and faster operative times. Large randomized controlled trials are required to investigate this relationship further. O068 The Laparoscopic Sleeve Gastrectomy for Morbid Obesity: Five Years Experience from an Asian Centre of Excellence Presenter: Sanoop K Zachariah Co-authors: Jason Yiu Kin Wat; Andrea Ooi, Po-Chih Chang; Ming-Che Hsin; Chi Kun Huang Bariatric & Metabolic International (B.M.I) Surgery Center, E-Da Hospital, Taiwan Background Laparoscopic sleeve gastrectomy is emerging as a popular ‘stand alone’ bariatric procedure. We report our five years experience with laparoscopic sleeve gastrectomy as a single stage bariatric procedure with a view to study the technical progress; learning curve; complications and follow up results. Methods Prospectively collected data of 228 patients (145 females and 83 males), who underwent laparoscopic sleeve gastrectomy for morbid obesity,from February 2007 to March 2012, was retrospectively analyzed. Results The mean age was 34.68 (range: 18-62) years and the mean preoperative body mass index was 37.42 ±4.75 (range 32.08 -65.69) kg/m2. Mean operative time was 60.63 ±27.37 minutes. The mean BMI decreased to 26.15±3.71 kg/m2 at 3 years (p<.001) and to 27.94 ±4.08 kg/m2at 5 years (p<.001). Mean percentage excess weight loss was 71.96±21.30 % at 3 years and 63.71±20.08 % at 5 years. The 30-day readmission rate was 3.07 %.The overall complication rate was 4.3 %, including strictures, leaks, peritonitis, gastro-cutaneous fistula and one (0.43 %) mortality. One patient with weight re-gain and another with stricture underwent conversion to Roux-en-y-gastric bypass. Complication rates significantly decreased after the first 50 cases (p0.022) suggesting an initial learning curve.Resolution ofdiabetes, hypertension, and hyperlipidemia was 66.67 %; 100 %, and 50 % respectively at 5 years. Conclusion Laparoscopic sleeve gastrectomy as a single stage bariatric procedure, is safe and durable, achieving weight loss and resolution of comorbidities upto 5 years. Adherence to technical details is pivotal in reducing complications associated with the initial learning phase. O069 Do We Really Need to Close Internal Hernia Spaces?

Presenter: Nehme J Co-authors: Chow A, Lo M, Hakky S, Ahmed A, Purkayastha S

Presenter: Ahmed Ahmed Co-authors: Thorrmela Vijayaseelan

Imperial College London., Charring Cross Hospital, United Kingdom Imperial College Healthcare NHS Trust, United Kingdom Aim The most commonly preformed operation for obesity is the Roux-en Y gastric bypass. There are two principle variations of this procedure, antecolic and retrocolic, depending on the Roux Limb orientation.The aim of this study is to compare clinical and technical outcomes between retrocolic and antecolic gastric bypass procedures. Methods An electronic search of PubMed, MEDLINE, Ovid, Embase and Google Scholar was performed utilizing keywords agreed in consensus by all Co-Authors. Relevant articles were assessed by two independent

Background Internal hernia (IH) is a known complication after gastric bypass. This study describes our experience with using an antecolic antegastric Roux limb without division of mesentery and without closure of IH defects and its effect on the incidence of IH. Method A retrospective chart review was performed of all patients undergoing a standard antecolic antegastric technique without division of mesentery and without closure of IH spaces (AA-LRYGB) between

OBES SURG (2012) 22:1315–1419 January 2008 and June 2010. Furthermore, a comparison was made in IH rates with a historical sample of retrocolic retrogastric LRYGB with mesenteric division and IH defect closure. Results Two internal hernias occurred in 212 patients followed up for 25 months (13-35 months), an incidence of 0.9 %.The site of internal hernia was at Petersen’s defect for one patient and at the jejuno-jejunostomy for the other. The mean time to intervention for an internal hernia repair was 355 days and average % excess body weight loss (%EBWL) in this period was 78 %. The historical retrocolic retrogastric group with mesentery division and IH defect closure, had IH in 52 cases (23 transverse mesocolon, 22 jejunojejunostomy, 7 Petersen’s defect) out of 2215 patients, an incidence of 2.4 %. Conclusion The results of this study demonstrate that in our hands using an antecolic antegastric approach without division of small bowel mesentery and closure of IH spaces, the incidence of internal hernia is less than the incidence seen when we routinely closed all internal hernia defects in the retrocolic retrogastric LRYGB. O070 Randomized Control Trials in Bariatric Surgery Wei-Jei Lee MD&PhD Depart. Of Surg. Min-Sheng General Hospital,National Taiwan University, Taiwan Background There was still lack of comprehensive review of level 1 evidence in obesity surgery, so we reviewed the literature for randomized controlled trials (RCTs) over the past 40 years in this field. Methods All RCTs from January 1972 to 2011 December published in the English literature were identified through a literature search engine using PubMed (www.pubmed.com). The search term used as bariatric surgery OR obesity surgery OR weight reducing surgery. Basic science and anesthesia-related pain management were excluded. The extracted trials were divided into four groups, as different intervention comparison, intraoperative surgical techniques, preoperative evaluation and postoperative care. Results The search criteria produced 753 manuscripts, of which 168 met eligibility criteria. Among 168 papers, 32 % was related to different intervention comparison, 48 % intraoperative surgical techniques, 18 % postoperative care and 2 % preoperative evaluation. There were 47 different journals of publication, which with Obesity Surgery (28.6 %) being most common followed by Annals of Surgery (11.9 %). Trials originated in 25 different countries led by United States (35.1 %). There was a generally progressive increase in published trials from 1972 to 2011 and 119 RCTs(70.8 %) were published in recent 10 years. Conclusions A trend of increasing RCTs was found in bariatric surgery. Although data from large, adequately powered, long-term RCTs are still lacking, any surgical intervention appears substantially more effective than medical care for the treatment of morbid obesity. O071 Standard Versus Banded Micro-Pouch Roux-en-YGastric Bypass: Long Term Results Presenter: Khaled Gawdat Co-authors: Ahmed Osman, Basem Al-Shayeb Institution: Department of Surgery, Ain-Shams School of Medicine, Cairo, Egypt Background There are many variables involved in performing Roux-en-Y gastric bypass. as the pouch size, stoma size, limb lengths involved. Varying combinations of these give different weight loss results and change eventual outcomes. The Fobi-Capella modification of the Roux-en-Y gastric bypass entails placing a prosthetic band around the gastric pouch to limit the pouch dilatation and improve weight loss results. The Sapala- Wood micro-pouch gastric bypass forms a very small pouch and adds a very long alimentary limb. Aim of work: A prospective study comparing two anatomically identical Rouxen-Y procedures in terms of pouch, stoma size and alimentary limb length with the only difference is the placement of a Fobi-Capella band around the gastric pouch. Materials and Methods From March 2000 to March 2004 294 patients had a laparoscopic Roux-en Y procedure , follow up ranged between 8 to

1331 12 years. All patients had identical gastric pouch size (Sapala -Wood micro-pouch) and similar gastro-jejunostomy size and had a 120 cm alimentary limb length. In Group I patients (97) the gastric pouch was not banded while in Group II patients (197) the gastric pouch was banded using an identical size pre-tied prolene mesh. The two groups were compared in terms of early and late complications, weight loss and food tolerance. Results The 2 groups had similar early & late complications rate except for band erosions (2 %) for group II patients. Group II showed better short and long term weight loss with 61 % EBWL for group I at 36 months compared to 89 % EBWL for group II. At 60 months group I showed 59 % EBWL compared to 82 % for group II. At 10 years group I patients showed 43 % EBWL compared to 74 % EBWL for group II. Group I patients had less vomiting and food intolerance. Conclusion Laparoscopic Banded Micropouch Roux-en-Y gastric bypass gives superior and more durable weight loss than the non-banded gastric bypass both in the short and long term. And that weight loss justifies its use despite the higher late complications and food intolerance rates. O072 Primary Gastric Bypass has Superior Outcome Compared to Revision Bypass Surgery Presenter: Vittal Rao Co-author: Rupa Sarkar,Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castel Hill Hospital, Cottingham, Hull, United Kingdom Introduction Revisional bariatric surgery is on the increase due to exponential growth of bariatric surgery over the last decade. We report the outcome of revisional bariatric surgery in a high volume centre. Methods A retrospective database review of patients who underwent revisional (RLRYGB) and primary gastric bypass (LRYGB) for morbid obesity was undertaken. Demographic profile and outcome (mean percentage excess body weight loss: %EBWL) was analysed. A general linear model using Wald chi square test was used for statistical analysis. Results 43 patients underwent RLRYGB (10 post vertical band gastroplasty; 33 post laparoscopic gastric band) and were compared with 700 patients who underwent LRYGB. Both patient groups were comparable demographically. Pre-op mean BMI (RLRYGB: 46; LRYGB:48) and mean excess body weight (EBW in Kg; RLRYGB:61; LRYGB:72) was recorded. Mean %EBWL at mean follow up (RLRYGB: 46 % at 26 months; LRYGB: 60 % 23 months) was analysed. The patients who underwent LRYGB had significantly higher %EBWL at last follow-up than patients who had RLRYGB (p<0.001). Pre op EBW was a statistically significant covariate, the higher the pre op EBW , the lower the %EBWL (p< 0.001). Conclusion Primary gastric bypass surgery should be offered at the first instance as outcome following revisional surgery is inferior to primary surgery in terms of %EBWL with obvious implications to improvement in quality of life and resolution of co morbidities. O073 Gastric Bypass is Associated with Rapid fall in BMI to Below 40 Even in Super Obese Patients Presenter: Vittal Rao Co-author: Rupa Sarkar,Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castel Hill Hospital, Cottingham, Hull, United Kingdom Introduction There is lack of consensus regarding the surgical procedure most suitable for super obese patients (BMI>50). We report a single centre experience of the efficacy of three common bariatric procedures in this category of extremely obese patients. Methods A retrospective database review of super obese patients who underwent bariatric surgery was undertaken. Type of surgery and outcome (mean BMI and mean percentage excess body weight loss: %EBWL) was analysed. Logistic regression model using Wald chi square test was used for statistical analysis.

1332 Results 379 patients underwent gastric bypass (LRYGB; n0271), gastric band (LGB; n 079) and sleeve gastrectomy (LSG; n029) laparoscopically. Pre-op mean BMI (LAGB:57; LRYGB:57; LSG:63) and mean excess body weight (EBW in Kg; LAGB: 94; LRYGB:91; LSG:111) was recorded. 91 patients were super super obese (BMI>60; LAGB: n 023, LRYGB:n052, LSG:n 016). Mean %EBWL and mean BMI at mean follow up (LAGB: 37 % & 45 at 47 months; LRYGB: 55 % & 38 at 25 months; LSG: 43 % & 45 at 19 months) was analysed. Pre op EBW was a statistically significant covariate; the higher the pre op EBW, the less likely the BMI at last follow up <40 (p<0.001). Patients who underwent LRYGB were significantly more likely to have BMI<40 at last follow up than the other two groups (LAGB & LSG) (p<0.001). Conclusion LRYGB is effective even in super obese patients in rendering this extremely obese cohort of patients to BMI <40 . O074 Results and Complications After Adjustable Gastric Banding Without Gastrogastric Imbrication Sutures Presenter: Sehoon Kang Seoul SKY Hospital, Korea (South) Background The main advantage of gastro-gastric suture in laparoscopic adjustable gastric banding is to prevent migration, slippage, and pouch dilatation. However, the necessity of this common technique has never been proven. We performed a prospective investigation of the outcomes using the Swedish adjustable gastric band (SAGB) without imbrication sutures. Methods From December 2010 and September 2011, 201 consecutive patients (male031, female0170) underwent laparoscopic SAGB. Those data such as demographic and morphologic, operative, and annual follow-up data were collected in a computerized data bank. The postoperative follow-up was done by the same surgeon. Results All patients were prospectively followed up for 1 year. All patients were available for follow-up at 1 year. The mean preoperative BMI was 39.5 kg/m (33-52). The mean operative time was 25±3 minutes (range 16-35). The fill volume at the operation was 8 mL. The fibrin glue was applied around the upper stomach area. The complications were slippage (2 cases), band migration (1 case) and pouch dilatation (1 case). There was no band erosion or mortality. Conclusions From our 1-year experience, we can state that SAGB without gastro-gastric suture is an effective bariatric procedure with few complications.

OBES SURG (2012) 22:1315–1419 We suspected the development of a gastropulmonary fistula between the stomach and left lower lobe bronchus, which was confirmed by an oral contrast swallow, CT abdomen, gastroscopy and bronchoscopy. She underwent a successful laparoscopic repair of the gastro-pulmonary fistula and was discharged well after 3 weeks. O076 The Safety, Feasibility and Results of one Staged LRYGB in 124 Consecutive Patients with BMI>50 kg/m2 in an Asian Center of Excellence Presenter: Ming-Che Hsin Co-authors: Sanoop K Zachariah, Andrea Ooi Se, Jason Y K Wat, Po-Chih Chang, Chih-Kun Huang Bariatric & Metabolic International (B.M.I) Surgery Center / E-Da Hospital, Taiwan Background Although, the Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well established bariatric procedure, the efficacy of LRYGB as a single stage procedure for patients with BMI>50 kg/m2 is still unclear. In this study, we report the results of 124 consecutive patients with BMI>50 kg/m2,who underwent a single stage LRYGB, in order to determine the safety, and efficacy of this procedure. Methods This is a prospective analysis of the 124 patients with BMI> 50 kg/m2, who underwent LRYGB as a single stage bariatric procedure, between February 2006 to March 2012. We also analyzed the results of the subgroups of BMI 50 to 60 kg/m2 (super obese) and BMI>60 kg/m2 (super-super obese). Results The mean operation time was 105±57 minutes; length of hospital stay was 2.53± 3.55 days. There were no conversions to open surgery and no mortality. Peri-operative complications occurred in 6 patients. Total 16 patients received revisional operations for the complications (peri-operative/long-term). The mean percent excess weight loss (%EWL) at 12, 24, 36, 48 and 60 months was 64.85 %, 67.92 %, 64.19 %, 59.43 % and 51.75 % respectively. There was no difference between the operating time, length of hospital stay, peri-operative, long term complications and revisional operations in the sub groups of BMI> 60 kg/m2 and BMI 50 to 60 kg/m2. Conclusions LRYGB is safe and effective as a single stage operation in extremely obese namely, the super obese and super-super obese. O077 Long-Term Outcomes of 2288 Laparoscopic Adjustable Gastric Bands over 15 Years

O075 Laparoscopic Repair of a Gastropulmonary Fistula After Sleeve Gastrectomy

Presenter: Peter Nottle Co-author: Ms Ingra Bringman, Susan Cairns

Presenter: Shanker Pasupathy Co-authors: Anantham Devanand, Aik Hau Tan, Christopher Liu, Shin Yi Ng, Ruban Poopalalingam

The Alfred Hospital , Melbourne Australia

Singapore General Hospital, Singapore Background Gastropulmonary fistula is a known but rare complication arising from bariatric surgery, gastrectomy, esophagectomy, splenectomy and pulmonary resection. We hereby report a successful laparoscopic repair of a gastro-pulmonary fistula following laparoscopic sleeve gastrectomy (LSG). Case presentation A 30 year old Malay female underwent LSG in October 2010 for morbid obesity in a different hospital. This was complicated by the formation of a subphrenic abscess from a staple line dehiscence. The abscess was drained laparoscopically and a jejunostomy tube inserted for feeding. A covered stent was placed endoscopically to cover the gastric leak at that time. The stent was removed 2 months later and she appeared to be well. However, she was non-compliant to the post-LSG diet and continued to feed orally in large amounts. She re-presented to our hospital with coughing of undigested food material, hemoptysis and fever, 16 months after her initial surgery. On examination, she was alert, non-toxic looking and had a SpO2 of 98 % on room air. Auscultation of her lungs revealed decreased air entry over the lower zones of the left lung. The abdomen was soft and non-tender. Her BMI was now 23.

Few reports of the long term results of laparoscopic adjustable gastric banding procedures exist in the literature. Long term outcomes of 2288 laparoscopic adjustable gastric bands performed from January 1977 to March 2012 are reported. Data was recorded on Lapbase data base, subsequently reviewed, and 82 % follow-up was achieved. 1853 (81 %) were female and 435 (19 %) were male . Mean age was 42 years, mean starting weight 117.7 kg and mean starting BMI 43.7 kg/m2. Mean number of comorbidities was 1.8 per patient. 364 required band red revision, the most common reasons being pouch dilatation or acute prolapse. 153 were removed for a variety of reasons, most commonly infection , patient intolerance, erosion , and oesophageal dilatation. Band revisions had zero mortality and low morbidity. 124 port revisions were necessary for infection, leaks , flipping and pain. There was one death in the primary bands from a pulmonary embolism which occurred on the day of surgery Percentage excess weight loss and BMI loss are graphed. Percentage excess weight loss was at 1 year 44.7 %, 5 years 54 %, 10 years 42.8 % and 15 years 62.7 %. BMI loss reflected the excess weight loss. Laparoscopic gastric banding is a safe , effective, bariatric procedure with low morbitity and mortality, and good long term weight loss maintained for 15 years. Revisional surgery rates are acceptable, and have a low mobidity and zero mortality in this series.

OBES SURG (2012) 22:1315–1419 O078 Retrospective Analysis of Roux en Y Gastric Bypass following Failed Vertically Banded Gastroplasty Presenter: Anupam Dixit MS MRCS FRCS Co-authors: A. Dixit(1), M.DeVisschere*, E.Van Dessel*, S. Van Cauwenberge * AZ Sint Jan Brugge-OostendeAV, 1 Guys & St. Thomas Hospital London Introduction Redo bariatric surgery is required in a high portion of patients who had Vertically Banded Gastroplasty (VBG) for complications and symptoms including insufficient weight loss/weight regain and symptoms of gastric outlet obstruction. Roux en Y Gastric Bypass (RYGB) is considered as the procedure of choice for revision of these cases. The aim of the study is to analyse the short- and long-term outcome of patients requiring revision RYGB following primary VBG. Methods 153 patients who had revision RYGB performed from November 2004Feb 2010 were included in the study. Parameters analysed were complications, hospital stay, 30-day re- admission rate and long-term weight loss (BMI). Results 122 females and 31 males underwent RYGB after failed VBG during study period. Mean age was 44.43 years (range 15-74 years) with an average pre-operative BMI of 33.5 (range 23.5-50.3). The mean hospital stay was 4.2 days. No mortality was reported during the study period. Early complications were reported in 4 patients, which were paraduodenal collection, pancreatitis, respiratory insufficiency and anastomotic haemorrhage respectively. RYGB led to a significant amelioration of symptoms and reduction of mean BMI to 27.5 with an average follow-up of 51.4 months. Conclusion RYGB following failed VBG is safe and effective with acceptable complications in centers performing these procedures routinely. O079 Laparoscopic Adjustable Gastric Banded Plication: A Case-Matched Comparative Study Surgery with Laparoscopic Sleeve Gastrectomy Presenter: Navdeep Chhabra Co-authors: Pattanshetti S, Goel R, Eng A, Tai C M, Tsai C C, Huang C K E-Da Hospital, Taiwan Background Laparoscopic sleeve gastrectomy (LSG) is an accepted standalone bariatric restrictive procedure and laparoscopic adjustable gastric banded plication (LAGBP) is an innovative technique combining the adjustability of gastric banding and gastric plication. We conducted a retrospective, comparative study of patients who underwent LAGBP and LSG in our institution regarding their percent excess weight loss (%EWL), resolution of comorbidities and complications. Methods We retrospectively analyzed the prospectively collected data of 60 patients: 30 each receiving LSG and LAGBP from May 2009 to October 2010 with at least I year follow up. Demographics, operative data, complications, percent of excess weight loss (%EWL) and resolution of co-morbidities were analysed and compared. Results LSG and LAGBP had a similar sex ratio and mean age (years) of 32.77 (8.17) and 30.37 (8.22) (p00.286) and mean BMI (kg·m-2) of 37.44 (3.52) and 37.3 (3.80) (p00.832). The co-morbidities ratio was also similar. Mean operative time(minutes) was longer in LAGBP: 62.45 (30.1) vs. 86.01 (21.88) (p00.001) but there was no difference in lengths of stay. Both groups had similar complication rates (6.67 %) and significant resolution of co-morbidities. The mean %EWL of LSG at 18 months was better than LAGBP but similar at 2nd year: 67.22 (15.03) and 66.93 (17.13) respectively. After LAGBP, mean frequency of band adjustment in 2 years was 1.50 (1.51) time. Conclusions Both groups exhibited excellent resolution of co-morbidities and weight loss at 2 years. LAGBP allows additional adjustability for more sustained weight loss. O080 Complications After LGCP Presenter: Hole´czy P. Co-authors: Bolek, M., Buzˇga M., Pasnisˇin, L., Havrlentova´, L. Vı´tkovice Hospital INC., Ostrava, Czech republic, Medical Faculty, Ostrava University, Ostrava, Czech republic Introduction The search for ideal bariatric-metabolic operation is still in process. Laparoscopic greater curvature publication has been presented recently as a promising procedure – simple, cheap and safe.

1333 Material and Methods in prospectively collected database the Co-Authors analysed their group of 38 patient from the point of view of postoperative complications in the time from 1.1.2011 to 31.3.2012. The complications were divided into 3 group – surgical, internal and others. Recorded interval was 30 days post op. The mortality was zero. Results Postoperative nausea and vomiting presented in all patients were treated by means of Ondansetron. This entity was not recorded as a complication. One major surgical complication was observed – gastric leak. The reoperation and prolonged drainage was needed. In one case pulmonary embolism was detected, inspite of all preventive measures. Two patients were readmitted for dehydrations and metabolic unbalance. Conservative treatments lead to quick recovery. Discussion Bariatric-metabolic operations are complex procedures with certain rate of morbidity and mortality. In the presented group mortality was zero. Above mentioned complication rate 8,33 % is being consider by the CoAuthors as fully acceptable. O081 Silastic Ring Vertical Gastric Bypass for Super-Super Obese (BMI 60 kg/m2): Short and Long Term Results. Presenter: Alberto Salinas Co-authors: Wilfredo Garcı´a, Maria Daniela Ramı´rez, Henry Garcı´a Hospital de Clı´nicas Caracas, Vanezuela Background surgery for super-super obesity presents a challenge because of severe comorbidities, technical difficulties and less weight loss in the long term. We present our experience with Silastic Ring Vertical Gastric Bypass (SRVGBP) in this population. Methods We performed a retrospective review of 175 consecutive patients that underwent SRVGBP between July 1995 and January 2011. Early comorbidities, late morbidity and weight loss were recorded. ResultsThere were 101 males and 74 females (mean age: 37 ys; range 1262). Mean BMI was 67 kg/m2 (60-100). Preoperative comorbidities were: HTN (46.8 %), OSA (34.2 %), arthropathy (25.1 %), type 2 diabetes (11.4 %), CAD (3.4 %), previous DVT (3.4 %). There were 167 open and 8 laparoscopic cases. Mean operative time was 126 minutes and mean hospital stay 2.3 days. Early complications were 3 gastric leaks (1.71 %), 2 pulmonary embolisms (1.14 %), 2 intestinal obstructions (1.14 %) and 1 death (0.57 %). Late complications were 28 incisional hernias (16 %), 2 Intestinal obstructions (1.14 %) and 8 silastic ring removals. Excess weight loss after the first year was 79 %; 2 to 6 yrs, 72 %, 7 to 11 yrs, 65 % and 12 to 16 yrs 66 %. Follow up in each group was 90 %, 57 %, 51 % and 50 % of patients respectively. BAROS questionnaire revealed 70 % of quality of life improvement. Conclusion SRVGBP is a safe procedure for patients with BMI 60 kg/m2. In experienced hands, operative time and hospital stay are short, morbidity is low and patients experience good long term weight loss. O082 Early and Midterm Outcomes Of Single Stage Laparoscopic Sleeve Gastrectomy - A Comparison Between BMI50Kg/m2 Presenter: Randeep Wadhawan Co-authors: Muneendra Gupta, Subrat Raul, Sanjay Verma, Farid Shah. Department of Minimal Access, Bariatric & GI Surgery, FORTIS Hospital, Vasant Kunj, New Delhi, India Background Laparoscopic sleeve gastrectomy (LSG) is being increasingly favoured as a stand alone bariatric procedure internationally. The evidence has indicated that LSG provides satisfactory weight loss with minimal morbidity and mortality. LSG has also been shown to improve co-morbidities such as diabetes and hypertension. We aim to compare the outcomes in terms of weight loss and resolution of diabetes of patients with BMI>50Kg/m2(super obese) with those of BMI<50 Kg/m2. Methods A retrospective review of prospectively collected data from November 2008-October 2011 consisting of 151 LSG’s was analysed in the department. All LSG’s were performed by a single surgical team, with the same surgical steps and similar size stomach pouch made over a 36 F bougie. We analysed the weight loss, % excess body weight loss(EBWL), length of stay, time taken for the procedure and resolution of Diabetes. Results Out of the 151 patients in our group 92 were females and 59 males. The age range was 23 years to 68 years with a mean of 44.3 yrs. The preoperative weight of our patients were 88 kg- 296 kg with a mean of 128

1334 kgs and the preoperative BMI range was 33Kg/m2 -116 Kg/m2 with a mean of 47.2Kg/m2.. We compared the results of patients with BMI<50(Group 1) and BMI >50(Group 2) by using T –Test measuring the p value where a p value of <0.05 is statistically significant. Weight loss in group 2 was more than group 1 and was statistically significant from 3 months to three years. However, results of the % EBWL was contrary to the results of the weight loss and was more in group1 which was statistically significant during the same period .We had 56 patients with history of diabetes and high glycosylated haemoglobin levels (HBA1C). The resolution of diabetes measured by the HBA1C levels was comparable in both the groups and not statistically significant. The average time taken for the procedure was 80.6 minutes and the average hospital stay postoperatively was 3.57 days. There was no significant morbidity or mortality in our study. Conclusions LSG provides satisfactory weight loss,% EBWL and resolution of co-morbidities in the short and medium- term in BMI<50 Kg/m2 results in the super obese showed inferior EBWL though there was comparable resolution of co-morbidities. Hence we may suggest that LSG can be recommended as a single stage procedure for a BMI< 50Kg/m2 , however, we may need more long term randomized studies before we can recommend it as a stand alone bariatric procedure in the super obese. O083 The Importance of Follow-Up in Adjustable Gastric Banding in Spain: Results in 132 Patients Operated on Presenter: Jesus Lago Co-authors: Sara Va´zquez, Enrique Mercader, Mercedes Sanz, Gabriel Pedraza, Fernando Ture´gano

OBES SURG (2012) 22:1315–1419 Results Elderly patients constituted 25.06 % of total Bariatric patients. Elderly patients had more pre and post operative morbidity than younger age. Less % of EBW loss is observed in elderly patients. There was significant improvement in co morbidities and quality of life after surgery. There was one death in elderly patients because of surgical complication. Discussion The number of patients undergoing bariatric surgery in the elderly group is expected to increase. They require meticulous investigations with specific tests to investigate the function of vital organs, screening for certain cancers, BMD scan. Pre op preparation should involve active chest physiology, Ambulation where possible and Build up of nutritional status. Post op, this group often requires ICU support, vigilant monitoring, Gentle hydration, early assisted ambulation and good nursing care. Follow up in this group requires regularity, encouragement to diet and supplements and periodic investigations. Bariatric surgery gives limited benefits in terms of weight loss and prolongation of life span but, improvement in quality of life and control of co morbid diseases is significant. Conclusion Bariatric surgery can be offered to the elderly obese patients only after proper selection and if the benefits outweigh the risk. O085 Robot Assisted Sleeve Gastrectomy Ileal Transposition (SGIT) for the Management of Type II Diabetes Mellitus in Patients with a BMI between 25-35 kg/m2 Presenter: Kulvinder Bajwa M.D., Co-authors: Brad Snyder, M.D., Philip Orlander, M.D., Kelly Wirfel, M.D., Erik Wilson, M.D. University of Texas Medical School at Houston, United States of America

Hospital General Universitario Gregorio Maran˜o´n/Clı´nica Fuensanta. Madrid, Spain Introduction Adjustable gastric banding (AGB) is a worldwide employed technique in the treatment of morbid obesity. In Spain, the number of patients treated with AGB is far lower than the average worldwide. We have assessed the outcome in 132 patients operated on since 2001, with results that are comparable to those reported in the literature, and try to address the reasons that might explain the difference of results reported from Spain. Results 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was of 39 years, and the mean BMI was of 43 (36 – 67). Follow-up was longer than 5 years in 61 patients. There was no mortality or severe morbidity. Eight patients (6.06 %) underwent reoperation, 3 among them for complications related to the reservoir, 4 for slipping of the band, and 1 for erosion into the stomach. %EBWL was maintained in 54.8 % of the patients followed-up for longer than 5 years, in 59.2 % of those operated on after 2006 and followed-up for longer than 3 years, and in 61.3 % of those operated on during the last 3 years and followed-up for longer than one year. Discussion and conclusions The results of our series are comparable to those reported in the literature and show that, provided that a close follow-up is implemented that parallels the one performed by most groups, AGB is a safe and effective technique of bariatric surgery also in our country.

Diabetes affects more than 20 million Americans and is the leading cause of heart disease, blindness, and limb amputations. Current treatments include life style modifications, insulin injections, and/or oral medication. However, medical treatments do not alter the progressive decline in pancreatic beta-cell function. Since medical therapy is not curative, a novel approach for treating this disease is needed, especially in non-morbidly obese patients. Weight loss surgeries in morbidly obese type II diabetic patients that bypass the foregut normalize plasma glucose levels before any significant excessive weight loss. Studies in Brazil and India have shown SGIT’s benefit in the morbidly obese diabetic population prompting study in the lower BMI diabetics. This feasibility study will demonstrate whether SGIT normalizes fasting blood glucose and HgbA1c in overweight (BMI 25-29.9) or obese (BMI 30-34.9) Type II diabetic patients. Secondary outcome measures include effect on cholesterol, blood pressure, and excess weight loss. This is the first human SGIT study in the USA. The first patient is a 50 year old insulin dependent diabetic with insulin resistance. Two weeks after Robot Assisted SGIT, her insulin has been discontinued. After the feasibility study, a formal study is planned. In conclusion, this metabolic surgery could be a novel and curative approach for non-morbidly obese Type II Diabetics in the Unites States. Further understanding of the enteroinsular axis could lead to further breakthroughs in the treatment of diabetes, metabolic syndrome, and cardiovascular disease in obese and non-obese diabetics. O086 Relevance of CT Scans in Diagnosis of Leakage in Bariatric Surgery

O084 Weight Loss Surgery in Patients Over 50 Years: A Comparative Study Presenter: Dr Sanjay Patolia Co-authors: Dr Hetal Patolia, Dr Mandeep kapadiya, Dr devendra chauhan

Presenter: Dupree A Co-authors: Wolter S, Busch P, Sauer N, Vashist YK, Izbicki JR, Aberle J, Mann O University Center Eppendorf, Hamburg, Germany

Asian Bariatrics& Cosmetics, India Introduction With the increase in life expectancy and obesity, the number of patients coming for Bariatric surgery over 50 yrs age has increased. This population is a high risk group for surgery because of old age with poor physical reserve, associated co morbid diseases and restricted physical activity. This study aims to analyze the risk and benefit of surgery in elderly population. Material & Method This is retrospective study of 359 patients operated between Jan 2006 to Jan 2012. A comparison was done between patients less than 50 yrs (269 patients) and more than 50 years (90 patients)of age one year after surgery.

Background Major complications in bariatric surgery are small but in case of occurrence severe. Because of the elevated BMI diagnosis of major complications like leakage of stapler lines seems to be not comparable with the diagnostic criteria in norm weight persons. We aimed to show the relevance of abdominal CT scans in diagnosis of leakage after sleeve gastrectomy in a patient collective of one year in a single center. Method All patients operated in 2010 were retrospective studied after any kind of bariatric surgery with special view on realized CT scans for diagnosis of stapler line leakage which required an operative intervention (n05). Results In 2010 a total of 191 bariatric procedures were performed, of these 87 sleeve gastrectomies and 104 RYGBs. In the whole collective a major

OBES SURG (2012) 22:1315–1419 complication rate of 5,7 % occurred, in 2,6 % we observed stapler line leakages after sleeve gastrectomy (n05) and no insufficiencies after RYGB. In 4 cases (4/5) CT scans were performed with no pathological findings in 75 %, in one case a hematoma with air entrapment is described without signs of stapler line leakage. In the following exploration all of them showed a leakage with intraabdominal pus and peritonitis. Conclusion In the detection of stapler line leakage after bariatric surgery, especially sleeve gastrectomies the CT scan captures a subordinated role. Clinical aspects and experience as well as blood parameters are of overriding importance in diagnosis of leakage after sleeve gastrectomy especially if there are no seminal findings in CT scan. O087 Primary Obesity Surgery, Endolumenal (POSE): Safety and Short Term Results Presenter: Sasindran Ramar Co-authors: Mr. D. Heath, Mr. P. Sufi Whittington Hospital NHS Trust, London,UK Introduction urgery for morbid obesity is effective and less invasive Methods in treatment of obesity arebeing pursued. Transoral Methods are attractive in that they are scar free and less invasive.The aim of our study is to assess the safety and short-term results of Primary ObesitySurgery Endolumenal (POSE). Methods We performed a retrospective analysis of prospectively collected data of 20 patients who under went POSE from March 2011 to November 2011 in a private hospital in United Kingdom, performed by a single surgeon. POSE involves endolumenal publication of the gastricfundus and antrum. Results All 20 patients underwent POSE successfully. The male to female ratio is 1:4. The mean age was 48 years (range 33-62 years). The mean length of stay 1.6 days. All patients described varying levels of pharyngitis, and one patient suffered hematemesis requiring blood transfusion. There was no conversion to other procedures or deaths. Three patients were excluded from analysis as they were lost to follow up. The average follow up was 8.9 months (range 513 months). The mean BMI and mean weight at the time of POSE were 34.3 kg/m (range 27- 45 kg/m) and 94.9Kg (range 68 kg – 131 kg) respectively. The mean weight and mean percentage excess body weight loss (EBWL) after POSE were82.9 kg (range 63 kg- 114 kg) and 43.3 % (range 0 %- 102 %). The average weight loss is 13.7 kg (range 0 – 54 kg). Conclusion POSE can be safely performed and 43.3 % EBWL achieved in short term follow up isencouraging. Long term follow up results will define the role of POSE in management ofobesity. O 088 Is There Any Way to Improve Bariatric Surgery Outcomes and Costs? Presenter: Mirto Foletto, Co-author: Michele Carron Dept Of Medicine, Anesthsiology And Intensive Care, Padova University Hospital, Italy Matching costs with standard of care is the biggest challenge of the new millenium, especially within a public health system, where most resources come from tax payers. Center of Excellence policy works in this way, although not targeting the whole surgical process behind.The aim of this study was to evaluate whether a modification to the approach of a patient candidate for bariatric surgery could impact on outcomes and costs. Methods Six-month activity regarding a single bariatric procedure (laparoscopic sleeve gastrectomy - LSG) at a single Institution was prospectively analyzed, before (group A) and after (group B) the activation of a "week surgery ward", that required dedicated pathways of care. The mean values of the following outcomes were measured in both group of patients: OR time, hospital stay (HS) and early complication rate (EC). The differences between the 2 groups were compared and statistically assessed. Differences in costs were derived from these data using the activity based cost (ABC) model. Results Both group were matched for size (55 vs 67), sex, mean age (47.2 vs 45.5) and BMI (48.4 vs 46.9). Mean OR (min) was 89.2±29 and 57.9±12, for group A and B, respectively with p<0.0001. Mean HS (days) was 5.3±2.6 and 3.4±0.5, for group A and B, respectively with p<0.0001. EC rate was 18.2 % in group A and 6 % in group B, with p<0.04. Group B show a mean advantage in term of costs of 2000 Eur.

1335 Conclusions Bariatric surgery, a model for elective surgery, can greatly benefit from improvements in patterns of care, in terms of outcomes and costs. Further studies are needed to confirm and refine these results. O089 Does Initial Fluoroscopy-Assisted Gastric Band Adjustment Produce Better Weight Loss? Personal Experience of Initial 100 Consecutive Patients Presenter: Seong Min Kim Co-authors: Jung Nam Lee, Woon Kee Lee Department of Surgery, Gil Medical Center, Gachon University of Medicine, Incheon, Korea (South) Introduction Little data exist with regard to an ideal filling protocol for band adjustment after placement of laparoscopic adjustable gastric bands. The CoAuthors investigated the effect of initial postoperative band adjustment under fluoroscopic guidance in morbidly obese patients undergoing treatment with laparoscopic adjustable gastric banding. Methods Postoperative band management over a three-year period is described. Three initial band adjustments were performed under fluoroscopic guidance with adjustment of the stoma diameter to 3-4 mm. Subsequent minor band adjustments were performed after clinical interview only except unusual situations. Results Between March 2009 and February 2012, consecutive 100 patients followed our current filling protocol. The group of patients included 90 women and 10 men, whose mean age at surgery was 32.6±8.4 years. The mean preoperative BMI was 34.8±6.3 kg/m2. The final filling volume in large bands at each adjustment was 4.6±1.1 cc, 6.1±1.2 cc, and 6.9±1.4 cc, respectively, and in small bands, 1.7±0.4 cc, 2.6±0.4 cc, and 3.2±0.5 cc, respectively. Percentage of excess weight loss (%EWL) was 17.1±11.4, 42.0±23.2, 63.3± 26.3, and 83.9±26.7 at 1, 3, 6, and 12 postoperative months. Adverse reactions to band adjustment were observed in six patients; stoma obstruction (n0 1), band slippage (n03), symmetric pouch dilatation (n01), and band erosion (n01). Four of the six patients underwent simple band deflation and gradual readjustment. Conclusion According to our preliminary results, initial band adjustments with adjustment of stoma diameter to 3-4 mm under fluoroscopic guidance were well tolerated by patients and resulted in greater weight loss within the first postoperative year. O090 Coventional Gastric Bypass After Failed Adjustable Gastric Banding: Experience and Results in 522 Cases. Presenter: Anupam Dixit MS MRCS FRCS Co-authors: A. Dixit(1), M.DeVisschere*, E.Van Dessel*, S. Van Cauwenberge * AZ Sint Jan Brugge-OostendeAV, United Kingdom

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Guys & St. Thomas Hospital London,

Introduction The preferred procedure for failed laparoscopic adjustable gastric banding (LAGB) is the fully-stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB). However, the safety of this secondary gastric bypass (SGB) has only been reported in small study groups. The aim of this study is to determine the early morbidity and mortality of this conversion procedure on a large group of patients operated in a single centre. Materials and Methods Between May 2004 to January 2012, 522 patients underwent a secondary FS-LRYGB after failed LAGB. Of the 522 patients, 107 patients had a removal of the gastric band prior to the SGB. The other 415 patients had a conversion procedure with removal of the band. Of this latter group either a one-step procedure (LAGB removal with FS-LRYGB during the same procedure) was performed either a two-step procedure (LAGB removal followed by FS-LRYGB in a second procedure a few months later).This study analyses the 30 day morbidity and mortality. Results The mean BMI was 39.7 kg/m. Thirty-three (6.3 %) patients had early complications (<30 days). Hemorrhage (2.7 %) was the most common complication. We had neither anastomotic nor staple line leakage. No patient died during the 30-days follow up period. Of the group with a conversion procedure with removal of the band (n0415) a one-step procedure was performed in 69.9 % (n0290) of the patients and a two-step procedure in 30.1 % (n0125). With increasing learning curve, the number of procedures performed in onestep also increased. Untill 2008, 52 % of the conversions were done in onestep. Since 2009, 82 % of the revisional cases were completed in one step.

1336 Discussion The implementation of the systematic approach and standardized principles of the primary FS-LRYGB* contribute both to a very low morbidity and a zero mortality rate in SGB. Nevertheless, carefull attention was made to certain surgical technical details and the initially restrained policy in performing the conversion procedure in one step was only gradually abandoned by our increasing learning curve. References * Dillemans B, Sakran N, Van Cauwenberge S, et al. Standardization of the Fully Stapled Laparoscopic Roux-en-Y Gastric Bypass for Obesity Reduces Early Immediate Postoperative Morbidity and Mortality: A Single Center Study on 2606 Patients. Obes Surg (2009); 19:1355-1364. O091 Initial Results of Imbricated Adjustable Gastric Banding Presenter: George Woodman, MD Introduction Imbrication is a technique of increasing interest to surgeons worldwide. We have explored the combination of adjustable gastric banding (AGB) and imbrication as a primary procedure (iBand) to provide more rapid weight loss than AGB alone. Methods After placing the band via pars flaccida technique we mobilize the greater curvature from 6 cm proximal to the pylorus to the lower level of the band, preserving the superior-most short gastric vessels. Four interrupted sutures are placed from 4 cm from the lesser curvature posteriorly to 4 cm from the lesser curvature anteriorly to ‘imbricate’ the greater curve. This ridge of imbricated stomach is then reinforced with a long running suture. Results Sixty patient have undergone iBand with an average OR time of seventy three minutes (range 49-104), all performed laparoscopically. Few patients experienced transient mild nausea; three patients required additional outpatient medications for nausea. Ninety eight percent (59/60) were discharged the same day with one kept overnight for nausea treatment. Baseline BMI was 46.0, with 2, 4, 6 month average %EWL of 22.0, 27.7, and 34.0. Mean BMI at 6 months is 38.3. Patients required minimal adjustments compared to typical AGB. There were no mortalities. Conclusions iBand appears to be a safe procedure with more rapid weight loss than typical AGB with less need for adjustments. Patients will continue to be followed to determine long-term safety and efficacy. O092 Surgical Complications in 1000 Consecutive Laparoscopicsleeve Gastrectomies Presenter: Francisco Pacheco Bastidas Co-authors: Hector Molina Zapata, Rimsky Alvarez Uslar, Marcos Rodriguez Barra, Andrea Alarcon Mendez Hospital Clinico Del Sur, Chile Background To improve decision of choosing the different surgical treatment of obesity, the risks of bariatric surgical procedures require further characterization. The aim of this study was to characterize surgical complications of sleeve gastrectomies in our group. Methods Prospective database from 2006 to February 2012 was reviewed. Study of 30-day outcomes in consecutive patients undergoing laparoscopic sleeve gastrectomy (LSG) in our Hospital. A surgical complications of 30-day was evaluated. Results There were 1000 patients who underwent LSG, Average age was 36,21 years (15-66); 82,4 % of patients were females; median body-mass index was 37,0 kg/m2 (30,0 – 62,8). There was one postoperative death (0,1 %), a patient who died at 18 posoperative day of ventricular fibrilation without surgical complication. The 30-day rate of patients had one major adverse outcome was 4,0 % (40 patients). In thisgroup 27patientscorrespondtoleakage (2,7 %). Of the leaks 6 patients were operated (22,2 %). The remaining 21 were treated with non surgical procedures (77,8 %). Covered stents were used in 8 patients (29,6 %). Leakage cured at 26,84 days (range 6-140). Leakeage cured at 55 days (7–140) in surgical group and at 19,8 days (6-60) in non surgical group. The remaining complications were 4 patient with hemoperitoneum, 4 patients with bowel injury, 1 patient with vascular injury. Of all patients 8 of them had to be re-operated (0.8 %). Two patients required conversion to laparotomy. Conclusions The range of complications in our serie is low, maybe because a high volume of procedures. The incidence of reoperation in our serie is low. After LSG It´s possible a non surgical treatment for leakage in a selective group of patients.

OBES SURG (2012) 22:1315–1419 O093 Bariatric Procedures Should Include Both Small Gastric Pouch and Gastric Bypass for Maximum Effectiveness Presenter: Robert Rutledge Institution: Center for Laparoscopic Obesity Surgery, United States of America Recently a review of the impact of various forms of general surgery for gastric cancer on patients’ weight and diabetes was performed. Methods A recent study by Kim et al from the Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea published in WorldJGastroenterol. 2012. The study reported on 403 gastric cancer patients with Type 2 Diabetes (T2DM) who underwent various forms of gastrectomy. The goal of the study was to assess to relation between surgical procedure and outcomes. Results Gastric cancer patients had either smaller (partial) or larger gastrectomy (subtotal). Patients underwent reconstruction with or without duodenal bypass (RNY/BII or Billroth I). BMI Reduction: Reduction of BMI was 8.3 + 7.9 in lesser gastrectomies and 14.2 + 9.2 in larger gastrectomies. Reduction of BMI was 7.6 + 8.0 without bypass (BI) as compared to bypass patients who had 11.4 + 8.7. Diabetes Improvement/Resolution: Improvement/Resolution of diabetes was 40 % in lesser and 60 % in larger gastrectomies. Improvement/Resolution of diabetes was 37 % without bypass (BI) as compared to bypass patients who had 52 % improvement/resolution. Conclusion These results suggest that Sleeve/Band/Plication can be expected to be significantly less effective. For the greatest success with weight loss and Rx diabetes; Bariatric surgical procedures should include Both: 1. Small Gastric Pouch and 2. WITH a Gastric Bypass. O094 A Review of Redo Surgeries Among 307 Bariatric Surgeries at an Indian Rural Centre Presenter: Muhammed Shereef Co-authors: Mohamed Ismail, Mahesh Rajagopal, Sreejith Nair, Hafiz Ansari Moulana Hospital, India Aim Because of the growing prevalence of morbid obesity, bariatric surgery is getting more and more important. According to the growing number of bariatric operations, the number of patients in need of revisionary surgery is also growing, mostly because of insufficient weight loss. The aim of this study was to review the redo surgeries among the 307 bariatric surgeries Method In a retrospective study redo surgeries were assessed among the 307 bariatric surgeries. Result Two patients who had undergone sleeve gastrectomy had to undergo gastric bypass ,one due to insufficient weight loss and another due to weight regain. Two patients who had undergone lap gastric banding had to undergo gastric bypass due to insufficient weight loss. Conclusion The need for redo surgery is equally required after sleeve gastrectomy and banding. Gastric bypass procedure is an effective revisional surgery for insufficient weight loss O095 Laparoscopic Conversion of Failed Gastric Bypass to Biliopancreatic Diversion: an Alternativ Method to Improve Weight Loss Presenter: Thomas Koestler Co-authors: Miroslav Peev, Zingg U Department of Surgery Limmattal Hospital Zurich, Switzerland Introduction Weight regain after short limb (SL) or very very long limb (VVLL) gastric bypassis a well-known problem. We introduce an alternative approach that improvesthe overall outcome in bariatric patients.

OBES SURG (2012) 22:1315–1419 Methods From total 12 patients, 50 % undergone a SL (150 cm) and 50 % a VVLL(common channel 100 cm) gastric bypass. We converted the initial operation intoa biliopancreatic diversion with an alimentary limb of 150 cm, common channel(CC) of 80-100 cm and a biliopancreatic limb (BL) of 300-400 cm. The average postoperative follow up was 26 months. Results The average Excess Weight Loss (EWL) after conversion was 41.2 % vs. 51,5%and the lost of BMI was 9,2 vs.11,8 for the mentioned groups. Earlypostoperative complications (<30 days) were observed in 25 % and late complications in 8 % of the patients. Hypoalbuminemia (<30 g) occurred in 25 %of the study participants with an average stool frequency of 4,5/d. One patient needed a reconversion because of a severe malabsorption. Discussion In our study we achieve additional lost of BMI and EWL by lengthening thebiliopancreatic limb in both groups. Even for the patients with a VVLL gastric bypass (CC of 100 cm), the lengthening of the biliopancreatic limb was the key feature leading to additional weight loss. Conclusion Lengthening of the biliopancreatic limb after SL or VVLL gastric bypass efficiently reduce the excessive body weight. In order to prevent a severe malabsorption a close selection and observation of the patients is needed.

1337 measured by the AD-EVA test instrument. 60 Patients (24 m/36f, 18 – 71 years) were tested prior to gastric bypass or gastric banding (Body Mass Index (BMI); M044.95, SD06.91) and following the respective operation (BMI; M033.92, SD07.23). Results Following surgery the variables “Addiction” (t011.15, p<.01) and “Binge Eating Disorder” (t02.13, p<.05) show significant changes across all patients and therefore confirm a positive effect. “Restrained Eating” and “Bulimia” remain unmodified after operation. There were significant differences between the two bariatric methods (p<.01). Conclusion A precise interdisciplinary evaluation is a prerequisite to decide between gastric banding and bypass technique as well as to define the need for pre- and postoperative psychotherapy. O098 Predicted Percentage Excess Body Weight Loss is Higher in the Long Term for Gastric Band Patients Undergoing Revision to Gastric Bypass Surgery Presenter: Rupa Sarkar Co-author: Vittel Rao, Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castle HillHospital, Cottingham, United Kingdom

O096 Safety and Feasibility of Totally Robotic Roux-en-Y Gastric Bypass in a High Volume Series Presenter: Keith Kim Co-authors: M.D.,Sharon Krzyzanowski, R.N. Cynthia K. Buffington, Ph.D. Florida Hospital Celebration Health, United States of America Background Over the last year there has been renewed interest in the application of robotic technology to bariatric procedures due to the advantages offered by the latest robotic system, the da Vinci Si platform, and to the short learning curve and reported safety of the totally robotic technique. We report the largest series of a single surgeon’s experience with totally robotic Rouxen-Y gastric bypass (TR-RYGB). Methods The study is a restrospective analysis of 535 TR-RYGB cases performed by a single surgeon. Outcome measurements include operative times, conversions, hospital stay, complications, and mortality. Results The learning curve was characterized by two periods of stabilization, a rapid decline in operative times over the first 30 patients and another stabilization period after 90 cases. Following stabilization, docking, console, and total operative times averaged 4, 60, and 80-90 minutes, respectively. There were 0 % conversions intra-operatively and a reoperation rate of 1.87 % early post-operative for hernia, obstruction, and bleeds requiring evacuation hematoma. The average length of hospital stay was 2 days and pain medication during hospitalization and following discharge was significantly less than for the laparoscopic or robotic assisted procedures. No leaks (0 %) occurred during the series. Thirty-day complication rates averaged 4.11 %. Long-term complications averaged 5.7 % and included strictures, gallbladder disease and ulcers. Mortality involved 3 cases that occurred > 6 months post-operatively, i.e. 1 myocardial infarct, 1 diabetes complication and 1 unknown cause. Conclusion Surgeon experience in a large series of TR-RYGB demonstrates the procedure’s short learning curve, its safety and feasibility. O097 Bariatric Surgery Affects Addiction to Overeating and Eating Disorders Presenter: K. Miller1 Co-authors: E. Ardelt-Gattinger2, D. Weghuber3, M. Meindl2 Surgery, Hallein Clinic, Hallein, Austria.; 2 Psychology, University Salzburg, Salzburg, Austria.; 3 Pediatrics, Private Medical University, Salzburg, Austria

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Background Bariatric surgery is the most effective treatment to improve or even to cure life threatening comorbidities and therefore considered as metabolic surgery. Little is known about changes of the psychological etiology and risk factors. Methods The present study concentrated upon mental symptoms which are considered to cause or promote obesity. The changes of symptoms were

Introduction Failure to lose weight is the most common indication for revisional bariatric surgery. We report the predicted trajectories for percentage excess body weight loss (%EBWL) of patients who initially underwent gastric band surgery (LAGB) and were subsequently revised to gastric bypass (LRYGB). Methods A retrospective database review of patients who underwent LAGB and then were subsequently revised to LRYGB for lack of progression in weight loss was undertaken. Demographic profile and mean %EBWL was analysed. Likelihood ratio chi square test was used for statistical analysis. Results 17 patients (M:F 01:16; Mean age: 41; range: 21-55) underwent LAGB for obesity (Mean BMI: 48; EBW: 72Kg). At follow up (mean : 36 months), mean %EBWL was 36. Due to lack of progression in weight loss, these patients underwent revision to LRYGB (Mean BMI: 42; EBW: 52Kg). At follow up (mean : 25 months), mean %EBWL was 39. The predicted trajectories for % EBWL were significantly different between the two groups (p 00.014). %EBWL was predicted to be higher for LRYGB group initially and then cross over at about 15 months to be lower than the LAGB group. At about 35 months, % EBWL was then predicted to rise for the LRYGB group and fall for the LAGB group. Conclusion Albeit the small sample size, it appears that %EBWL may be achieved on a quicker and prolonged basis in patients who undergo LRYGB as opposed to patients who undergo revision surgery from band to gastric bypass. O099 The Effect of Gastric Bypass for Type 2 Diabetes Patients with Lower BMI: The Outcomes of 24 months Follow-Up Presenter: Kyung-Yul Hur Co-authors: Myung-Jin Kim Soonchunhyang University hospital, Korea (South) Backgrounds Treatment outcomes of laparoscopic gastric bypass for nonobese T2DM patients areexpected to be outstanding, but long term results has not been reported yet. This report is the resultsof laparoscopic MBG(minigastric bypass) for T2DM patients with BMI<30 kg/m2 , more than 24monthsfollow up. Methods One hundred and forty patients who had uncontrollable type 2 diabetes without obesityunderwent laparoscopic MGB from Sep. 2009 and were followed up regularly. Total 30 patients werefollowed up more than 24 months. Preoperative mean BMI was 26.0 kg/m2. Results One year after gastric bypass, 21 out of 30 patients (70 %) were under the goal of treatmentfor diabetes which was defined as HbA1c level <7 % according to ADA criteria.And interestingly, two years after surgery, the 24 out of 30 patients (80 %) were under 7 % of HbA1c.The mean HbA1c level was decreased from 9.14 to 6.66 % and 6.49 % after first and second year respectively. There were neither severe complications nor rebound hyperglycemia.

1338 Conclusions This is the preliminary report focused on treatment effect of laparoscopic MGB inT2DM patients with BMI less than 30 kg/m2 in Korea. Although further studies are required todetermine late postoperative complications or cure of diabetes, the MGB for non obese type 2diabetic patients seems to be one of potent therapeutic modality. O100 Laparoscopic Sleeve Gastrectomy: 300 Consecutive Cases Without Leak and Mortality Presenter: Giuseppe Marinari Co-authors: Vincenzo Borrelli, Gabriele D’alessandro, Andrea Centurellli Humanitas Gavazzeni, Italy Introduction Stand alone Sleeve Gastrectomy (SG) is a rapidly growing operation: it offers a medium-term weight loss comparable to other major procedures, with minimal nutritional consequences and good quality of life. Nevertheless, eventual surgical complications reported, particularly leaks, have varying rates, and are difficult to solve. Patients-technique Since October 2010 300 obese patients (224 F) have been submitted to SG by us. Average BMI was 44.8 (36-71), average age 43 (19-70). In 48 cases a T2DM was present, 102 had hypertension, 43 OSAS, and 1 patient was cirrhotic. A 4 trocars tecnique has been used, the great curvature section started 5 cm from pylorus and was conducted until a point 1-2 cm distant from esophagogastric junction. Great attention has been made to respect lesser curvature vascularization, particularly at the angulus, to avoid stenosis. Bougie was 36 F; buttress has been used in all procedures. Results Out of the 300 patients we observed the following complication: 6 cases of bleeding (1 intraluminal and 2 peritoneal, conservatively treated, and 3 peritoneal that requested a relaparoscopy), 1 case of pneumonia; both leak and mortality was zero. Mean operative time has been 72 minutes (40-120), mean hospital stay 5.5 days (4-7). Comorbidities were irrelevant to morbidity. Discussion In our experience laparoscopic SG has a low rate of complications (global morbidity 2.3 %, bleeding 2.0 %, relaparoscopy 1 %, pneumonia .003 %, mortality and leak incidence was nil), showing to be a safe procedure. Standardization of the tecnique seems to be the best prevention for avoiding surgical complication. O101 Outcomes of Revision and Reversal of Laparoscopic Gastric Banding Presenter: Adi Yavetz Co-author: Ruthi Maltz, Odeda Benin-Goren, Subhi Abu Aid, Tel Aviv Sourasky Medical Center, Israel Obesity is a major health problem affecting 61 % of the Australian population. Laparoscopic gastric banding (LAGB) has been shown to be a safe and effective treatment for the morbidly obese, but just as with other procedures, revision and reversal procedures are required. This paper details the outcomes of 517 revisions and removals carried out by one surgeon between March 1998 and March 2012. 364 consecutive revision laparoscopic band procedures and 153 reversals were performed in 507 patients. Patients were followed for a mean period of 36 months. For the revision patients, weight change in terms of BMI and percentage excess weight loss were examined along with complications and patient tolerance. For the reversals, complications were measured and the incidence of further bariatric surgery and its outcomes were measured. For the revisions , the BMI remained stable with a mean change of+ 0,25 kg/m2 ( % excess weight loss 45.76 at 3 years and 52. 1 % at 5 years). The overall complication rate was 15.4 %, most commonly recurrent pouch formation at 8.2 %. For the reversals, wound infection was the commonest complication at 3.5 % mostly in patients with erosions. Further surgery was requested by 56 (37 %) of patients, mostly sleeve gastrectomies. Revision and or reversal LAGB is well tolerated by most patients, and in this series the preliminary outcome data indicate that a revision procedure stabilises weight loss, but does not result in further weight loss and 1/3 of patients will request further surgery following reversal.

OBES SURG (2012) 22:1315–1419 O102 Single Port Biiliopancreatic Diversion Withouth Gastrectomy Presenter: J. Joaquı´n Resa Co-authors: Mo´nica Valero, Javier Lagos, Elena Gonzalvo, Jose Luis Garcı´a Calleja, Jose AntonioFata´s Royo Villanova Hospital, Spain Background Laparoscopic surgery has imposed in the treatment of morbid obesity. One of the ways we are exploring is the development of single port techniques. Technique We used the device gelPoint, which contains a gel’s membrane. We perform the abdominal opening around the umbilicus and 3 trocars are placed: 1 of 5 mm, one of 10 mm for the optics of 30 degrees and one of 12 mm. First opens a window in the lesser omentum, carried out a gastric greater curvature dissection. Horizontal gastric section is performed with 60 mm/ blue staplers.60 cm of ileum are measured from the caecus, making a mark. We continue the upward extent up to 3 meters total, performing with the 60 mm/blue stapler gastrojejunal anastomosis. Then we perform yeyunoileal anastomosis and close the mesenteric hole through laparoscopic Prolene suture. Let Jackson Pratt drainage in left hypochondrium. Discussion The emergence of devices that allow us to reduce the number of incisions until a single hole opens up a field of new possibilities. This is the way we think, easier to perform single port biliopancreatic diversion. GelPoint elasticity let us the use of conventional materials, does not need articulated tongs. Umbilical location is less traumatic and more aesthetic. We think that they are indicated in obesity surgery, by minor trauma, which produces a beneficial psychological effect on patients and aesthetic advantages. O103 Laparoscopic Gastroileal Bypass for Diabetes Treatment in Nonmorbidly Patients Presenter: J. Joaquı´n Resa Co-authors: Mo´nica Valero, Javier Lagos, Elena Gonzalvo, Jose Luis Garcı´a Calleja, Jose Antonio Fata´s Royo Villanova Hospital, Spain Background Since 2000 we have performed more than 500 laparoscopic biliopancreatic diversion without gastrectomy (LBPD-G) for morbid obesity treatment with excellent results. In 2008 we began to treat diabetes in nonmorbidly obese patients through LBPD-G with 200 cm alimentary limb plus 200 cm common limb with 92 % of diabetes resolution. To simplify the technique and avoid steatorrhoea we developed the laparoscopic gastrileal bypass, an operation between biliopancreatic diversion and minigastric bypass. Methods Prospective study on oral glucose loads in 51 severe diabetic patients (body mass index [BMI] >30 and <35, HbA1C >7.5 %) before and at 1, 3, 6, 12, 18 and 24 months after laparoscopic gastroileal bypass with a horizontal gastric trasection and 300 cm gastroenteral anastomosis from ileocecal valve. Results Of the 51 patients enrolled, the mean age was 48.6 years, mean BMI was 33.61, mean fasting plasma glucose was 187.3 and mean HbA1C was 8.9. The mean BMI at 1, 3, 6, 12, 18 and 24 months after operation were 30.25, 28.51, 27.41, 26.55, 25.71 and 25.64, respectively. The mean HbA1C at 1, 3, 6, 12, 18 and 24 months after operation were 7.2, 5.8, 5.7, 5.5, 5.7 and 5.6, respectively. Resolution of type 2 diabetes was achieved in 39 patients at 3 months and 48 at 12 months after gastroileal bypass. The mean operating time was 32 minutes, without complications and mortality. Single port laparoscopic was accomplished in 6 patients. Conclusion Laparosopic gastroileal bypass seems to be a promising procedure for the control of T2DM and the metabolic syndrome. O104 Laparoscopic Biliopancreatic Diversion Without Gastrectomy Presenter: Mo´nica Valero, Co-authors: J. Joaquı´n Resa, Javier Lagos, Jorge Solano, Elena Gonzalvo, jose Luis Garcı´a Calleja, Jose Antonio Fata´s Royo Villanova Hospital, Spain Background Demonstrate the effectiveness of the laparoscopic biliopancreatic diversion without gastrectomy in terms of the loss of weight, the decrease of

OBES SURG (2012) 22:1315–1419

1339

the comorbidities, its few postoperative complications and the degree of patient satisfaction. Material and methods Present the results of the 252 patients treated between February 2002-2012 at our drive through laparoscopic biliopancreatic diversion without gastrectomy. They are 69,84 % women, with an average age of 46,47 and an average BMI of 50,22. Associated diseases: HTA (51,19 %), DM (29,36 %), Dislipidemia (17 %) and OSAS (27,67 %). Results 100 % of the cases was carried out by laparoscopy, without any conversion. The average surgery time was 74 minutes. The average stay is 6,96 days. There have been complications in 5.13 % being outstanding 5 anastomosis leaks (1,97 %) with 4 reoperation, 6 digestive haemorrhage (2,38 %), an hemoperitoneum (0,39 %) and a PET (0,39 %). Thinning has reached 80 % of weight lost. The resolution of the co-morbidities is summarized in 48,83 % of HTA, 89,18 % of Diabetes, 100 % of Dyslipidemia and 90 % of the SAOS. Long-term metabolic complications are hyperparathyroidism (30,4 %), anemia (22,8 %), hypoproteinaemia (10 %), malnutrition (0.75 %), vit A deficit (10,4 %) and failure of thinning (1,2 %). 84 % have given us the highest score in the survey of satisfaction. Conclusions It has been demonstrated that through the laparoscopic biliopancreatic diversion without gastrectomy we obtained good results of thinning and reduction of diseases associated with low incidence of postoperative complications. Laparoscopic surgery also decreases stress on the patient and the postoperative stay.

that in non-obese patients with T2DM, the levels of incretin and insulin changed as a consequence of gastric bypass. Methods: From March to December in 2011, 12 non-obese patients (mean BMI; 26.2 kg/m2) with not well-controlled (mean HbA1C; 9.5 %) underwent gastric bypass surgery. Values related diabetes including incretin (gastric inhibitory peptide [GIP] and glucagon-like peptide-1 [GLP-1]) levels were measured before and 1 month after gastric bypass surgery. All values were measured in response to an oral glucose tolerance test. Results One month after surgery, BMI decreased by 2.1±0.7 kg/m2. Mean HbA1C level decreased by 1.6±2. Oral glucose-stimulated insulin levels increased and GLP-1 levels also increased sharply. Also, oral glucosestimulated GIP levels decreased. Conclusions Early after gastric bypass in non-obese T2DM patients, control of T2DM is achieved without significant weight loss. Release of incretin after oral glucose is improved. It may not be wholly accounted for by weight loss but could be a consequence of changes of the enteroinsular axis, particularly in the incretins.

O105 Laparoscopic Adjustable Gastric Band (AGB) as a Revisional Procedure for Weight Regain Following Laparoscopic Roux-en Y Gastric Bypass (RYGB).

The pathophysiology of Obesity and Type 2 Diabetes Mellitus has becoming increasingly complex with the new research showing a large role played by hormones of gastro intestinal tract. There is now increasing understanding of the role of Ghrelin in control of apetite and satiety. Energy intake and expenditure are controlled by complex mechanism. There is ever expanding knowledge about glucagon like peptide 1 (GLP1) and gastrointestinal inhibitory peptide (GIP) in glucose homeostasis. In addition other hormones like amylin, cholecystokinin, peptide YY, leptin, adiponectin also play an important role in weight regulation. The precise borders between what constitutes metabolic surgery and what is bariatric surgery are not clear. This paper will attempt to lucidly bring out the role of various hormones and their affect on maintenance of appetite, energy expenditure, weight gain and glucose homeostasis to better understand the concept of Diabesity.

Presenter: A.A. Warsi Co-authors: E. Van Dessel, F. Goudsmedt, F. Akin, S. Van Cauwenberge, B. Dillemans AZ Sint Jan AV, Belgium Background Up to 15 % of RYGB fail to loose 50 % of excess body weight or experience weight regain after 18 months, and are deemed to have failed surgery. Revisional procedures following RYGB help achieve the target excess body weight loss (EWL). Aims To analyse the short term outcome of AGB as a revisional procedure in a tertiary referral large volume centre after failed primary RYGB. Method Retrospective analysis of prospectively collected data on patients from Jan 2010 until Dec 2011, performed by one surgeon. Data was collected on demographics, operative details, complications, length of stay, and early %EWL. Results There was a total of 40 patients (2 males, 38 females), median age 44.1 years (24-68). The mean follow up was 13 (6-24) months. FU is complete at 1 year for 14 patients, at 18 months for 9 patients. The mean interval from RYGB to AGB was 4 years (range 1-12). There was no mortality. The 30- day morbidity included 1 re-laparoscopy for infected haematoma, 1 laparotomy for internal herniation and band slippage in the same patient. After 12 months there was 1 incisional hernia and 2 band slippages. Mean additional 21 % of EWL was achieved after band refill in the group of patients with follow up greater than 1 year. Conclusion AGB as revisional procedure for failed RYGB is feasible with good short to medium term results. O106 Incretin Levels and Control of Diabetes One Month After Laparoscopic Gastric Bypass Surgery in Non-obese Patients with type 2 Diabetes Presenter: Myung-Jin Kim Co-author: M. D., Kyung-Yul Hur, M. D., Ph. D. Institution: Department of Surgery, Soonchunhyang University, College of Medicine, Seoul, Korea

O107 Role of Gastro Intestinal Hormones in Obesity & Glucose Homeostasis Presenter: Sumeet Shah Max Super Speciality Hospital, India

O108 Towards Zero Infection in Bariatric Surgery Presenter: Sumeet Shah Max Super Speciality Hospital, India Infection is a major cause of morbidity and even mortality after surgery. Hospital and procedure related infections add to costs and have been approached as one of the major concern by World Health Organization (WHO) also in its campaigns - ‘Clean Hands – Safe Hands’ and ‘Safe Surgery, Saves Lives’. Bariatric patients have an even lesser expectation and tolerance for post operative infection as it is viewed as a procedure done for cosmetic benefit. There is also a high goal set by advent of minimal access techniques due to which the patient perceives the operation to be of a lesser magnitude. Despite best efforts, post operative infections are a reality with which all surgeons have to contend over a period of time. However, certain measures can be taken and strategies devised to minimize the wound complications, deeper infections and sepsis even further. These could be related to patient preparation, instrument sterilization, stricter OR controls and better use of antibiotics. This paper will discuss all these measures towards achieving a goal of zero infection in bariatric surgery. O109 Complications in 298 Consecutive Cases of Sleeve Gastrectomy Presenter: Dr. Deep Goel Co-author: Dr. Ravindra Vats, Dr. V.P. Bhalla BLK Super Speciality Hospital, India

Background Bariatric surgery is an efficient procedure for remission of type 2 diabetes (T2DM) in the morbid obesity. However in Asian countries, mean BMI of T2DM patients is about 25 kg/m2. Various data on patients undergoing gastric bypass surgery suggest that control of T2DM after surgery occurs rapidly and may not be wholly accounted for by weight loss. We hypothesized

Background laparoscopic sleeve gastrectomy is now established as a viable option in treatment of morbid obesity. In the Indian context it is the commonest bariatric option being performed. It is relatively easy to learn and do. Complications are reported in 1-3 %of patients undergoing the sleeve gastrectomy.

1340 Though infrequent they present a formidable management challenge when they occur. We present our experience with complications occurring in our series of 276 sleeve gastrectomies. Patients and Methods Sleeve gastrectomy was performed in 276 patients with morbid obesity from June 2007 to February 2012. There were 92 males and 184 females. A standard surgical procedure as described by Ren et al with minor modifications was used. All patients had protocolised post-op management. Retrospective analysis of case sheets and review of operative videos was done to record – 1-Intra op bleeding requiring means other then harmonic control 2-Intra op events -considered complications 3-Immediate post-op complications The commonest sites of bleeding were

& & & &

High gastric vessels cases-3 % Spleenic capsular tear -2 % Serosal vessels or stomach wall -13 % Suture line bleeding -82 %

Intra-op complication were classified as % of case with bleeding requiring blood transfusion- 3 cases (1.08 %) % of case with leaks as demonstrated by insuffulator and dye test –None % of cases with misfiring stapler with absence of staples on one side- one case (0.2 %) In one patient there was narrowing of GE junction which was noted preoperatively. Pouch was created from the remaining part of fundus and gastric bypass was done. There was injury in the lower part of esophagus while doing leak test through bougie in one patient. In one patient there was persistent ooze from the splenic bed for which splenectomy was done Immediate post-op complications:

& & & & & & & & &

Bleeding necessitating re-exploration – 1.08 % Bleeding necessitating Blood transfusion -1.08 % Leak- 0 % Pulmonary embolism - 0 % Delayed complication Surgical – None Metabolic have not been included in this paper. Intra-op mortality –None Immediate post op mortality- one.

Conclusion Laparoscopic sleeve gastrectomy is a useful primary bariatric procedure. Our experience shows that the procedure can be performed with low complication ratein a unit dedicated to advanced laparoscopic work. O110 Incidence of Clinically Symptomatic Cholelithiasis After Bariatric Surgery Presenter: Ismael Court Co-authors :Juan E. Contreras MD, Pablo Marin MD, Ismael Court MD, Jorge Bravo MD, Gustavo Czwiklitzer MD, Percy Brante MD,James Hamilton MD Section of Bariatric& Metabolic Surgery. Bariatric Surgery Department. Clinica Santa Maria. Santiago Chile. Background Obesity alone and rapid weight loss induced by bariatric surgery could be a risk factors for the development of symptomatic Cholelithiasis. The decision to perform prophylactic cholecystectomy at the time of bariatric operations, is still not clear. Aim Describe the incidence of clinically symptomatic cholelithiasis (suggestive clinical presentation and confirmation by some method of image) after bariatric surgery. Methods Retrospective descriptive study. 268 patients from 2009 to 2010 underwent Roux-en-Y gastric bypass (RYGBP) or Laparoscopic Sleeve Gastrectomy (LSG) in Clinica Santa Maria, Santiago, Chile. We determinate the incidence of syntomatic cholelitiasis after surgery. Maximum of 36 months follow up. Results 8,2 % (22) of patients have had cholecystectomy before bariatric surgery. 5,6 % (15) of patients underwent cholecystectomy simultaneously with bariatric surgery because they had preoperative ultrasound positive for cholelithiasis. 231 patient followed. 14,3 % (33) had

OBES SURG (2012) 22:1315–1419 symptomatic cholelitiasis during the follow up. The diagnosis was by ultrasound in the 66,6 % of patient. The main weight loss at the time of diagnosis was 26 kg (57,3 lb). The main time between the surgery and the diagnosis was 13,9 months. There were not major differences between both surgical techniques. Conclusion This study shows a 14,3 % incidence of symptomatic cholelithiasis after bariatric surgery. It is necessary more information to determine predictive risk factors for gallstone formation and the best moment to search them after surgery, in order to avoid symptomatic episodes. O111 Clinical Characteristics of Postoperative Peritonitis Following Bariatric Surgery Presenter: Pierre Fournier Co-author: P. Montravers, G. Dufour, , C. Muller, R. Bronchard Jean-Pierre Marmuse Bichat Claude Bernard University Hospital, Department of General Surgery, Paris 7-Denis Diderot Paris, France Background Few data are available on postoperative peritonitis (POP) following bariatric surgery. We report the clinical, microbiologic and outcome characteristics of an ICU cohort (2000-08) of morbidly obese patients (pts) admitted for POP. Methods Demographic data, surgical characteristics, severity at the time of diagnosis and microbiologic results were collected. Mortality and morbidity (reoperation, duration of mechanical ventilation, ICU and hospital stay) were noted. Results are presented as median (extremes) or proportions. Results 31 pts (19 (61 %) female, 45 (26-58) year old, 140 (100-185) kg) were admitted in a median delay of 10 days after gastric banding (n 014), by-pass (n 014) or sleeve gastrectomy (n 03). None of them had underlying disease, 29 % had diabetes, and 48 % received antibiotics (AB) at the time of reoperation for a median of 3 days (d). Relaparotomy was made in a delay of 10 d after initial surgery and reported mainly suture leakage (n 014) or bowel perforation (n 012). On the day of relaparotomy, SAPS II score was 42 (13-97), SOFA 8 (1-18), 68 % of the pts received vasoactive support, 61 % had a PaO2/FiO2 ratio 300 mol/L. 71 % of the pts had a polymicrobial infection yielding mainly streptococci (n 021), fungi (n 010) and enterobacteriaceae (E. coli n 07). Empiric AB consisted in combination in 87 % of the cases (pip-taz n 023, aminoglycosides n 021, fluconazole n 018, vancomycine n 013) and was judged adequate in 22 (71 %) pts. An immediate favorable outcome was reported in 11 (35 %) pts while 18 (58 %) pts required subsequent reoperations (1-7 additional operations). The duration for AB therapy was 10 (1-18) d, mechanical ventilation 11 (0-49) d and ICU stay 19 (1-59) d. Overall, 10 (32 %) pts died in a delay of 11 (1-49) d. Conclusions POP following bariatric surgery are characterized by high morbidity and mortality rates in young pts with few underlying disease. The organisms cultured from the surgical samples are close to the oropharyngeal flora but Gram negative bacilli and fungi require combination therapy until identification and susceptibility testing are available. Keyword (Complete): peritonitis ; health-care related infection ; morbid obesity O112 Acute Improvement in Insulin Resistance After Laparoscopic Roux-en-Y Gastric Bypass: are 3 Days Enough to Correct Insulin Metabolism? Presenter: Gil Faria Co-authors: John Preto, Eduardo Lima da Costa, Ana Beatriz Almeida, Jose´ Costa Maia, Joa˜o Tiago Guimara˜es, Conceic¸a˜o Calhau, Anto´nio Taveira-Gomes Department of Surgery, Faculty of Medicine, University of Porto, Portugal Background For overt type 2 Diabetes Mellitus (T2DM) to establish, both insulin resistance and B cell dysfunction are required. Although the medium to long-term improvement in insulin resistance and T2DM after RYGB are well documented, few studies have analyzed the acute effects after this surgery. Understanding these effects might help to explain some of the physiologic adjustments after surgery and help in managing

OBES SURG (2012) 22:1315–1419 insulin resistance states and controlling the hypoglycemic treatment for bariatric patients. Methods We recruited a prospective cohort of 55 consecutive female patients that underwent primary laparoscopic RYGB between January and June 2011. Blood samples were collected preoperatively and at the 1st, 3rd and 5th postoperative days after an overnight fast. We evaluated the glycemic profile and insulin resistance. Results After Gastric Bypass, there is a significant increase in HOMA-IR on day 1 (2.36 vs 3.12; p 0.032), followed by a rapid decrease from day 3 forward (3.12 vs 1.70; p <.001). There was a statistically significant difference (p< .05) at all time-points compared with baseline. HOMA-IR levels at day 5 were not significantly different from values at 6 months (1.24 vs 0.93; p0.09). By day 5 after surgery HOMA-IR had lowered 47 % of its baseline value. The blood levels of glucose and insulin closely matched those of HOMA-IR. We could observe an increase in the 1st post-operative day followed by a decrease until the 5th day. The values of blood glucose and insulin at the 6th post-operative month were not different from the values at day 5. Conclusion RYGBP results in a rapid improvement in insulin resistance and a clinically significant decrease in the fasting glucose and insulin levels. This improvement is significant at the 3rd post-operative day and by the 5th day patients express insulin resistance levels that are similar to those expressed 6 months after surgery. This work highlights the acute metabolic impact of surgery; and understanding the behavior of insulin and glucose after surgery might improve our knowledge of the pathophysiology of diabetes and lead to novel therapies and tailored surgical approaches. O113 Evaluation of 372 Patients Submitted to Sleeve Gastrectomy in 2 to 10 Years of Follow Up , Considering Weight Loss and Co-morbidities Presenter: Antelmo Sasso Fin Co-author: Flavia Cruz Franca Sasso Fin, Gibran Sassini, Brazil Objective To analyze the effect of Sleeve Gastrectomy (SG) in 372 patients, considering weight loss and co-morbidities. Material and Methods Were analyzed 372 patients (102 males and 250 females), submitted to SG since 2002 until 2012.The BMI (Body Mass Index) range: from 31 to 65 kg / m, average of 41 kg / m. The age range: from 15 to 72 years, the average of 32 years. Co-morbidities: Sleep Apnea 3 % (11 patients), Diabetes Type 2/Insulin Resistance(DM II) 12 % (44patients)without insulin use, Orthopedic Problems 15 %(56 patients) ,Gastroesophageal Reflux (GERD) 22 % (82 patients) evaluated by upper GI, Systemic Arterial Hypertension (SAH) 25 % (93 patients). Results The weight loss was a progressive range from 70 % to 100 % of the excess weight, average of 89 %; after 2 years 35 % of patients regain 5 to 7 % of initial weight and stabilized. The co-morbidities results were: DM II (without insulin use) remised in 100 % of cases. SAH normalized in 71 patients (76 %). The GERD was 15 % (56 patients) in the post-op but only 8 % of initial group (30 patients) had GERD before the surgery, so 52 (14 %) patients that had GERD before the surgery were cured of GERD. Conclusions The SG could sustain the weight loss after 5 years. There was 100 % in control of DM II in patients undergoing SG. The treatment of SAH was improved. The GERD didn’t present relationship with the SG in this group, some patients were cured and the others presented GERD after the SG. O114 Glucose Metabolism Status in Patients with Morbid Obesity Before and After Gastric Bypass

1341 impaired glucose tolerance (IGT), 42 % - impaired glycaemia (IG), 22 % - type 2 diabetes (TD 2). In NGT group mean fasting glucose was 5,2+0,3 mmole/L, while fasting insulin was 28,8+2,5 IU/mL (normal - 8,6 IU/mL) and C-peptide – 3,9+ 0,3 ng/mL(p<0,01). Insulin and C-peptide levels were significantly increased in 99,4 % of patients. In type 2 diabetes group mean fasting glucose was 11,2+1,2 mmole/L, fasting insulin 26,6+0,3 IU/mL, C-peptide – 3,2+0,5 ng/mL (p<0,01). Results At 5 years of follow-up 29 % of all patients had NGT, 31 % - IGT, 36 % IG, 4 % - TD 2. In NGT mean fasting glucose was 5,1+0,1 mmole/L, fasting insulin 8,1+ 3,6 IU/mL, fasting C-peptide - 1,8+ 0,8 ng/mL. In TD 2 group fasting glucose was 6,1+0,3 mmole/L, fasting insulin 12,8 +0,7IU/mL, fasting C-peptide - 1,4+ 0,6 ng/mL (p<0,01). . Conclusions Gastric bypass provides significant glucose metabolism improvement. In NGT group fasting glucose, insulin and C-peptide normalized. In TD 2 patients fasting glucose normalized , fasting insulin and C-peptide decreased in comparison to preoperative levels. O115 Multivariate Analysis of Factors Predicting Successful Discharge Within 23 hours of Laparoscopic Bariatric Surgery Presenter: Menon A, Co-authors: Al-Rashedy M, Thawdar P, Akhtar K, Senapati PS, Ammori BJ Department of Obesity and Metabolic Surgery, Salford Royal Hospital, Salford, UK Introduction Ambulatory bariatric surgery (23-hour stay) has been advocated to cope with increased demand, but there are no guidelines stating which patients are suitable. This study aims to identify predictive factors associated with successful ambulatory stay, in order to improve patient selection. Methods A retrospective analysis was performed on patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric banding (LAGB) between October 2008 and January 2012 at our institution. Multivariate logistic regression was used to identify factors predicting successful discharge within 23 hours of surgery. Patient demographics, preoperative body mass index, procedure type, comorbidities, and operating time were used as independent covariates. Results: are presented as odds ratios (OR) and 95 % confidence intervals (CI). Results 548 patients underwent laparoscopic bariatric surgery during the study period. 28 % of patients were successfully discharged within 23 hours (27 % after LRYGB, 32 % after LSG, and 52 % after LAGB), but this was significantly lower in diabetics (22 % vs. 50 %, p<0.001). Multivariate analysis confirmed diabetes to be an independent predictor of unsuccessful 23 hour discharge (OR 0.53, 95 % [CI] 0.32-0.87, p00.013), and LAGB of successful discharge compared to LRYGB (OR 2.69, 95 % [CI] 1.116.53, p00.028). However, the incidence of diabetes was significantly lower amongst patients who underwent LAGB compared with LRYGB (19 % vs. 50 %, p<0.001). Discussion Non-diabetic patients can be selected for ambulatory laparoscopic bariatric surgery, and more so if they were undergoing LAGB. The association of diabetes with longer stay could be addressed with better coordination of clinical services to manage altered postoperative glycaemic control. O116 Results of Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) in Asian Type-2 Diabetes Mellitus patients with BMI <32

Presenter: Lavryk A., Co-author: Lavryk O., Dmitrenko O.

Presenter: AKH Eng, Co-authors: CK Huang, CH Lo, A Shabbir, R Goel, PC Chang, S Pattanshetti, N Chhabra

National O.O. Shalimov Institute of Surgery and Transplantology, Ukraine

E-Da Hospital, Singapore

Aim To evaluate gastric bypass effect on glucose metabolism in patients with morbid obesity. Materials and Methods 45 patients during 2001 – 2009 survived Fobi-Capella gastric bypass. Observation period: 5 years. Before procedure mean body weight was 150,7+24,2 kg, BMI - 51,04+9,2 kg/m2. OGTT results: 14 % of patients had normal glucose tolerance (NGT), 22 % -

Background The Asian criteria for bariatric surgery includes patients of BMI >32 with associated comorbidities. The last 5 years has seen the emergence of metabolic surgery in patients who do not fulfil these BMI criteria. We report our experience in patients with BMI 32. Methods Between December 2007 and November 2011, 84 patients with Type-2 diabetes mellitus underwent LRYGB in our IRB-approved clinical

1342 study. All patients underwent preoperative evaluation by a surgeon, endocrinologist, dietitan, psychiatrist and physiotherapist. Results There were 32 males and 52 females with average age of 46 (16-68) years. Preoperative BMI was 27.6±2.9. Preoperative HbA1c was 9.49 %± 1.72 %. Operative time was 99±53 minutes and length of stay was 2±2 days. Median excess weight loss at 12, 24, 36 and 48 months was 106 %, 102 %, 101 % and 99 %. Average postoperative BMI was 22.3, 22.8, 22.9 and 23.0 respectively. At 12 months, 56.5 % of patients achieved diabetes remission (HbA1c< 6.5 %).The average postoperative HbA1c at 6, 12, 24 and 36 months was 6.7 %, 6.6 %, 6.9 % and 6.0 % respectively. Other comorbidities such as hyperlipidemia also showed improvement. There were 4 complications: leak (1), bleeding (2), stricture (1). One patient had malnutrition which was treated with additional dietary supplements. There were no mortalities. Conclusion Patients with BMI 32 benefit from LRYGB with remission or improvement of diabetes. This is achievable without excessive weight loss or morbidity. Randomised trials with medical control arms are required to confirm and delineate the extent of benefit from LRYGB. O117 Laparoscopic Gastric Bypass as a Revisional Procedure for Gastric Staplings: A Single Centre Experience and Some Lessons Learnt Presenter: Mr Arun Dhir, FRCS, FRACS, Co-authors: Mr. S Blamey, FRACS, FACS, Mr Z Dubrava, FRACS Monash Medical Centre, Melbourne, Australia Background Australia has seen a large number of modified gastric stapling cases in the pre1990 era. The procedure was done as an open operation involving, stapling one third of the length of stomach parallel to the lesser curve from the angle of His. At the lower end of this staple line, three Ethibond (Johnson & Johnson) sutures were used to prevent pouch dilatation and provide restriction. While this procedure provided good results in majority in the short term, several complications/failures were noted in the long term. Most notable were weight regain due to gastro gastric fistulation caused by staple line breakdown and stomal stenosisleading to either excessive weight loss or maladaptive eating habits. We present our experience of 18 patients who had gastric stapling revisional surgery for above complications. Method: Eighteen patients of gastric stapling were operated between 2010 to April 2012. Two patients were revised to lap gastric band while the other 16 had a gastric bypass. Brief video highlighting our technique and some tricks to reduce chances of leak,in light of a revisional procedure, would be presented. None of the patients had a gastrostomy tube for distalstomach venting. Results 16 patients underwent laparoscopic revisional gastric bypass for a failed gastricstapling operation. Technical modifications included careful attention to pouch formation, stapleline reinforcement and resection of the scarred segment of stomach. No gastrointestinal leaks were reported. Conclusion Resectional gastric bypass remains a proven technique for failed gastricstapling.The procedure has a steep learning curve and experience in primary gastric bypass is essential before embarking on these cases. O118 Laparoscopic Removal of Poor-Outcome Gastric Banding with Concomitant Sleeve Gastrectomy: A Comparative Study Presenter: Aayed R. Alqahtani, MD1, Co-authors: Mohamed Elahmedi, MBBS2, Hussam Alamri, MBBS2, Valerie A. Zimmerman, PhD2, Ali M. Ahmed, MD3, Rafiuddin Mohammed, Msc4 1

Associate Professor and Director, Obesity Chair, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia;2Research Associate, Obesity Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia;3Assistant Consultant Pediatric Surgeon, King Fahd Medical City, Riyadh, Saudi Arabia;4Researcher, Obesity Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia Introduction There are few reports of the safety and effectiveness of laparoscopic removal of gastric banding with concomitant sleeve gastrectomy (Redo). Accordingly, we compared outcomes after Redo with

OBES SURG (2012) 22:1315–1419 those following laparoscopic sleeve gastrectomy (LSG) as a primary procedure. Methods We retrospectively reviewed records of 36 patients who underwent Redo and 128 who had LSG as a primary procedure, performed by a single surgeon between March 2008 and January 2012. Results Redo and primary LSG patients preoperative age was similar (mean age 34.7±10.3 years vs. 33.6 ±9.0 years; p00.29). Redo patients had a significantly lower BMI at the time of surgery, mean BMI 43.3±7.1 kg/m2 vs. 47.8±8.2; (p<0.01). Redomean operative time was significantly higher, 137± 37 minutes vs. 99±30 minutes; (p<0.01). Complications in 2 (5.5 %) Redo patients included 1 pneumonia and 1 wound infection. Complications in 9 (7.0 %) primary LSG patients included 1 leak (reoperated), 1 pulmonary embolism, 2 staple line bleeds, 2 pneumonia cases, 2 nausea and vomiting and 1 wound infection. All patients recovered uneventfully and there were no mortalities in either group. Mean excess weight loss 3, 6, 12 and 24 months after Redo was 30.5 % (n024), 48.4 % (n018), 66.4 % (n014) and 80.1 % (n012), compared with 33.3 % (n075), 53.9 % (n061), 71.9 % (n085) and 84.6 % (n023) after primary LSG (p>0.05). Conclusion Complications and weight loss outcomes after Redo are similar to when LSG is a primary procedure. LSG produces safe and excellent weight loss results when performed in concomitance with removal of failed gastric banding. O119 Management of Staple Line Leaks After Laparoscopic Sleeve Gastrectomy: Ultimate Challenge in Bariatric Surgery. The Experience of a Leading UK Centre Presenter: 1. Adamo M, 2. M ElKalaawy, 1. Co-authors: A Rotundo, M ElKalaawy, M Banks, K Dawas, M Hashemi, M Mughal, A Jenkinson, M Adamo 2. M ElKalaawy, A Rotundo, R Batterham, Y University College Hospital, London and Medical Research Institute, Alexandria. Egypt Laparoscopic Sleeve Gastrectomy (LSG) is rapidly gaining popularity as a “stand-alone” bariatric procedure. Weight loss and comorbidity resolution compares well with gastric-bypass. LSG creates a high pressure system in the stomach that isresponsible for resistance to the treatment of staple-line leaks with prolonged hospital stay and increased mortality. Methods 10 LSG patients were treated for leaks between October 2007 and March 2012; 7 had LSG carried out in our Institution, 3 had surgery elsewhere. Mean age was 43 years (range 20-66 years), preoperative BMI 48Kg/m2 (range 40-59Kg/m2), M/F ratio 3/7. Overall incidence of staple line leaks after LSG in our Institution was 1.5 %. Results 5 patients had early-leaks (EL) between 2-5 days postoperatively; 5 patients had late-leaks (LL), between 21-41 days postoperatively. Six patients (4EL and 2LL) were acutely unwell and treated surgically. Four patients (1EL and 3LL) were managed non-surgically. Multiple repeated surgical and/or non surgical procedures were necessary for patients suffering persistent leakage. Surgical procedures included: laparoscopy and washout, laparotomy with washout and laparotomy/completion gastrectomy plus Roux-en-Y reconstruction. Non surgical procedures included: endoscopic clipping with over-thescope-clip, endoscopic stenting across the OGJ, percutaneous CT-drainage and enteral/parenteral nutrition (Table). Management was initiated within 12 hours from the clinical diagnosis of the leak. Cumulative length of stay ranged between 5-80 weeks with 3-11 admissions per patient. One patient (EL) suffered CVA with neurological sequelae. There was no mortality. Conclusions Leaks after LSG are uncommon but challenging; completion gastrectomy may be ultimately required. Early intervention is vital in acute patients to avoid fatalities. O120 Remission of Type ll Diabetes in Obese Patients After LSG and LRYGB Predicted by Perioperative Glucose Measurements Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom Ability to predict diabetes remission after bariatric surgery have implications for postoperative care, aid in choosing surgical procedure and help plan metabolic surgery for DM.

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Case records of 242 consecutive morbidly obese type 2 diabetics who underwent gastric bypass or sleeve gastrectomy from Jan 2006 to Dec 2011 were analysed . 202 patients had the complete data set . Unremitting diabetes was confirmed if they were still on hypoglycaemic medication, fasting plasma glucose(FPG) remained >7 mmol/L; or HbA1c remained>7 %. There were 161 LRYGB patients, 24 antral stunting sleeve gastrectomy (AStLSG) patients and 17 antral sparing sleeve gastrectomy(ASpLSG) patients. Diabetes remitted in 83.8 %, of LRYGB and 89 % of AStLSG(single stage) patients. Further 11.2 % of LRYGB & 5 % of AStLSG patients had glycemicimprovements. 62.3 % of ASpLSG patients had remission of diabetes and a further 12 % had improvements in glycemic control. Preoperative blood glucose level was lower after dieting in remitting diabetics(7.4±1.2; p-<0.05) vs. unremitting diabetics(12.1±1.1). No difference in Intraoperative blood glucose levels was observed between groups(10.72±0.5206)vs.(9.643 ± 0.8065). However, postoperative blood glucose levels were significantly lower for remitting diabetics (7.3 ±0.45;p-<0.01) vs. unremitting diabetics (11.22 ±1,1) . ANOVA analysis revealed 3rd postoperative day glucose level to be statistically lower for remitting diabetes (p-0.01). Duration of Diabetes was shorter for remitting diabetics vs. unremitting diabetics(5.9 vs.11.4; p-<0.005). Waist circumference appears to be smaller for those who achieved remission(133.3 vs.156.4 cm;p-0.009). Perioperative blood glucose measurements, duration of diabetes and waist circumference of diabetics appear to have predictive value in remission of diabetes.

effectiveness as a single stage procedure. We compared outcomes of antral stunting (AStLSG) (single stage procedure in patients with BMI range 3552 kg/m2) vs. antral sparing (ASpLSG) (part of two staged Duodenal switch in patients with BMI over 60 kg/m2)LSGs A retrospective analysis of LSGs performed by single surgeon between January 2006- Jan2012 was undertaken. In ASpLSG group of patients the division of stomach starts at 6 cm from pylorus and 36ch oro-gastric tube was used, in AStLSG group dissection started at 2 cm and 30ch oro-gastric tube was used for calibration. AStLSG patients mean age-31.5 yrs; sex M:F-102: 401, ASpLSG, age, 44.5 yrs, M-24;F-36 Mean operating time was 93.9 min (range040–140). Mean length of hospital stay was 2.2 days (range02–7).AStLSG patients (n0503) achieved significantly better weight loss at one year compared to ASpLSG patients(n 074) with %excess weight loss 58.23±17.59 % vs. 36.34 ±12.43 %,p < 0.005). DM, hypertension & OSA resolved in 62 %,65 % & 91 % of AStLSG vs. 88 %, 71 % &100%ASpLSG).Further follow up of AStLSG patients revealed 82 % (range 54-96 %) excess weight loss at 2 years(n0138) and 88 % (range 72 %-100 %) at 4 years (n078) Postoperative mortality one in each group, both related to sleeve rupture/leak, other complications included significant bleeding was encountered 3 & 1 %.. Our results suggest AStLSG is effective, safe single-stage bariatric surgical procedure for treatment of obesity. Long term efficacy is yet to be established.

O121 Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass - a Randomized Prospecitve Trial

O123 Complications of Laparoscopic Adjustable Gastric Banding: 10-year Experience

Presenter : Piotr Kalinowski1 Co-author: Rafa Paluszkiewicz1, Piotr Remiszewski1, Tadeusz Wro´blewski1, Janina Biaobrzeska-Paluszkiewicz 2 , Bogna Ziarkiewicz-Wro´ blewska 3 , Mariusz Grodzicki1, Marek Krawczyk1

Presenter: Kee Yuan Ngiam, Co-authors: Ganesh Ramalingam, Anton KS Cheng, Khoo Teck Puat Hospital, Singapore

1

Medical University of Warsaw, Department of General, Transplant and Liver Surgery, Warsaw, Poland, 2Food and Nutrition Institute, Warsaw, Poland, Medical University of Warsaw, Department of Pathology, Warsaw, Poland

3

Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass a randomized prospecitve trial Piotr Kalinowski1, Rafał Paluszkiewicz1, Piotr Remiszewski1, Tadeusz Wro´ blewski 1 , Janina Biaobrzeska-Paluszkiewicz 2 , Bogna ZiarkiewiczWro´blewska3, Mariusz Grodzicki1, Marek Krawczyk11Medical University of Warsaw, Department of General, Transplant and Liver Surgery, Warsaw, Poland2Food and Nutrition Institute, Warsaw, Poland3Medical University of Warsaw, Department of Pathology, Warsaw, Poland Background RYGB is a well established bariatric prcedure of restrictive and malabsorptive nature and LSG is a restrictive procedure that is becoming more and more popular recently. A randomized, prospective trial was conducted to compare these two procedures with focus on glycemic control and lipid metabolism. Methods 72 patients were included in the study and randomized into two treatment groups of 36 patients each. The intervention was RYGB in one group and LSG in the other and the follow-up period was at least 12 months. The data were collected at baseline and at 6 and 12 months after the surgery and included assessment of body weight, weight lost (%EWL), body mass index (BMI), fasting glucose (FPG), insulin, glycated hemoglobin (HbA1c), cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL) and estimation of low density lipoprotein (LDL) and homeostatic model assessment (HOMA) index. Results Weight loss was significant after RYGB and LSG. Both procedures caused a significant improvement in FPG, HbA1c and TG (p<0.05) but not HDL. RYGB influenced significantly insulin and HOMA insulin resistance index. Conclusion Both procedures lead to significant weight loss and improvement in TG, HDL, FPG and HbA1c (p<0,05). RYGB caused improvement in all of the studied parameters. LSG caused not significant increase in TC and LDL and not significant improvement in insulin and HOMA index (p0ns).

Background Laparoscopic adjustable gastric banding is associated with a unique set of complications. From 2001-2011, we have performed 371 laparoscopic adjustable gastric bandings for morbidity obese patients in Singapore. We describe the management of the complications arising from gastric banding. Methods Patient data was prospectively collected and the patients were followed up at the Weight Management Clinic. Patients who have been lost to follow-up were actively contacted by telephone and electronic means. Operative data was collated from operative notes and interviews with the surgeons. Results 26.0 % of patients who underwent laparoscopic adjustable gastric banding developed complications with 2 mortalities (0.5 %). Of the patients who had complications, 22.4 % had band prolapse, 19.4 % band erosion, 9.2 % band leak, 27.6 % dilated oesophagus, 22.4 % tubing/port related problems, 2.0 % gastric leak and 11.2 % infectious complications related to band/port. 31 patients (31.6 %) needed a second operation for related complications with 3 Roux-en-Y gastric bypasses, 5 having laparoscopic sleeve gastrectomies, 1 laparoscopic biliary-pancreatic diversion and 22 having other minor procedures like band removal, new band insertion, suturing of band, change of port and trimming of lap band tubing. Overall, 51 % of all patients who had the LAGB procedure have a band in place on long term follow up (including re-inserted bands). Conclusion Laparoscopic adjustable gastric banding is associated with unique complications that require subspecialty management to ensure minimal long term sequelae and continued weight loss. This would ensure that patients achieve their intended weight loss outcomes despite complications of the initial surgery. O124 Novel Metabolic Surgery: Loop Duodeno-Jejunal Bypass with Sleeve Gastrectomy for The Treatment of Type 2 Diabetes Mellitus: Preliminary results

O122 Antral Stunting Sleeve Gastrectomy Achieves Superior Weight Loss Compared with Antral Sparing Sleeve Gastrectomy

Presenter: Chih-Kun Huang Co-authors: Po-Chi Chang, Ming-Che Hsin, Rajat Goel, Satish Pattanshetti, Navdeep Chhabra, Sanoop Zachariah , Andrea Ooi

Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia

Bariatric & Metabolic International Surgery Center, E-Da Hospital, Taiwan

Homerton University Hospital NHS foundation Trust, United Kingdom Laparoscopic sleeve gastrectomy (LSG) was originally used as a bridge to definitive surgery in high risk patients. However, recent data support its

Background Loop duodeno-jejunal bypass with Sleeve gastrectomy (LDJBSG) is a new surgical procedure in treating type II Diabetes Mellitus, combining sleeve gastrectomy and single-anastomosis of duodenojejunal bypass. We reported the preliminary surgical results of this prospective study.

1344 Methods From Oct 2011 till April 2012, totally 22 patients receiving LDJB-SG were enrolled in this study. The procedure combining duodenal exclusion, bypassing proximal jejunum and sleeve gastrectomy (SG), by leaving 100 mL gastric tube and joining 200 cm of jejunal loop to first part of duodenum with side to side (functional end to side) anastomosis. Results 10 men and 12 women with a mean age of 49.7 (33-64) years and a mean BMI of 28.3 (21.8-38.8) kg/m2 were evaluated. 16 patients’ BMI were less than 30 and preoperative insulin injection was found in 4 patients. Duration of diabetes was 7.4 years in average (1-20) and mean HbA1C was 8.3 % (6.1-12.5). Average operation and hospitalization times were 131.1 (86-210) minutes and 1.1(3-7) days, respectively. There were no intraoperative complications or surgical mortality. There was only one patient developed stricture of gastric tube needed strictureplasty. Mean BMI and HbA1C at 1, 3, 6 months was 24.7, 22.7, and 22.6 and 7.26 %, 6.2 % and 5.4 % respectively. Conclusion LDJB-SG is a new metabolic procedure with few complications and superior glycemic control in this preliminary report. Long-term follow up will be essential to confirm it to be a standardized procedure. O125 Salavage Laparoscopic Gastric Bypass in Leaked Sleeve Gastrectomy : A Preliminary Experience, Double Trouble or no Trouble ? Presenter: M. Narwaria., Co-authors: M. Manisegaran Dept of Bariatric,metabolic,minimal access and Gastroenterology surgery, Asian Surgicentre, Ahmedabad, India Background Laparoscopic sleeve gastrectomy has been accepted as both primary and first stage or a bridge before a purely malabsorptive or a combined bariatric surgery procedure.Leak remains the most serious life threatening complication that increases both the morbidity and mortality. Conservative treatment in leak management requires prolonged hospitalisation to contain sepsis and establish a controlled fistula until fistula heals.Nutritional support requires an enteral or a parentral access which leads to increase in the hospitalization cost and delay in convalescence.We here in report our experience in doing a salvage laparoscopic gastric bypass in leaked sleeve gastrectomy as a defenitive treatment which reduces the need for prolonged hospitalization and early convalescence Methods In 520 number of Laparoscopic sleeve gastrectomy that we have performed between May 2004 to June 2011,we encountered 4 leaks, out of which in 2 patients we had performed a salvage laparoscopic gastric bypass for leak near the gastroesophageal junction form the basis of this study Results Four patients developed leak at 3,4, 5 and 8 th day postoperative period, Three patients readmitted after being discharged ,early leak is defined has those that presented before 7 days and late after 7 days. One patient presented with symptoms after 7 days after surgery. A CT scan was the method used to confirm leak in all patients. Two patients where managed by conservative treatment, among which one patient who had a controlled fistula was treated with prolonged nasojejunal tube feeding, in the other patient laparoscopic lavage and multiple drain with attempted repair at leak site was done who developed re-leak was manged by endoscopic treatment by placing a covered esophago gastroduodenal endoluminal stent. In two patients a rescue laparoscopic gastric bypass was done has a defenitive management. The leak closed in all the four patient with healing time ranging from 21 to 90 days for the patients managed conservatively and there was no re-leak in the patients managed by gastric bypass. Conclusions A persistent vague non-specific abdomnial symptoms after sleeve gastrectomy should not be neglected, a high index of suspiscion is required to rule out a leak after sleeve gastrectomy. Contrast enhanced CT scan is the best method to establish anastomotic leak .Early diagnosis and intervention is the key stone for effecient management and to avoid both morbidity and mortality. Aim of conservative(non-operative) is to establish a controlled fistula, sepsis control and nutritional support are corner stones in this treatment. Effective non-operative management defenitevely reduces the mortality but the morbidity is increased due to the long time taken for these fistula to heal. This leads to a prolonged hospital stay and delay in return to work. There is no doubt that Rescue bypass with serosal patch cover of the leak site with the jejunal limb is a major undertaking in this setting of early leaks ,but it appears to be a safe and a defenitive procedure in safe hands and in selected patients,for it reduces the hospitalization days and early return to work .

OBES SURG (2012) 22:1315–1419 Keywords Rescue/salvage gastric bypass.sleeve gastrectomy.leak.Morbid obesity.non-operative management.Defenitive management O126 Surgical Management of Diabesity –An Indian Perspective Presenter: Dr Mahendra Narwaria Co-author: Dr M.Manisegaran Dept of Bariatric, metabolic, minimal access and Gastroenterology surgery, Asian Surgicentre, Ahmedabad, India The advantage of Bariatric surgery apart from the non specific benefit of weight reduction the specific benefit of resolution of Type 2 Diabetes, this effect is independent of weight changes being proved by the early normalization of insulin action after surgery when body weight is still high (1).Baraitric surgery is an appropriate treatment for type 2 diabetes and obesity not achieving recommende treatment targets with medical theraphies, especially when there are associated ather co-morbidites ,it should be an accepted option in theses patients with BMI> 32.5. Weight loss causes lipid depletion of target cells particularly in the muscular tissue, with consequent return to glucose utilization as the energy source, and thus the disappearence of insulin resistance. It is a well established fact in the effective management of type 2 diabetes (independent of bariatric surgery) weight reduction is important for normal glycemic control with therapy by reducing the peripheral insulin resistance. It was the chance observation of loss of weight( 5-15 %) associated with improvement of diabetes mellitus following Billroth gastrectomy in a patient with carcinoma stomach paved the way for gastric bypass. Diabetes mellitus affects nearly 150 million people all over the world. This number may double by 2025 (4) and India will be the global capital for diabetes. The dramatic increase in the prevalance of obesity and diabetes is a global health issue .The problem is complex, and will require strategies at many levels to prevent ,control and manage. Obesity has increased exponentially throughout the world in the last few decades .It implies serious morbidity ,and decreased life expectancy and is a leading cause of preventable death in developed world .It is the type 2 diabetes that predominates in about 90 % cases and is associated with intolerance to Glucose and overweight .The treatment for this was based on a combination of dietetic-behavioral procedures and medical therapy with oral hypoglycemic and in more sever cases insulinotheraphy with variable success rate .At present evidence are in favour for bariatric surgery ,for the best control and also cure for type 2 diabetes in obese patients. Both the Restrictive procedures(Laparoscopic adjustable banding (LAGB),Laparoscopic Sleeve Gastrectomy (LSG ) and malabsortive procedures (Laparoscopic biliopancreatic diversion (LBPD),Duodenal switch(LDS),Laparoscopic BPD-DS ) Cause improvement or resolution of diabetes. The most common laparoscopic bariatric procedure Gastric bypass(LGBP) which is a combination of restriction and malabsortive procedure also causes resolution of diabetes and weight loss, Rapid and sustained glycemic control is achieved within days after gastric bypass even before significant weight loss .The complication of bariatric surgery include anastamotic and staple line leaks (3.1 %), wound infection (2.3 %), pulmonary events (2.2 %), and hemorrhage ( 1.7 %).These morbidities are lower after Laparoscopic surgery, which costitute a steadily increasing proportions of bariatric surgery . O127 Bariatric Surgery in Morbidly Obese Adolescents: Outcomes in a Single Center Presenter: Ronit Grinbaum Co-authors: Ido Mizrahi, Muhammad Ghanem, Ahmed Eid, Hadassah Mount Scopus University Hospital, Jerusalem, Israel Background We present our experience with bariatric surgery in obese adolescents at a single institute Methods Patients 18 years old underwent laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic gastric bypass (LRYGB) from 2002 to 2012. The percentages of BMI loss, improvement of co morbidities were analyzed with regard to the different procedures. Results A total of 60 patients aged 12-18 years underwent LAGB (29), LSG (27), and LRYGB (4). 41 (68.3 %) were females mean age 16.7±1.3. Mean preoperative weight and BMI was 127.7±20.3 kg and 45.7±6.8 kg/m, respectively. 14 (23.3 %) had preoperative co-morbidities, including DM type II 5 %,

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dyslipidemia 13.3 %, hepatic steatosis 40 %, HTN 10 %, OSA 3.3 % and osteoarthritis 1.7 %. One LAGB patient underwent a negative exploratory laparoscopy due to abdominal pain, and one LSG patient underwent exploratory laparoscopy due to bleeding. Of the 29 LAGB patients 9 (28 %) underwent revisional surgery. 4 repositioning of the band and one removal due to slippage, of which 2 eventually underwent LSG. 4 patients underwent revision to LRYGB due to intolerance and failure. Mean BMI at 1 year was 33.1±6.4 for all procedures (LAGB 33.9, LSG 31.6, and LRYGB 30). Comorbidities improved or resolved in all but one patient. Conclusion Despite the significant BMI reduction for all procedures, substantial number of LAGB patients had to undergo revisional surgery. In our experience, LSG as a treatment of obese adolescent patients is safe, with good short – mid term weight loss and resolution of co-morbidities.

latter required reoperation. Late complications were gastroesophageal reflux on 4 patients and 2 cholelitiasis. Excess weight loss (EWL) was month6 81.6± 24 %, year1 91.5±30 %, year2 86.8±32.2 %, year3 89.0±31.1 %, year4 81.3± 33.8 % and year5 76.6±24 %. At five years, 34(68 %) patients were located, of those five (14.7 %) did not reach an EWL>50 % and one patient required conversion to gastric bypass. In a LRYGB series matched by age, sex and gender 5-year EWL was 91.5±30.3 % (p<0.001). Conclusion LSG proved to be a safe and effective primary procedure for the morbidly obese with lower BMIs. LSG is inferior to gastric bypass in terms of excess weight loss, however it has lower morbidity rates.

O128 Sleeve Gastrectomy Versus Gastric Bypass for Type 2 Diabetes with a BMI Below 35 kg/m2

Presenter: Dr. F. Goudsmedt Co-authors: Dr. F. Akin, Dr. A. Warsi, Dr. S. Van Cauwenberge, Dr. B. Dillemans

Presenter: Jose Salinas Co-authors: Juan Pablo Ramos, Andrea Vega, Lissette Leiva, Fernando Crovari, Gustavo Pe´rez, Ricardo Funke, Alejandro Raddatz, Camilo Boza

AZ Sint-Jan Brugge-Oostende AV, Belgium

Pontificia Universidad Catolica de Chile, Chile Introduction An increasing number of new techniques designed specifically to treat type 2 diabetes mellitus (T2DM) in mild obese patients has arouse with confusing results in terms of safety and effectiveness. The objective of this study is to report the results of two standard bariatric procedures in T2DM patients with a BMI<35 kg/m2. Material and Method A review of our prospectively collected database was done for patients with T2DM and a BMI<35 kg/m2 submitted to laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2008 to 2012. Remission of T2DM was according to the consensus of ADA2009. Results A total of 121 LRYGB and 59 LSG cases were performed. There were no difference in preoperative age or BMI. Preoperative BMI was 32.8±1.6 and 32.3 ±1.4 kg/m2 for LRYGB and LSG respectively (p 0ns). There were 23(19 %) and 0 patients on insulin in LRYGB and LSG respectively. Early complications occurred in 7.4 % and 3.4 % after LRYGB and LSG respectively (p 0ns). In the LRYGB group after a median of 19 months HbA1c dropped from 8.2±1.8 to 5.8± 0.4. In the LSG group after a median of 14 months HbA1c dropped from 7.2(6.48.6) to 5.8(5.8-6.0). Complete and partial remission on follow-up was 71.7/24.2 % and 87.7/8.8 % for LRYGB and LSG respectively. Conclusion Standard bariatric procedures proved to be safe and effective in T2DM with a BMI<35. LSG achieved higher rates of remission probably because of preoperative selection bias. A randomized control trial is needed to see which procedure is more effective for this group of patients.

O130 Predicting Factors for Developing an Internal Herniation After Laparoscopic Gastric Bypass

Introduction Internal herniation (IH) is a significant source of morbidity after a laparoscopic Roux-en-Y gastric bypass (LGB). The diagnosis relies on a high degree of clinical suspicion and a low threshold for laparoscopic exploration. The aim of this study was to identify patients prone to develop an IH. Methods A retrospective review of all explorative laparoscopies between 2007 and 2011, in patients with a history of LGB, was performed. A control group was selected from a prospectively collected database of 6015 patients with LGB. Univariate and multivariate analysis were performed. Results Seventy-five patients with IH were included, 19 patients with intraabdominal adhesions and 8 patients with normal findings were excluded. The mean age before surgery was 33 years in the IH group versus 40 years in the control group (P<0.001). The average initial BMI was 38.4 vs 40.0 kg/m (P00.01) in the control group, the average maximum percentage excess weight loss (%EWL) was 88.5 % vs 79.6 % (P00.04). Twenty-four percent of patients with IH had previous surgery in the upper abdomen versus 7.3 % in the control group (P<0.001). Using logistic regression, a high %EWL (P00.006) and previous surgery in the upper abdomen (P<0.001) were identified as predictive factors for developing IH. Conclusion In this study we identified that young age, low initial BMI, a high %EWL and a history of surgery in the upper abdomen are independent predicting factors for the development of an IH. Identifying those risk factors can lead to a faster diagnosis leading to better patient care. O131 Does Gastrectomy Play a Role in Metabolic Control of Type 2 Diabetic Patients Submitted to Gastric By Pass? A Prospective Trial Presenter: Drs. E. Lanzarini, Co-authors: J.C. Molina, P. Cuevas, H. Lembach, I. Lara, L. Gutierrez , A. Csendes University of Chile Clinical Hospital, Chile

O129 Five-Year Results After Laparoscopic Sleeve Gastrectomy as a Stand-Alone Procedure for Morbid Obesity Presenter: Jose´ Salinas Co-author: Carlos Maldonado, Lissette Leiva, Andrea Vega, Alex Jones, Fernando Crovari, Ricardo Funke, Gustavo Pe´rez,Alejandro Raddatz, Luis Iba´n˜ez, CamiloBoza Pontificia Universidad Catolica de Chile Introduction Long-term results after laparoscopic sleeve gastrectomy (LSG) are usually in super-obese patients submitted as a first-stage procedure with modest weight loss. The objective of this study is to describe the long-term results of LSG in morbid obese as a primary procedure. Material and Method Non-concurrent cohort of 50 LSG cases operated between December 2005 to January 2007 in our institution. Follow-up was done using our prospectively electronic database, clinical charts, outpatient visits and phone interview. Results A total of 50 LSG cases were identified. Seventy percent were female, preoperative age and BMI was 36.5±12 years and 37.3±3.8 kg/m2. Comorbid conditions were arterial hypertension 30 %, insulin resistance 54 %, dyslipidemia 52 % and type 2 diabetes 4 %. Operative time was a median of 96 minutes. Hospital stay was 3(2-16) days. No conversion was required. Early complications were one patient with portal-venous thrombosis and 1 leak, the

Introduction The role of gastric resection in patients with type 2 diabetes (T2DM) submitted to bariatric surgery is under discussion. The aim of this study is to compare metabolic control results and BMI between patients submitted to laparoscopic conventional and resectional gastric bypass. Methods Prospective clinical trial with 50 patients with BMI between 25 and 35 kg/mt 2 and T2DM, divided in two groups. Group A were submitted to conventional RYLGBP, and group B to resectional RYLGBP. BMI and metabolic control parameters (glycemic level, glycated hemoglobin, Cpeptide, total cholesterol and triglyceride levels) were compared during a 2 years follow up. Results In the preoperative control, BMI was 30,3 and 30,5 kg/mt 2, glycemia 137 and 179 mg/dl, glycated hemoglobin 7 and 8,9 %, C-peptide 2,95 and 3,5 ng/ml, total cholesterol 199 and 207 mg/dl and triglycerides 227 and 356 mg/dl, for group A and B respectively. After a two years follow up, the average level of BMI was 22,8 and 24,6 kg/mt 2 for group A and B respectively, meanwhile glycemic levels reached 84 and 100 mg/dl; glycated hemoglobin 5,3 and 6,1 %; C peptide 1,3 and 1,5 ng/ml; total cholesterol 183 and 160 mg/ dl and triglyceride level of 86 and 130 mg/dl for group A and B respectively. None of these differences were statistically significant. Conclusion Resectional gastric bypass does not demonstrate significant differences in BMI and metabolic control in type 2 diabetic patients with BMI 25-35 kg/mt2 in comparison with conventional gastric by pass during a 2 years follow up.

1346 O132 Dyslipidemia Evolution After Bariatric Surgery. A Comparison Between Gastric Bypass vs Sleeve Gastrectomy at 5 Years of Follow Up Presenter: Nicola´s Quezada Co-authors: Alex Jones, Carlo Marino, Julia´n Herna´ndez, Aron Kuroiwa, Alex Escalona, Gustavo Pe´rez, Fernando Crovari, Ricardo Funke, Fernando Pimentel, Camilo Boza Digestive Surgery Department, Division of Surgery. Ponthifical Cattholic University of Chile. Satiango, Chile Introduction It is well known that bariatric surgery improves obesity related comorbidities. Nevertheless, long term evolution of dyslipidemia has not been extensively described. Aim To report the evolution of dyslipidemia of our historical bariatric surgery database comparing gastric bypass (GB) vs sleeve gastrectomy(SG). Methods Retrospective analysis of our database. Dyslipidemia was defined as standard criteria according to ATPIII. Lipid profile was analyzed at several points in the follow up period, then mean and SD was calculated. Also the % of dyslipidemic patients was calculated at each time. Results 70 % were female patients in each group. Initial BMI and post operative %EWL was similar for both groups. Data is presented comparing GB vs SG showing the % of dyslipidemic patients. Total Cholesterol: Preop: 45vs48, Month6: 6vs31, Month12: 15vs36, Month60: 31vs45. HDL Cholesterol: Preop: 26vs23, Month6: 4vs6, Month12: 4vs3, Month60: 5vs0. LDL cholesterol: Preop: 39vs49, Month6: 4vs21%, Month12: 9vs25, Month 60: 18vs36. Triglycerides: Preop: 47vs43, Month6: 10vs16, Month12: 8vs15, Month60: 20vs54. Conclusions Dyslipidemia reaches a high rate of cure at 6 to 12 months post op for GB and SG, nevertheless recurrence is high at long term follow up for both procedures. Sleeve gastrectomy has a good initial effect and it is maintained for HDL cholesterol, but the Total, LDL Cholesterol and Tryglicerides rise over time. Gastric bypass has a better control of dyslipidemia at long term follow up. O133 Laparoscopic Sleeve Gastrectomy with SPIDER. Technical Aspects and Learning Curve Presenter: Michel Gagner, M.D. FRCSC, FACS, University of Montreal, Canada Laparoscopic Sleeve Gastrectomy is rapidly becoming one of the preferred surgical interventions for weight loss Worldwide. It is classically performed with multiple trocars in the upper abdomen with a selected site for extraction of the fundus and left sided gastric body. In order to decrease the abdominal pain, potentially promoting a faster recovery, single trocar surgery in the umbilicus can be performed. The SPIDER Surgical System is a platform using flexible instrumentation (graspers and scissors) that permits a triangulation on the exposure of the greater gastric curvature and non-fencing instrumentation. Once inserted, mobilization of the greater curvature and exposure of the left crus is completed, and the MIDSLEEVE bougie is inserted with the distal balloon pointing towards the pylorus. Stapling is initiated lateral to the tube, approximately 4 cm from the pylorus with a green cartridge with bioabsorbable seam guard for the whole stomach. A methylene blue test eliminates a low probability of leaks, and suturing is usually not necessary. Extraction using the SPIDER is rapid and easy from the umbilicus. A series of 30 cases over 3 months has demonstrated a decline in operating time from more than >1 hour to 20-30 minutes in selected cases. The best patient for this procedure remains a female patient with no previous upper abdominal surgery and a BMI less than 50. Since 75 % of patients are female, it is likely that 2/3 of bariatric patients will benefit from such procedure in the near future. O134 Results of Bariatric Surgery In Patients with Body Mass Index <35 kg/m2 Presenter: Dr. A. Torres Co-authors: Dr. M. Torres, Dr. A. Torres, Md. Andrade A. Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed”, Ecuador Background Patients with obesity class I (BMI of 30-34.99), have predisposition to diabetes, hypertension and dyslipidemia. This study investigates the

OBES SURG (2012) 22:1315–1419 improvements of these co-morbidities in patients that had undergone a bariatric procedure. Methods After approval of an internal review board and with adhesion to the Health Insurance Portability and Accountability Act guidelines, a retrospective review was conducted of a prospective database of 42obese class I patients who underwent bariatric proceedings between 2008-2011. Levels of fasting glucose, glycosylated hemoglobin, lipid profile, weight and BMI were measured in preoperative andpostoperative periods. Results 30 women and 12 men participated, with a mean preoperative BMI of 33.9. Laparoscopic gastric sleeve was performed in 34 patients (81 %) and laparoscopic Roux-en-Y gastric bypass in 8 (19 %).Of these, 25 (60 %) had type 2 diabetes, 1 glucose intolerance, 27 (64 %) hypertension, 25 (60 %) dyslipidemia, 17 (40 %) sleep apnea, 8 (19 %) osteoarthritis. Postoperative findings revealed an average BMI of 26.5, with loss of weight of 41.4 pounds. From the 25 diabetic patients, 5 (20 %) got remission and 12 (48 %) improved their condition. The patient with glucose intolerance showed improvement. Of the 27 patients with hypertension, 9 (33 %) showed remission and 13 (52 %)improvement. In dyslipidemia 5 (20 %) showed remission and 13 (52 %) improvement. Obstructive sleep apnea was resolved in 10 (59 %) and improved in 1 (6 %). Osteoarthritis was resolved in 1 patient (12 %) and improved in 5 (63 %). Conclusion Bariatric surgery may significantly improve or resolve co-morbid conditions in patients with metabolic obesity class I. O135 Dissection of Small Vessels of the Gastric Fundus in Vertical Sleeve Gastrectomy Presenter: Dr. Torres JP. Co-authors: Dr. Torres M, Dr. Torres A, Md. Andrade A Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed”, Ecuador Introduction As in any surgery, complications can occur in 1 to 3 % of the patients; in between this range, ischemia of the upper pole of the spleen is seen in a 0.5 %, according to the literature, dueto section of short vessels in the gastric fundus. This makes the dissection of the gastric vessels appropriate at this level when necessary. Objective This study wants to demonstrate that the dissection of the short vessels during a sleeve gastrectomy on the gastric fundus is possible in certain cases, decreasing the risk of ischemia of the upper pole of the spleen. Methods We present a video of one of the 10 procedures we have performed so far, that shows dissection of the short vessels at the gastric fundus, especially those vessels which could cause significant ischemia. During the intra-operative period we can see that the spleen doesn´t change its appearance.. Conclusions Complications in a specialized team are uncommon, but it is always preferable not to have them. Short vessels dissection is very important since it would avoid significant ischemia of the upper pole of the spleen that could lead eventually to a splenectomy. O136 Hiatoplastia in Bariatric Patients with Gastroesophagealreflux Due to Hiatal Hernia. Our Results Presenter: Dr. Torres A. Co-authors: Dr. Torres JP, Dr. Torres A, Md. Andrade A., Dr. Max Torres Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed”, Ecuador Introduction Gastroesophageal reflux (GERD) ranges between 8 % to 26 % and is rising. A direct relationship between obesity and GERD is not established, however obesity is a predisposing factor, and losing weight is recommended for treatment of patients with GERD symptoms. Laparoscopy has allowed surgical treatment of both pathologies: GERD and obesity. Therefore hiatoplastia plus gastrectomyis recommended. Objective Presentation of short-term results of obese patients with GERD treated with laparoscopichiatoplastia and gastrectomy. Materials and Methods We performed a retrospective, observational, descriptive study of obese patients with GERD, treated with laparoscopic vertical gastrectomy and hiatoplastia between 2007-2010, including all obese patients with BMI over 30, candidates of vertical gastrectomy as bariatric treatment, who had symptoms of GERD despite normal upper gastrointestinal endoscopies.

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Results The study included 79 patients: 62.02 % female, 37.97 % male, mean age 43.6 years, with the following symptoms: regurgitation, heartburn, early satiety, atypical cough, halitosis and dysphagia, independent of the outcome of upper gastrointestinal endoscopy. Clinical diagnostic accuracy was 91.78 %.Average surgical time was of 107 minutes (range: 60-150’), dissection of the hiatus was performed, pulling down the esophagus into the abdominal cavity, with primary repair (hiatoplastia), vertical gastrectomy and fixation of the Hiss angle to left diaphragmatic pillar. Short term evolution: 3 patients with recurrent GERD symptoms and 2 with intense dysphagia. Conclusions It is possible to correct symptoms associated with GERD in obese patients, having 4.1%recurrence. Systematic preoperative assessment and experienced surgical group are required for a proper treatment planning and surgery.

February 2010 to March 2012. The percentage of excess weight loss, resolution of diabetes mellitus, other co-morbidities, and procedure related morbidity was studied. A non-matched comparison was performed with eight patients who underwent a (LRYGB) for similar indications in the concomitant period. Results It was seen that the percentage of excess weight loss and resolution of diabetes mellitus, hypertension, dyslipidemia, and other co-morbidities at the end of 1 year, after laparoscopic sleeve gastrectomy in NIDDM patients was comparable to that in published evidence. Conclusions Long-term studies are needed to evaluate the efficacy of LSG as a standalone procedure in the treatment of non-insulin dependent diabetes mellitus associated with morbid obesity in Indian patients.

O137 10 Years Outcome of Laparoscopic Gastric Banding in Super Obese Patients

O139 Gastric Bypass After Gastric Band Placement

Presenter: V. Frering Co-authors: D. Lazaridis

Presenter: JAV Carim Co-author: FB Carim, Quintanilla C, A Carestiato Day Hospital Our Lady of Lebanon, Nova Friburgo, RJ, Brazil

Unit of Bariatric Surgery, “Espace Medico-chirurgical” de la clinique de la Sauvegarde Lyon – France Background Laparoscopic adjustable Gastric Banding (LAGB) is effective in weight loss treatment, as well as being a minimally invasive method, totally reversible and adjustable to the patient’s needs. Super obese patients (BMI> 50) are considered as higher risk patients in terms of morbidity and mortality. We report our experience performing LAGB on 365 super obese patients. Methods from 1997 to 2006, 5838 patients underwent an LAGB. Out of them 417 patients were super obese. Foreign patients were excluded from this study, and 365 were included. The study refers to 10 years follow-up. Results Mean preoperative weight was 149,3 kg (+/-20,3 kg), mean BMI 55,48 kg/m2 (+/- 4,8 kg/m2), 46 patients had BMI >60 (12,6 %) and 10 BMI >70 (2,7 %). There were 86 male (23,56 %) and 279 female(76,44 %). Mean age was 40 years old (+/-11,2). There were no death, cardiopulmonary complications, intraoperative bleeding or conversion to open laparotomy. Only 9 patients were hospitalized more than 48 hours for transient digestive intolerance resolved with medical treatment. After fast weight decline in the first 3 years, stabilisation of weight occurred between 4th and 10th. Results were good and stable during this period, according to Reinhold’s criteria: 33,85 % excellent (BMI<30) and 20 % of good results (30
The adjustable gastric band procedure is a widely used around the world, withits preference for use in Australia followed Europe, has greatly increased theiruse in the U.S. and has good results in our country, mainly in selectedpatients. The aim of this study is to conduct technical basis points when thepatients had gastric slippage or unsatisfactory weight loss in post operativeperiod.Of our 500 patients 196 were reoperated for us during 6 years later that led usto change the procedure for gastric bypass in these 196 patients. We had fourgastric lesions that were sutured, two fistula that closed in a week and 15 days respectively, 8 stenoses that were dilated and 5 did not require dilation.We used two accesses to the section of the stomach, above the original siteof the band in the slip and below in failure of procedure, thus seeking to avoidsevering the stomach at the site of fibrosis. Method Demonstrate the technical points of surgery according to the sequence thatwe used: Access to the abdominal cavity advantage of four portals surgerypreviously and added two others, seeking release of adhesions following thepath of the tube and band, the band opened and removed from the site. Weaccessed the small curvature of the stomach and shot the first clip, then usethe gastric pouch staple green, covered the staple line in both the stomach(gastric pouch and residual stomach), we use a handle food 1.2 m and 60cmbiliopancreatic loop with mechanical anastomosis, jejunal gastrointestinal sidejejunojejuno anastomosis with closure of meso and added drainage ofthe abdominal cavity.In all 18 patients with stenosis underwent dilation, ranging from 3 to 4sessions, and patients showed good results.We conclude that when the adjustable gastric band weight loss failure orslippage has to be converted to gastric bypass. Our work had a good results 6 months later after surgery of the change procedure and now we considerealready patients with 6 years O140 Relaying of Gastric Band After Failure or Complication of a First Band Results of a Series of 125 Patients Presenter: Dr. Marie-Cecile Blanchet Co-author: Fontaumard, Gignoux, Frering Clinique de la Sauvegarde, France

Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India. Background Morbid obesity and non-insulin dependent diabetes mellitus (NIDDM) are fast-rising epidemics in the Indian sub-continent with unique native clinical profiles and colossal impact. As significant preventive strategies are not in place, radical interventions such as bariatric surgical procedures become viable treatment options. Laparoscopic sleeve gastrectomy (LSG) is now emerging as a standalone bariatric procedure globally. 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), which by many is considered a more radical intervention. The aim of this study was to analyse the resolution of diabetes and other comorbidities in morbidly obese NIDDM Indian patients who underwent LSG. Methodology A prospective analysis was done of twenty six non-insulin dependent diabetic patients who underwent a technically standardised LSG from

Introduction The surgery is the most effective treatment of the morbid obesity. This treatment can cause a failure or complication. We report our experience on relaying a second gastric band after failure or complication of a first band having led to its ablation. Material and Methods From January 1st, 2006 till January 1st 2012, 125 patients benefited from a relaying of gastric band concerning the recurrence of morbid obesity after failure or complication of a first band. It includes 8 men and 117 women. The average age in the first band amounts 33 years ( 15-61 ) with an average initial BMI of 41 ( 35-59) , while the average age in the reintervention amounts 40 years ( 19-68 ). The main reasons for an ablation of the band are the sliding n084 (67 %), the migration n021 (17 %) and the intolerance n010 (8 %). Results The average deadline between the pose of the gastric band and the ablation amounts about 4 years 1/2 ( 0-14 years), while the average deadline between the ablation and the relaying averages 11 months ( 2 month 7 years). The results in term of BMI: BMI allocates BMI mini BMI rests(bases) BMI

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breaking news 41 ( 35-59 ) 26 ( 17-46 ) 36 ( 23-54 ) 32 ( 16-54 ) The average loss of points of BMI is 9 with regard to the BMI of departure. The average follow-up is of 22 months ( 2-65 ). Twelve patients have been reoperated (9 %): 10 because of a sliding (2 benefited from a bypass), and 2 because of the failure (defeat) of this second band in term of loss of weight (these two other patients also benefited from a bypass). Discussion The indication of relaying of a gastric band has to be adopted after a multidisciplinary dialogue at a motivated patient who has obtained a good result of its first gastric band. This second band can allow to obtain a result satisfying in term of loss of weight. It is necessary to force the patient to a follow-up prolonged as after any bariatric surgery.

Hiatus hernia. Weight loss was seen in all patients. All patients experienced total to near resolution of pre-operative symptoms within the one month period. Combined laparoscopic Hiatus hernia repair and sleeve gastrectomy is a safe operation in obese and morbidly obese patients with Hiatus hernias. In short term follow-up, this approach has demonstrated effective symptom control as well as weight loss. Long term follow-up is necessary to determine the durability of this operation in morbidly obese patients.

O141 Laparoscopic Fundectomy and Hiatal Hernia Repair with Absorbable Mesh as Teatment of Intrathoracic Sleeve Migration

Presenter: Rishi Singhal Co-authors: Pritesh Mistry, Ruhee Kahki, Avril Krempic, Missba Ahmed, Paul Super

O143 Laparoscopic Gastric Banding in the Super Obese and SuperSuper Obese

Presenter: Gianfranco Silecchia Dept of Medico-Surgical Sciences and Biothecnologies, Division of General Surgery, “Sapienza” University of Rome - Italy Background Laparoscopic Sleeve Gastrectomy (LSG) is an effective “definitive” bariatric procedure. However, the incomplete fundectomy and/or the missed diagnosis of hiatal hernia (HH) could impair the clinical outcome of LSG: insufficient weight loss (IWL), weight regain (WR) or “de-novo” development of gastroesophageal reflux disease (GERD) symptoms. Patient Seven morbid obese pts (mean BMI 47.8 kg/m2), underwent LSG between 2004 and 2008, during the follow-up complained of severe GERD symptoms and WR (4 patients). Upper GI endoscopy, X-ray and CT scan showed the intrathoracic stomach migration and a “neofundus” in patients with WR. Thus laparoscopic intra-abdominal reduction of the migrated stomach and crural repair with non absorbable suture plus absorbable shaped mesh (bio-A , WL & Gore, Inc ) was carried out in all patients and Re-Sleeve in cases with “neofundus” . Result The procedure was completed laparoscopically. no peri and postoperative complications. Three months later there was a resolution of the GERD symptoms and discontinuation of PPI treatment in all patients and an additional weight loss (BMI 29.4 kg/m2) was observed in patients underwent a Re-Sleeve gastrectomy. An upper gastrointestinal contrast study was performed 3 months after surgery, with no evidence of HH recurrence. Conclusion The incomplete dissection of the gastric fundus and of the stomach posterior wall don’t allow an adequate “fundectomy” and it could result in a impairment of LSG clinical outcomes. Moreover the presence of a crural defect should always be carefully investigated during LSG. The “de-novo” development of GERD symptoms after LSG could be related to a missed diagnosis of HH. The prosthetic reinforcement of the hiatoplasty with absorbable mesh seems to be feasible and safe.

Upper GI and Minimally invasive unit, Heart of England NHS Foundation Trust, Birmingham, UK Background LAGB has gained acceptance for patients with BMI<60 but uptake for the super obese patients has not been universal. We present outcome data on patients with BMI 60 who underwent gastric banding at our unit. Methods Between July 2003 and Dec 2009, 2521 patients underwent LAGB. Of these, 153 patients had a BMI 60. They had a mean age of 42.6 years (range 19–65), mean pre-operative weight of 185.5 kg (range 132–268) and mean pre-operative BMI of 68.7 kg/m2 (range 60–98.9). Fluoroscopy-guided adjustments were performed. Complications and weight loss were compared between the two groups (BMI 60 and BMI<60). Results The mean duration of the procedure was 59.5 minutes (range 40-140). There were no conversions to open procedure. More than 95 % of patients were discharged within 24 hours. % Excess BMI loss at 3, 6, 12, 24, 36 and 48 months in BMI 60 was 18.3±9.1 %, 22.4±11.9 %, 27.5±16.5 %, 34.7± 22.3 %, 34.2±22.9 % and 33.9±22 % respectively. % Excess BMI loss in BMI <60 (2368 patients) over the same time period was 24.9±12.9 %, 32.6± 18.8 %, 36.7±19.9 %, 40.7± 20.8 %, 43.6 ±25 % and 47.6± 34 % respectively. Although the weight loss in the BMI<60 group was statistically higher than the BMI 60 group, this difference continued to reduce over the follow up period. Conclusion These results demonstrate that this procedure is successful in producing weight loss and at the same time has a very low complication rate. Although the rate of weight loss is initially slower in the higher BMI’s, this gradually improves with a meticulous follow up. O144 Portal-Mesenteric Thrombosis Following Laparoscopic Sleeve Gastrectomy - A Rare but Potentially Serious Complication

O142 Combined Hiatus Hernia Repair and Laparoscopic Sleeve Gastrectomy in Obese Patients with Symptomatic Hiatus Hernias

Presenter: Marcos Berry, MD; Co-authors: Lionel Urrutia, MD; Patricio Lamoza, MD; Ricardo Rossi, MD

Presenter: Ashish Vashishtha

Bariatric Surgical Unit, Clinica Las Condes, Santiago-Chile

Max Health Care, New Delhi, India

Introduction Portal-mesenteric vein thrombosis(PMVT) has been reported in up to 1 % of patients after having undergone a laparoscopic sleeve gastrectomy(LSG) and can cause significant morbi-mortality. We report our experience with this complication. Material and Methods We evaluated the incidence of PMVT in a consecutive series of LSG from April 2006 to January 2012,patient characteristics, risk factors, clinical presentation, extent of thrombosis,treatments,and sequelae. Results 1013 patients underwent LSG, 3(0.3 %),presented PMVT.2 males and 1 female, mean age 35(31-38),mean bmi 36(32-42),mean operative time 91 min (80-95),all received enoxaparine 40 mg sc daily during hospitalization,and were discharged on pod 3.The major complaint of all patients was epigastric pain at mean pod 29(14-59).Two patients were tobacco smokers,the female was taking oral contraceptives,and one had a family history of venous thrombosis. Diagnosis was made with abdominal angioCT which revealed thrombi in the portal vein in all, one with extension to the splenic vein and another to mesenteric and splenic veins. Two patients were managed successfully with anticoagulation. The patient with mesenteric vein thrombosis required surgery due to small bowel ischemia. All patients are clinically asymptomatic at 26 months(3-42) mean follow-up. Thrombophilia studies were positive in 2 patients, and are pending in one. Follow-up angioCTs demonstrate normal vasculature in 2,and partial resolution of thrombi in 1.

Obesity is a risk factor for gastroesophageal reflux disease and hiatal hernia. Studies have demonstrated poor symptom control in obese patients undergoing fundoplication. The ideal operation remains elusive, however, addressing both obesity and the anatomic abnormality should be the goal. Hurdles for a bariatric operation exist including insurance coverage, patient desires, and patient suitability when choosing an operation. We present a series of patients who underwent Sleeve gastrectomy combined with hiatus hernia repair with short-term outcomes. We retrospectively identified 10 morbidly obese (BMI>35 kg/m2) patients who presented between 2007 and 2012 for management of Hiatus hernia. All patients had a combined primary Laparoscopic Hiatus hernia repair and Sleeve gastrectomy. Hiatal hernia closure was performed in all with or without mesh overlay reinforcement after complete intraabdominal reduction of the viscera. In addition, greater curvature mobilization and sleeve gastrectomy was performed. Charts were retrospectively reviewed to collect pre-operative, operative, and short-term post-operative results. Laparoscopy was successful in all 10 patients. On pre-operative endoscopy, all patients had type III paraesophageal hernia.Postoperatively Upper GI esophagram was performed on all patients with no short-term recurrence of

OBES SURG (2012) 22:1315–1419 Discussion Although PMVT is a rare complication,it must be considered in the differential diagnosis of abdominal pain in the days or weeks following LSG.Prompt diagnosis is crucial to properly treat these patients.Thrombophilia was frequently identified as an underlying cause in our experience. O145 Post – Operative Nutritional Management Of Morbidly Obese Patients With Liver Disease Presenter: C. Remedios Co-authors: A.G Bhasker, M. Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai Background NASH is a common occurrence in patients with morbid obesity; however liver cirrhosis is mostly an unexpected finding intra operatively. The choice of bariatric surgery depends on the operating surgeon; however the post – operative nutritional management of these patients’ is very challenging. The long term goal is to prevent further deterioration in the liver function and to optimize nutritional state postsurgery. Aim The aim of this study is to provide an overview of the nutritional management of patients with liver disease that have undergone bariatric surgery at our center. Methods This is a retrospective review of morbidly obese patients with liver disease who underwent bariatric surgery. Anthropometric measurements, liver enzymes, total protein, serum albumin and globulin, A/G ratio, serum electrolytes, serum iron, vitamin D3 and serum calcium evaluated. Management of these patients, through the liquid phase and transition to solid phase has been studied and reported. Results We managed 5 patients with a mean child pugh score of 6.40.Mean weight was 128 kgs and mean BMI 41.845 kg/m2. Male to female ratio was 4:1. Only 1 patient was diagnosed with liver cirrhosis pre – operatively. 4 out of the 5 patients had alcohol induced liver disease. 3 were diabetic and hypertensive. 1 had dyslipidemia and 2 had sleep apnea. All patients underwent laparoscopic sleeve gastrectomy. 1 patient was planned for a laparoscopic gastric bypass finally underwent a LSG on finding liver cirrhosis intraoperatively. This patient underwent a successful liver transplant 1.5 years post LSG. All the patients were started on clear oral fluids 1 day post – operatively. Patients were started on a hepatic specific nutritional supplements post – operatively. Multivitamins, iron, calcium, vitamin D3 were administered accordingly 7 days post – operatively. Abstinace from alcohol was mandatory along with increased frequency of meals / liquids – atleast every 2 hourly. The mean excess weight loss % at 1 year was 53.746 %. 1 patient has discontinued all drugs and is presently only on a general multivitamin. 1 patient has undergone a laparoscopic duodenal switch 2 years post LSG. Conclusion Bariatric surgery is effective in the treatment of metabolic syndrome in patients with liver disease. These are patients with specific nutrient needs and should be monitored closely and regularly to prevent nutrient deficiencies, hypoglycemia , ascites and encephalopathy. It is imperative to maintain a delicate balance of fluid, protein and sodium post – surgery. The shift in this balance can have catastrophic complications like of fluid overload, hepatorenal syndrome and progression of liver disease. The bariatric Nutritionist forms an important prong in the management of patients with liver disease undergoing bariatric surgery.

1349 Material and methods This prospective observational study was commencedin January 2006. 52 patients with uncontrolled T2DM and a body mass index (BMI) between 30 – 35 kg/m2 elected to undergo LRYGB. Duration of diabetes ranged from 3.5 to 14.5 years (Median: 8.4 years). 62 % patients were hypertensive and 60 % on statins. Remission of T2DM and other components of metabolic syndrome were assessed on the basis of American Diabetes Association (ADA) criteria. All patients were followed up for 5 years. Results Median % EWL was 72.2 % at 1 year and 67.8 % at 5 years. 84.6 % of these patients achieved euglycemia, 73.1 % achieved complete remission, 23.1 % partial remission and 3.84 % no remission at 1 year. Weight regain was seen in 8 patients. They were restarted on antihypertensive drugsand statins, hence bringing down the complete remission rates to 57.7 % and partial remission rates up to38.5 % at 5 years. However 96.2 % improvement was seen at the end of 5 years. Conclusions LRYGB is a safe, efficacious and cost effective method to treat patients with uncontrolled T2DM with BMI between 30 and 35 kg/m2. A younger age, early onset T2DM and higher Cpeptidelevels serve as predictors of success after surgery. The improvement after surgery in hyperglycemia, hypertension and dyslipidemia may help in controlling micro and macro vascular complications in the long-term and hence decrease morbidity and mortality associated with T2DM. O147 Avoidance of Slippage and Erosion - Results from Over 5000 Patients Who Underwent Gastric Banding Presenter: Rishi Singhal Co-authors: Avril Krempic, Missba Ahmed, Paul Super Upper GI and Minimally invasive unit, Heart of England NHS Foundation Trust, Birmingham, UK Introduction LAGB is one of the most prevalent procedures for surgical treatment of obesity. However, uptake of this procedure has not been universal. This is in part due to the perceived lower weight loss achieved, but mainly due to the complications following this procedure. Methods Between April 2003 and December 2011, more than 5000 patients underwent LAGB at our unit. Data collection included demographics, body mass index and weight both preoperatively and every year successively. It included complications and any re-operations that these patients may have had. All bands were placed using the same technique using pars flaccida insertion, Birmingham stitch and 2 gastrogastro sutures. The band was always placed in aretro-gastric sub-fascial pericrural tunnel. Results The median follow-up was 4 years. To date 107 complications have required re-operation. Of the main complications, there were 3 complete slippages (emergency surgery performed). There were 31 partial slippages or antero-lateral pouch dilatations which were treated by band deflation and band re-positioning on elective operating lists. There were 6 erosions which were treated by removal and subsequently replaced in 2 cases. Conclusion A previous meta-analysis from our unit has confirmed that slippage and erosion are closely related. Anterior slippage rates can be largely avoided by use of a gastropexy suture. Placement of the band in a retrogastric, subfascial, pericrural tunnel offers excellent posterior anchorage thus preventing posterior slippage and posterior pouch dilatation. We believe this technique coupled with careful band fixation can eliminate/reduce all forms of erosion, band slippage and pouch dilatation.

O146 Roux-en-Y Gastric Bypass Stands the Test of Time. Five Year Results in Low BMI (30 to 35 Kg/m2) Indian Patients with Type 2 Diabetes Mellitus

O148 Adherence to Psychological and Nutritional Follow Up and the Incidence in Weight Loss, at Two Years After Sleeve Gastrectomy

Presenter: M. Lakdawala Co-authors: S. Shaikh, S.M. Bandukwala, C. Remedios, M. Shah, A.G. Bhasker

Presenter: Paula Diaz PS, Co-authors: Angeles Frias PS, Sandra Navarrete PS, Marcela Kasija PS, Juan E. Contreras MD, James Hamilton MD, Ismael Court MD

Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India

Section of Bariatric & Metabolic Surgery.Bariatric Surgery Department.Clinica Santa Maria.Santiago Chile

Background The biggest challenge that India faces today is a steep rise in non communicablediseasesespecially type 2 diabetes mellitus (T2DM). Aim of this study was to evaluate the long-term results oflaparoscopic Roux-en-Y gastric bypass (LRYGB) viz excess weight loss, complications and remission ofT2DM in Indian patients with uncontrolled diabetes in the BMI range 30-35 kg/m2.

Background Theoretically an adequate follow up in Bariatric Surgery is related to an adequate weight loss. Aim Describe the adherence to psychological and nutritional follow up (FU) and the incidence in % excess weight loss (%EWL), at 2 years after Sleeve Gatrectomy (SG).

1350 Methods By telephone interview we performed an evaluation of 107 consecutive patients that were underwent to SG between May 2009 and December 2010 in Clinica Santa Maria. The survey consisted in 14 Likert-type questions, which assessed variables of adherence, emotional factors, quality of life and physical activity. Spearman, Anova and Fisher descriptive statistic tests were performed. Results Female 88 (65 %), male 47 (35 %). Average age 38,5 years, average BMI 39.5. %EWL more than 50 % in 86.9 % of the patients at the time of survey.Adequate adherence (more than 6 FU appointments) in 30 % of psychological FU and 24 % of nutritional FU. 66 % believed that emotions like anger, grief and anguish make more difficult to achieve lifestyle changes after surgery. 87 % believed that their quality of life improved significantly after surgery. Although 99 % think that they should do physical activity 3 times a week, only 57 % really do it. Conclusions There is not statistical significant between and adequate FU and %EWL in this group, at 2 years after surgery. Probably %EWL at this point still depends on the effects caused by the surgery itself. Patients think that once the adequate weight has been reached, they could do their own food pattern. Long term FU is important to maintain this affirmation. O149 Effects of Sleeve Gastrectomy with Ileal Interposition (sg-ii) on Diabetes Mellitus Type ii (dmt2) in Obese Patients: a CaseControl Study Versus Intensive Medical Treatment. Presenter: Diego Foschi, Co-authors: Andrea Rizzi, Matteo Uccelli, Silvia Basilico’, Fabio Corsi, Consuelo Vecchio, Maurizio Bevilacqua, Luigi Sacco University Hospital Background In obese patients, medical treatment of DMT2 seldom causes metabolic remission, whereas bariatric surgery seems to be effective. This case-control study, compares SG-II versus intensive medical treatment of DMT2 in obese patients. Methods Between September 2009 and December 2011, 40 obese patients between 18 and 65 years, were admitted into the study. (Age:43,6±18,3 yrs. F:M 02.6, BMI: 41,5±6,4 ). The length of diabetes was 6,23 ±5,85 years. Glucose serum level mean was 169.3±31,4. The HbA1c level mean was 8,91±2,4.40 patients with the same anthropometric and metabolic characteristics were selected as medical treatment control group. The operation was SG-II: gastric pouch (160 ml), total intestinal alimentary limb: 4 meters, ileal interposition: 1-1,75 m. depending on the blood glucose levels. The medical treatment was conventional intensive therapy. The primary end point was the rate of diabetes remission (fasting glucose serum levels<100 mg/dL, HbA1c< 6,5 %) with or without medical treatment, 6 and 12 months after the operation or the beginning of medical treatment. Results 32 patients completed 1 year follow–up. SG-II group had better results with 98 % remission of glucose levels vs. 7 % in medical group. 97 % remission of HbA1c vs. 3 %. 100 % stopped medical treatment vs. 0 %.The mean weight reduction after the operation was 39,6±17,4 kg whereas the control group had no significant weight changes. Conclusion In obese patients, SG-II causes DMT2 remission in 98 % of the patients with a significant advantage in comparison with medical treatment. O150 An Interesting Case of Laparoscopic Sleeve Gastrectomy in a Complicated Post Gastric Banding Presenter: Dr. Milind Joshi Co-authors: Dr.Mohit Bhandari,Dr.Shilpa Bhandari, Dr. Manoj Kela, Dr. Arun Mishra SAIMS, Portugal A forty year old male patient with BMI 65 was admitted with complaints of weight gain since last three years. He was operated for gastric banding in 2006. He had BMI of 40 at that time as per the surgical records available with him. Patient had started regaining weight since last three years leading to his present status. Contrast enhanced Computerized tomography (CECT) scan was done to know the anatomy of the stomach, position of the band, status of adhesions of the stomach to liver and omentum. The band was seen applied in oblique fashion in the CT and there were adhesions present with the liver

OBES SURG (2012) 22:1315–1419 capsule.Decision to remove the gastric band and laparoscopic sleeve gastrectomy was taken as a first step procedure for the morbid obesity. During surgery, the findings of the CT scan were confirmed regarding the band position and adhesions. The interesting thing was the band had eroded the stomach along its anterior surface and still there were no signs of perforation peritonitis. The stomach was divided into two halves by the band and the band surface had sealed the perforation and was itself acting as a stomach wall. The band was divided and laparoscopic sleeve gastrectomy was done. The perforated stomach portion was removed along with the excised specimen of the sleeve. Patient had uneventful recovery. O151 Management of Ventral Hernias in Patients Undergoing Bariatric Surgery Presenter: Dr. Anil Sharma Co-authors: Dr. Pradeep Chowbey, Dr. Rajesh Khullar, Dr. Vandana Soni, Dr. Manish Baijal Institute of Minimal Access, Metabolic and Bariatric Surgery,Max Healthcare Institute Ltd., Saket, New Delhi, India There is a relatively high incidence of ventral hernias in patients with morbid obesity. This is probably due to the significantly increased intra-abdominal pressures and higher rates of wound complication in these patients. Many patients seeking surgical treatment for morbid obesity therefore often suffer concomitant anterior abdominal wall hernias. Their management in patients undergoing bariatric surgery remains difficult and controversial. The principles of hernia repair are a tension-free repair and the use of prosthetic mesh. The controversy arises due to presence of a mesh for repair in a situation where a potential for contamination of the mesh with gastrointestinal contents exists. Allternatively, a primary repair has a high potential for recurrence and deferring the repair may result in bowel obstruction. It is necessary to develop a rational approach to the management of ventral hernias in patients undergoing bariatric surgery for morbid obesity. A review of literature and our own experience will be discussed. O152 Revisional Surgery After Laparoscopic Adjustable Gastric Banding Presenter: Dr. Vandana Soni Institute of Minimal Access, Metabolic and Bariatric Surgery,Max Healthcare Institute Ltd., Saket, New Delhi, India Introduction Laparoscopic adjustable gastric banding (LAGB) is popular for its simplicity and reversibility. However long term (band related) complications and poor weight loss outcomes often result in revision of the band. We share our experience of revisional surgery following LAGB. Materials n Methods The practice of Bariatric surgery at our centre began with the laparoscopic adjustable gastric band in 2003. We performed a retrospective analysis of patients having undergone LAGB between December 2003 and December 2005. By March 2011, out of 118 patients, 25 patients (21.2 %) had undergone band removal while 21 patients (17.8 %) had an additional revisional bariatric procedure 6-12 weeks following band removal. The age and body mass index (BMI) of patients undergoing revisional surgery ranged 24 to 62 years and 29 to 57 Kg/m2 respectively. Seventeen patients underwent a laparoscopic roux en Y gastric bypass and laparoscopic sleeve gastrectomy was performed in 4 patients. Follow up was from 11 to 37 months. Results All procedures were completed laparoscopically. The band was removed in 13 patients due to weight regain, 5 of these patients had esophageal dilatation and in 3 patients the band had eroded into the stomach. Five patients had inadequate weight loss, 5 patients developed band slippage and gastric prolapse and in 2 patients the band leaked. The mean excess weight loss (EWL) at 3 months was 33+ 7.4 % and at 6 months was 54+ 14.9 %. The overall mean weight loss was 63.8 % (range 46 to 88 %). There was no major morbidity or mortality. There were 7 (33.3 %) minor complications. All patients except one were discharged 2 days following surgery. One patient 62 year old female ( revised to LSG) was discharged 5 days following surgery due to poor oral intake. She also required blood transfusion postoperatively due to fall in hemoglobin levels. Conclusion Laparoscopic adjustable gastric banding may require revision due to inadequate weight loss or band related complications. Revisional procedure following reversal of gastric banding can be safely performed laparoscopically.

OBES SURG (2012) 22:1315–1419 We recommend band reversal and revisional procedure to be performed on separate occasions to minimize morbidity. O153 Fast Tracking in Bariatric Surgery- Has the Time Come? Our Experience Presenter: Dr Lakhsmi Jayaram Institute of Minimal Access, Metabolic and Bariatric Surgery,Max Healthcare Institute Ltd., Saket, New Delhi, India Introduction Obesity is a major health problem with clearly established health implications in view of its association with multiple comorbidities. Bariatric surgery has now become the gold standard treatment modality for morbid obesity. The dramatic rise in the incidence of obesity and increasing awareness of the patients has led to an increase in the number of bariatric procedures. The concept of “Fast tracking after anesthesia “was first introduced as an” approach to decrease the time” to achieve tracheal extubation after cardiac surgery. The idea of fast tracking is that the patients are transferred directly from the OR to the step down unit (ward ), bypassing the HDU (Phase I) thus reducing the costs and a better resource utilization. The ability to deliver a safe and effective anesthesia with minimal side effects and a rapid recovery is mandatory for “fast tracking” patients after surgery Morbidly obese patients undergoing bariatric surgery have multiple co morbidities and thus any surgery on them is associated with increased morbidity and mortality. If we can achieve early ambulation in these patients in the postoperative period , the complications in the form of thromboembolism etc. will be reduced. An effective perioperative management of the patient comprising of adequate preoperative optimisation, maximising oxygen reserves, multimodal analgesia and prevention of post-operative nausea and vomiting can contribute to early ambulation in these group of patients. We present our experience of five hundred and twenty five morbid obese patients who underwent fast tracking after bariatric surgery. Conclusion Fast tracking in bariatric patients is a feasible option in high volume bariatric surgery centre with a dedicated team comprising anesthesiologists, bariatric surgeons trained technical and paramedical staff and with clearly defined clinical pathways. O154 Mid Term Metabolic Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass Presenter: Dr Rajesh Khullar Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Healthcare Institute Ltd., Saket, New Delhi, India Introduction Metabolic syndrome is a conglomeration of high risk factors that accelerate the onset of cardiovascular disease and diabetes and increase the chances of suffering from acute MI and stroke. The syndrome is closely linked to excess body weight and is known to improve and resolve following weight loss. Objective Our aim was to evaluate morbidly obese patients with metabolic syndrome undergoing laparoscopic roux-en-Y gastric bypass (LRYGBP) for its effect on various components of the syndrome over a period of 2-3 years. Methods A retrospective analysis of 458 patients having undergone LRYGBP from 01-01-2007 to 31-12-08 was done. Patients were diagnosed to have metabolic syndrome according to IDF guidelines. Sixty % were females, the mean age of the patients was 40.25 years (range 17- 62 years), the mean BMI was 44.78Kg/m2 (range 36.73- 62.3 Kg/m2). Patients having any two criteria positive apart from morbid obesity were selected for the study. A hundred and eighty two patients were diagnosed with MS at time of surgery. These patients were evaluated on the status of the MS criteria at 12 month intervals following surgery. Results Preoperatively 182 patients (39.9 %) were diagnosed with MS. One hundred and fifty five patients (85 %) maintained annual follow up. The mean reduction in BMI at 12 months, 24 months and 48 months was 35.3Kg/m2, 27.7 kg/m2 and 27.8Kg/m2. The number of patients with MS decreased to 12 (7.7 %) (p<0.01) at I year follow up , this improvement persisted in patients at 24 months and 48 months follow up. The various components of MS vis-a`-vis HT, DM, low HDL and raised Triglycerides all showed improvement or resolution. Improvement was measured by adecrease in number and/ or dosage of medication for hypertension,HbA1c level and serum values of HDL and S Triglycerides.

1351 Conclusion The incidence of MS is high in the obese population. Following laparoscopic Roux-en-Y gastric bypass MS is seen to resolve or significantly improve. This improvement correlates well with the weight loss of patients. There is also improvement seen in all components of MS. O155 Metabolic Outcomes After Roux-en-Y Gastric By Pass Surgery in Patients with Low BMI (<35 kg/m2) Presenter: Dr Pradeep Chowbey Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Healthcare Institute Ltd., Saket, New Delhi, India Metabolic syndrome (MS) is a conglomeration of factors which increase the risk of CVD and related adverse events. These factors include central adiposity i.e. an increase in waist circumference, insulin resistance i.e. Type 2 DM, high blood pressure, deranged lipid profile i.e. high cholesterol and triglyceride levels and low levels of high density lipoproteins and hyperuricemia. Additionally Type 2 DM is associated with significant morbidity involving multiple organ systems of the body. These include 25 times increased risk of renal failure, 20 fold risk of blindness, 40 fold risk of amputation, three fold risk of stroke and five-fold risk of myocardial infarction. Although medical management has shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors, poor compliance and access to care and adverse side effects of some treatments limit the success of medical management strategies in fully controllingT2DM and Metabolic syndrome. The LRYGBP has resulted in dramatic remissions rates of T2DM (82 %) and other components of MS in severely obese patients with superior clinical outcomes in retrospective comparisons with patients treated with conventional medical management. Aim The objective of the group was to assess the effects of LRYGB on health of individuals with T2DM and other metabolic abnormalities with BMI between 30 and 35 Kg/m2 and central obesity. The primary endpoint of diabetes control and co-morbidities was taken as an HbA1c <6.5, a Triglyceride level of< 150 mg/dl, an HDL level of>40 mg/dl and blood pressure<130/80 mmHg. Material and methods Sixty nine patients were prospectively followed from December 2007 to December 2008. Patients had a body mass index (BMI) less than 35 Kg/m2 with T2DM and at least one more component of MS. Evaluation was done at 3, 6, 12, 24, 36 months. The male to female ratio was 27:42 and mean BMI was 33.1Kg/m2. The LRYGB was performed using a 25 mm circular stapler with a biliopancreatic and alimentary limb length of 50 cm and 100 cm respectively. Results There was significant improvement seen in all components of MS. Patients with T2DM showed remission in 89 % of patients which persisted up to 36 months post surgery. This was documented as an HbA1c level of<6.5 without medication. Similar results were seen with 95 % and 98 % correction in HDL and Serum Triglycerides levels respectively. Seventy one percent of patients with Hypertension no longer required medication. Conclusion Laparoscopic Roux en Y gastric bypass appears to improve and even induce remission in patients with T2DM. Similar improvement was also seen in other components of MS. We are presently conducting a trial evaluating the role of LRYGB, laparoscopic sleeve gastrectomy and standard medical management in patients of T2DM and a BMI between 27.5-32.5 Kg/m2. O156 Coversion of Fundoplication to Roux-en-Y Gastric By Pass Presenter: Daniel B. Leslie Co Author’s : Robert B. Dorman, Nikolaus F. Rasmus, Federico J. Serrot, Nikki Voulgaropoulos, Bridget M. Slusarek, Barbara K. Sampson, Henry Buchwald, and Sayeed Ikramuddin Introduction Conversion of Fundoplication to Roux-en-Y gastric bypass (RYGB) results in significant weight loss and resolution of co-morbid illness. To date, very little long-term data exists for this revisional procedure. Materials and Methods Patients who underwent a conversion of fundoplication (Nissen or other) to RYGB between 2000 and 2011 were identified in our bariatric database. Electronic health records and telephone surveys were reviewed for weight loss and the presence of GERD symptoms and the use of GERD medications. Results Twenty eight patients (female/male024/4) underwent laparoscopic (n017) or open (n011) surgery by 3 different surgeons and mean weight follow-up (100 %) was 3 years. Average preoperative BMI and weight were

1352 43.1 kg/m2 and 119 kg; 3 patients had BMI below 35 kg/m2. Average length of stay was 4 days. Post-revisional BMI, weight, and %excess weight loss were 32.0 kg/m2, 87 kg, and 61 %. No major short-term complications occurred, and there were no mortalities. At least 13 patients continue to use daily acid reduction medication treatment, and 7 patients report ongoing GERD symptoms. Indications for GERD therapy also include nonspecific abdominal pain, pre-RYGB history of Barrett’s esophagitis, and documented gastrojejunal ulcer. Discussion These data show that conversion of fundoplication to RYGB is performed on patients with lower average BMI than our typical RYGB cohort. Weight loss is significant and the majority of patients no longer have GERD symptoms several years after surgery. Conclusion Complications are similar to larger cohorts of patients undergoing RYGB. Ongoing therapy for acid reduction is not uncommon. O157 Mid-Term Outcomes of the Mini-Gastric Bypass Presenter: Jacques Himpens

OBES SURG (2012) 22:1315–1419 27.3+3.7(22.8-39.3)kg/m, obtained after some 3 years (p00.01). Excess Weight Loss (EWL) was 72.8+25.6(64.7-80.9)% at 3 years and 57.3+29.0 (36.3-66.8)% after 9 years (p00.001). After 9 years, 26 patients were taking Proton Pump inhibitors (PPI) for newonset GERD, versus 3 after 3 years. After 9 years, 14 patients had developed a sweets eating habit versus 5 after 3 years. After 9 years, 56.6 % of the patents were satisfied with the procedure Conclusion LSG results in acceptable weight loss after 9 years but at the cost of a second operation in 37 % of the patients. Two out of 3 patients took PPI’s after 9 years and one out of 3 had developed a sweet tooth. Only half of the patients were happy with the procedure, most likely because of the prevalence of GERD and weight regain. O159 Reoperations After Weight Regain or Insufficient Weight Loss After Laparoscopic Roux-en-Y Gastric Bypass Presenter: Jacques Himpens Co-authors: Giovanni Dapri, Guy-Bernard cadie`re,

The European School of Laparoscopy, Brussels, Belgium The European School of Laparoscopy,Brussels Belgium The mini-gastric bypass (MGB) is a controversial procedure because of concerns of biliary reflux in the gastric pouch and into the esophagus.Patients and Method:In our department MGB is performed instead of Roux-en-Y gastric bypass in primary cases because of fears of glycemia issues, likely linked to the presence of an alimentary limb. In case of preoperative gastro-esophageal reflux disease (GERD), a hiatoplasty(HP)or wrapping of the upper part of the remnant around the gastro-esophageal junction (“Nissen”)or both was performed. The patients treated by MGB between 31-10-2007 and 31-03-2011 are reviewed.Results:372 (41 men) patients out of a total of 492 (75.6 %) treated by primary MGB were available for review.. Age at surgery was 34 years (range 18-67). BMI was 40.6+16.0 (30-57) kg/m. Overall, 14 patients underwent a “Nissen”, 52 a HP, and 72 a “Nissen”+HP (total 138037.1 %). Hospital stay was 4.3 days (2-62).Five patients (1.3 %) developed a leak, treated by transformation into laparoscopic Roux-en-Y gastric bypass (LRYGB). Eight patients (2.1 %)suffered an anastomotic bleeding, successfully treated by gastroscopy in all. BMI after 26 months (range 12-52) was 26.6+4.3(20.2-32.8) kg/m, for an EWL of 69.9+8.5(62-82)%. Six patients (1.6 %) suffered an internal hernia. Five patients (1.3 %) presented an anastomotic ulcer, requiring reoperation (transformation into LRYGB) in 3. Two patients (0.5 %) developed an incisional hernia, symptomatic by new-onset biliary vomiting. For the patients without anti-reflux construction, 13 patients (5.6 %) developed reflux symptoms, requiring conversion into LRYGB in 6 (2.6 %)(NS). For the patients who benefited from anti-reflux construction, 3 (2.2 %) required conversion to LRYGB for biliary vomiting.Conclusion:The MGB assures good weight loss, but at the cost of a leak rate of 1.3 % . Internal hernia does occur.. A significant number of patients (1704.6 %) required conversion to LRYGB for leaks, anastomotic ulcer or (bile) reflux, the latter including 3 (2.2 %) of the patients who had undergone an anti-reflux construction. O158 Laparoscopic Sleeve Gastrectomy, Long Term Outcomes Presenter: Jacques Himpens Co-authors: Giovanni Dapri, Guy-Bernard Cadiere

Introduction Some 12 years after having introduced laparoscopic Rouxen-Y gastric bypass in our department, we are faced with a number of patients either regaining weight or without acceptable weight loss at any time. This retrospective study analyzes the laparoscopic reoperations performed for weight issues after LRYGB, performed as a primary (PGB) or as a revisional procedure (RGB), usually after adjustable band (LAGB) Methods Between January 1, 2001, and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB, a median of 2.6 years (1-8) after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9 %). Thirty-nine of these patients underwent the bypass as a primary procedure (PGB). Results The mean body mass index (BMI) before the revisional procedure was 39.1+11.3 kg/m (30.8–51.8), down from 42.7+19.7 kg/m (33.0–56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4+9.3 % (-1.0–29.1). The corrective operation consisted of transformation into distal bypass in 19 patients (16 after PGB), laparoscopic refashioning of the bypass in 12 (4 after PGB), placement of a non-adjustable (Fobi) ring in 10 (all after PGB), sleeve gastrectomy in 9 (all after PGB) and plication in 8 patients (all after RGB). After the corrective procedure, with a follow-up of approximately 4 years, mean BMI was 29.6+12.4 kg/m (18.0-45.5), for a significant additional % EWL of 53.7+9.8 % (2.0–65.8). The overall severe complication rate was 20.7 %, and the reoperation rate was 10.4 %. Most reoperations occurred after distalization and after Fobi ring placement. The overall leak rate was 12.1 %. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed repeat reconversion after distal bypass. The satisfaction index was good in just over 50 % of the patients. Conclusion Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity, especially after secondary bypass. Leaks can usually be handled nonsurgically. Patient satisfaction is only fair.

Institution: European school of laparoscopy,Brussels, Belgium O160 12 Year Outcome of Laparoscopic Adjustable Band Gastroplasty The laparoscopic sleeve gastrectomy (LSG) procedure has become a popular bariatric procedure. Long term outcomes are still essentially unknown. Aim and Method This study was designed to evaluate the 9+ years results of LSG, performed at our department in accordance with two benchmark publications (Annals of Surgery, Himpens et al., 2010 and SOARD panel consensus, Rosenthal et al. 2012) Out of 53 patients, 41 were available for evaluation. Thirty patients were female. Age was 44 (26-71) years median, BMI 39.1+5.4 (31-57) kg/m. Follow-up was 9.2 (9.0-10.0) years median Results One patient required seromytomy for stenosis. Two patients (4.9 %)requiredhiatoplasty for reflux disease (GERD). Fifteen patients required another operation for weight regain [2 re-sleeve, 4.9 %, 13 Duodenal Switch (DS) (42.0 %)]. Reoperation for weight issues were performed after 4+ .8 years (3.2-5.0) after the initial surgery. The results are registered as intention to treat, thus including the revisional operations. BMI at 9+ years was 30.1+6.5(25.0-39.6) kg/m, up from a nadir of

Presenter: Jacques Himpens, MD Guy-Bernard Cadie`re, MD, PHD, Michael Vouche MD, Benjamin Cadie`re MD, Giovanni Dapri, MD. The European School of Laparoscopic Surgery, Department of Abdominal Surgery, Saint Pierre University Hospital, Brussels, Belgium Laparoscopic adjustable band gastroplasty has been performed in our department for over 17 years. The long-term results of this procedure remain controversial. The aim of this analysis is to assess the long-term (over 12 years) results of the procedure, including the incidence of complications, reoperations, weight loss figures, satisfaction index, quality of life and evolution of comorbidities and their treatment. Methods Between January 1, 1994 and December 31, 1997, 151 consecutive morbidly obese patients benefited from the laparoscopic placement of an

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adjustable gastric band. A retrospective review of a prospectively established database was performed after 12+ years. The data available from the records were supplemented by the answers to questionnaires sent to all patients involved. The responders to the questionnaire were invited to an office visit during the second half of 2009, for participation in this study. Results Operative mortality was zero. Overall patient follow-up was 54.3 % (82 patients); median follow-up time was 13 years (12-15). Of the 82 patients available for follow-up, 8 patients were male and the overall median age at the time of surgery was 50 years (28-73). Long-term mortality was 3.7 %, but the causes of death were not related to the surgical procedure. Among the patients examined, 22 % experienced minor complications, and 39 % experienced severe complications, 28 % of which were band erosions. Seventeen percent of the patients were converted to Roux-en-Y gastric bypass by laparoscopic approach. Overall (intention to treat) mean excess weight loss (EWL) after more than 12 years (70 patients evaluated in the office) was 42.8 % (24-143). Of the latter 70 patients, 36 (51.4 %) still had their band at the time of reassessment and their EWL was 48 % (38-58). The number of patients treated for hypertension increased from 20 to 23 (29.3 %) (NS) after 12 years; the number of non-insulin dependent diabetic patients increased from 5 to 11 (14.10 %)(NS) and the number of patients on CPAP for sleep apnea increased from 2 to 6 (7.59 %)(NS). The overall satisfaction index was good to very good in 60.2 % of patients. The quality of life score (BAROS) after more than 12 years was neutral. Conclusion With a follow-up that extended to only about half of the patients treated and was based on an intention-to-treat evaluation, placement of an LAGB appears to create an excess weight loss of 42.8 % after 12 years. Among those interviewed, 60 % of the patients were satisfied and the quality of life index was comparable to the average among the non-surgical population. However, close to one out of three patients experienced band erosion, and close to 50 % of the patients required removal of their bands. The reoperation rate was 60 %, and there was no beneficial influence on comorbidities. Seventeen percent of the patients were successfully converted to laparoscopic gastric bypass.

common association of obesity with moderate to severe sleep apnea, usage of sedative analgesia may have adverse outcome in the form of respiratory depression , which is the most dreaded adverse event associated with the perioperative pain management. Sedatives, analgesics, and anesthetics alter airway tone, and can lead to airway obstruction and even death after minimal doses of sedatives and anesthetics . These can be further aggravated with hypoventilation, immobilization and thromboembolism from administration of narcotic analgesics in the postoperative period .The morbidly obese (MO) patients can benefit from a technique that can produce analgesic effects with out significant adverse effects on the respiratory function and ambulation. Opioid-sparing multimodal postoperative pain management strategies have been effectively used and validated for weight loss surgeries (WLS) and should become the standard of care to overcome the adverse effects of opioids, and the complications associated with sedation and delayed ambulation . With the increasing trends in obesity, more and more anesthesiologists are encountering morbidly obese patients for bariatric and non bariatric surgical procedures. Even though pain management in the obese patient remains a key area, there is paucity of data and a lack of consensus to guide the clinician. We share our experience of post operative pain management by combining the minimal dose of opioids with non-steroidal anti inflammatory drugs, paracetamol and dexmedetomidine infusion with loco-regional blocks wherever possible in 800 patients undergoing bariatric surgical procedures in this center in last two years.

O161 Late Complications AfterSleeve Gastrectomy

Clinica Antofagasta, Chile

Presenter: Jacques Himpens

Introduction The use of drains as a routine after laparoscopic bariatric surgery have not been adequately defined. Objectives To assess the need and importance of routine use of drains after laparoscopic bariatric surgeries. Materials and Methods We report a case series, prospective, non randomized study on patients with BMI greater than 30, which underwent laparoscopic sleeve gastrectomy or gastric bypass; between november 2009 and march 2012. On the last 145 surgeries drains were not used. Information was tabulated using Microsoft Excel and statistical analysis with stata 10.0 Results The group was compromised of 444 patients, 120 men (27 %) and 324 women (73 %), with an average age of 35.7 (15-66) years, and an average BMI of 38.9 (30 - 64). 366 patients underwent laparoscopic sleeve gastrectomy (82 %) and 78 underwent laparoscopic gastric bypass (18 %). Drains were used in 299 patients (67 %) vs 145 patients (33 %) in which drains were not. In patients with drains there were 5 (1,7 %) cases of intraperitoneal bleeding (2 required surgeries) and 1 (0,3 %) gastrointestinal bleeding, no leaks or abdominal collections in this group. In the group without drains there were 2 (1,6 %) cases of intraperitoneal bleeding (1 requiring surgery), 1 (0,8 %) subphrenic collection treated with surgery and antibiotics, 1 (0.8 %) gastrointestinal bleeding, 1 (0,8 %)leak of the gastroyeyunal anasthomosis treated with surgery and antibiotics successfully. The complication rate between the groups were not statistically diferent Conclusion The use of drains after laparoscopic bariatric surgery as a routine does not reduce postoperative complications in our study.

Institution: The European School of Laparoscopy, Brussels, Belgium The major undesirable side effect of laparoscopic sleeve gastrectomy (LSG) is persisting gastro-esophageal reflux (GERD), which usually is treated by transforming the sleeve into a Roux-en-Y gastric bypass (RYGB). Another significant issue weight regain, usually appearing after a period of successful weight loss. Whereas a weight regain of up to 10 % of the lost weight can be considered normal, higher values should be addressed, especially since co-morbidities like arterial hypertension and diabetes mellitus type II can reappear. Patients who present weight regain because of volume eating, can be treated by a re-sleeve operation, provided the gastric tube appears dilated on Barium Swallow. This re-sleeve procedure however carries a significant complication rate. As an alternative restrictive procedure, several surgical groups advocate the transformation into a RYGB. In our experiencehowever RYGB is not followed by significant loss o regained weight Patients who regain weight because of grazing or junk eating can be helped by adding malabsorption. The natural malabsorptive complement after sleeve is obviouslytheduodenal switch (DS). Weight regain after sleeve gastrectomy is thus not uncommon. Unlike most bariatric procedures, however, sleeve gastrectomy has a logical complementary treatment, the duodenal switch, which can be safely and successfully performed by the laparoscopic approach. The most important contraindication against DS is gastro-esophageal reflux (GERD). In case of GERD combined with significant weight regain, anatomical flaws like retained fundus, de novo hiatal hernia or stenosis must be addressed rather than conversion into bypass, the most widely accepted solution for post LSG reflux. O162 Pain Management in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery : Our Experience

O163 Routine Abdominal Drains After Laparoscopic Bariatric Surgery a Comparative and Retrospective Study of 444 Patient Presenter: Rodrigo Villagra´n Co-authors: Angelo Bizjak, Carlos Flores, Gino Bizjak, Marisol Yan˜ez, Paulina Fuentes, Gloria Bustos, Sofia Araya

O164 “Preoperative Weight Loss in Super Obesity: Influence on Perioperative Morbidity and Mortality in Patients undergoing Gastric Bypass”

Presenter: Dr Aparna Sinha

Presenter: Santo MA Co-authors: Riccioppo D, Pajecki D, Kawamoto F, Matsuda M, Cecconello I

Max Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Healthcare, New Delhi

Institution: Digestive Surgery, Hospital das Clı´nicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

Pain management continues to remain key aspect in the perioperative anesthetic care and single most important determinant of patient safety. Due to

Introduction Super obesity (SO) is increasing in greater proportions, and now represents 30 % of morbidly obese patients. In SO morbidity and mortality

1354 rates are greater. The preoperative weight loss in SO decreases operative time, and apparently diminishes morbidity. Based on these data, we initiated a program of preoperative weight loss for the SO. The treatment is based on hospitalization, low-calorie diet, biometrics control and physical activities, aiming to analyze weight loss and influence of weight loss in the perioperative outcome. Materials & Methods Thirty patients underwent our SO preop weight loss program, from 2006 to 2011. The mean age was 46 years, and mean BMI of 66 kg/m2 and the majority was female. All patients underwent gastric bypass after the weight loss. The average caloric intake was 5 cal/Kg/day. Results The mean weight loss was 1.9 kg/week, and after 14 weeks the mean weight loss was15.2 % of initial weight. The mean hospital stay was 21.3 weeks, and the mean weight loss was 19.7 %. All had satisfactory recovery from surgery. The mortality was null. In the last five years, from the total of 592 surgeries, 193 was performed in SO. The SO and general morbidity was 11.14 % and 20.2 %, respectively, and mortality 0.84 % and 2.07 %. Discussion In SO a preoperative weight loss is an important tool to reduce surgical risks. Hospitalization, with low-calorie diet and multidisciplinary followup is a safe and effective way to achieve weight loss preoperatively. Conclusion After a mean of 19,7 % of initial body weight loss, the studied group showed an important decreasing in morbimortality when compared with our previous experience. Preoperative weight loss should be encouraged in SO, and a specific program can significantly diminish surgical risks in this complex group of obeses. O165 Review of Novel Surgical Therapies for T2DM - Do They Have a Role? Presenter: Ravindra Date Co-authors: Sarah Walton, Lancashire teaching Hospitals NHS Trust, United Kingdom Background Bariatric surgery can offer a remission of type 2 diabetes mellitus (T2DM) in 78 % of obese patients. The prospect of using surgery for non-obese patients is attractive and has stimulated interest and the emergence of innovative surgical techniques. They exploit the benefits of conventional surgery whilst reducing its complications through less extensive or invasive techniques to treat T2DM patients. The literature was reviewed to evaluate role of investigational surgery in the treatment of T2DM. Methods Pubmed search of literature was performed by both the authors independently to identify original studies offering unconventional surgery to patients with an intention to cause remission of diabetes. Results Innovative surgeries like omentectomy (O) (n06), Ileal interposition (II) (n04), duodenal jejunal bypass (DJB) (n06), mini-gastric bypass (MGB) (n02) and endoscopic DJB liner (DJBL) (n05) have been reported. O, II and DJB as independent procedures have not shown significant remission of T2DM. The DJBL has been used primarily in superobese patients so far and can improve glycaemic control but is associated with significant complications including migration of the device and upper GI bleeding. The MGB may show better glycaemic control than the other novel surgeries, achieving euglycaemia in 72 % of patients with BMI <35 kg/m2. Conclusion Unlike conventional metabolic surgeries, innovative surgical techniques on their own do not demonstrate benefit in patients with T2DM. MGB is an encouraging technique with potentially fewer complications than conventional laparoscopic gastric bypass, but further studies are required to evaluate this. O166 Esophageal Perforation by Drainage Tube Masquerading as Staple Line Leak After Laparoscopic Sleeve Gastrectomy; A Case Report Presenter: Kaushal A Co-authors: Vindal A, Lal Pawanindra, Chander J, Puri A S Maulana azad medical college, New Delhi, India Laparoscopic sleeve gastrectomy is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. However, utility of drain placement in laparoscopic sleeve gastrectomy remains controversial.

OBES SURG (2012) 22:1315–1419 We report our experience of unexpected esophageal perforation caused by drainage tube in a 35 yr old female with a BMI of 49 kg/m2 who underwent laparoscopic sleeve gastrectomy at our institute. Patient developed a large paragastric hematoma on post operative day 1 and was managed conservatively. Two weeks later she noticed food particles in drain and reported to emergency. Gastrograffin study revealed a leak just below gastroesophageal junction. Patient was put on nasojejunal tube feeds until drain output reduced significantly. Upper G I endoscopy done after 3 months revealed a lower esophageal defect. Endoscopic clips were applied to achieve closure of defect. Patient was kept on liquid diet until drain output became nil which was then removed. This unusual complication, in our opinion, has not been reported anywhere in literature. O167 Internal Hernia After Gastric Bypass. Frecuency of Open Mesenteric Defects in Obstructed Patients, Patients with Abdominal Pain and Asymptomatic Patients. Presenter: Nicola´s Quezada Co-authors: Alex Jones, Carlo Marino, Julia´n Herna´ndez, Aron Kuroiwa, Alex Escalona, Gustavo Pe´rez, Fernando Crovari, Ricardo Funke, Fernando Pimentel, Camilo Boza Digestive Surgery Department, Division of Surgery. Ponthifical Cattholic University of Chile. Satiango, Chile Introduction Small bowel obstruction (SBO) after gastric bypass occurs in a frecuency of 2 -10 %, and the most frecuent cause is internal hernia through open mesenteric defects (OMD). Nevertheless it has not been described the frecuency of OMD in patients with intestinal obstruction, patients with abdominal pain but not in an emergency setting and in asymptomatic patients explored for other reasson (cholelithiasis) Aim To describe our experience in the treatment of 117 patients with SBO after gastric bypass and to describe the frecuency of OMD in 3 different populations (described above). Methods 117 obstructed patients were described, 80 % female. Protocols were revised, final diagnosis and OMD were recorded. Also, protocols of 23 patients with abdominal pain after gastric bypass without SBO and 90 patients explored due to cholelitiasis were revised to know the frecuency of OMD. Results The three most frecuent causes of SBO were internal hernia (69,2 %, 50 % entero-enteral), adhesions (20 %) and bezoar (4 %). OMD were present in 73,5 % of patients with SBO and 22 % had 2 simultaneous OMD. Of the 23 patients going to exploratory laparoscopy due to abdominal pain, 65 % of them had at least one OMD. Also, 90 asymptomatic patients explored due to cholelitiasis showed 20 % of OMD. Conclusions Internal hernia due to OMD was the most frecuent cause of SBO. Notably OMD were highly frecuent (65 %) in patients with abdominal pain without SBO and 20 % in asymptomatic patients, thus if any colickly abdominal pain appears, patients should go to laparoscopy looking for OMD. O168 Management of Implant Related Complications After Banded Gastric Bypass Presenter: Kuesters S, Co-authors: Gruenneberger J, Karcz WK, Institution: University of Freiburg, Germany Introduction There is a growing importance for implants in bariatric surgery. In the USA, the number of Adjustable gastric bandings implanted is growing, there is growing interest for the banded gastric bypass and other, new operations, like the banded sleeve gastrectomy were presented. However, the implantation of synthetic materials can lead to severe complications, both in the short or long follow up after the operation. Patients and Methods In our collective of patients after banded gastric bypass and banded sleeve gastrectomy we observed several ring related complications including opening of the ring and intraluminal migration. Results We present a video of an intraluminal ring migration, which could be treated endoscopically. The ring was transsected using laser and extracted successfully.

OBES SURG (2012) 22:1315–1419 Conclusion In case of an intraluminal ring migration after banded gastric bypass or banded sleeve gastrectomy, an endoscopical removement of the ring is possible, however, a subsequent monitoring of the patient is necessary. O169 A Prospective Comparison Study of Visceral and Subcutaneous Fat Reduction in Morbidly Obese Subjects Undergoing Laparoscopic Gastric Banding, Sleeve Gastrectomy and Roux-En-Y Gastric Bypass

1355 As ultima ratio we performed open revisional surgery. An extremely widened Roux-en-Y-anastomosis with a huge (8 cm of length) blind loop at the end of the BP-limb was resected and the gastroileal junction was reconfectionated. Result 6 months postoperatively we find an extremely happy and resocialized patient with further EWL of 25 kg and persisting negative H2-breath-test-results. Conclusion Blind-loop-syndrome following bariatric surgery may cause stigmatizing symptoms (foetor ex ore) and should be corrected surgically. O171 Cardio-Vascular Risk Reduction After gbp for Type 2 dm in Patients with BMI<35KG/M2

Presenter:Ido Mizrahi, MD*1 Co-authors: Ronit Grinbaum, MD*1, Natali Loubashevsky, MD*2, Natalia Simanovsky, MD*2, Haggi Mazeh, MD*1, Muhammad Ghanem, MD*1, Ahmed Eid, MD*1, Nahum Beglaibter, MD*1.

Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao

Hadassah Mount Scopus University Hospital, Jerusalem, Israel

Ruby Hall Clinic , Pune, India

Background Visceral fat (VF) plays a major role in the development of metabolic syndrome associated with obesity. Our study’s aim is to compare the extent of VF and subcutaneous fat (SCF) reduction measured by ultrasonography (US) after laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-En-Y gastric bypass (LRYGB). Methods Thirty nine morbid obese patients were prospectively evaluated by US before surgery and 3, 6, and 12 months following surgery, to determine VF and SCF thickness. Results Three statistically comparable groups of morbidly obese patients underwent LRYGB (n 012), LSG (n 016) and LAGB (n011). The three groups did not differ in initial age, gender, BMI, VF, or SCF. Final body mass index (BMI) reduction was highest after LRYGB followed by LSG and LAGB (15±1.5 vs. 14.1±0.9 vs. 7.5± 0.8, p<0.001). LSG was most efficient in VF reduction, followed by LRYGB and LAGB (7.1±0.5 vs. 5.5 ±0.7 vs. 3.6±0.8, p00.003). SCF reduction was also highest after LSG followed by LRYGB and LAGB (3.1±1 vs. 2±0.6 vs. 2 ±1.8, p00.08). When comparing only LSG to LRYGB, no statistical significant difference was seen in weight loss or BMI reduction. However, the difference in VF reduction (7.1± 0.5 vs. 5.5±0.7 p00.08) and SCF reduction (3.1 ±1 vs. 2 ±0.6, p00.06) was marginally significant. Conclusion LSG and LRYGB appear to be more effective in reducing VF layer then LAGB. Sonographic measurment of VF and SCF may serve as a simple and efficient tool in the postoperative evaluation of fat reduction in various body compartments in bariatric patients.

Background Metabolic syndrome (MS) is known to increase coronary heart disease (CHD) risk in diabetics. Improvement in MS and glycemic control can reduce this risk. United Kingdom Prospective Diabetes Study ( UKPDS) risk engine predicts the absolute risk of CHD in this population. This study aims to evaluate absolute CHD risk in Type 2 Diabetic patients with Body mass index between 22 and 34.99Kg/M2 before and after gastric bypass. Methods Sixteen Type 2 diabetic patients with BMI less than 35Kg/M2 and CPeptide more than 1 ng/ml were prospectively evaluated using UKPDS risk engine preoperatively &at 9 months after GBP.For analysis paired T test was used. Results The mean age and HbA1C was 44±22 yrs and 11±3.5 % respectively. The calculated mean Pre and Post-operative CHD risk and the Pre and Postoperative fatal CHD risk was 15.58 and 5.033 and 10.553 and 2.687 respectively. Pre & Post-operative stroke risk and Pre & Post-operative fatal stroke risk was 4 and 2.687 and 0.633 and 0.3 respectively. Statistically significantdifference was found between pre and post operative CHD & fatal CHD risk. Conclusion GBP does reduce the risk of CHD in type 2 diabetic patients with BMI<35Kg/M2. Further studies with a larger sample & long term results are needed.

O170 Treatment of Persisting Blind-Loop-Syndrome After Revised Redo-BPD Presenter: Dr. Karl Rheinwalt Co-authors: Dr. Karl Rheinwalt, Dr. Sebastian Kolec, Dr. Andreas Plamper (1st abstract) A. Plamper, F. Ehresmann, S. Kolec, E. Kleimann, K. Rheinwalt Dept. of Bariatric and Metabolic Surgery, St. Franziskus-Hospital Cologne, Germany Introduction Blind-loop-syndrome with bacterial overgrowth is a rare condition following bariatric surgery. It causes symptoms like dyspepsia, abdominal pains, nausea and foetor ex ore leading to severe deterioration of quality of life. Material and Methods The current medical literature has been revised. We present one outstanding case from our own experience. Case 38 years old lady with history of open VBG at the age of 21 years (with BMI 52,5 kg/qm) followed by fat-apron-resection, cholecystectomy and open Redo-biliopancreatic diversion for weight regain 12 years later. 3 months after BPD onset of severe stigmatising foetor ex ore and dyspeptic symptoms. Incisional hernia repair and open blind-loop-resection at the gastroileostomy followed within 2 years. After this stage she presented for the first time in our institution desperately asking for elimination of persisting bad breath. Furthermore she complained reduced satiety and weight regain. Endoscopic studies, radiography and CTscan showed dilatation of the gastroileostomy and of the upper alimentary limb without blind-loop-formation. The H2-Glucosebreath-test was highly positive. Bowel decontamination with Rifaximin (Xifaxan®) followed by recolonisation with Perenterol® and probiotics led to only temporary relieve.

O172 Effects of Sleeve Gastrectomy on Metabolic Changes and the Evolution of Liver steatosis: Preliminary Results Presenter: Arantxa Cabrera Co-authors: Arantxa Cabrera, Fa`tima Sabench, Merce` Herna´ndez, Santiago Blanco, Margarida Vives, Antonio Sa´nchez, Daniel del Castillo University Hospital of Sant Joan. Faculty of Medicine. IISPV.Rovira i Virgili University. Spain Introduction Laparoscopic sleeve gastrectomy is a good treatment for severe morbid obesity. The objective of this study is to identify the degree of liver steatosis before and after sleeve gastrectomy and metabolic changes produced. Also evaluate the prevalence of H. pylori in relation to such changes. Material and Methods 65 morbidly obese patients operated on in the last 24 months. An intraoperative liver biopsy is performed to determine the degree of steatosis. A gastroscopy is performed preoperatively with antral biopsy to determine H. pylori. At 18 months postoperatively, a percutaneous liver biopsy guided by CT is performed again. Results Significant improvement in main laboratory parameters one year after surgery. The distribution of intraoperative hepatic steatosis is 46.4 % grade I, and 21.5 % and 20.1 % for grades II and III. A 12.3 % had normal liver biopsy. At 18 months postoperatively, with 20 % of the biopsies performed, 61.5 % improves the degree of steatosis, 30 % holds the same grade and one patient worsens the degree of steatosis. Patients with more severe steatosis are those with an excess weight loss increased (p <0.001). 22 % of the sample is positive for H.pylori, with no differences between sexes or in relationship with the postoperative weight loss. In H. Pylori negative patients, there is no improvement of steatosis at no case (p<0.05). Discussion The prevalence of H. pylori is found in the lower limits of the accepted range for such patients. Their presence does not imply a lower weight loss in our patients undergoing surgery. Conclusions Sleeve gastrectomy produces a significant improvement in metabolic parameters and hepatic steatosis, more related to metabolic and weight improvement than with liver parameters themselves.

1356 O173 Is Laparoscopic Roux-en-YGastric Bypass (lgby) in the Elderly (age>60) as Safe and Effective as in the Younger Population? A Case-Control Study Presenter:A. Suppiah Co-author: A. Suppiah, M. Peter, R. Sarkar, A. Carlisle, V. Rao, P. Sedman, P. Jain Castle Hill Hospital, Cottingham, HU16 5JQ, United Kingdom Introduction Elderly obesity is increasing in the West. Laparoscopic Roux-en-y Gastric Bypass (LGBY) leads to weight loss and morbidity resolution in a young population but there are only minimal reports of LGBY in the elderly population. We report safety and efficacy of LGBY in the largest series of elderly (age>60) patients, and then compare these against case-matched controls. Materials and Methods Retrospective analysis of all elderly (E) patients age> 60 years undergoing LGBY between 2006 - 2011. Controls (C) were selected based on matching order of 3 criteria: (a) Pre-operative BMI (b) Sex and (c) Follow-up duration. Results All case-matched elderly-control pairs had LGBY within 6 months of each other. Inter-group pre-operative BMI correlation(R2) was 0.994. Each group consisted 46 patients (37 female, 9 male) with median age 62.5 (60.1 – 71) and 44 (24.3 – 58.8). There was no difference in sex, pre-operative BMI (E: 46.7 vs. C: 46.8) or follow-up (E: 23.2 vs. C: 23.0 months). Median excess weight loss was 67.4 % (E) vs. 71.6 % (C) and median total weight loss was 33.4 % (E) vs. 34.9 % (C). 85 % (E) vs. 87 % (C) patients achieved >50 % excess weight loss within this period. There was no difference in mean hospital stay of 3.9 (E) vs. 3.0 (C) days and in mean morbidity rates of 8.7 % (E) vs. 6.5 % (C). Conclusion LGBY in the elderly (age>60) is safe, and produces similar weight loss to younger controls. Larger studies with longer follow-up are required to further assess benefits in this group.

OBES SURG (2012) 22:1315–1419 Appropriate exposure of the left lobe of the liver is crucial to perform bariatric surgery but can be challenging in obese patients. Traditional liver retractors require placement of additional ports and may not assure adequate exposure. EndoliftTM (Virtual ports, Richmond, VA) is an internally anchored retracting device that does not require an additional port and anchoring to any external device that limits the patient’s position and adds clutter to the operating table. This provides an adequate visualization of the dorso-lateral portion of left liver lobe and thus the angle of His that is critical for most bariatric procedures. Surgical procedure The device was inserted through an existing 5 mm port with the applier. After the exposure of gastroesophageal junction, one of the attached two clips (one on either end) was anchored to the left crus of the diaphragm while the other was fixed to the peritoneum above the right lobe of liver through the falciform ligament. In this process, the device lifted up the left lobe of liver and provided an adequate laparoscopic view of the angle of His. Results We have used Endolift for 31 LRYGB and 2 LSG (1 single incision SG). There were 24 females and 9 males with mean age of 46 (25-65) and mean body mass index 45.0 kg/m2 (33.6-56.1 kg/m2). The mean operative time was 136.5 min (77-231 min). The time required for the placement of Endolifttm was 2-5 minutes. In all patients, the device provided an adequate visualization to complete the bariatric procedures. No-device related complications were observed perioperatively. Conclusions The approach to the upper part of stomach was satisfactory with EndoliftTM in bariatric cases. It has potential benefits in single incision laparoscopic bariatric procedures. O176 Laparoscopic Plicated Sleeve Gastrectomy Presenter: Tomasz Rogula MD Co-authors: Neil Orzech, MD Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio

O174 Sleeve Gastrectomy in Type 2 Diabetic Obese Patients Presenter: Marcos Berry, MD Co-authors: Lionel Urrutia, MD; Patricio Lamoza, MD; Rodolfo Lahsen, MD; Ricardo Rossi, MD Bariatric Surgical Unit, Clinica Las Condes, Santiago-Chile Introduction We report our experience in treating type 2 diabetic (T2DM) obese patients with laparoscopic sleeve gastrectomy (LSG), analyzing the percentage of excess weight loss (%EWL), metabolic performance after surgery, and morbimortality. Material and Methods A prospective series of obese, well controlled T2DM patients underwent LSG consecutively between April 2006 and July 2011 and were followed with a strict protocol. Results Fifty patients, 29 male and 21 female, mean age 50 years (24-70), were operated upon and underwent follow-up for a mean of 18 months (6-46). Mean preoperative versus follow-up BMI were 36.3 (30.2-51) and 27.65 (21.335), respectively, and the mean %EWL was 80.5 %. Mean preoperative fasting glucose levels and HbA1C decreased from 151 mg% (84-250) to 95 mg% (72-120) and from 7.05 % (5.2-11.6) to 5.79 % (5.3-6.9), respectively, during follow-up. At follow-up, 82 % of patients did not require further oral treatment for diabetes, while 18 % witnessed a significant decrease in dosage of medication and/ or were being progressively tapered off of medication. There were no conversions. Two patients (4 %) presented postoperative morbidity: one presented a haemoperitoneum and another presented a perigastric haematoma – both were managed non-operatively. There was no mortality in this series. Discussion LSG is a safe and effective treatment for mild and well controlled T2DMpatients, achieving very good metabolic control. Further follow-up is necessary to evaluate long term results and may provide valuable information in optimizing patient selection for this procedure.

Laparoscopic sleeve gastrectomy and greater curvature plication have gained popularity as potentially less risky operations. Both methods work through similar restrictive mechanism. Sleeve gastrectomy requires removal of majority of the great curvarute and prepyloric stomach. Major risks of the sleeve gastrectomy include strictures at the incisira and leak. Adding plication of the entire stapler line brings several advantages: reinforcement of the stapler line, better control of diameter of the plicated sleeve and potentially improved weight loss by incorporating stump of the greater curvature acting as a volume occupying mass, thus increasing restriction. The antrum can be plicated without stapling, decreasing costs of the surgery. Surgical Procedure:10 patients: 8 males and 2 females; mean age 42; mean BMI 48 kg/m2 (min 42- max 56). A gastroscope was used for calibration. Short gastric vessels were taken down with a harmonic scalpel. The greater curvature resected with 3-4 blue Endo GIA 60 mm linear staplers, starting at about 15 cm proximally from the pylorus, above the angular notch, leaving the pyloric antrum intact. The antrum was plicated with non-absorbable 2.0 Surgidac running suture, starting at about 2-3 cm proximally from the pylorus. Singlelayer plications continued upwards, including the entire stapler line in decreasing amount, under endoscopic visualization to avoid narrowing and gastric folds obstructing the gastroesophageal opening or the pylorus.Results. No major complications were observed perioperatively. Upper GI with gastrographin in post operative day 1 confirmed no leak or obstruction. 4 patients had mild nausea which resolved within 7-10 days. 3 patients had 11-12 months follow up, 5 patients 5-7 months and remaining 2: 2-3 months. Mean weight loss: 73 % EWL in 12 months, 61 % in 6 months and 28 % in 2 months. The mean operative time was 98.0 min (60-159 min). The mean length of hospital stay was 2.6 days (2-4 days). Conclusion Laparoscopic plicated sleeve gastrectomy combines advantages of sleeve gastrectomy and gastric plications and appears to be promising. Further studies, more patients and longer follow up are currently under investigation to determine its safety and efficacy.

O175 Clinical Experience with a Port-Free Internal Liver Retractor in Bariatric Surgery

O177 Robotc Sleeve Gastrectomy. First Results of 70 Cases

Presenter: Hideharu Shimizu Co-authors: Poochong Timratana, Tomasz Rogula

Presenter: Ramon Vilallonga Co-authors: Fort, Gonzalez, Caubet, Armengol

Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio

Universitary Hospital Vall d

OBES SURG (2012) 22:1315–1419 The sleeve gastrectomy is already regarded as a unique technique and definitive identity within the range of procedures used for surgical treatment of morbid obesity. There is already extensive experience with gastric banding and gastric bypass in robotics but almost no experience with vertical gastroplasty. Objective The Da Vinci robot was incorporated in March 2009. It was felt that the sleeve gastrectomy was the procedure of choice for beginners in robotics.Patients and method.From May 2010 until January 2012, there have been 70 fully robotic tubular gastroplasty. The surgical technique has followed the same principles of the conventional technique. In all cases, the staple line reinforced: in 59 patients with a manual suture polypropylene continuous 2/0 and the remaining 11 cases with reabsorbable material (Seamguard ®, Gore ®). Results Thus, 70 patients have been operated, (44 females/26 males), mean age 43 years (15-61), initial weight of 120KG (82-177), excess weight 65Kg (27-105) and mean BMI 48 (36-61) respectively. Of note, 3 patients were teenagers with 15, 16 and 17 years with a BMI of 48, 47 and 42 respectively. The average time of docking was 6 minutes. The mean operative time with the robot was 83 minutes. Mean hospital stay was 3 days. In the group of 11 patients with Seamguard ® reinforcement, two leaks were observed. By contrast, in the group of 52 patients with stapling line reinforcement no leaks were observed. Perioperative mortality was nil. After a mean follow-up of 12 months, average weight, overweight and BMI loss was 87 kg (73-150), 63 kg (19-94) and 33Kg/m2 (24-53), respectively. Discussion The sleeve gastrectomy is a feasible and safe procedure. The application of robotics is an increase in reliability and safety. In our experience, manual stapling line reinforcement appears to be superior to the reinforcement of the staple line with absorbable material. In this regard, the use of robot Da Vinci provides better access to the area and mink hiatal without increasing the overall time surgery. Conclusions The robot facilitates the preparation of a manual suture reinforcement, in our experience, avoid the potential appearance of leakage at this level. Without entering into topics Economists, even more studies are needed to confirm a hypothetical advantage of robotic surgery over the conventional laparoscopic approach O178 Glycaemic Control After Gastric Bypass Surgery in Morbidly Obese Patients with Diabetes Mellitus: An Asian Experience Presenter: Kee Yuan Ngiam, Co-authors: Lin Yee Koong, Ganesh Ramalingam, T’zu Jen Tan, Anton KS Cheng

1357 Background Preoperative prediction of weight loss after gastric bypass could help surgeons to manage surgical lists and patients expectations. There seems to be some evidence for impaired results in patients with metabolic syndrome. It is yet to be known whether preoperative metabolic control might improve surgical results. Methods We recruited a prospective cohort of 118 consecutive patients that underwent primary laparoscopic RYGB with at least 1 year of follow-up (Between January 2007 and February 2011). Patients were evaluated for clinical and laboratory findings preoperatively and at 12 months after surgery. A multivariate linear regression was built for the outcome of excess weight loss 12 months after surgery (%EWL12). Results Most patients were female (93.2 %), with a mean age of 37 years (1960) and a BMI of 46.4 (36.8-59.9). After 12 months, the mean BMI was 29.7 kg/m^2 with a corresponding %EWL of 79.6 %. Half (50 %) of the patients had a %EWL12 greater than 80 %. The patients with %EWL > 80 % were younger (35 vs. 39 y; p00.03), had lower BMI (44.7 vs 48.0 kg/m^2; p < .001), lower glucose levels (0.91 vs 1.00 g/dL;p 00.03) and lower pre-operative CRP (10 vs 14 mg/dL; p 00.04). Patients with high blood pressure (35.3 % vs 61.2 %; p0.005) and metabolic syndrome (41.8 % vs 60.8 %; p0.04) were less likely to achieve %EWL12>80 %. After correction for initial BMI (Coeff0-1.36; p<.001) glucose level was the only factor (inversely) related with %EWL at 12 months (Coeff0-29.27; p<.001). The %EWL12 can be predicted by %EWL0171 - 1.37BMI - 29.27GLU. These 2 factors explain ~25 % of the variation in weight loss at 12 months. Conclusion By multivariate analysis, patients with lower BMI and better glycemic control present higher %EWL at 12 months. Much of the variation in %EWL is yet to be explained by other factors, however, pre-operative optimization of glycemic control, might improve the surgical results. O180 Internal Hernias and Angina Abdominis After Laparoscopic Gastric Bypass: The Challenging Management of an Underestimated Problem Presenter:Federico Marchesi, Co-authors: Ziccarelli A., Tartamella F., Pattonieri V., Roncoroni L. Universita` degli Studi di Parma, Clinica Chirurgica e Terapia Chirurgica, Parma, Italy

Khoo Teck Puat Hospital, Singapore Background Glycaemic control following gastric bypass surgery had been advocated as a major advantage for performing bariatric surgery in morbidly obese patients with diabetes mellitus. We review our centre’s results for resolution of diabetes following gastric bypass surgery. Methods This is a retrospective review of 22 consecutive patients with Rouxen-Y gastric bypass from Aug 2008 to Jul 2011. 14 patients had pre-existing diabetes mellitus confirmed by oral glucose tolerance test (fasting > 0 7.0 mmol/L and at 120 min>011.1 mmol/L or HbA1C >6.0 %). Diabetes was considered to have resolved if the patient had random glucose of<05.6 mmol/ L or HbA1C <6.0 % or if glycaemic control is achieved without use of oral hypoglycaemic agents. Results Using these criteria, 6 patients had resolution of diabetes following surgery. 2 patients achieved glycaemic control through diet before surgery. The median time to diabetes resolution is 110 days (Range 35-332 days). This translates to a 50.0 % (6/12) resolution of diabetes post gastric bypass. 2 out of 6 (33.3 %) patients used oral hypoglycaemic agents at least once after bypass surgery but all 6 patients were off all oral hypoglycaemic agents within 1 year of surgery. Conclusion Gastric bypass is effective in correcting obesity related diabetes mellitus in the short term. This is consistent with current international data for metabolic outcomes after gastric bypass. Longer follow up is necessary to determine if this procedure confers enduring normoglycaemia without medications. O179 Pre-operative Glycemic Control is Directly Related with Weight Loss After RYGB

Introduction Internal hernia represents one of the most common late complications of Roux-en-Y gastric bypass (RYGBP), with an estimated incidence varying from 0.7 % to 3.25 %, reaching 6 % considering only procedures with transmesocolic alimentary loop. Such an incidence only accounts for complicated hernias, while the majority of internal hernias appear as a recurrent episode of postprandial colic pain (angina abdominis). The latter cases are probably the most challenging to diagnose, to treat and to prevent.. Case series we present a video of four cases of laparoscopic evaluation in patients with recurrent, non-complicated, postprandial abdominal pain (angina abdominis) after RYGBP. All the patients were middle aged females (mean age: 39.5), previously submitted to an antecolic RYGBP; mean EWL was 90.4 % at the time of the intervention. Preoperative study revealed in all cases a partial or complete twist of the mesenteric axis at CT scan. None presented with an acute syndrome (occlusion, leukocytosis, shock) and they were all operated on in a non-urgent setting. A Petersen non-complicated hernia was detected in three patients, and reduction with stitch fixation was performed, while an adhesion to an intraperitoneal mesh with loop rotation was detected in the last case, and treated by a laparoscopic adhesiolysis. Postoperative course was uneventful for all the patients (hospital stay:2.5 days), and abdominal pain resolution was achieved at follow-up. Conclusions Laparoscopic exploration yields a sure diagnosis and a safe and effective treatment of non-complicated internal hernias after RYGBP. O181 Reduced Port Approach in Bariatric Surgery

Presenter: Gil Faria Co-authors: John Preto, Eduardo Lima da Costa, Ana Beatriz Almeida, Jose´ Costa Maia, Joa˜o Tiago Guimara˜es, Conceic¸a˜o Calhau, Anto´nio Taveira-Gomes

Presenter:Dr Abhay Agrawal Co-author: Dr Jugal B Agrawal

Department of Surgery, Faculty of Medicine, University of Porto, Portugal

Institution : SevenHills Hospital, Asian Heart Institute, Mumbai, India

1358 With the high prevalence of obesity in India and increase in volume of Bariatric cases we embarked on an idea of making the Laparoscopic Sleeve Gastrectomy more comfortable to our patients. We present our experience of 150 cases done with reduced number of ports and also reducing operative time by better theatre co-ordination and techniques and significant reduction in pain score. We routinely use Advanced Bipolar Sealing device instead of Harmonic Energy source. We routinely do not catheterize or place drain and avoid naso gastric rubes and on table leak test.

OBES SURG (2012) 22:1315–1419 Conclusion The lesser sac approach is both safe and feasible. It also appears beneficial in patients who have had previous surgery or have abdominal wall herniae with omental adhesions to the anterior abdominal wall. O184 Laparoscopic versus Open Duodenal Switch: A Long-term Retrospective Review of Outcomes and Complications Presenter:Robert Dorman Co-authors: NF Rasmus, FJ Serrot, N Voulgaropoulos, L Bach, BM Slusarek, BK Sampson, H Buchwald, DB Leslie, S Ikramuddin

O182 Robotic Bariatric Surgery in India Institution : University of Minnesota, United States of America Presenter: Dr. Rajkumar Palaniappan Department of Minimal Access & Bariatric Surgery, Apollo Hospitals, Chennai, India Introduction Major advantages of robotic surgery are precision, less pain, and reducedcomplications. Further advantages are articulation beyond normal manipulation andthree-dimensional magnification, resulting in improved ergonomics. Methods Three patient underwent Robotic Bariatric surgery by the same surgeon. Twosleeve gastrectomies with India’s first was performed on 29 December 2011 and India’sfirst Robotic hand-sewn gastric bypass was performed on 1 February 2012. Minimalmodifications were done in port placements as per robotic ergonomics and sameoperative technique and preoperative protocol were followed like in conventional / SILSbariatric procedures. Results A total of three bariatric procedures were performed. The procedure wassuccessfully performed in all patients. Mean operating time was 125 min for sleevegastrectomy and 264 min for gastric bypass. None of the patients required conversion tolaparoscopic / open procedure. 3D imaging gives the depth perception and more tissuedifferentiation and greatly enhances vision. Hand-sewn gastrojejunostomy was easierthan in laparoscopy. Patients needed less post-operative analgesia and recoveredearly. There were no mortalities or postoperative complications noted during the follow up period. Conclusion Robotic Bariatric Surgery is feasible and has very short learning curve forlaparoscopic surgeons. It enhances task performance due to 3D imaging and intuitiveskills and minimizes errors and pain following bariatric surgery. Robotics also can be put to its maximal use for Gastric Bypass with hand sewn gastrojejunal anastamosis. However more studies are needed to study its cost effectiveness and its strongindications in bariatric surgery. O183 Laparoscopic Roux-en-y Gastric Bypass for Morbid Obesity- the Lesser SAC Approach Presenter : Gemmill E.H. Co-authors: Ahmed J. Royal Derby Hospital, United Kingdom Introduction Most gastric bypass surgery reconstructions utilise an anterior colic approach. Evidence is conflicting on whether this is superior to a retrocolic approach through the supracolic compartment. Here we present our results from a lesser sac/retrocolic approach. Method Data was collected from a prospective database of all Roux-en-Y gastric bypasses performed by a single surgeon from mid December 2009February 2012 at the Royal Derby Hospital, England. All cases used a 5 port approach. The gastrocolic omentum was divided along with any retrocolic adhesions. Following pancreas identification, a window was created through a pliable section of transverse mesocolon from its superior aspect. The small bowel was identified from the DJ flexure and delivered through the window into the supra-colic compartment. Following jejunojejunal anastomosis 0-ethibond used to close the mesenteric defect, the jejunum mostly returned to the infra-colic compartment; and 0-ethibond used to repair the transverse mesocolon defect and Petersen’s space. Results Roux-en-Y gastric bypass using a retorcolic approach was attempted in 226 cases. In 5 patients (4 male, 1 female, 2 having had previous operations) bypass was not technically possible due to a thickened, folded down transverse mesocolon. There was no mortality; or significant haemorrhage encountered from the middle colic artery. Only 1 patient required a reoperation (for an internal hernia several months post initial surgery.)

Introduction There is very little data comparing long-term outcomes between laparoscopic and open biliopancreatic diversion with duodenal switch (DS). Materials and Methods Patients who underwent primary DS between 2005 and 2010 were identified. Health records and prospective surveys were utilized to record perioperative events, complications, and changes in both body mass index (BMI) and co-morbid illness. Results There were 190 DS patients identified with 178 available for followup (93.7 %). Mean follow-up time was 3.7±1.6 years. LDS was performed in 36.4 % (n063) of patients. The average BMI was 52.4±9.2 and 52.0± 9.2 kg/m2 (P00.82) for ODS and LDS, respectively; the average age was 45.7±12.1 and 42.7±9.6 years (P00.04) for ODS and LDS, respectively. Type 2 diabetes, hypertension and dyslipidemia were present in 28.7 %, 57.4 % and 53.7 % of ODS patients compared to 36.8 % (P00.19), 60.7 % (P00.40) and 55.7 % (P00.46) LDS patients. Operative time was not significantly different between groups (309 vs 311 min), but length of stay (LOS) was shorter for LDS patients (4.7 vs 6.0 days, P00.01). There were no significant differences in weight loss or resolution of comorbidities between the two groups. Wound infections were similar between groups, but ventral hernia repairs (15.5 % vs 1.6 %, P<0.01) were more common among ODS patients. There were 5 deaths (4.5 %) beyond 30 days following ODS. Discussion This study provides some of the best long-term data available comparing LDS and ODS from an experienced center. Conclusion LDS provides similar weight loss and comorbidity resolution with patients experiencing similar operative times, shorter LOS and fewer reoperations. O185 Modified Nissen Fundoplication After Roux-en-y-gastric Bypass for Obesity: an Antireflux Surgery Alternative Presenter : Nilton Tokio Kawahara1, Co-author: Clarissa Alster1, Fause Maluf-Filho2, Akemi Koyaishi1, Campos G3. Sao Paulo, Brazil; 2Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Clinicas Hospital (USP-SM), Sao Paulo/SP, Brazil; 3University of Wisconsin School of Medicine and Public Health, Department of Surgery, Wisconsin/USA. Introduction Roux-en-Y gastric bypass (RYGB) has always been advocated for the treatment of obese patients with gastroesophageal reflux disease (GERD) as an alternative to fundoplication. Some obese patients with no previous GERD can develop the disease after the RYGB. We hypothesized that if an antireflux surgery should be performed even post RYGB it would be an effective treatment for GERD symptoms in selected patients post bariatric surgery. Method From March 2008-March 2012, 20 postoperatory RYGB patients who complained of GERD symptoms were evaluated: pre and postoperatory manometry and 24 h-pHmetry were performed. If both exams were positive for GERD and hypotony of LES, patients were advised to undergo the modified anti-reflux surgery. The fundoplication was made by a 3 cm 360o laparocopic wrap using the excluded stomach around the esophagus (34 Fr bougie in situ), preserving a previous construction of a vertically oriented proximal gastric pouch, with a 75-150 cm Roux limb, a 50 cm jejujojejunostomy beyound the ligament of Treitz and a 12 mm manual gastrojejunal anastomosis.This study was approved by the review board, and informed consent was obtained from all patients. Statistical analysis was made using Fisher’s test. Results Mean age was 35+ 4.2 y/o, 60 % were women and the mean BMI was 41,02+ 3.2. The patients had no complications and experienced successful resolution of GERD symptoms (Visick 3 to 1; and reflux symptoms score 33 to 2). One year follow up showed asymptomatic patients without GERD or dysphagia. 50 % of patients had 10 % weight loss after the fundoplication.

OBES SURG (2012) 22:1315–1419 O186 Early Gastrointestinal Hemorrhage After Laparoscopic Roux-en-Y gastric Bypass (RYGBP): Incidence and Management Presenter : Suter Michel Co-authors: Clerc Daniel, Donadini Andrea, Calmes JM, Giusti V, Demartines N Department of Visceral Surgery1 and Division of Diabetology, Endocrinology and Metabolism2, University Hospital CHUV, Lausanne, Switzerland. Department of surgery, Chablais Hospital, Aigle-Monthey3, Switzerland Background Early gastrointestinal hemorrhage after laparoscopic RYGBP is unusual, but can be fatal. Diagnostic modalities and treatment are not standardized. Methods Retrospective review of our experience and of the literature. Results 26 (1,8 %) of 1467 RYGBP patients developed postoperative intraluminal hemorrhage. All patients bleeding in the excluded stomach were reoperated. In the majority of the 21 others, the origin of bleeding remained unknown except for two marginal ulcers, and one who required laparoscopic exploration. Our treatment protocol involves cessation of heparin prophylaxis, replacement by intermittent compression stockings, high-dose etamsylate, and transfusions as necessary. Only 2 (9,5 %) required re-laparoscopy: negative in one patient with dysfibrinogenemia, hemostasis at the jejunojejunostomy after angio-CT localization in the other. 335 cases were found among 13’042 patients (2.6 % - range 0.9-9.4 %) in 22 published series. Endoscopic management had a success rate of 83-85 % provided the source is at the gastrojejunostomy. In cases with hemodynamic instability, surgical exploration is necessary, the use of laparoscopy being debated. CT angiography to localize intra-digestive hemorrhage is described, with sensitivity and specificity exceeding 85 %, but its value has not been assessed in the setting of post RYGBP hemorrhage. Conclusions Most post-operative intraluminal hemorrhages after RYGBP can be treated conservatively, except when the source is in the excluded stomach. If hemorrhage persists, or is associated with persistent hemodynamic instability, a laparoscopic approach for exploration and hemostasis is feasible and safe. The use of CT angiography as an early diagnostic tool can be a useful adjunct. O187 Adolescent Obesity and Bariatric Surgery. A New Bariatric Program in a Center Of Excelence in Barcelona. Preliminary Results Presenter: Ramon Vilallonga Co-authors: Fort, Gonzalez, Caubet, Armengol Universitary Hospital Vall d Childhood obesity has become a serious health condition. Recent data suggest an increasing number of children aged below 18 years with overweight and even obesity reaching even a 16 % of all them. For these reason and to respond to this increasing problem, our hospital and specially the adult bariatric department with the colaboration of the pediatric and adult endocrinology department, the paidopsychiatrist department, anesthesiology department and the clinical nutrition department have decided to create this surgical area. Results. A systematic review of the courrent literature has been done in order to establish the criteria for including adoelscent patients for surgery. Since december 2011, three pediatric obese children have undergone a totally robotic sleeve gastrectomy as a sole and standard technique to treat these patients. Mean BMI was 51Kg/m2. There were no convertions and no postoperative complications. Discusion. Without intervention, extremely obese children may continue to suffer from obesity as adults and a decreased quality of life is expected. Surgical treatment is accepted for children with Tanner 4 or 5, and BMI>40 Kg/m2 with or without co morbidities in our department. Other criteria have been included in our protocol. Conclusion. A multidisciplinary team is necessary to approach these patients. Adult’s bariatric surgeons have an important role in order to develop such an important program. Robotic surgery has benefits compared to laparoscopic approach. Robotic surgery can be an interesting approach for these patients in order to avoid complications by increasing intra operative precision. A continuous analyse of our experience will be required. O188 Endoscopic Management of Fistulas after Sleeve Gastrectomy Presenter: I.Khamaysi, Co-authors: A.Suissa, K.Yassin, S.Bakumenko, A.Mahajna, B.Bishara, A.Assalia Rambam Health care campus, Israel

1359 Background Gastric fistula after laparoscopic sleeve gastrectomy( LSG) for morbid obesity, is considered to be the most dreaded complication. Its management is difficult and could be associated with considerable morbidity and mortality. Objective To assess an endoscopic strategy to manage gastric fistulas. Design Retrospective study. Setting Tertiary-care university hospital. Patients All consecutive patients from July 2007 to December 2011. Intervention Successive procedures for endoscopic management of the fistula with stents, clips and sealants. Main Outcome Measurements Fistula closure and complications of the endoscopic intevention. Results Twenty patients (12 males, mean-age 36.5 years, range 18-60 years) with gastric fistulas after LSG underwent multiple endoscopic procedures (1-6). Location of the fistulas was just distal to gastro-esophageal junction in 90 % and in the distal gastric sleeve in 10 %. Eighteen patients (90 %) managed successfully endoscopicaly. The other 2 patients were re-operated ( total gastrectomy and gastric bypass). Two patients were treated by over-the-scope-clips (OTSC), 9 patients- by insertion of stents (1-4), 7 patients-by stents and OTSC and 2 patients- by OTSC and glue. Stent migration occurred in 88 % of patients. The mean time until resolution of the fistula was 6.6 weeks (range 1-16 weeks) with a mean of 3 endoscopic procedures per patient. No complications attributed directly to the endoscopic management were recorded. Limitations Moderate sample size, retrospective study. Conclusion Although most of patients needed multiple interventions, the endoscopic management of gastric fistula after LSG, achieved resolution of the fistulas in the majority of patients, with minimal morbidity. O189 Long Term Results of Gastric Banding in Asian Patients: A 1:2 Matched Case Control Study Presenter: Paul Super Co-authors: Rishi Singhal, Missba Ahmed, Avril Krempic, Paul Super Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK Introduction Uptake of LAGB has been limited in the Asian sub-continent. This is in part due to the perceived lower weight loss and a higher incidence of complications in these patients. We thus conducted a 1:2 matched case control study comparing Asian with Caucasian patients who underwent LAGB. Methods Between April 2003 and December 2009, 29 Asian patients underwent LAGB. These patients were randomly matched with Caucasian patients on the basis of age, sex, pre-operative BMI, co-morbidities and length of follow up. Each Asian patient was matched with two Caucasian patients (1:2 matched study). Results Of the 29 Asian patients, 9 had diabetes requiring medications preoperatively. The mean pre-op BMI for both groups of patients was 52 kg/m2. There was no statistical difference in the groups with regards to age, sex or comorbidities. There was statistically more weight loss in the Caucasian patients as compared to the Asian cohort at 3 and 6 months post-operatively. However, this difference was lost at 12 months upto 4 years of follow-up. There was no statistically significant difference in HbA1c, metformin dose, insulin dose, mean arterial pressure, total serum cholesterol and triglycerides in the diabetics (9 Asians vs. 18 Caucasians) at any of the time points examined. Conclusion Asian patients seem equally tolerant to LAGB in the long term. Their weight loss and co-morbidity resolution is similar to that of a matched Caucasian cohort. Surgical technique is thus more likely to account for regional differences than the inherent characteristics of an Asian population. O190 Obesity, Metabolic Syndrome And Physical Activity in Indian Adults Presenter: Mahak Sharma Ranjana Mahna, Institute of Home Economics. University of Delhi, India Metabolic syndrome is a major health problem worldwide, increasing the risk of cardiovascular diseases and diabetes. Modern lifestyles have decreased physical activity which is a leading cause of obesity, a major determinant of metabolic syndrome. The present study was done to assess the association of physical activity and metabolic syndrome in 1500 urban adults. Anthropometric measurements were taken and blood pressure was measured. Blood lipid

1360 profile and blood glucose levels were assessed. Physical activity assessment was done by a suitable structured questionnaire and Physical Activity Level (PAL) was calculated. By NCEP (ATPIII) criteria, 750 subjects (44.9 % males and 55.1 % females) with metabolic syndrome (MS) and 750 non-metabolic syndrome (NMS) subjects were identified. The major components of MS were low HDL levels in 85 % and elevated waist circumference in 80 % of the MS subjects. Elevated blood glucose levels were found in 65 %, elevated triglycerides in 50 % and elevated blood pressure in 55 % of the MS subjects. There was a significant difference (p<0.00) in the PAL value of MS and NMS subjects, indicative of MS subjects being less active as compared to NMS. Regular physical activity would help curb the growing menace of obesity and co morbidities of metabolic syndrome. O191 Laparoscopic Management of Late Perforation at the JejunoJejunal Anastomosis Following Laparoscopic Gastric Bypass for Morbid Obesity Presentet: Ramya Kalaiselvan Co-authors: M Al-Rashedy, M Abu Dakka, BJ Ammori Salford Royal NHS Foundation Trust, Manchester, United Kingdom Background Late perforation at the Jejuno-jejunal (J-J) anastomosis following laparoscopic Roux-en-Y gastric bypass (RYGB) for morbid obesity is an extremely rare and potentially life-threatening complication. Methods This is a retrospective review of the database of all patients at the senior author’s bariatric institutions that aims to identify patients with J-J perforation, to describe the incidence of this complication, identify management options and squeal. The results are presented as mean (range). Results Between April 2002 and April 2011, 1414 patients underwent laparoscopic RYGB, which included 1366 primary and 48 revision procedures. The operative mortality was 0.2 %. Three patients developed late perforation of the J-J anastomosis (0.21 %) at 7, 9 and 18 weeks respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy. One patient was managed laparoscopically with peritoneal lavage and transcutaneous tube fistulisation (jejunostomy) of the perforation using a Foley catheter. All patients recovered well postoperatively. However, there was one mortality in which the last patient presented 42 days later with peritonitis and died secondary to re-perforation. Conclusion Perforation of the J-J anastomosis following laparoscopic gastric bypass is a rare delayed complication that presents within 2-5 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously. O192100 Cases of Bariatric Surgery in a Multi-Ethnic Asian Population Presenter: Alvin Eng Co-authors: KW Tham, S Ganguly, HC Tan, WH Chan, S Pasupathy Singapore General Hospital, Singapore Background Bariatric surgery is relatively uncommon in Asia compared to Western society. Our hospital’s integrated weight loss program comprises both medical and surgical components. We report the first 100 cases of bariatric surgery by our centre. Materials & Methods Between September 2008 and March 2012, 100 patients underwent bariatric surgery in Singapore General Hospital. All patients underwent preoperative evaluation by a surgeon, endocrinologist, dietitian, psychologist and physiotherapist. Results There were 40 males and 60 females with average age of 40.18 (1966) years. The ethnic composition was 44 % Chinese, 30 % Malay, 23 % Indian and 3 % others (Arabic, Caucasian, Eurasian). Preoperative BMI was 42.8±9.22. Excess BMI Loss (EBMIL) at 3, 6, 9 and 12 months was 39.9 %, 50.7 %, 56.9 % and 51.1 %. EBMIL at 12 months in Chinese, Malay and Indian patients was 55.0 %, 33.5 % and 60.3 %. There were 4 complications requiring laparoscopic intervention: staple line bleeding, wound hematoma, jejunostomy leak and jejunostomy obstruction. 3 of the 4 complications occurred in Malay patients. There was one death which occurred 17 days after discharge when the patient’s Automatic Implantable CardioverterDefibrillator (AICD) failed to activate. The post-mortem showed no intraabdominal complications.

OBES SURG (2012) 22:1315–1419 Conclusion Bariatric surgery is developing rapidly even in our conservative Asian society. There were no deaths directly attributable to surgery in our series and the rate of serious complications is 4 %. Malay patients appear to have lower weight loss and higher complication rates although further investigation is necessary to determine whether it is due to small sample size or an underlying cause. O193 Change in Serum Level of Micronutrients After One Year Follow Up of Laparoscopic Sleeve Gastrectomy Presenter: Richa Jaiswal1 Co-authors: Sandeep Aggarwal2, Mahesh C Misra2, Departments of Dietitics1, Surgical Disciplines2, All India Institute of Medical Sciences, New Delhi, India Background Micronutrient deficiency is very common in India which leads double burden of over nutrition and micronutrient deficiency in obese patients. Laparoscopic Sleeve Gastrectomy (LSG) become very popular mean for long term sustained weight loss without major nutritional deficiency over Malabsorptive procedures. We report the impact of LSG on change in serum level of micronutrients in one year follow up. Methods 50 patients with a mean age of 39.15 years (range, 18-65), mean BMI of 45.3 kg/m2 underwent LSG at AIIMS, New Delhi. We included only those patients who underwent LSG and their all 4 follow up records including baseline, three month,6 month and one year serum values of iron, calcium, vitamin B12, and folic acid were available with their weight loss pattern. Patients diet were modified initially weekly, after 3 weeks every 3 monthly based on their previous intake, serum values, availability of food items and acceptance. Dietary intake was assessed by diet diary and 24 hour Dietary Recall. Results All 50 patients have a 1 year follow-up with significant weight loss. In 20 % of patients mild iron deficiency anemia was found before LSG. These patients were advised oral iron supplementation along with appropriate diet to enhance iron absorption. No significant change in serum values were observed after 3 months follow up. After 6 months of follow up 47 % patient were suggested multivitamin and iron supplementation to avoid iron deficiency anemia based on their steep fall in serum values of iron and folic acid in comparison to baseline levels,12 % patient were advised oral calcium supplements. 2 patients needed intramuscular vitamin B12 supplementation within 3 months of surgery due to nutritional complications and inadequate dietary intake. After 1 year of follow up no significant change was found in serum levels of micronutrients as it was attenuated before. Conclusion LSG along with diet has been effective in providing significant weight loss. LSG has additional advantage over gastric bypass because it does not reduce micronutrients absorption pathway. It is observed that sudden change in diet pattern and limited food options for longer period may develop aversion and hinder food intake which subsequently lead micronutrient deficiency. This can be corrected with close nutritional supervision. Limitation Sample size is small. Patient’s serum values were not compared with obese patient’s blood parameters those who did not go under weight loss surgery. O194 Single Incision Sleeve Gastrectomy Utilizing SPIDER® Surgical System: Case Series of 23 patients Presenter: Shyam Dahiya, MD, Lakewood, California, USA Tri City Medical Center, United States of America Introduction This is a report of a single surgeon series of 23 laparoscopic, single-incision sleeve gastrectomies utilizing the SPIDER® Surgical system. Methods and Procedures A 12 mm trocar is inserted at the umbilicus, and the SPIDER device is inserted within the same umbilical incision (but a separate fascial incision) on the umbilical ring. The total skin incision length is approximately 3.5 cm. A 5 mm scope is inserted through the SPIDER device for visualization. Two flexible graspers are inserted into the SPIDER device for tissue manipulation. A 5 mm vessel sealer is introduced through the 12 mm trocar for gastrolysis. For stapling division, an articulating stapler is used. The specimen is removed with the SPIDER device at the end of the procedure. Results 23 sleeve gastrectomies were performed. The mean age was 39 years. The mean BMI was 43 (+/- 5 standard deviation, 39 min, 59 max). The mean total operative time was 92 minutes (+/- 54 standard deviation,

OBES SURG (2012) 22:1315–1419 42 min, 200 max). The mean follow up period was 277 days (+/- 123 standard deviation, 22 min, 508 max). In 21 of 22 cases, no Nathanson liver retractor was used because the SPIDER flexible arm provided necessary liver retraction. No interoperative or post-op complications were observed. No cases were converted to open, and no cases required additional ports. Conclusions The SPIDER® Surgical System is feasible as a single incision system to perform gastric sleeves. Further study of this novel technology is recommended. O195 Incidence of Gastrojejunal Stricture After Laparoscopic Roux-en Y gastric Bypass and Roux Limb Course Presenter: Lara Ribeiro Parent Co-authors: Denis Chosidow Konstantinos Arapis Pierre Fournier Jean Pierre Marmuse

1361 Results There was no significant expression of TNF-, IFN-, IL-4 and IL-17A in pre and postoperatively. However, was observed expression of IL-10 in 14 of 17 patients preoperatively and significant decrease in the expression of this cytokine in the postoperative period (p00.0052). Conclusion Long term insulin treatment before surgery may have contributed to high levels of IL-10 preoperatively, because insulin has antiinflammatory effects. The decrease in its expression may be due to the fact that most patients are not using insulin or oral hypoglycemic agents after surgery. O197 Resolution of Type 2 Diabetes After Gastrectomy for Gastric Cancer with Long Limb Roux-en Y Reconstruction: A Prospective Pilot Study Presenter: Seung Ho Choi Co-authors: Whan Sik Kim, Jong Won Kim, Chul Woo Ahn

Hopital Bichat Claude Bernard, France Background The Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent short-term complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. The aim of the present retrospective study was to determine the rate of gastrojejunostomy stricture in a large cohort of patients and to identify patient or technique factors predisposing to such complication after laparoscopic RYGBP for morbid. Methods From November 2000 to November 2010, 1142 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic (group AA) and the retrocolic (group RA) technique was used in 572 and 570 consecutive patients respectively. All procedures were performed using a circular stapled anastomosis and absorbable sutures. Results There were no significant difference with respect to gender, age, BMI and obesity related co-morbidities between the two groups. Patients were followed for 18 to 99 months (mean 48.8 months). During follow-up, 48 patients developed a gastrojejunal anastomotic stricture (4.2 %), 35 in the antecolic group (6.1 %) and 13 in the retrocolic group (2.3 %). The mean time to onset of gastrojejunal anastomotic stricture symptoms after surgery was 1 month ranging from 1 to 3 months. All the patients were successfully treated using endoscopic pneumatic dilatation. On multivariate analysis, the antecolic technique was identified as a risk factor of GJS (p0 0.0016). Conclusion A significant lower incidence of gastrojejunal stricture was observed in the retrocolic group. The results of our study have shown that the use of the antecolic technique is a risk factor for appearance of GJS after LRYGB. O196 Immunological Evaluation in Patients with Type 2 Diabetes Mellitus Submitted to Duodenal-Jejunal Exclusion with Ileal Interposition Without Gastrectomy Presenter:Guilherme Azevedo Terra Co-authors: Ramos, M.C.; Crema, E.; Takeuti, T.D.; Ribeiro, V.M.; Rodrigues Junior, V.; Terra Junior, J.A.; Silva, L.M.; Silva, A.A. Federal University Of Triangulo Mineiro, Brazil Introduction Immunological and inflammatory mechanisms play a significant role in the development and progression of type 2 diabetes mellitus. HERBER et al., 2009, observed that high concentrations of TGF- 1 indicates a high risk for progression of type 2 diabetes and reported that subclinical inflammation leads to insulin resistance and beta cell dysfunction. The surgical treatment with the duodenal-jejunal exclusion and/or ileal interposition has shown useful for clinical management of type 2 diabetic patients. Objectives Evaluate the expression of IFN-, TNF-, IL-4, IL-10 and IL-17A, in the preoperative and postoperative (6 months after surgery) in 17 patients with type 2 diabetes mellitus and submitted to duodenal-jejunal exclusion and ileal interposition, without gastrectomy. Methods The dosages of cytokines were performed with commercial kits (R &D Systems, Billings, MT, USA), by ELISA, with a detection limit for each cytokine of 10 pg/mL. The results were determined by the difference between the absorbance obtained: 405 and 490 nm, measured in an automatic ELISA reader.

*Department of Surgery, and **Department of Endocrinology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Background It is unclear whether metabolic surgery is effective in non-obese T2DM and the result after gastrectomy and conventional reconstruction for gastric cancer and non-obese T2DM are not satisfactory for improvement of T2DM. Materials and Methods Prospective sing-arm pilot study with Roux-en Y reconstruction after gastrectomy was evaluated on its safety and efficacy as a potential cure for T2DM in patients with 15 non-obese gastric cancer. After gastrectomy, the gastrointestinal tract was reconstructed by Roux-en-Y gastrojejunostomy or esophagojejunostomy. The biliopancreatic and Roux limb were 100-120 cm long each. Results There was no surgery- related mortality, but four cases experienced complications (26.7 %). Before surgery, the mean BMI was 25.2±3.4 kg/m2 and mean HbA1c was 7.7±1.4 % with antidiabetic medications. The mean BMI decreased to 21.7±3.1 kg/m2 (p<0.05) and the mean HbA1c decreased to 6.3±0.8 % (p<0.05) 6 months after surgery. At the end of the study, the level of FPG in 11 patients (78.6 %) returned to normal, and HbA1c decreased to<6 % without any antidiabetic medications. Conclusions Long limb Roux-en Y reconstruction after gastrectomy is safe and has the potential to cure T2DM in non-obese gastric cancer patients. Randomized controlled trial is needed to confirm this result. Keywords: T2DM, Roux-en Y, gastrectomy, gastric cancer, non-obese, metabolic surgery O198 Laparoscopic Adjustable Gastric Banding – Indian Experience Presenter: Dr Arun Prasad MS, FRCS, FRCSEd Apollo Hospital, New Delhi, India Laparoscopic adjustable gastric banding was one of the early morbid obesity procedures that got popular in India. The reversibility and low perioperative morbidity made it popular amongst surgeons and patients. We present our experience of patients who have been on a more than 5 years follow up. From January 2005 to March 2007, a total of 23 patients underwent this procedure of which 18 have had a regular follow up for 5 years or more.Excess weight loss was 46.2 % after 1 year, 55.3 % after 2 years, 45.9 % after 3 years, 41.9 % after 4 years and 41 % after 5 years. One patient underwent band removal due to inadequate weight loss. There was one incidence of reservoir port infection that was managed conservatively. O199 Comparison of Excess Weight Loss and Body Composition Between Diabetic and Non-Diabetic Patients Following Gastic Bypass or Sleeve Gastrectomy Prresenter : Pier Paolo Cutolo Co-authors: Giampalo Formisano, Gabriella Nosso, Antonella Santonicola, Giuliana Vitolo, Luigi Angrisani. General and endoscopic surgery unit S.Giovanni Bosco Hospital, Italy Background Bariatric surgery provides excellent results in term of weight loss and improve associated metabolic disorders such as type 2 diabetes mellitus

1362 (T2DM). There is low evidence in literature about changes in body composition in relation to different bariatric procedures and the presence of T2DM. Aim of this study is to evaluate changes in body composition in diabetic obese patients vs. non-diabetic obese patients who underwent different bariatric procedures, Gastric bypass (LRYGB) or Sleeve Gastrectomy (SG). Methods the Body composition of obese patients eligible to surgery was evaluated by bioelectrical impedence analysis (Tanita BC 418-MA) before and 1-year after surgery. A variation test was used to analyze results (BMI and body composition). Results 46 patients underwent bariatric procedures: 20 patients LRYGB and 26 patients SG. 21 patients preoperatively suffered from T2DM and 25 did not. Data concerning BMI and body composition were collected at baseline and 1year follow-up in four subgroups of patients: obese non-diabetic patients (group 1) and obese diabetic patients (group 2) who underwent LRYGB, obese non-diabetic patients (group 3) and obese diabetic patients (group 4) who underwent Sleeve gastrectomy. At 1-year follow-up, fat mass and fat-free mass differences in percentage were statistically significant in each subgroup. There were no statistically significant differences as regards BMI, fat mass and fat-free mass percentages between subgroups 1 and 2 as there were, in contrast, between group 3 and 4. Conclusions bariatric surgery can induce good results in term of weight loss, reduction of fat mass as well as fat-free mass improvement. Obese diabetic patients submitted to Sleeve Gastrectomy have a worse improvement of fat mass and free-fat mass compared to non diabetic patients submitted to the same procedure. O200 The Significance of Routine White Cell Count (WCC) And CReactive Protein (CRP) Measurements Following Laparoscopic Roux-en-y-gastric Bypass (LRYGB) Presenter: A.A. Warsi, Co-author L. Heptinstall, M. Asaria, F. Passafiume, M. Jaw, M. Barecca, D. Whitelaw and V. Jain Institution: Luton and Dunstable Teaching Hospital, Luton, U.K Background Routine measurements of C-reactive protein (CRP) and white cell count (WCC) following Laparoscopic Roux-en-y gastric bypass (LRYGB) are controversial (Cole et al). Aims Our aim was to assess whether such measurements could predict post operative complications and increased length of stay (LOS)>3 days. Methods Post-operative CRP and WCC were collected prospectively on 107 patients who underwent LRYGB between September 2011 and January 2012. Results 40 patients were male and 67 female. The median (range) age was 54 (21-68). Only 11 patients had an increased LOS (1 anastomotic leak, 5 inadequate pain control, 3 drop in haemoglobin, 1 UTI and 1 pneumonia). The median CRP and WCC on day 2 of the patients with an increased LOS was 165.9 and 11.9 respectively, compared to 70.2 and 9.75 for those discharged within 3 days.Of these 11 patients with an increased LOS, 7 had an elevated CRP (>100) day 2 post-operatively, and 8 had an elevated WCC (>11). Of the remaining 96 patients, 18 had an elevated CRP day 2 postoperatively, and 25 had an elevated WCC. A two tailed Fisher’s exact test found a CRP over 100 and a WCC over 11 on day 2 to be associated with an increased LOS (p00.002 and p00.02 respectively). Conclusion Day 2 measurement of CRP and WCC with values over 100 and 11 respectively, can predict higher morbidity and increased LOS in hospital. O201 Long Alimentarylimb (200 cm) vs Standard Limb (150 cm) Roux-Y Gastric Bypass for Patients with BMI Between 40 -50 Kg/m2, and Longalimentarylimb%EWL Evolution for Patients with BMI over 50 Presenter: Nicola´s Quezada Co-authors: Alex Jones, Carlo Marino, Julia´n Herna´ndez, Aron Kuroiwa, Alex Escalona, Gustavo Pe´rez, Fernando Crovari, Ricardo Funke, Fernando Pimentel, Camilo Boza Digestive Surgery Department, Division of Surgery. Ponthifical Cattholic University of Chile. Satiango, Chile Introduction Roux-Y gastric bypass is the gold standard procedure for tratment of morbid obesity. Nevertheless, there is no agreement in the lenght of the alimentary limb

OBES SURG (2012) 22:1315–1419 Aim To evaluate our results of long alimentary limb (LAL, 200 cm) for patients with BMI with morbid obesity and to describe %EWL in superobese patients treated with LAL gastric bypass. Methods Retrospective analysis of our database. LAL were created with 200 cm and standard limb (SL)with 150 cm. Biliopancreatic limb was standard at 25 – 30 cm from Treitz. Results 285 patients with LAL and 375 with SL with BMI between 40-50 were described. % of EWL were as follow (LAL vs SL, mean±SD): Month 6: 70±29 vs 66±17, Month 12: 82±20 vs 82±18, Month 24: 82±21 vs 84±19, Month 36: 84±23 vs 79±20, Month 48: 79±24 vs 78±24, Month 60: 76±20 vs 71±24 (p>0.05). In patients with BMI over 50, LAL%EWL evolution was as follow: Month 6: 59±12, Month 12: 70±17, Month 24: 75±18, Month 36: 74±22, Month 48: 64±20, Month 60: 67±20, wich was significantly lower compared to BMI 40-50 (p<0.01) Conclusion LAL Roux-Y gastric bypass does not offer better % of EWL in patients with BMI between 40-50. Patients with BMI over 50 and LAL Roux-Y Gastric bypass had acceptable %EWL, but were lower compared to BMI between 40-50. O202 Laparoscopic Butterfly Gastroplasty – Evaluation of a New Technique Presenter: Essam Abdel-Galil, Alaa Abbas Mostafa Department of Surgery, Ahmed Maher Teaching Hospital. Ain Shams university, Cairo Egypt Abstract The restrictive bariatric procedures. (Vertical banded gastroplasty , gastric band and sleeve gastrectomy ) are an effective procedures for the long term control morbid obesity specially for the bulk caters . the cardinal complications after this procedures are weight regain due to pouch dilatation solid food intolerance and reflux disease due to the tubular shape of the pouch . Methods From Jan. 2007 through Jan. 2011 laparoscopic butterfly gastroplasty was attempted in 480patients median age was 32, with median preoperative BMI 48, the butterfly gastroplasty (micro funnel shaped pouch) banded with a prolene mesh . Results Average excess weight loss of one year was 70 %. The mean operating time was 45 min. the outlet calibration was accurate and easy. There was no leak or mortality. Conclusion Butterfly gastroplasty . (Micropouch funnel shaped pouch) using the gastric cardia only is an effective way to prevent pouch dilatation and therefore prevent weight regain occyrred in high percentage of patients underwent the original VBG, of mason. The pouch being micro-funnel rather than tubular-shaped prevent solid food intolerance and reflux disease. The way of constraction of the butterfly allow easy accurate outlet and less costs combined cervical epidural and general anesthesia was better. Keywords: Butterfly, Gastroplasty, Bariatric, Epidural Video001 Laparoscopic Conversion of Nissen Fundoplication to Rouxen-Y Gastric Bypass for Morbid Obesity: Challenging and Technical Feasibility Presenter: Nasser Sakran Co-author: Dr. Dillemans Bruno, Belgium.Dr. Asnat Raziel, Israel. Dr. Ahmad Assalia, Israel. Hillel Yaffe Medical Center, Israel Background With the demand for weight loss surgery increasing, surgeons are likely to encounter with increasing frequency patients desiring these operations who have had previous foregut surgery. We present a case of a morbidly obese patient with previous laparoscopic Nissen fundoplication who was successfully treated by conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). Clinical case We present the case of a 40-year-old obese man, body mass index (BMI)040 kg/m, who underwent laparoscopic Nissen fundoplication for GERD. After 6 years from the procedure, considered his high BMI, the patient was advised to undergo laparoscopic conversion of Nissen fundoplication to LRYGB. Video presentation The video illustrates all the important surgical steps required to convert this patient to a LRYGB: adhesiolysis between the liver and the stomach, dissection of the diaphragmatic crura and gastroesophageal fat pad, taking down of wrap to avoid stapling over the Nissen fundoplication,

OBES SURG (2012) 22:1315–1419 unwrapping the fundoplication and creating the gastric pouch. The fundus was resected and a standard antegastric, antecolic gastric bypass was performed. The patient is currently one year out from surgery. His BMI is 28 kg/m, and he reports satisfaction with the procedure. Conclusion Laparoscopic conversion of Nissen fundoplication to LRYGB is technically difficult and carries greater complication rates. RYGB results in effective weight loss, controls reflux symptoms, and may be the procedure of choice in morbidly obese patients with previous antireflux surgery, and obese patients requiring surgical treatment for gastroesophageal reflux disease. V002 Transumbilical Sleeve Gastrectomy Using Rigid Instruments: Surgical Results and One Year Follow-Up in 212 Patients Presenter: Jose´ Ignacio Fernandez Co-author: Jose´ Ignacio Fernandez, Cristian Ovalle, Carolina Cabrera, Jaime de la Maza Centro Integral de Nutricion y Obesidad, Clinica Tabancura, Chile Background Transumbilical approach has demonstrated to be safe in several surgical procedures. Sleeve gastrectomy with transumbilical approach (TUSG) had been reported, with different technique variations. The objective of this report is to present surgical results and one year follow-up of a simplified TUSG, using rigid instruments. Methods A total of 197 (93 %) women and 7 men (7 %) underwent TUSG. Operative technique involves transumbilical incision, Introduction of GelPoint® multiport, and a 5 mm metallic accessory trocar in the left flank. Rigid instruments were used in all patients. The greater curvature dissection was made from 4 cm proximal to the pylorus, to the left crus. Gastric section is completed with stapler, and calibrated with a 36fr boogie. Results Patient BMI ranged from 30 to 46.7 Kg/m2 (mean BMI: 34±3.1 Kg/m2) Mean operative time was51.6±15 minutes. Five patients (2.4 %) presented early complications, hemoperitoneum in three cases, one antral leak, and one intestinal perforation. No conversion to conventional laparoscopy or open technique was required. There was no mortality. Mean length of hospital stay was 2.2±1.1 days. Cosmetic result was satisfactory for all the patients. EWL at 3, 6 and 12 months was 83±0.3 %, 107±38 % and 119±40 % respectively. Mean BMI at 3, 6 and 12 months was 27.1±2.8, 25.2±3, and 24.3±2.6 Kg/m2 respectively. Two patients developed incisional hernia (0.9 %) as late complication. Conclusion TUSG with the exposed technique it’s safe, with good short term weight loss, and excellent cosmetic results. Longer follow-up is required to establish the real incidence of late complications like incisional hernia. V003 Revisional Bariatric Surgery. The “single step” Laparoscopic Conversion from Gastric Band to Gastric ByPass Presenter: Fabrizio Bellini Co-author: Pietro Pizzi Bariatric and Metabolic Surgery, Desenzano Hospital, Italy Introduction Patients who fail to achieve satisfactory weight loss after gastric restrictive operations are a difficult subset of patients to treat. In case of EWL <30 % and a high residual BMI, is mandatory a revisional surgery. The single step approach from failed Gastric Band to LRYGBP is our operation of choice. Materials & Methods From 2003 to 2011, 3287 patients underwent gastric band. As rescue procedure, we have carried out 71 (2,29 %) LRYGBP. Modus operandi - careful dissection, wide mobilisation and clear visualisation of angle of His - the 4,8 mm cartridges are used to transect the stomach 2 cm away from the gastric band scar Results No conversion to open surgery, no deaths or leaks, no post-op bleeding, no others major complications. The post-operative course was comparable to the LRYGBP performed as primary procedure. Average EWL 69 % at 24 months. Discussion & Conclusions The ideal operation to control recurrent obesity in patients, who are “true non-responders”,has not yet been defined. Patients with inadequate weight loss following gastric bandages present a challenging problem. In addition bariatric revisional surgery is a major concern, that requires team skill and advanced laparoscopic experience. The conversion

1363 to LRYGBP in one step seems to be able to provide an acceptable percentage of complications and durable weight loss. Adhesions from previous surgery are increasing the possibility of complications. In our experience, the revisional “single step”, is feasible and achieves the same percentage of morbidity of the operations performed as a primary procedure. V004 Secondary Laparoscopic Sleeve Resection After Gastric Bandingi in Super-Super Obese Patients Presenter: Martin Thurnheer Co-authors: Philipp Bisang Kantonsspital St.Gallen, Switzerland Introduction Super-super obese patients with secondary band intolerance who refuse a secondary bariatric procedure at the time of band removal usually suffer from weight regain to at least the baseline weight. Asked for a secondary bariatric procedure at this point, we prefer a 2-stage procedure, with a laparoscopic sleeve resection first, followed by a malabsorbtive procedure, since morbidity and mortality rates are much higher in these patients than in morbidly obese patients. Materials and Methods So far, we have performed a secondary laparoscopic sleeve resection (slSleeve) after band removal in 3 super-super obese patients. The patient in the video was female, 45 y old, and had a BMI of 70 kg/m2. The delay after band removal was 10 y. Results This video with the following key steps demonstrates our technique of slSleeve. After placing 5 trocars extensive adhesiolysis of the proximal stomach is performed, displaying both crura of the diaphragm and the angle of His. Then a dorsal crurorrhaphy is performed. The greater curvature of the stomach is dissected from 3 cm oral to the pylorus to the angle of His, followed by the resection along a 32 french gastric tube. We used 7 reenforced green and gold cartridges of the 60 mm linear stapler. Discussion Although our experience is limited to 3 cases (with no major complications), in the hands of an experienced surgical team, slSleeve seems to be a safe and efficient procedure for super-super obese patients after band removal. V005 Stapler Mishaps in Bariatric Surgery Presenter: Sarfaraz Baig Co-authors: Dr B Ramana Bariatrics and Metabolism Initiative, India Introduction The outcome of bariatric procedures is largely dependent on the performance of the staplers. Technical issues can translate into misfiring, stress on the surgeon and leaks. Methods and Results Between 2008- 2012, we performed 122 bariatric procedures of which 90 required staplers during LSG or LRYGB. In one procedure the stapler fired but failed to open. In another situation the stapler pins at the antrum started to come off after firing requiring suturing. In three occasions, during stapler firing the tissue got divided even before releasing the gun. In one bizarre situation during firing, the spring and small components of the gun disintegrated and spilt all over the abdomen. Once the anvil of the circular stapler got snapped off from the tube at the cricopharyngeal level requiring endoscopic retrieval. In many occasions the buttress on the staplers came off while inserting it through reusable 12 mm trocars. All these situations needed careful decision making, frequent suturing, endoscopy and loads of patience. Conclusions One should be alert about the possibility of stapler mishaps and be ready to deal with them. V006 Migration of Gastric Band with Inttestinal Obstruction Presenter: JAV Carim Co-author: Carim FB,Quintanilha C, Carestiato A, Alexandre Naegele Day Hospital Nossa Senhora do Libano, Brazil The adjustable gastric band procedure is being currently usedthroughout the world widely mostly in Australia, followed by Europe. Its usehas also had wider

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and wider acceptance in the US. In patients with a BMIabove 35Kg/m2 presenting comorbidities. In Brazil, it has presentedsatisfactory results in some particularly selected patients. The objective of this presentation is to show an erosion of the band with theirmigration to the jejunum bringing about intestinal obstruction. We haveexperienced intestinal obstruction caused by the late band migrating into thestomach and subsequently causing an obstruction in the jejunum somewhere around 60 cm at Treitz angle. A 44 year old patient lost more than 60 % of excess weight after 18 months of placement, unfortunately she completely abandoned our service,and soon after, regained weight and developed abdominal pain with clearevidence of a migration. The patient had a jejunal obstruction and attemptedremoval of the band via endoscopy, which was impossible due to its attachment to the jejunal loop, site of obstruction. By means of laparoscopy, it was withdrawn after opening band jejunal then suturing and with nofurther complications. We are led to believe that the placement procedure of gastric bandingmethod is feasible, with good results, but its monitoring by a multidisciplinary team should be mandatory, otherwise serious complications do occur and can lead to unpredictable consequences.

used for bariatric procedures, and this surgery may be the next step in minimally invasive surgery. Video: The high Definition video contains the following steps: Creation of an elliptical skin flap around the umbilicus of 5 cms The incision is deepened until the fascia and creating adequate space for insertion of trocars. Using a Veress needle,pneumoperitoneum is created with 16 mmHg Three separate trocars are inserted through the fascia.10 mm for the camera, left hand working 12 mm and right hand working 5 mm Curcillo trocar. Liver retracted using the Liver suspension tape created using a corrugated tube. The jejunum is divided at 75 cms from the DJ flexure.Jejunostomy done with 125 cms as the alimentary limb and the enterotomy closed handsewn. The mesenteric defect closed with 2-0 Prolene. The gastric pouch of 30-40 ml created using the perigastric technique, and a vertixcally oriented pouch created over a 36 F bougie. The gastrojejunostomy done using 35 mm blue staples and the enterotomy closed handsewn with 2-0 PDS sutures. Leak test performed.

V007 Laparoscopic Esophago Gastricanastomosis Post Gastric Band Esophageal Stenosis

V010 Laparoscopic Gastric Band for the Treatment of Failed Roux en Y Gastric Bypass

Presenter: Maher K. Hussein, M.D., F.A.C.S.

Presenter: Maher K. Hussein, M.D., F.A.C.S.

Department of Surgery, American University of Beirut Medical Center, Beirut – Lebanon

Department of Surgery, American University of Beirut Medical Center, Beirut – Lebanon

Complication of Gastric Band is well known including, migration, slippage, pouch dilatation, Esophageal dilatation and reflux. This video will showed the treatment of rare complication of Esophageal Stenosis post Laparoscopic Gastric Band, attempts of esophageal dilatation done several times that failed. The video shows the technical details of Esophago Gastric Anastomosis over a 36 French Catheter. Patient had smooth postoperative course with repeat gastrograffin swallow done 5 days later that revealed absence of leak. Conclusion Bariatric procedure should be done in specialized centers that can deal also with the complication of the procedure.

Laparoscopic Gastric Bypass is a Gold Standard technique for the treatment of Morbid Obesity but associated with 15-20 % failure rate. We report our experience at The American University of Beirut – Medical Center of 5 cases of failed Gastric Bypass that was treated successfully with Laparoscopic Gastric Band on top of the Gastric Bypass with excellent result. The video will demonstrate the steps used to insert the band. Conclusion Laparoscopic Gastric Band can be safely used in Roux En Y Gastric Bypass Failure.

V008 Revisional Surgery After Sleeve Resection and Gastroplication The problem of the Expanding Fundus Presenter: Dieter Birk Co-authors: Peter Djalali, Marlise Fritz, Sarah Hess

V011 Treatment of Delayed Gastric Bypass Bleedingby Combined Endoscopic & Laparoscopic Approach Presenter: Praveen Raj Co-authors: P Senthilnathan, B.Vijay,Parimala, Roja Ramani, Palanivelu C Gem Obesity&Diabetes Surgery Centre,Gem Hospital&Research Centre, India

Protestant Hospital Zweibru¨cken, Germany Sleeve Resection is the restrictive operation of choice in German hospitals specialising in bariatric surgery. Over the last five years the operations performed and entered in the national quality assurance study has doubled each year. Gastroplication is increasingly performed since 2010. As a result of the huge rise of these operations, revisional surgery has become more and more frequent. The video submitted highlights one of the main problems after these restrictive procedures: The enlargement of the fundus remnant. Patients suffering from this usually present with weight regain and the ability to eat large meals again, however sometimes the enlarged fundus does not permit a proper transit through the stomach and frequent emesis is resulting. In various cases the problem of the fundus and its correction is presented in the 8 minute Video V009 Single-Incision(Single Site Multiport) Laparoscopic Gastric Bypass Presenter: Praveen Raj Co-authors: P Senthilnathan, B.Vijay,Parimala, Roja Ramani, Palanivelu C

Laparoscopic Gastric Bypass complications are well-known including leak, early postoperative bleeding, jejeunojejunal hernia, jejeunojejunal stenosis, and Peterson defect hernia. We will present delayed Gastric bleeding 6 weeks post surgery referred from other hospital after transfusion with 6 units of PC due to erosion of left Gastric artery into the suture line. The video will show the steps used by endoscopy to localize the bleeding site and laparoscopic approach to control the bleeding, and redo the anastomosis site. Conclusion treatment of Gastric Bypass complication is feasible by minimal invasive surgery in advanced center in Bariatric Procedures. Video012 Complication of a Displaced Bougie During a Laparoscopic Sleeve Gastrectomy - Rescue By Conversion to Laparoscopic Gastric Bypass Presenter: Randeep Wadhawan Co-authors: Muneendra Gupta, Subrat Raul, Sanjay Verma, Farid Shah. Department of Minimal Access , Bariatric & Gastrointestinal Surgery , FORTIS Hospital, Vasant Kunj, New Delhi, India

Gem Obesity & Diabetes Surgery Centre,Gem Hospital&Research Centre, India Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. Recently, the concept single-incision laparoscopic surgery has been

Introduction Laparoscopic sleeve gastrectomy (LSG) has become a standard one-step procedure for the surgical treatment of morbid obesity. Although this is a simple operation, complications have been observed. Most frequently encountered major complications include leaks, suture line haemorrhage, major organ injury and post-operative strictures. The LSG procedure is

OBES SURG (2012) 22:1315–1419 performed using either an endoscope or a bougie for gastric sleeve sizing. We report an unusual complication where the displaced bougie and subsequent misfiring of the staplers in LSG resulted in a complete stricture at the body of the stomach, therefore requiring a rescue conversion to a laparoscopic Rouxen-Y gastric bypass(LRYGB). Case Report We report the case of a 44-year-old female with a BMI (Body Mass Index) of 42 kg/m2 planned for a LSG. She had Type 2 Diabetes for 3 years managed on oral hypoglycemic agents. Standard LSG procedure with a 36 F bougie was being performed. However, prior to firing the fourth stapler we realized that the bougie had got displaced. We suspected that we may have created a complete stricture at the level of the body of the stomach which was confirmed by upper GI endoscopy intraoperatively. We immediately converted to a standard LRYGB . Postoperatively the patient had an uneventful recovery. Eight months postoperatively the patient is doing well with a complete resolution of Diabetes, an excess weight loss of 48 % and a BMI of 34. Discussion & Conclusions LSG has increased in popularity because of easy execution but we should always ensure that a bougie or an endoscope should be in proper place prior to the gastric sleeve resection. The staplers should be fired with a high degree of caution. Inadvertent stricture of the sleeve should be diagnosed by an upper GI endoscopy intraoperatively and the management should be a conversion to LRYGB. V013 Laparoscopic Treatment of Sleeve Leak WithRoux en Y Gastric Bypass Presenter: Praveen Raj Co-authors: P Senthilnathan, B.Vijay,Parimala, Roja Ramani, Palanivelu C Gem Obesity&Diabetes Surgery Centre,Gem Hospital&Research Centre, India Leak is one of the common complications of Laparoscopic Sleeve Gastrectomy that entail prolonized Hospital stay morbidity and even mortality. We report the treatment of 5 cases of complicated leak post sleeve gastrectomy that failed all conservative measure to heal including stenting by Laparoscopic Roux En Y Gastric Bypass all were curved. The video will show the steps used to dissect the Gastroesophegeal are identifying the leak and Roux En Y Gastric Bypass. Conclusion Sleeve Gastrectomy level can be handled by minimal invasive surgery in advanced centers in Bariatric surgery. V014 First Reported Lethal Abdominal Injury from Buttress Material During Bariatric Surgery Presenter: Hussein Faour* Co-authors: Essam ElSheikh**, Dina S. Badran**, Samy A Ibrahim**, Wissam Fakih*, Osamah Al Sanea*

1365 material which was applied to condensed gastric tissue brought together by staples creates a oscillating knife like effect with each breath that could potentially cause damage of surrounding structures. Conclusion Use of hard synthetic buttress material carries significant potential damage that should be taken into consideration. Keywords: Endostapler , Reinforcement , Postoperative complication , Sleeve gastrectomy V015 Our Technique of Single Incision Gastric Bypass-Case Experience of 20 Cases at a Tertiatry Hospital of Central India Presenter: Dr Mohit Bhandari Co-authors: Dr Milind Joshi Dr Arun Mishra Dr Shilpa Bhandari Sri aurobindo medical college and pg institute, India Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce lessthan-ideal cosmetic results. We describe single incision gastric bypass using a gelpoint port (applied medicals) to treat morbid obesity. Twenty morbidly obese patients (8 males and 12 females) with mean BMI 38 underwent Roux-en-Y gastric bypass with this technique. During the operation, we used a needloscopic instrument (2 mm stryker)for liver traction. A 2.5 cm transumblical incision was made and a gelpoint port is inserted. Multiple access upto four can be made by a gelpoint port.one access is used for the optical 5 mm telescope ,two others for suturing and a separate 12 mm port for stapler. The length of the biliopancreatic limb was kept as 75 cm and alimentary limb 150 cm for all the patients. Enterotomy closure and gastrojejunoastomy was done by conventional hand suturing using a 2.0 vicryl. The mean operative time was 2.5 hours . There was no leak and no significant comorbidity except one patient developinf post operative lt sided lung consolidation which was treated by active chest physiotherapy and broad spectrum antibiotics. Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring. V016 Our technique of Laparoscopic Duodenal Jejunal Bypass with Sleeve Gastrectomy-Experience of 40 Cases from a Tertiary Hospital of Central India Presenter: Dr Mohit Bhandari Co-authors: Dr Milind Joshi Dr Arun Mishra Dr Shilpa Bhandari Ssri aurobindo medical college and pg institute, India

*Bariatric Center Of Excellence, Royale Hayat Hospital, Jabriya, Kuwait; * Corresponding Co-Author. Bariatric Center Of Excellence, Royale Hayat Hospital, PO Box 179, 32002, Jabriya, Kuwait; ** Department of Forensic Medicine, Ministry of Interior, Kuwait Background Sleeve gastrectomy is gaining popularity as a primary operation. Staple-line reinforcement with synthetic buttress material is proposed to reduce bleeding and leak. Methods We report the first lethal injury from preloaded buttressed staples (DUET TRS SULU, Covidien) during bariatric surgery. Results A 36-year old morbidly obese female (BMI040) had an uneventful laparoscopic sleeve gastrectomy using Duet TRS Green Loads (Covidien) and she was discharged on postoperative day 2 tolerating liquid diet. On postoperative day 7, patient collapsed within minutes after feeling sudden weakness and lethargy while preparing food for the family. She was pronounced dead within minutes from the arrival of the paramedics. Autopsy revealed fresh bleeding along the retro-gastric bed reaching the spleen and dissecting into the abdominal wall musculature as well as the chest wall musculature as well as injury to the splenic artery as it lies between the pancreas and the sleeved stomach. The area of injury corresponded to the crossing on two staple fires just at the level of the incisura. In 2012, Covidien has voluntarily recalled all DUET cartridges intended for endoscopic thoracic surgery after receiving reports of 3 deaths and 13 serious injuries due to adjacent tissue injury in the thoracic cavity. We believe the hard synthetic

With the established role of bariatric surgeries in resolution of type 2 diabetes even in moderate bmi individuals laparoscopic duodenal jejunal bypass with sleeve provides advantage of sizing the remnant stomach to avoid excess weight loss and also maintains the accessibility of remnant stomach by endoscope for future surveillance. We devised our technique to perform this procedure.40 patient (22 male and 18 female) with a bmi between 27 and 50 with type 2 diabetes mellitus were operated at our centre.The procedure was performed with 4 ports and 1 nathansons retractor. Mobilization of greater curvature of the stomach is done 5 cm from the pylorus in patients with bmi more than 35 and 7 cm from pylorus with bmi less than 35.A 36 fr gastric calibration tube is used to perform conventional sleeve gastrectomy in patients with bmi more than 35 and a 40 fr tube in patients with bmi less than 35.Later the first part of the duodenum is dissected from the pancreas and divided by a linear cutter stapler at 2 cm from the pylorus.The length of biliopancreatic limb and alimentary limb is 50 and 100 cm respectively in patients with bmi less than 35 and 100 cm and 150 cm in bmi more than 35. Greater momentum is split till the base of transverse colon and a antecolic totally hand sewn end to end 4 layer anastomosis is made on a 36 fr bougie between the first part of duodenum and jejunum taking care of not damaging the pyloric muscles during gastrotomy. In our series of 40 cases we had no leaks and just one anastomotic site stenosis.

1366 We feel that our technique is feasible and simpler to perform and is a good alternative for roux en y gastric bypass. V017 Two Port Laparoscopic Roux en YGastric Bypass Presenter: Wissam Fakih Co-authors: Osama Alsanea, Hussein Faour, Mohamed al Sayed Institution: Royale hayat hospital. Kuwait Background Sleeve gastrctomy is relatively an easy procedure to perform using incision laparoscopic surgery in a way without compromising visualization and getting results equivalent to conventional laparoscopy at our institute. While the single port option to patients who demand scarless surgery is available in sleeve safely and efficiently, to our knowledge it hasn’t benn available for ROUX en Y gastric bypass to be performed by same dexterity and safety, so it has benn used in most patients who ask for scarless surgery without compromising the technique. We have made it possible to perform a two ports gasric bypass with the same visualization, safety and effective outcome, so it was applied to all patients. So far we have performed 9 procedures with smooth perioperative course and similar weight loss curve. We have inserted a SILS port throught the umbilicus and a 5 mm left flank incision not evident on the anterior abdominal wall for suturing and a veress needle for liver retraction. A single horizontal and vertical staplers were used to create the gastric pouch and linear gastro–– ejunostomy. Closure of all anastomosis was done using running 2––0 absorbable intracorporeal suturing. Both potential hernia defects were closed as well using the usual manner. This technique can be performed at no extra cost to patients. V018 IncreasingRestriction by Endoscopic Clipping in Patients After Gastric Bypass Presenter: Yunus Yavuz Co-authors: Asım Cingi ˙Istanbul Bilim University & Marmara University, Turkey Inadequate weight loss and weight regain after bariatric procedures are major dilemmas waiting to be solved. Loss of restriction is one of the major causes for this complication. Restriction could be increased by several Methods including endoscopic clipping. In this group of patients, we have utilized OTSC clips (Ovesco, Tu¨bingen, Germany) in order to decrease the surface area of the gastrojejunal anastomosis. In one patient clip application was carried out twice. RYGBP0Roux-en-Y Gastric Bypass The clips were placed under general anesthesia and patients were in supine position. Gastrojejunal anastomoses were squeezed and the areas were reduced. The detailed technique of endoscopic clipping will be presented during video presentation. Endoscoping clipping is a reproducible procedure and most the clips stay in place years after the application. It might be an effective treatment alternative in patients gaining weight after RYGP. V019 Cosmetically Superior Approach to Sleeve Gastrectomy Utilizing a Dual Incision PeriumbilicalApproach Presenter: Helmuth T. Billy Ventura Advanced Surgical Associates, United States of America Methods and Procedure 15 consecutive patient underwent laparoscopic sleeve gastrectomy using a dual incision periumbilcal approach. All procedures were completed using a flexible laparoscopic platform. A single 12 mm incision was made in the left periumbilical skin fold. The flexible laparoscopic single site platform was introduced via a 15 mm skin incision at the right periumbilical skin fold. A 2.9 mm nathanson liver retractor was used to retract the left lobe of the liver selectively. True right and left instrumentation and triangulation was preserved utilizing a single site for instrumentation. In all cases the greater curvature of the stomach was taken down utilizing harmonic scalpel. A 38 french bougie was used to calibrate pouch size. A 60 mm laparoscopic stapler was used to perform the vertical staple line. Staple line reinforcement was used selectively. Over sewing of the staple line was not performed.

OBES SURG (2012) 22:1315–1419 Results Average operative time was 78 minutes. Hospital stay was 1.8 days. BMI ranged from 34 to 54. There were no leaks. Intravenous dilaudid was administered as needed to control pain. Average patient received 3 one mg doses of dilaudid over 24 hours. There were no reoperations. Conclusions Superior cosmetic results can be achieved using a flexible laparoscopy operating platform in patients undergoing sleeve gastrectomy. Operative time and length of stay are similar to conventional rigid laparoscopy. No leaks were discovered. Laparoscopic sleeve gastrectomy can be performed in a reasonable time with minimal complications utilizing flexible laparoscopy. Routine over sewing of the staple line is not necessary. V020 Resection of an Extended Afferent Stump in the Remission of Chronic Diarrhea Presenter: Keith Kim, M.D. Co-authors: Sharon Krzyzanowski, R.N. Cynthia K. Buffington, Ph.D. Florida Hospital Celebration Health, United States of America Introduction The Roux-en-Y gastric bypass (RYGB) operation is a standardized procedure, varying only with regard to limb lengths and pouch size. This video shows the unexpected finding of an anatomical alternation to the RYGB in a patient suffering from chronic diarrhea. Methods A 52-year old female who had recently had a RYGB presented at a local hospital 3 months postoperatively with food intolerance, perfuse diarrhea (15 bowel movements/day), chronic abdominal pain, dehydration, and electrolyte imbalance. She was hospitalized for 10 days, placed on TPN and referred to our bariatric clinic. An upper GI was performed with no evidence of obstruction or stricture. On consent, exploratory laparoscopy was performed. Results Robotic exploration found at the jejunojejunal junction that the afferent stump of the biliopancreatic limb extended to the gastric pouch for a length of approximately 30 cm. The segment was resected, leaving a 1-2 cm afferent stump. The total operative time was 62 minutes with minimal blood loss and no complications intra- or postoperative. Ten days following surgery, the patient no longer required TPN and, for the first time since her initial RYGB operation, was able to consume food without abdominal pain and diarrhea. Conclusion Anatomical alternation of the RYGB that extends the length of afferent stump may result in bacterial overgrowth and associated consequences including chronic and perfuse diarrhea. V021 Anti –Slippage: New Surgical Technique Fixing LAGB Presenter: Pierre Fournier Co-authors: Pietro Pizzi, Alberti Alessandro, Pizzi Mattia, Gianfranco de Lorenzis Institution : Bichat Claude Bernard University Hospital, Department of General Surgery, Paris 7-Denis Diderot Paris, France Introduction Experience gained over many year of Bariatric Surgery, in particularconcerning positioning of gastric band by videolaparoscopy, has allowed the development ofa new anti-slippage surgery technique. Method The surgical technique , is to place, downstream of the gastric banding, a nonabsorbable stitch (Ticron 00) which solidarizes with the large gastric curve, the gastricanterior wall and the small gastric curve; Results Since November 2010 to March 2012, has been effected 454 LAGB. Added the newanti-slippage stitch to the two stitchs gastro-gastric for tunnelling the band new-Haga(Helioscopie System), there were no slippages. Conclusions The follow up for the anti-slippage stitch is still short term.A longer period ofobservation of patients who underwent gastric band surgery with this new technique, willallows to evaluate the surgical effectiveness V022 Repair of a Chronic High Sleeve Gastrectomy Leak by Revision to Gastric Bypass Presenter: Keith Kim, M.D. Co-authors: Sharon Krzyzanowski, R.N. Cynthia K. Buffington, Ph.D. Florida Hospital Celebration Health, Saudi Arabia Introduction This video shows the feasibility of sleeve conversion to gastric bypass in the treatment of a high sleeve leak.

OBES SURG (2012) 22:1315–1419

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Methods A 43-year old male having a BMI of 38.4 and numerous co-morbidities, i.e. depression, hypertension, obstructive sleep apnea, coronary artery disease, underwent a sleeve gastrectomy (SG) for weight loss and improvement or resolution of co-morbidities. The gastric resection was performed over a 36 bougie using peri-strip buttressing materials. The surgery was uncomplicated and followed by an unremarkable postoperative course. The patient was discharged on post-operative Day 2. One week following discharge, the patient presented with an abrupt onset of intense epigastric pain, and was found to have contrast extravasation and a perigastric fluid collection on CT. Results The patient was managed initially with percutaneous drainage, IV antibiotics and NPO, followed by stent placement. The overall course was a non-healing chronic fistula located in close proximity to the EG junction. Definitive management was a revision to Roux-en-Y gastric bypass (video). Conclusion High sleeve leaks can be very difficult to manage. Revision to Roux-en-Y gastric bypass is a feasible management option for a chronic nonhealing proximal sleeve fistula.

now been taken to the bariatric surgery field. Here, we present our initial experience with laparoscopic gastric plication. Methods Here, we present the first 6 cases of robotically assisted laparoscopic gastric plication. Each entire procedure was done using the robot and without the participation of the assistant scrub surgeon. Results All six procedures were completed without incident. All of the patients had and excellent recovery after surgery, especially in terms of pain control and food tolerance. Discussion The well-known advantages of robotic assistance, which have been described for other surgical procedures, were clearly demonstrated in the bariatric patients who underwent this procedure.

V023 Technical Tips For Sleeve Gastrectomy with One Layer of Buttressing Material.

Introduction A 64 year old lady (BMI 41.3) was referred to the Royal Derby Hospital for consideration of sleeve gastrectomy. Her extensive co-morbidity included haemodialysis for polycystic kidney disease, previous failed renal transplant (midline approach), type 2 diabetes and radiotherapy for Hodgkin’s lymphoma. She was able to slowly walk for only 20-30minutes. Method In this video we present a 6 port laparoscopic approach sleeve gastrectomy along a 32 F tube. Results Previously undiagnosed polycystic liver disease resulted in difficult visualisation of the stomach as significant adhesions were found between the liver and omentum. Despite this the surgery was completed laparoscopically. 11 months later the patient has lost 63 % of her excess body weight, has stopped all diabetic medication and is able to walk for 1.5 hours. Conclusion This approach is still possible in more challenging cases such as polycystic liver and kidney disease where gastric visualisation may be difficult.

Presenter: Drs. Hector Conoman Co-authors: Cristobal Guixe, Franz Delgadillo. Cencolap, Chile Introduction Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (SG). In order to reduce these complications, the staple line can be reinforced with buttressing material. Objetive The aim of this video is to present our experience in the realization SG in obese patients with one layer of buttressing material and show the technical tips for correct use of the one layer of Gore Seamguard and avoid mistakes in this technique. Methods The video presentation of one selected patient who underwent SG with buttressing material and edited for showing the tips to correct use of one layer Gore Seamguard. Conclusions The staple line reinforced with one layer of buttressing material diminish the rate of bleeding and leaks and may be less time consuming. There are technicals tips that must be considered in the diferents steps that we have developed to perform this surgery. V024 Single Incision Laparoscopic Sleeve Gastrectomy Presenter: Dr Arun Prasad MS, FRCS, FRCSEd Institution : Apollo Hospital, New Delhi, India Single incision laparoscopic surgery (SILS) and Laparoscopic Sleeve Gastrectomy are procedures that are rapidly gaining popularity. It was a matter of time that both would get merged for the treatment of morbid obesity. We present our experience of 11 patients who underwent this procedure. Safety and feasibility were the key areas of concern. Patients underwent surgery between March 2011 and Feb 2012. The procedure was done using the Covedien SILS port and trocars set. One roticulating 5 mm Covedien grasper was used. Liver retraction was done using the Stryker minilap needle grasper. Mean time for the surgery was 85 minutes. There were no intraoperative or post operative complications in this group. Patients have shown good weight loss so far. Long term results awaited. V025 Robotically Assisted Laparoscopic Gastric Plication: A Fully Robotic Bariatric Procedure Presenter: Amador Garcı´a Ruiz de Gordejuela Co-author: Jordi Pujol Gebelli, Anna Casajoana Badı´a, Almino Ramos, Manoel Galvao, Gustavo Rodrigues, Alfredo Sadowski Hospital Universitari de Bellvitge, Spain Introduction Robotic surgical devices have begun to invade every specialist surgical practice. They offer significant advantages including 3D vision, high accuracy and four degrees of freedom movement. These advantages have

V026 Sleeve Gastrectomy- But Where is the Stomach? Presenter: Gemmill E.H., Ahmed J. Royal Derby Hospital, United Kingdom

V027 Novel and Cheaper Device for Laparoscopic Liver Retraction Presenter: Jyotsna Kulkarni Co-authors: Satish Pattanshetty Kulkarni Endo Surgery Institute, India Aim Minimal access surgery at the gastro-oesophageal junction requires exposure and retraction of the left lobe of the liver. The purpose of this article is to review our experience with a simple, safe, cheap and easy to prepare device, that can be placed internally to retract the liver. Materials and Methods We used this device in 10 consecutive patients undergoing bariatric procedure in our institute. Three patients underwent laparoscopic gastric bypass and seven patients had laparoscopic sleeve gastrectomy. We used simple corrugated drain and number 2/ 0 ethilon on straight 30 mm long needle. Corrugated drain was cut into 2 pieces of 6 cm by 2 cm each. Number 2/0 ethilon was securely fixed to the center of the drain and the suture and the needle were left intact. The liver was pierced through and through from its under surface, about 2 cm from its edge, with the needle. Once the needle emerged from the upper surface of the liver, it was pierced through the anterior abdominal wall and pulled. This allowed the corrugated drain to hold the under surface of the liver snuggly and retracted the liver upwards. In a couple of cases where the left lobe of liver was heavier, we applied two such devices at two different sites on the liver. At the end of the procedure, the suture was released and the corrugated drain was pulled out. The entry and exit points of the needle on the liver were inspected for bleeding. If needed, monopolar diathermy hook was used to coagulate these points. Results In all the 10 patients, the liver retraction was very satisfactory. There was no liver injury. No other additional retraction device was required. Conclusion We all know that various Methods of retraction of liver are used in laparoscopic surgery to expose the stomach and the gastro-oesophageal junction. Some of these are – Nathanson’s retractor, fan retractor, snake retractor, grasper, suction cannula etc. All these devices require an additional port near the xyphoid process. Nathanson’s retractor is self retaining but expensive and requires a special device on which it has to be mounted. All other retractors require an additional assistance and one has to watch out for liver injury. Our method is simple, safe, cheap and easy to prepare. It is a self retaining device – requiring no port and no additional assistance . This is very important, especially in the era of Single Port Access Surgery.

1368 V028 The Advantages of the Fully Stapled Laparoscopic Roux-en-Y Gastric Bypass Presenter: Sakran Nasser Co-authors: Dillemans Bruno, AZ Sint-Jan AV, Brugge, Belgium. Assalia Ahmad, Rambam Health Care Campus, Haifa, Israel. Hillel Yaffe Medical Center, Hadera, Israel. Aim The Roux-en-Y laparoscopic gastric bypass is considered as the golden standard among the surgical bariatric options. Several techniques and variations forms for performing the LRYGB were described. Methods In this Video, we present the technique of the fully stapled LRYGB procedure: 1- A small window is made between the lesser omentum and the lesser curvature of the stomach, entering the lesser sac 5–6 cm below the gastro-esophageal junction. All the gastric branches of the nerve of Laterjet are conserved. 2- Creation of the gastric pouch (30-40 ml) around 34-Fr gastric lavage tube using a 60-mm linear staple 3.5-mm staple height. 3- Creation of the gastrojejunostomy with 25-mm circular stapler 3.5-mm staple height introduced intra-abdominally. The anastomosis is made end to side (functionally end to end). 4- The Roux limb is fashioned in an antecolic-antegastric manner 5- The Roux limb is "right oriented". The cut end is facing the left of the patient and the anti-mesenteric side faces the patient’s right. 6- Creation of the jejunojejunostomy with 60-mm linear stapler 2.5-mm staple height.The anastomosis is made side to side. 7- The opening for the insertion of the stapler is closed with 60-mm linear stapler 2.5-mm staple height. 8- At the end of the procedure, the anastomosis is tested for leaks by forcefully injecting methylene blue and air through the 34-Fr gastric tube. Conclusion Based on more than 4000 procedures performed, FS-LRYGB seems to be a reproducible and safe technique that potentially reduces complications. V029 Laparoscopic Management of Marginal Ulcer Perforation After Gastric Bypass Surgery Presenter: Sasindran Ramar Co-authors: Mr.D.Heath, Mr.P.Sufi Whittington Hospital NHS Trust, London,UK. Background Perforation of a marginal ulcer is an uncommon complication after gastricbypass surgery. Laparoscopic management of this complication is an ideal way to managethis problem. Anastomotic or marginal ulcers occur in 0.6 to 16 % of patients afterlaparoscopic Roux-en-YGastric Bypass (LRYGB). Case Report A 42 years old female presented with epigastric pain to the emergencydepartment. She was tachycardic, tachypnoeic and had an elevated white cell count of14,000 cells/ml3. Clinically she was peritonitic and the chest x-ray revealed preumoperitoneum. 22 months prior to this episode she had undergone a LRYGB for obesity(Diabetic, Weight 120. BMI 37 kg/cm2). Her weight at this admission was 86 kg, BMI 26 kg/cm2.Three ports were used and diagnostic laparscopy was performed. There was purulentperitonitis with extensive fibrinous deposits in the peritoneal cavity. The upper abdominalcavity contained an inflammatory phlegmon involving the transverse colon and omentum. Aperforation at the gastrojejunal site was identified using methylene blue dye test.An omental patch was used to suture close the perforation with absorbable sutures. Two 20Fr Robinson drains were places and ports were closed. A gastrograffin study at day 2 did notreveal any leak of contrast. She was started on oral fluids and was discharged home on day 5on proton pump inhibitors.Gastroscopy on follow up showed the presence of shallow marginal ulcer and she is underclose follow up. Conclusion Laparoscopic closure of marginal ulcer perforation is feasible and safe. V030 Revisional Bariatric Surgery for Recurrent Obesity: a Single Centre Experience in Singapore. Presenter:Kaushal AS Co-author: S Bandera, A. Koura, J Rao Institution : Tan Tock Seng Hospital, Singapore

OBES SURG (2012) 22:1315–1419 Background A decade ago laparoscopic gastric banding was the single most popular surgery for morbid obesity in Singapore. However, the long term complication and failure rate of bands is around 30 %. We are now increasingly performing revision bariatric surgery for recurrent obesity secondary to band failure and complications. We are also seeing pouch dilation of previous sleeve gastrectomy. Aim To show the technical aspects of revision bariatric surgery and discuss issues of single vs. multi-stage revision and selection of appropriate secondary procedures through video presentations. Methods In 2011, we performed 8 revision procedures. Most of the cases had laparoscopic gastric banding as the initial procedure except one (sleeve gastrectomy). We present three short videos –

1. 2. 3.

Removal of gastric band and conversion to Sleeve gastrectomy. Removal of gastric band and conversion to Roux-en-Y gastric bypass. Conversion of Sleeve gastrectomy to Bilio-pancreatic diversion.

Conclusions Gastric banding is going out of vogue in Singapore due to the increased long term complications. Removal of gastric band and conversion to secondary procedure can be performed in the same setting safely with minimal morbidity. Appropriate selection of secondary procedures can give rise to good outcomes in terms of weight loss and resolution of co-morbidities. V031 Novel Approach for Repair of Anterior Gastric Prolapse Following Adjustable Gastric Banding Presenter: George Woodman, MD Introduction Acute anterior gastric prolapse is not uncommon following adjustable gastric banding (AGB). Typical revision techniques involve tension and often on inflamed tissue. This can potentially result in failure of the revision or ultimate erosion. We have a technique which does not involve tension and is simple to perform. Methods Once the prolapse has been reduced, the prolapsed portion requires stabilization. Rather than perform gastro-gastric approximation over the AGB, we secure the prolapsed anterior stomach down to the greater curvature of the stomach. This is done with interrupted sutures placed in a 180 degree fashion under no tension. This prevents undo tension that can ultimately cause recurrence or erosion. Results We have performed this technique in 9 consecutive patients with acute anterior gastric prolapse without perioperative morbidity or mortality. All patients were discharged the same day. Conclusions Anterior gastric prolapse following AGB occurs acutely in most cases and prompt attention allows preservation of the AGB. Proper technique can salvage the AGB and prevent recurrence of this complication and potentially prevent other morbidity such as erosion. V032 Video Presentation on Ileal Interposition- How I Do It Presenter: Mahesh Rajagopal Co-authors: Mohamed Ismail, Srijith Nair, Muhamed Shereef, Hafiz Ansari Moulana Hospital, India V033 Laparoscopic Conversion of an Open Loop (mini-) Gastric Bypass to Roux-en-y Gastric bypass: an ’un-relaxed’ Experience Presenter: Sherif Awad Co-author: Sherif M Hakky, Sanjay Purkayastha, Jonathan Cousins, Ahmed R Ahmed Institution : Imperial Weight Centre, United Kingdom Abstract In this video we present the case of a 56-year old female (BMI 47 kg/ m2) who presentedhaving failed to achieve significant sustained weight loss following an open loop (mini-) gastricbypass (LGB) performed in 1977. Although the original operative records were unavailable,preoperative barium meal demonstrated a large gastric “pouch” with little restrictivecomponent.

OBES SURG (2012) 22:1315–1419 Laparoscopic revision of LGB to Roux-en-Y gastric bypass (RYGB) isdemonstrated.Co-morbidities included type II diabetes mellitus, hypertension, asthma, myasthenia gravis,fibromyalgia and obstructive sleep apnoea. She also underwent open cholecystectomy in1980. Adequate abdominal muscle relaxation was achieved using remifentanil and lidocaineinfusions to supplement the general anaesthetic (no muscle relaxant used given history ofmyasthenia gravis).Diagnostic laparoscopy demonstrated extensive adhesions in the upper abdomen and asignificant fundal component coupled with a large gastric “pouch” following previous LGB. Extensive adhesiolysis and dissection were undertaken to define the original gastric “pouch”and retrocolic small bowel loop forming the gastro-jejunal anastomosis. This loop was stapled(Echelon Flex 60 blue, Ethicon Endo-Surgery) thereby freeing the small bowel back to theduodeno-jejunal flexure. Multiple applications of Echelon Flex 60-green (with Seamguard®,Gore®) were used to construct a new proximal 30 ml gastric pouch. Standard RYGB was thenfashioned utilising a 50 cm biliopancreatic limb and a 100 cm (retrocolic) alimentary limb. Finally, side-to-side stapled gastro-jejunostomy and jejuno-jejunostomy anastamoses werefashioned. The patient made an uncomplicated postoperative recovery (without requiring highdependency care) and was discharged on day 5. V034 Gastric Plication and LAGB Presenter: Carlos Casalnuovo, Author : Ezequiel Ochoa de Eguileor, Claudia Refi, Horacio Rosas Centro de Cirugia de la Obesidad - Hospital de Clinicas, Argentina The video shows the LAGB technique with the additional procedure of Gastric Plication (internal sleeve). After the band implanted, we start with dissection of the greater curve with harmonic scalpel 4 cm apart the pylorus until the left crus of the diaphragm. The 1st row is with separate stitches of ethibond 2/0, 2 cm apart. In the upper stomach (fundus) stitches (4-5) have 4 bites (2 of the posterior and 2 of the anterior wall). The rest of the stitches (8-12) usually have only 2 bites (1 of the posterior and 1 of the anterior wall). In the 2nd row we use continuous suture of prolene 2/0 and a reference of 32 F bougie to ensure a patent lumen. Complications and the surgical time are discussed. We compared with a same number of patients with LAGB only, in the same period, and evaluated the percentage of excess weight loss (%EWL) in the follow up, the number of adjustments necessary, and also the subjective early satiety. The advantage of the method is a minimal invasive surgery, ambulatory, no gastric fistulas, early satiety (1st 3 months), less adjustments number, and less or nil slippage risk. The disadvantage is the longer surgical time and controversial benefit of better long term results in %EWL. We need the test of time, including more number of patients. The question to answer is: Are we adding a real advantage or a potential complication? V035 Laparoscopic Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass as an Anti-Reflux Procedure Following A Previous Open Heller’s Myotomy Presenter: Sherif Awad Co-authors: Sherif M Hakky, Sanjay Purkayastha, Jonathan Cousins, Ahmed R Ahmed Institute :Imperial Weight Centre, United Kingdom In this video we present the case of a 58-year old man (present BMI 44 kg/m2) who presentedwith severe gastro-oesophageal reflux (GOR) having previously undergone an open Heller’smyotomy (left thoracotomy incision) for Achalasia, followed by sleeve gastrectomy in 2007(original BMI 57 kg/m2) to aid weight loss. Preoperative barium meal demonstrated impairedmotility in the entire oesophagus with gastro-oesophageal reflux to the level of the midoesophagus. Laparoscopic revision of the sleeve gastrectomy to Roux-en-Y gastric bypass(RYGB) was undertaken as an anti-reflux procedure.The patient’s co-morbidities included type II diabetes mellitus, hypertension, hyperlipidaemia,hypothyroidism, previous abdominoplasty and DVT/PE following the sleeve gastrectomy.Diagnostic laparoscopy demonstrated adhesions from previous surgery and a normal but very thickened gastric sleeve. After adhesiolysis, the angle of His was defined and a 30 ml gastricpouch fashioned using multiple firings of the Echelon Flex 45 green (with Seamguard®,Gore®) sized using a 34 F orogastric tube. Standard RYGB was then fashioned utilising a 50 cm biliopancreatic limb and a 100 cm alimentary

1369 limb. An antecolic-antegastric side-to-sidestapled gastro-jejunostomy was fashioned and gastro-enterotomy closed in 2 layers using 3/0Vicryl and silk. A side-toside stapled jejunojejunal anastamoses was fashioned andenterotomy closed using 3/0 Vicryl. The patient made an uncomplicated recovery and wasdischarged on postoperative day 3 with ameliorated GOR symptoms. V036 Combined Laparoscopic-Endoscopic Assisted T-tube Insertion for the Management of Post-laparoscopic Sleeve Gastrectomy Leak Presenter: Ali Warsi Luton, and, Dunstable, Universit,y Hospital, England. Background Laparoscopic sleevegastrectomy (LSG) is one of the most common bariatric procedure performed nowadays. The most troublesome complication of LSG is gastric leak (GL). Treatment of leak can be challenging.Ttransforming it into an open fistula bymeans of T-tube insertion is considered a valuable treatment option. To minimize laparoscopic dissection at the site of the leak and facilitate T-tube insertion, we have developed a combined laparoscopic-endoscopic assisted technique. Methods From Jan 2003 to Feb 2012 we performed 175 LSGs. Mean preoperative BMI was 51.8 kg/m2 (36.5-80). Three patients (1.7 %) developed a staple line leak. Technique After minimal laparoscopic dissection of the peri-leak abscess cavity, a guide-wire is endoscopically fed across the mucosal tear into the peritoneal cavity and withdrawn through one port. A polypectomy snare is then anchored to the guide-wire and retrieved through the mouth. A 16/20Fr T-tube is secured to the snare and positioned with the two short arms in the stomach and the long arm out into the port. Two additional drains are positioned: one in each sub-diaphragmatic space. Results Patients were initially NJ fed and subsequently started on oral feeding after a mean of 11 days (+/- 6). All patients had an uneventful recovery and were discharged home with the T-tube in place. Conclusion In our preliminary experience this technique seems safe and effective in the management of GL. V037 Removal of Gastric Band and Biliopancreatic Bypass Derivation Due To Weight Regain Presenter: Dr. Torres JP. Co-authors: Dr. Torres M. Dr. Torres A, Md. Andrade A. Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed” Summary This is the case of a 54 years old patient, operated 5 years ago with a laparoscopic placement of a gastric band. His initial weight was of 110Kg achieving a weight loss of 40 kg. The patient cameback due to failure of treatment, having a weight regain of more than he had lost (60Kg). He arrivedat the consultation with a weight of 170Kg (BMI 56). Removal of gastric band and a biliopancreaticderivation was performed. Objective Presentation of a case plus video of a laparoscopic band removal and performance ofa biliopancretic bypass. Materials and Methods In this video we present the laparoscopic removal of a gastric band and performance of abiliopancreatic derivation. We demonstrate the procedure, technique and tools for dissection. The technique for extraction of the gastric band is detailed as well as the performance of a biliopancraticderivation with minimally invasive techniques. Conclusions The laparoscopic placement of a gastric band is a technique of low morbidity and mortality and allows an appropriate excess weight loss. However, when the outcomes are unsatisfactory, thereexist alternatives, in this case a biliopancreatic derivation. V038 Enteroendocrine Surgery: Principles and Techniques Presenter: H.M. Virgen-Ayala1, Co-author(s): 2 , L.M. Flores-Cha´ vez 3 , E. Gonza´ lez-Reyes 3 , JA Reynoso-Betancourt 3, E. DelVillar-Madrigal2 , D. Dı´az-Caldero´ n 4. 1

University of Guadalajara, Surgical Clinic Department, Guadalajara, Me´xico. Instituto Mexicano del Seguro Social, Jalisco, Me´xico. 3University of Guadalajara, School ofMedicine, Jalisco, Me´xico. 4Hospital General De Occidente, Jalisco, Me´xico

2

1370 Background Anatomodigestive changes of the gastrointestinal tract (GIT) based on resection and exclusion ofsegments that focus on restriction and malabsorption have been developed in the last 60 years. Our aim is to present the techniques of the novel enteroendocrine procedures. Methods Laparoscopic fundogastroinvagination (FGI) based on anatomical changes starts with transversalinvagination of the fundus applying interrupted sutures, followed by a longitudinal invagination ofthe greater curvature (GC) of the stomach with two lines of continuous sutures: First line at theavascular region and the second at the bifurcation of the gastric vessels in the lesser curvaturepreserving the invagination of 5 cm of the gastric antrum. Laparoscopic ileal interposition (II) starts by identifying and isolating 1.5mts of ileum 50 cm distal to the ileocecal valve, interpose the ilealsegment 30 cm after the ligament of Treitz; the three intestinal segments and the isoperistalticside-toside anastomosis are done using a white EndoGIA linear stapler to reestablishgastrointestinal continuity, mesentery defects are closed as well. Results Case 1. 54 yr old female with morbid obesity, T2DM and HTA who two months after FGI+IIreduced weight (96.7 to 85 kg), BMI (39.7 to 34.92 kg/m2) with a median of blood glucose of(103.12±11.10 mg/dl) with no medication. Case 2. 50 yr old female with obesity and T2DM who 18 month after FGI+II reduced weight (113to 83 kg), BMI (37.3 to 27.41 kg/m2) and HbA1c (6.5 %). Conclusions The enteroendocrine procedures preserve the length and the complete exposition of food to themucosa of the GI tract without exclusion or resection of intestinal segments modifying the courseof metabolic diseases such as obesity and T2DM. V039 Duodenal Switch as Malabsorptive Revisionary Option After Conventional and Banded Gastric Bypass Presenter: Karcz WK, Co-authors: Kuesters S, Grueneberger J. University of Freiburg, Germany The revisionary bariatric surgery is growing. Also the reoperations after the gastric bypass operations. The laparoscopical advanced operation: the RYGB conversion into the BPD-DS or SADI-S is a standard operation for the chose cases in our department. We would like to present a film with stomach reconstructions and some tricks what we learned from our last cases. Discuss the strategy and present our results after Introduction: of malabsoption in revisionary bariatric surgery. V040 Removal of Gastric Band and Performing of Verticalgastrectomy with Reforced Auto Sutures Presenter : Dr. J. P. Torres Co-authors: Dr. Max Torres, Dr. A. Torres, Md. Andrade A.

OBES SURG (2012) 22:1315–1419 Diagnostic laparoscopy revealed extensive adhesions between sleeve and undersurface of liver. These were divided together with further adhesions in left upper quadrant. Staple line followed till finding superolateral out pouching part of sleeve herniating through hiatus. This was resected using Echelon Flex 60 green (with Seamguard®, Gore®). A 30 ml gastric pouch was made using same stapler. Standard RYGB was then fashioned utilising a 50 cm biliopancreatic limb and a 100 cm antetrocolic alimentary limb. The patient made an uncomplicated recovery and was discharged on postoperative day 2 GOR symptoms completely resolved. V042 Weight Regain After Gastric Sleeve Procedure and Conversion from Sleeve to Bypass Presenter: Dr. Torres A. Co-authors: Dr. Torres M, Dr. Torres JP, Md. Andrade A. Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed”, Ecuador Introduction Tubular gastrectomy is used as an alternative to gastric bypass; however each procedure has to be chosen appropriately, making sure that results in weight loss are adequate andlong term sustainable. Less than 1 % of the patients who underwent gastric sleeve, presented weight regain or insufficient weight loss. When this technique fails, it is possible to extend the resection with the same laparoscopic approach, complemented with a derivative procedure or gastric bypass. We present the case of a patient who underwent the 2 procedures; within two years the procedures failed, so a laparoscopic review was performed to find the problem at the gastrojejunal anastomosis. Objective Presentation of a case and video of a patient after a gastric sleeve plus the conversion togastric bypass with laparoscopic revision. Materials and Methods This case report involves a patient who underwent two previous bariatric surgeries: GastricSleeve and further conversion to Gastric Bypass because of a significant weight regain. The results weren’t as expected, so a laparoscopic review was performed (the video presents the review to be conducted in our patient in her third laparoscopic surgery.) We demonstrate the procedure, technique and tools for dissection. The technique for identification of the gastrojejunotomy is detailed until the end, where we can find a dilatation of the union. Conclusions Laparoscopic sleeve gastrectomy is a technique of low morbidity and mortality and with an appropriate excess weight loss; however when results are unsatisfactory, there is a second alternative: the conversion to gastric bypass. V043: Techique of Banded Gastric Bypass : Tips and Tricks

Objective Getting to know the main indications for removal of gastric band in obese patients and thepossible surgical alternatives for their treatment. Summary This is the case of a 31 years old patient, operated 6 years ago from a laparoscopic placement of agastric band. The patient´s pre-operative weight was of 100 kg, achieving a weight loss of 45 kg.Treatment failed with a gain of weight of more than his initial weight (59 kg), reaching a weightof 159 kg (BMI 56). He came to consultation for removal of the gastric band and performance of asleeve gastrectomy. V041 Laparoscopic Revision of Sleeve Gastrectomy to Roux-en-y Gastric Bypass for Severe Gastroesophageal Reflux Secondary Sleeve Proximal Herniation Into Chest Cavity Presenter: Mr. Ahmed Ahmed Co-authors: Sanjay Purkayastha, Sameh Mikhail Imperial College NHS Trust Abstract In this video we present the case of a 61-year old lady (BMI 49 kg/m2) who presented with epigastric pain, reflux symptoms and regurgitation 3 years following a laparoscopic sleeve gastrectomy in 2008. Preoperative barium meal demonstrated a hiatus hernia containing much of gastric fundus, the calibre is then narrowed to a degree typical following a sleeve gastrectomy. Her initial sleeve surgery was uncomplicated. BMI was initially 67 and came down to 49. She discontinued Anti-hypertensives & home CPAP. However she had severe symptoms affecting her quality of life.

Presenter: Dr J S Todkar Co-authors: S S Shah, P Shah, Neeta Sawant, Ayesha Rehman, Neha Singour, Amruta Bhalerao Ruby Hall Clinic , Pune, India Laparoscopic Roux N Y gastric bypass has proven itself as the gold standard bariatric surgery . It is also one of the operations which explores multiple anti diabetic mechanisms. It has got a restriction and a malabsorptive component. This is particularly important to maintain the restriction effect to achieve long term effect. One of the main factors in the weight regain after a few years after LRYGBP is attributed to the gastric pouch dialatation . To overcome this problem the application of the non adjustable ring ( Fobi ring ) over the gastric pouch during primary surgery is suggested to prevent this pouch dialatation in future. This video is to demonstrate the technical pearls in formation of a banded gastric bypass. Video044 Laparoscopic Management of Band Erosions After Banded Micro-Pouch Roux-en-y Gastric Bypass Presenter: Prof. Khaled Gawdat Co-authors: Basem Elshayeb Ain-Shams school of Medicine, Egypt

OBES SURG (2012) 22:1315–1419 Background Banding of the gastric pouch of the Roux-en-Y gastric bypass (the Fobi- Capella technique) helps improve the weight loss and weight maintenance results after gastric bypass surgery. Placing a prosthetic material around the gastric pouch has its own set of complications as band sliding and band erosions. In the Banded micro-pouch Roux-enY gastric bypass banding is performed using a prolene mesh. Erosion of the gastric band is a serious complication and laparoscopic management of such problem is not easy. Aim of work: A video presentation demonstrating the steps, technique and difficulties encountered in the laparoscopic management of band erosions. Materials and methods Of 1843 banded micro-pouch Roux-en-Y gastric bypass procedures performed 37 patients had band erosions (2 %). Results The video demonstrates the technique used in treating band erosions by resecting the upper part of the alimentary limb, lower part of the gastric pouch and gastric fundus. Reconstruction is done by gastro-jejunostomy. Conclusion Erosion of the gastric band is a serious complication of the banded micro-pouch Roux-en-Y gastric bypass that occurs in a small percentage of patients. Laparoscopic management of eroded gastric bands is a technically challenging but a feasible procedure. V045 Initial Experience with Single-Incision Laparoscopic Roux-en-Y Gastric Bypass Presenter: Tomasz Rogula MD; Co-author: Hideharu Shimizu, MD; Neil Orzech, MD, Helen Heneghan, MD, Philip Schauer, MD Bariatric and Metabolic Institute, M66-06 Cleveland Clinic, 9500 Euclid Avenue Cleveland, Ohio 44195 Introduction With the recent advances in laparoscopic techniques and instrumentation, bariatric surgeons have been provided with an opportunity to perform the same procedures through smaller incisions and fewer ports. We have developed a technique for single-incision laparoscopic Roux-en-Y gastric bypass (SI-LRYGB). Surgical Procedure A semicircular 4-6 cm skin incision was made above the umbilicus. One 12 mm and two 5 mm trocars were placed in a triangle. Then, a side to side jejunojejunostomy was created using a linear stapler with subsequent closure of mesenteric defect. The left lobe of liver was suspended upwards with 2-0 silk stitch on the Keith needle, passed through apex of the left lobe of liver, which provided adequate visualization of the stomach with minimal injury to the liver. A small horizontal gastric pouch was created and a 2.0 cm-long gastrojejunostomy was created in an antecolic - antegastric fashion, using a linear stapler with subsequent closure of Peterson’s space. No drains were placed. After removing all the trocars, the fascial defect of 12 mm port site was repaired. Results Five patients underwent SI-LRYGB. There were four females and one male with mean age of 41 (28-57) and mean body mass index 45.4 kg/m2 (39.1-49.7 kg/m2). The mean operative time was 168.0 min (150-189 min). The mean length of hospital stay was 2.6 days (2-6 days). No major or minor complications were observed perioperatively. Conclusions Our techniques for SI-LRYGB appear to be promising. Further studies are needed to determine the safety and efficacy of SI-LRYGB. V046 Revision Surgery for Failure of Roux en-Y Gastric Bypass (Video Presentation) Presenter: A.G. Bhasker Co-authors: M. Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Bariatrics is an evolving science. Any procedure with low rate of complications, durable weight loss andadequate resolution of comorbidities can be considered as a gold standard procedure. Roux en Y gastricbypass was considered to be a gold standard procedure until recently. Off late there have been reports ofweight regain after this procedure. Some studies have also reported resurgence of type 2 diabetes after afew years of roux en y gastric bypass.Causes of weight regain after roux en y gastric bypass include stomal dilatation, pouch dilatation,gastrogastric fistula and loss of malabsorption in

1371 due course.Here we present a couple of videos depicting pouch revision and limb lengthening after roux en y gastricbypass. 1. Pouch revision: 52 year old lady underwent gastric bypass 10 years back. She presented to uswith weight regain of almost 50 % of her excess weight. Endoscopy and barium studies revealed adilated gastric pouch. A laparoscopic pouch revision with a fresh gastro jejunal anastomosis wasdone for this patient. 2. Limb lengthening: 48 year old female patient underwent gastric bypass 7 years ago. Shepresented with weight regain as well as resurgence of type 2 diabetes and dyslipidaemia. Bariumstudies and UGI endoscopy revealed a normal stomal diameter and pouch size. Laparoscopiclengthening of the alimentary limb was done with a 150 cm common channel legth. Weight regain after gastric bypass is a complex issue and complete evaluation by a nutritionist,psychologist and a surgeon are must. Holistic management by a multidisciplinary team is essential forbest results. V047 Laparoscopic Conversion of Sleeve Gastrectomy To Roux Een y Gastric Bypass Presenter: Dr Aditi Agrawal, Co-authors: Dr Aparna Govil Bhasker, Dr Muffazal Lakdawala. Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Background Sleeve Gastrectomy is a refluxogenic operation. A large hiatus hernia or severe Gastroesophageal RefluxDisease (GERD) are contraindications for doing a sleeve as it leads to exaggeration of symptoms andposes a risk of Barrett’s oesophagus in future. RYGB should be the procedure of choice for all obesepatients with Hiatus hernia and Gastroesophageal Reflux Disease (GERD). Methods A 50 year old male patient who underwent Laparoscopic Sleeve Gastrectomy 1 year ago presented to uswith severe Reflux dysphagia and excesscive weight loss. An upper GI endoscopy revealed a largehiatus hernia with reflux esophagitis. Laparoscopic revision of sleeve gastrectomy to RYGB with cruralrepair was done. Operative time was 120 minutes. Blood loss was 110 ml. Orals were started after 48hours. Results Patient did well postoperatively and was discharged after 2 days. He had a relief of his symptoms of reflux Conclusion Revisional Bariatric surgery is more challenging than the primary surgery owing to the distorted anatomy, fibrotic tissue, longer time required for surgery, more blood loss and greater chances of leak andinfection. Hence, it is important to do the right procedure for the right patient to start with. RYGB is theprocedure of choice for all patients with persistent Gastroesophageal Reflux Disease (GERD) after asleeve gastrectomy. V048 Cases of Circular Stapled Gastrojejunostomy – Lessons Learnt in Preventing Mishaps Presenter: Dr. Manish Baijal, Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is the commonest Bariatric surgical procedure performed worldwide and at out institute which is an ICE, founder COE in New Delhi, India. Till recently, the standard circular stapled Gastrojejunostomy was performed using a technique that involves a 25 mm stapler with a staple height of 4.8 mm. As our experience grew we shifted to a 3.5 mm staple height circular stapler that led to added safety of surgery in terms of reduced incidence of leaks, bleeding and anastamotic stricture. We follow a technique of per-oral introduction of anvil which carries a potential of serious complications if not learnt and performed well. We share our experience with a video presentation of mishaps and innovations in performing the procedure which not only is safe but also reduces the surgical time and learning curve. Conclusion Circular stapled Gastrojejunostomy using a per-oral technique with a 25 mm, 3.5 mm stapler is a safe technique with shorter learning curve and operating times. Safety tricks are to be learnt and implemented to prevent mishaps and potential serious complicat.

1372 V049 An Interesting Case of Laparoscopic Sleeve Gastrectomy in a Complicated Post Gastric Banding Presenter: Milind joshi Co-author: Dr.Mohit bhandari, Dr.Shilpa Bhandari, Dr. Manoj Kela, Dr. Arun Mishra Institution : SAIMS, India A forty year old male patient with BMI 65 was admitted with complaints of weight gain since last three years. He was operated for gastric banding in 2006. He had BMI of 40 at that time as per the surgical records available with him. Patient had started regaining weight since last three years leading to his present status. Contrast enhanced Computerized tomography (CECT) scan was done to know the anatomy of the stomach, position of the band, status of adhesions of the stomach to liver and omentum. The band was seen applied in oblique fashion in the CT and there were adhesions present with the liver capsule. Decision to remove the gastric band and laparoscopic sleeve gastrectomy was taken as a first step procedure for the morbid obesity. During surgery, the findings of the CT scan were confirmed regarding the band position and adhesions. The interesting thing was the band had eroded the stomach along its anterior surface and still there were no signs of perforation peritonitis. The stomach was divided into two halves by the band and the band surface had sealed the perforation and was itself acting as a stomach wall. The band was divided and laparoscopic sleeve gastrectomy was done. The perforated stomach portion was removed along with the excised specimen of the sleeve. Patient had uneventful recovery. Conclusion Redo obesity surgery needs a high surgical competence. V050 Unheld Veress Needle as a Liver Retraction in Bariatric Surgery: Description of a New Technique Presenter: Wissam Fakih Co-authors: Osama Alsanea, Hussein Faour, Mohamed al Sayed Royale hayat hospital, kuwait Background After laparoscopic surgery, most of the time patients complain of pain and later of the scar of the 5 mm incision used for liver retraction. Methods initially we have performed over 350 laparoscopic procedures using a 5 mm epigastric incision with a free Alice clamp pinching the diaphragmatic peritoneum which allowed excellent visualization of the gastro–esophageal junction and proper dissection of the area whenever needed. As we have moved toward single incision surgery it became important to eliminate the epigastric scar and maintain excellent visualization. However it required to be held by hand and the potential of injury from movement ecsist. We have inserted percutaneously the veress needle to its full length in the epigastrium to reach the diaphragm exposing the gastro–esophageal junction and to avoid injury of the liver and the diaphragm due to tremor and uncontrolled movements by the assistant we have held the veress needle from its hub by a table mounted scope holder. So far we have performed more than 300 different bariatric procedures including provisional surgeries. We haven’t found case where we can’t perform his technique and none of the patients had undesirable scar or pain from the puncture site. V051 Anatomical Closure of Trocar Site By Using Tip Hole Needle and Redirecting Suture Hook (video) Presenter: Ahmed E. Lasheen • Co-authors: Awni Elzeftawy , Abdel-Hafez M. Ahmed , Wael E. Lotfy Zagazig university, Egypt Background The incidence of trocar site incisional hernia following laparoscopic surgery is reported to be relatively high. Themain reasons are trocar diameter and design, pre-existing fascial defects, and some operation- and patientrelated factors. The goal of this article is to present a new procedure for anatomical closure of the trocar site to prevent its herniation. Methods In this study, 120 patients underwent laparoscopic cholecystectomy from June 2006

OBES SURG (2012) 22:1315–1419 through February2009 at the General Surgery Department, Zagazig University Hospital, Egypt. After the laparoscopic procedurewas complete, the trocar sites were closed in anatomical layers by using a tip hole needle and a redirecting suturehook. The mean follow-up period was 2 years for any complication at these trocar sites. Results The mean hospital stay was 1.2 days, the mean age of the patients was 49.4 years, and the mean time toplace one suture was 5 min. No trocar site hernia occurred with this technique during a mean follow-up of 2 years. Seven patients developed superficial infection at the trocar site and no mortality was reported. Conclusion Good closure of the trocar site in layers by using a tip hole needle and a redirecting suture hook willprevent trocar site herniation. Keywords: Tip hole needle , Redirecting suture hook , Trocar site closure V052 SADI-S as a Revision Procedure After Gastric Bypass Operation Presenter: Karcz WK, Kuesters S, Co-author: Gruenneberger J. University of Freiburg, Germany In Europe the number of gastric bypass procedures and other bariatric operations are increasing. It is interesting that Fobi gastric bypass modification is more popular every year. The revisionary surgery operations counts are also growing. Since over 4 years the single anastomosis duodeno-ileal bypass with sleeve resection have place in Bariatric and metabolic surgery. Since the operation was developed we are using the technique as secondary operation after RYGB and Sleeve procedure. We would like to present our technique of duodeno-ileal anastomosis using the new sutures. P001 Outcomes of Bariatric Surgery at BMI Abu Dhabi Compared to ACSNSQIP Bariatric Surgery Programs Presenter: Abdelrahman Nimeri Co-authors: Awadelkarim Mohamed MD 1 , Eelaf El Hassan MD 2 ,, Karen McKenna RN 4 , Mohammed Al HadadMD 3 , Michel Bussieres MD3, Samer Ellahham MD5, Wayne Wasden5, Nicolas Turrin PhD5, NidalDehni MD3 Abdelrahman Nimeri MD3 SKMC managed by Cleveland Clinic,United Arab Emirates Background BMI Abu Dhabi is a multi disciplinary Bariatric surgery program at SKMC, a 693 bed tertiary referralhospital and the only international multispecialty ACS NSQIP participating center. Our aim is to comparecohort, technique and outcomes of bariatric surgery at BMI Abu Dhabi to North American ACS-NSQIPhospitals of similar size. Methods We queried the ACS-NSQIP database for bariatric surgery codes between 2009 and 2011 for hospitals>500 beds. Statistical analysis was performed. A P-value <0.05 was considered significant Results We performed 151 bariatric surgeries, compared to a total of 21,403 at other ACS NSQIP hospitalsStatistically, significant differences were observed in our patients’ mean age (36.6 versus 44.9 years),ASA scores (ASA 1-2 in 77.5 % versus 36.1 %), BMI (47 kg/m2 versus 45.5 kg/m2), history of Diabetes(diabetes in 19.9 % versus 27.5 %), blood pressure (hypertension in 23.2 % versus 53 %), and risk factors (none in 60.3 % versus 29.4 %). Our patients had more resectional surgeries (gastric bypass and sleevegastrectomy 94 % versus 65.6 %) and less outpatient surgery (0.7 % versus 16.4 %). Rates of reoperation (2 % versus 2.1 %), DVT (2 % versus 0.3 %), UTI (1.3 % versus 0.8 %), bleeding requiring blood transfusion(2 % versus 1.4 %) and postoperative occurrences (0.1 % versus 0.1 %) were similar. Hospital stay waslonger by 0.5 days (p<0.001). Our program achieved a zero mortality rate (versus 0.2 % p<0.001) with nooccurrences of post operative sepsis signifying a clinically relevant leak. Conclusion We operated on an overall heavier, younger demographic with fewer comorbidities. The longer LOS couldbe attributed to the larger proportion of resectional surgeries and less outpatient procedures done at BMIAbu Dhabi. We had lower mortality, and postoperative sepsis despite performing a larger proportion ofresectional surgeries compared to other ACS NSQIP hospitals. Keywords: BMI Abu Dhabi, SKMC, Bariatric Surgery Outcomes, ACS NSQIP2

OBES SURG (2012) 22:1315–1419 P002 Complications of Roux-En-Y Gastric Bypass, Performed by Laparatomy Presenter: L. V. Sima Co-authors: A. C. Sima, R. G. Dan, G. M. Breaza, O. M. Cretu University of Medicine and Pharmacy “Victor Babe” Timioara, Emergency City Hospital Timioara, Romania Introduction Bariatric surgery is a method of treating morbid obesity, which raises more and more interest in the past years. Among all types of intervention, the most frequently used is Roux-en-Y gastric bypass, an intervention both restrictive and malabsorbtive, which leads to best results for weight loss. In Romania, bariatric surgery, and especially Roux-en-Y gastric bypass, is not widely practiced due to poor addressability of patients, both by lack of information, and the poor recommendation from general practicioners and specialists in metabolic diseases. Material and Method The study group includes 14 patients aged between 18 and 65 years, with BMI above 40 kg/m2. The study aims to present the complications that occured in this group of patients in which we performed Roux-en-Y gastric bypass in the Surgery Department of the Emergency City Hospital Timisoara. The surgery was performed by xifoumbilocal laparotomy tehnique, because we don’t have the tehnique needed to perform in this cases laparoscopic surgery. Subsequently, patients were followed postoperatively at 1 month, and then every 3 months, up to 2 years. Results The only complications we found were wound infections and incisional hernias. Conclusions Introducing some changes in terms of restoring the abdominal wall, we hope to eliminate these complications. P003 Intra Abdominal Re-Adjustment of a Gastric Band Presenter: Claessens Frank Co-author: Bessemans Steven Ziekenhuis Maas en Kempen, Belgium Some gastric bands offer the possibility to be closed in 2 different diameters. Patients whose gastric bands are closed in the narrowest position and who have reached a BMI of 20, with an already completely deflated band have reached the minimum of restriction. In order to provide less restriction to allow these patients to gain some weight again, one can and should surgically adjust the closing position of the gastric band. This poster describes our experience with this process between 2003 – 2011 P004 Laparoscopic Adjustable Gastric Banding: Sutured Band Fixation vs. Non-sutured Technique Presenter: Cerny, S. Co-authors: Sla´decek.P. Hospital Na Frantisku, Prague, Czech Republic Introduction Laparoscopic adjustable gastric banding ( LAGB ) is one of the most popular minimally invasive restrictive procedures. The operative technique originally included band fixation with gastro-gastric sutures. Since September 2006 we revised this technique to prefer non-suturing technique for LAGB.We present , discuss and compared the outcomes of these two techniques. Material and Methods We evaluated retrospective 400 obese patients submitted in our department to LAGB since February 1998 until December 2009 , considering surgical technique,surgery duration, early postoperative and late complications . Their clinical signs, imaging exams , operations and reoperations, hospitalisation files were evaluated. 200 patients operated upon prior to September 2006 were compared with 200 patients operated with non-suturing technique. Results The mean follow-up of the patients was 52 months ( 24- 96). Mean (range) age of the patients ( male/ female ratio 24:76) was 38,2 years(2063).Mean(range) preoperative weight was 121,2 kg ( 89-188).Mean(range) preoperative body mass index was 44,5 kg/m2(36,2-64,4).Patients lost to

1373 follow up was nearly 22 % at 5 years and 33 % at 8 years.Mean percentage of excess weight loss( % EWL) was 36,2 at 1 year and 51,2 at 7 years. Among 200 patients from group with sutured band fixation (1998-2006) 14 % presented slippageand 6 % erosion .Of the 200 patients(2006-2009),who underwent LAGB without band fixation, 3 % developed a band slippage and 1 % developed band erosion. Conclusion Highest incidence of complications(band slippage or erosion) occurs in sutured band fixation technique. There is correlation between the incidence of complications and type of technique . Non-suturing technique for LAGB seems to be simple and faster , reduces band slippage or erosion rates . These complications can lead to failure of the LAGB. P005 The New Options in Metabolic and Bariatric Surgery - DIOS with Gastric Plication, DJOS with Gastric Plication or Sleeve Presenter: Karcz WK, Kuesters S, Co-authors: Gruenneberger J. University of Freiburg, Germany Several surgical procedures are nowadays available in Bariatric and Metabolic Surgery, including: gastric bypass (CRYGB), sleeve gastrectomy (LSG), gastric plication (LGP), biliopancreatic diversion with duodenal switch (BPD-DS), adjustable gastric band (LAGB) and single anastomosis duodeno-ileal bypass with sleeve resection (SADI-S). It is interesting that Fobi gastric bypass modification is more popular every year. We would like to present our modification of two different bariatric operations techniques: SADI-S and LGP. This combination allowed us to develop Duodeno-Ileal Omega Switch with Gastric Plication (DIOS-IP) as an alternative operation to BPD-DS, SADI-GS. The Duodeno-Jejunal Omega Switch with Gastric Plication or Sleeve (DJOS-GP(S)) was develope as alternative to Gastric Bypass procedure. P006 International Prospective Randomized Study: Banded Versus Conventional Laparoscopic Roux-en-Y Gastric Bypass – 2 Years Results Presenter: Karcz Wk, Lemmens L, Co-authors: Buckari W, Ribeiro R, Nora M, Greve Jw, Szewczyk T, Miller K, Kusters S. University of Freiburg, Germany M. Fobi and coworkers developed banded gastric bypass (BRYGB) in 1998 (publication year). Safety and feasibility are demonstrated with an increased excess weight loss more than 70 % and no increased postoperative complications. Bessler’s research group seems to prove the advantages of BRYGB in the single centre prospective trial. The studies are performed in ten centres of excellence worldwide using standardised gastric bypass procedures. Our study Inclusion criteria: age 21-60 years, BMI 40 kg /m2 to 50 kg/m2, eating habit: sweet eater and volume eater. We would like to present 2 years results of our study. We evaluated the additional restrictive silastic ring function which avoid the dilatation of the gastro-entero anastomosis and adjacent small bowel with consecutive better postoperative weight loss and significantly improved long-term weight maintenance. Additionally, we would like to present the following secondary endpoints: safety of operation techniques, incidence and comparison of side effects, evaluation of postoperative pouch dilation, quality of life, and changes in metabolic comorbidities. Our observation showed increased BMI reduction after BRYGB. It was difficult to convince the patients to become traditional gastric bypass surgery and undergoing the randomisation in several centres P007 Successful Venous Thromboprophylaxis in Patients Undergoing Roux-en-YGastric Bypass Presenter: Ajay Gupta Co-authors: K Mahawar, A Alhamdani, M Boyle, S Balupuri, N Schroeder, PK Small City Hospitals Sunderland, United Kingdom

1374 Obesity and surgery are risk factor for venous thrombosis with its attendant morbidity and mortality from pulmonary embolism. We wish to share our experience of using a simple protocol in our unit. Methods Retrospective analysis of prospectively collected database was used. In our series of 750 patients undergoing RYGB, 20 patients had risk factors for DVT prior to surgery (17 previous DVT, two venous oedema, one obesity hypoventilation syndrome). A combination of mechanical and pharmacological thromboprophylaxis (TEDS, Flotron boots and Dalteparin 5000 units subcutaneous injections commenced preoperatively) in conjunction with hydration and early ambulation was used in all patients. Dalteparin was used until patient was discharged. Patients were encouraged to continue using their TEDS for a further period of two weeks Results No patient developed DVT/ PE within 30 days while an additional 2 developed DVT later on after re-operation within 1 year. Two patients suspected of deep vein thrombosis had a normal duplex scan. One patient had a DVT two years later, following a road traffic accident. Three patients in our series were suspected of pulmonary embolism. However, all of them had it excluded by CTPA. Conclusion Successful venous thromboprophylaxis can be achieved if a combination of peri-operative mechanical and pharmacological thromboprophylaxis is used with adequate hydration and early ambulation. P008 Total Oversewing in Sleeve Gastrectomy - Is It Worth It? Presenter: Rheinwalt K Co-authors: Rheinwalt K, Plamper A, Ehresmann F, Kolec S, Kleimann E Department of Bariatric and Metabolic Surgery, St. Franziskus-Hospital, Scho¨nsteinstr. 63, 50825 Cologne, Germany Introduction Laparoscopic sleeve gastrectomy (LSG) remains among the most frequently performed bariatric operations. It is considered to be a procedure with good results and minimal risk for complications. However, leakage of the stapling line remains a serious issue to be addressed. Several solutions for reinforcement of the stapling line have been tried in order to reduce the rate of leaks and bleeding. We therefore evaluated the data of our patients regarding the rate of these two complications. Methods The data of all patients who were treated by LSG for morbid obesity in our institution between 2007 and 2011 was prospectively collected. The cases were divided into two groups whether a complete oversewing of the stapling line was performed or not. The groups were analyzed for complications including leak rates and bleeding. Results In the quoted period, a total of 90 patients underwent LSG, of which 6 redo cases were excluded. Thus, 84 LSG were performed as primary procedure. 41 operations did not include a complete oversewing of the stapling line (group I). 43 procedures were performed including total oversewing (group II). Two leaks occurred in each group, resulting in a leak rate of 4,88 % in group I and 4,65 % in group II. One patient in group I died in consequence to a leakage. The only bleeding event was found in group I (2,44 %). Conclusions In our experience, oversewing of the stapling line does not influence the incidence of leakage in LSG. It might however reduce the number of bleeding events. P009 Laparoscopic Conversion of Sleeve Gastrectomy to A Duodenal Switch Presenter: Dr Aditi Agrawal, Co-authors: Dr Aparna Govil Bhasker, Dr Muffazal Lakdawala. Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Background Inadequate weight loss is known after a laparoscopic sleeve gastrectomy in super obese patients. Duodenal switch is the choice of second stage surgery in most of these patients as 65-80 % of excess initial weight loss is reported. Methods We report a 19 year old female who underwent a SILS sleeve gastrectomy and reported tous after a year with inadequate weight loss. Her initial BMI was 56.45 kg/m2 at the primary surgery whichdecreased to 47.62 kg/m2 at the end of 9 months. At 1 year she experienced weight regain and the BMIincreased to 50.81 kg/m2. Intraoperatively there was retained fundus and dilatation of the sleeve in view ofhigh initial BMI.

OBES SURG (2012) 22:1315–1419 Results Operative time was 100 minutes and blood loss was approx 20 ml. Post operative recovery was uneventful. Conclusion Duodenal switch is an excellent procedure for those patients who have had insufficientweight loss or weight regain after sleeve gastrectomy. The long term protein, mineral and vitamin loss is amajor concern. P010 PCOS – A Metabolic Problem. Does Bariatric Surgery Hold the Key? Presenter: Dr Shalabh Mohan Co-authors: Dr Kaushiki Dwivedee, Dr Atul NC Peters, Dr Yogesh Gautam Institute of Bariatric and Minimal Access Surgery, Primus Super Speciality Hospital, New Delhi Introduction Morbid obesity is now achieving epidemic proportions throughout the world, and consequently a larger number of female patients in the reproductive age group are seeking bariatric surgery. The association of obesity with infertility and PCOS has been well established. While the role of bariatric surgery in controlling or even completely resolving obesity related co-morbidities such as diabetes, hypertension, sleep apnea, etc has been well established, the effect of weight loss through bariatric surgery on fertility and childbirth outcomes has not yet been fully demonstrated. Materials and Methods A retrospective analysis of data from 217 patients of morbid obesity operated by a single bariatric team from 2007 to 2011, revealed 64 female patients under the age of 45. Of these, 28 patients had documented PCOS as per Rotterdam Criteria, with 12 of them having previously taken infertility treatment. Results All patients showed improvements in one or more of the assessed parameters for PCOS - oligo or anovulation, hirsutism, acne, free testosterone levels and fasting insulin levels. 5 patients in the PCOS group conceived after surgery. Discussion Bariatric surgery is not so much a treatment aimed at achieving weight loss as it is a treatment for metabolic disturbance. There is clear evidence of improved outcomes in fertility and reduced risk of pregnancy related complications after bariatric surgery and weight loss. We suggest that there is a case for considering bariatric surgery for treatment of morbidly obese patients with PCOS. P011 Laparoscopic Roux-en-y Gastric Bypass (lgby) Beyond the Age of 60: Age Is Not a Limit! Presenter: A. Suppiah Co-authors: M. Peter, A. Carlisle, R. Sarkar, V. Rao, P. Sedman, P.K. Jain Castle Hill Hospital, Cottingham, HU16 5JQ, United Kingdom Introduction Obesity and obesity-related morbidity in the elderly is increasing in the West. Laparoscopic Roux-en-y Gastric Bypass (LGBY) leads to weight reduction and resolution of obesity-related morbidity in the young population. There are only minimal reports of LGBY in the elderly population. We report safety and weight-loss efficacy in the largest series of LGBY in elderly (age> 60) patients. Materials and Methods All patients aged>60 undergoing LGBY at a single institution between 2006 and 2011 with minimum 1 year follow-up. Results 46 patients (37 female, 9 male) median age 62.5 (60.1 – 71) underwent LGBY with medianfollow-up 23.2 (12-55) months. Median preoperative weight was 126.5 kg (87-171) compared to urrent weight 82.2 kg (52-123). Median pre-operative BMI was 46.7 (39-63) compared to current BMI 31.3 (22-45) with median BMI decrease of 16 (4-33). Median total body weight loss 33.4 % (8-55) andmedian excess weight loss was 67.4 % (36-113). The majority - 85 % (39/46) patients achieved >50 % excess weight loss within this period. Mean obesity-related morbidity decreased from 3.33 to 1.94 post-operatively with complete resolution in 40 % and improvement in 51 % conditions. Median hospital stay was 3(1 - 16) days. There were 9 % (4/46) complications (1 reoperation, 1 collection treated conservatively, 1 cardiac arrhythmia, 1 respiratory tract infection) and no mortality. Conclusion LGBY in the elderly (age>60 years) can be performed safely, and with substantial weight loss and reduction in obesity-related morbidity. Further comparisons with case-matched controls and quality of life studies are required to assess long-term benefit.

OBES SURG (2012) 22:1315–1419 P012 Morbid Obesity and Metabolic Surgery: Initial Experience of a Single Centre at Central India Presenter: Milind joshi Co-author: Dr.Mohit bhandari, Dr.Shilpa Bhandari, Dr. Manoj Kela, Dr. Arun Mishra SAIMS, Portugal Aim and objective To present initial experience of metabolic and morbid obesity surgery at a single centre in central India. Material and Methods The patients of morbid obesity using BMI as a guideline and even non obese patients of type 2 diabetes mellitus were evaluated completely to consider their fitness for surgery as per the standard norms. Associated co morbidities were also evaluated. Patients were operated by laparoscopic sleeve gastrectomy (LSG), Roux en Y gastric bypass( LGB), modified duodenal switch procedure. Post operatively patients were reassessed and are under regular follow up. Results Total 230 patients have been operated since last three years. The male and female ratio is 1.5:1. The average BMI being 40. Total number of LSG is 150, LGB is 60 and modified duodenal switch procedure done in 20 patients. The major co morbidities present in the series were diabetes type 2, hypertension, sleep apnea syndrome, pickwikian syndrome, osteoarthritis. The average weight loss of the patients is 42.5 kg with a range of 30 to 55 kg. The euglycemia is achieved in 80 % of the patients at an average period of 6 months follow up. The mortality related to surgery is nil. The post operative complications were leak after LSG(n01), severe GER post LSG(n01), early electrolyte disturbances(n 03), transient vomiting(n 030), anastomotic stenos is(n03), transient hypoglycemia(n010), starvation ketosis( n02). Conclusion Comparable results with any reputed centre were achieved in our initial experience.

1375 Object of Study To evaluate the efficacy and safety of Laparoscopic Sleeve Gastrectomy (LSG) as a stand alone bariatric procedure for morbidly obese patients and to evaluate the resolution of co-morbidities in the patient population. Materials & Methods This is a retrospective study of patients who underwent LSG at IMAS, SGRH from 2009-2011. A total of 108 patients were included in the study. All these patients underwent LSG for Morbid Obesity (BMI>37.5 or >32.5 with co-morbidities). A sleeve of stomach was created over 38 fr GCT and the staple line was oversewn with PDS 2-0 sutures. An intra-operative check gastroscopy was performed in all cases. Patients were followed up at 7 days, 1 month, 3 months, 6 months, 1 year and thereafter yearly. Summary of Results There were 33 male and 75 female patients in the study. Mean pre-operative weight was 120.22 Kg (81 – 196 Kg) and mean preoperative BMI was 46.66 (35.2–74.6) Kg/m2. 29 % patients were diabetic, 42 % patients had Hypertension, and 42 % patients had Obstructive Sleep Apnea. At 1 year follow up, the mean weight reduced to 86.48 Kg. Mean BMI reduced to 32.93 Kg / m2. Resolution of Diabetes occurred in 78.94 %, resolution of HTN occurred in 62 %, and OSA improved in 93 % patients. Mean Quality of life index improved from 2.7 to 8.2. Conclusion The study underlines the efficacy of LSG as a stand alone bariatric procedure for morbidly obese population with significant resolution of comorbidities. Long term results are needed to substantiate the preliminary results. P015 Laparoscopic Roux-en-Y Gastric Bypass Aged 19 – 71 Years: Successful Through the Ages? Presenter: A. Suppiah Co-authors: M. Peter, A. Carlisle, R. Sarkar, V. Rao, P. Sedman, P.K. Jain Castle Hill Hospital, Cottingham, HU16 5JQ, United Kingdom

P013 Revision to Sleeve Gastrectomy for Hyperinsulinemic Hypoglycemia After Gastric Bypass Presenter: Hans Eickhoff Co-authors: Ana Guimaraes, Paulo Roquete, Carlos Vaz Obesity Center, Hospital Santiago, Setubal & Obesity Center, Hospital da Luz, Lisboa, Portugal Introduction Bariatric surgery is an effective treatment for severe and morbid obesity. Control of comorbidities will considerably improve in these patients. Nevertheless, some patients submitted to gastric bypass will experience symptoms of neuroglycopenia, possibly due to excessive GLP-1 mediated insulin release. Methods In 2007, a 47-year-old female patient with morbid obesity was submitted to gastric bypass after failure of gastric banding (BMI 41.5 kg/m2 before conversion). Four years after surgery, the patients started to complain about post-prandial dizziness and occasional lipothymias. She would shorten intervals between meals to avoid symptoms with subsequent moderate weight regain (10 kg). Modification of diet with reduction of fast absorbing carbohydrates ameliorated symptoms only slightly. The OGTT with simultaneous determination of insulin revealed an insulin peak of 114.6 U/ml at 60 minutes and hypoglycemia at 120 minutes (54 mg/dl). Conversion to sleeve gastrectomy was proposed to relieve symptoms and maintain the favorable results of bariatric surgery. Results Conversion to sleeve gastrectomy was undertaken laparoscopically (duration: 165 minutes). Postoperative course was uneventful and the patient was discharged 48 hours after surgery. The patient started to lose weight and no more neuroglycopenic events were observed during follow-up. The postoperative OGTT showed a return to a physiologic situation with a peak insulinemia of 35.6 U/ml at 60 minutes and normoglycemia at 120 minutes (79 mg/dl). Conclusion Reestablishing the physiologic duodenal passage by conversion of gastric bypass to sleeve gastrectomy represents an excellent therapeutic option in patrients with neuroglypopenic symptoms after gastric bypass. P014 Results of Laparoscopic Sleeve Gastrectomy as a Stand Alone Bariatric procedure in>100 Morbidly Obese Patients Presenter: Vivek Bindal Co-authors: Parveen Bhatia, Sudhir Kalhan, Mukund Khetan, Suviraj John Sir Ganga Ram Hospital, India

Introduction Laparoscopic Roux-en y Gastric Bypass (LGBY) is effective when using strict selection criteria. Age is amongst the discriminatory criteria used in assessing optimal risk: benefit ratio when offering LGBY. We report our experience of LGBY in all age groups. Methods Prospective database of LGBY patients (2006-2011) with minimum 1-year follow-up. Group A (age 19 - 29), Group B (age 30 - 39), Group C (age 40 - 49), Group D (age 50 - 59), Group E (age 60 - 71). Results 311 patients (47 male, 264 female) with median age 44 (19 – 71) were included. Individual groups numbers and median age: Group A (n 0 18; 26.5 years), Group B (n 062; 36.2 years), Group C (n 0108; 44.3 years), Group D (n 069; 55.0 years) and Group E (n 046, 46.3 years). There was no significant difference in pre-operative BMI (46.6 - 49.5) between groups. Overall median follow-up was 23.5 months with no difference between individual groups’ follow up (19-25 months). Median % Excess Weight Loss was 61.7 % (Group 1), 69.9 % (Group 2), 69.9 % (Group 3), 64.8 % (Group 4) and 67.4 % (Group 5). Median % Total Body Weight Loss was 34.8 % (Group 1), 34.9 % (Group 2), 34.9 % (Group 3), 31.8 % (Group 4) and 33.4 % Group 5. There was trend of increased median hospital stay (2.4 days in Group 2 – 3.0 days in Group 5). Conclusion LGBY leads to successful weight loss in all groups with individual ages 19- 71 years. LGBY should be offered to any age group provided the usual selection criteria are met. P016 Technical Bases of Gastric Plication Versus Sleeve Gastrectomy in Experimental Bariatric Surgery Presenter: Arantxa Cabrera Co-authors: Arantxa Cabrera, Fa` tima Sabench, Merce` Herna´ ndez, Santiago Blanco, Margarida Vives, Antonio Sa´nchez, Daniel del Castillo University Hospital of Sant Joan. Faculty of Medicine. IISPV.Rovira i Virgili University, Spain Introduction Gastricplication (GP)is an emergingtechnique of bariatric surgerythat does not involveresection of thefundus. Longtermeffectsweightandmetaboliceffects arestill unknown. The aimof this paper isthe descriptionof the surgical techniquein experimental animalsand theprotocol usedfor the comparisonofanthropometric and metabolic dataaftersleevegastrectomy (SG).

1376 Materials and Methods Sprague-Dawley rats 7 weeks old (12PG+12SG+6 sham group). High fat (Cafeteria) diet for 4 weeks. Priorto surgery: extractionofblood (3 cc). Daily monitoring ofweight andintake. Weekly controlof blood glucose. Surgery: Midline laparotomy(4 cm). Greater curvaturedissectionand ligation ofvasa recta. GP: invagination and longitudinal sutureof thegastricgreater curvatureand therumen. SG: longitudinalgastrectomywithpartial resectionof the rumen anddoublecontinuous suture. Results Interventiontime: 27 min (GP)and 45 min (SG).Mortality 0 %. Postoperatively, the weight anddailyintake is weekly calculated, as well as the blood glucose. Sacrifice takes place 4 weeks aftersurgery withbloodcollection by intracardiacpuncture together withliver andgastricwall biopsies. Discussion Failure toperformthe resectionof the fundus(the mainproducer ofghrelin) may not regulatethe sensation ofsatiety inmorbidly obese patientsundergoing GP surgery. Biochemical andhormonal analysis will complete the study. Conclusion GPis a relativelyfasterand less laborious technique thanSG. This fact, at the clinician, maybe a factorworking in its favor, but by weightand metabolicimplications, in particular, hormonal implications (ghrelin) are still to be well determined. P017 Influence of the Axcess Weight Loss on Control of Type ii Diabetes After Gastric Bypass Presenter : Santo MA Co-author: Kawamoto F, Riccioppo D, Pajecki D, Garms A, Matsuda M, Pinto Jr PE, Cleva R, Cecconello I Institution : University of Sao Paulo School of Medicine, Brazil Introduction The gastric bypass has influence on the improvement of type II diabetes. The weight loss is related to amelioration of diabetes, but it is not clear the relationship between the amount of weight loss and diabetes control. Objective Analyze the influence of EWL on improving diabetes after one year of gastric bypass. Materials and methods 29 patients type II diabetes, 24 women and 5 men, mean age of 56.9 years, mean BMI: 48.2 kg/m2, mean HbA1c: 8.1, underwent standard gastric bypass retrospectively analysed one year after operation with EWL > 40 % (mean 57 %). Concerning diabetes control, the patients were divided into two groups: Group A, patients who achieve HbA1c <6.5 (n 021) and in group B those maintained HbA1c>6.5 (n 08). Results In all patients the decrease of mean A1c was significant (8.1 to 6.1, p< 0.05). In both groups the decrease was also significant and similar (8 to 5.9 in group A, and 9.2 to 7.6 in group B). The %EWL in group A was 59 % and in group B 57 % (p>0.05) with no difference in the Mann Whitney test. Discussion With at least 40 % of EWL there was improvement on diabetes. In the patients who did not achieve the control target (A1c<6.5) the weight loss was similar that the patients who achieve it. Conclusion Weight loss after gastric bypass is an important factor for the improvement of type 2 diabetes. Despite of amelioration of diabetes in all patients studied, similar EWL in some patients did not result in control of the disease (A1c<6.5).

OBES SURG (2012) 22:1315–1419 improve the skills of the nursing staff and to decrease the stress levels caused by the rapid technological changes taking place in medicine. Results Presentation and implementation of an updated protocol by means of DA management workshops. Description of the different devices available at the hospital. Design of a poster to provide staff with a quick and easy reminder of the different points. Interdisciplinary participation in the creation of a protocol improves the quality and safety of the treatment given to the patients because it decreases stress levels in professionals. Conclusions All of this reduces the time spent on each perioperative process and therefore the cost of operations. The development of this protocol is particularly important given the current crisis and spending cuts. P019 Comparison of Two Different Techniques of Gastric Banding to Decrease the Incidence of Postoperative Complications Presenter : Sami Ahmad Co-authors: Sufian Ahmad, Ralph Matkowitz Obesity Center Stuttgart, Gastriccenter, Klinik Rotes Kreutz Frankfurt/ Germany, Jordan Obesity center/Amman, Jordan Background Morbid obesity (MO) is a world wide problem, and its’ incidence is increasing at an alarming rate. Surgical therapy has been shown to result in significant and sustainable weight loss in comparison to medical management of the disease. Gastric banding is one of the surgical procedures. Specific complications of the gastric banding are slippage and erosions. In this study we observed the incidence of complications comparing two different banding techniques Objectives To analyze prospectively, the outcomes of gastric banding regarding complications in two groups of patients with two different techniques we randomized the patients coming for gastric banding to our center during the period 2009-2011. Method 210 morbidly obese patients underwent Laparoscopic gastric banding for weight reduction, 180 were available for follow up. 88 patients in group A with 3 stitches of fundocardial stitches as band fixation. 92 patients in group B with with one stitch fundocardial and one stitch below the band fundobody. Otherwise the operation steps were standardised. Gender and BMI distribution in both groups were similar. Follow up visits monthly in the1st year, 3 months visits in the 2nd year, then once yearly at least. Early and late post-operative complications as well BMI change and quality of life were observed Result Mortality rate was (0.0 %) in both groups. In Gr. A we had 3 slippages (3.4 %) and and 1 erosion (1 %.) In Gr. B we had Zero of both. Mean excess weight loss ( EWL) and all other parameters were similar in both groups Conclusions Decrease the fixation stitches and putting one stitch under the band seems to be effective to decrease the incidence of complications in 23 years follow up. P020 Nutritional Deficiencies Before and After Four Different Bariatric Procedures Presenter: Schweiger Chaya1, Co-authors: Bahar Raz2, Keidar Andrei1

P018 Airway Care Protocol in Bariatric Surgery 1

Presenter: Maguy Blaise Vizcaino Co-authors: Mª del Mar Cabistan˜ Dubrule, Mª Milagros Go´mez Segura, Liliana Cabistan˜ Dubrule, Patricia Cid Verge University Hospital of Sant Joan. Spain Introduction Our objective is to create/update a protocol for systematizing the care of the airway in people who are going to undergo bariatric surgery, and to improve the quality of care and safety throughout the process. It is often difficult to decrease the stress experienced by the nursing staff who have to manage the airway. Methods Review of the criteria established by scientific societies and specific adaptation of the Catalan Society of Anaesthetists’ Guide (SCARTD). Literature review of the difficult airway (DA) and of the care of patients undergoing bariatric surgery. Consensus between the nursing staff and anaesthetists at the hospital. Creation of a quick guide to the material available at the hospital and how this should be used, thus unifying the criteria applied by the nursing staff. To

Department of Surgery Bariatric Service, Rabin Medical Center - Beilinson, Petach Tiqwa. 2Hebrew University School of Medicine, Jerusalem. , Israel

Abstract Background Nutritional deficiencies are common among bariatric patients after surgery. Moreover, it has been reported recently that substantial percentage of bariatric surgery candidates suffer of nutritional deficiencies (ND) even prior to operation. Objective To assess prevalence of ND amongst bariatric surgery candidates and to evaluate the risk factors for ND development after four different bariatric procedures. Methods Blood tests results were collected prospectively from 262 (112 Gastric bypass(RYGB),19 Duodenal Switch(DS),80 Sleeve Gastrectomy (SG) and 51 Gastric Banding(LAGB) bariatric patients preoperatively, 36 month and 6-12 month and 12-24 month postoperatively. Multivariate logistic regression model was performed to identify the risk factors for ND development postoperatively. Results The prevalence of the ND preoperatively were 56 % for Hyperparathyroidism (HPTH), 33 %-Folic Acid (FA), 28 %-B12 deficiency, low Ferritin

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and Hb levels were found amongst 10 % and 13 % respectively. Among patients with normal preoperative tests the prevalence of ND after RYGB,LAGB,SG,DS were 10 %,36 %9 %,60 % for Folic Acid deficiency respectively (p < 0.01). 31 %,41 %23 %17 % for B12 deficiency and 21 %,15 %,12 %, 60 % for anemia. The most contributing factors for FA deficiency development were: young age (p00.01, OR00.96) and type of procedure (DS operation p < 0.01, OR 09.57). B12 deficiency and anemia were more prevalent in patients with low preoperative (p < 0.01 OR 02.56 and OR 07.6 respectively). Ferritin deficiency were influenced by abnormal preoperative measurements (p < 0.01, OR 09.33), male gender (p00.04, OR 02.37). Conclusions Substantial percentage of the bariatric surgery candidates suffer of ND even prior to operation. ND developed postoperatively is mostly affected by low preoperative blood test results. 2 P021 A Review of Alcohol Metabolism Post-Surgery and Potential Health Consequences Presenter: Cynthia Buffington PhD Co-author: Keith Kim, MD Florida Hospital Celebration Health, United States of America Introduction Bariatric procedures that alter gastrointestinal anatomy may affect alcohol metabolism in a manner that could adversely influence health status and personal well-being. This literature review examines the effects of bariatric operations on alcohol metabolism and the associated health outcomes, including alcohol abuse. Methods Studies of alcohol metabolism following diet or bariatric procedures are reported along with health outcomes and the risk for alcohol abuse. Results Studies find that negative energy balance, such as occurs following most bariatric procedures, affect alcohol metabolism, i.e. gastric metabolism and hepatic ethanol clearance via the alcohol dehydrogenase (ADH) and microsomal ethanol metabolism (MEM) systems. Such changes increase blood alcohol content (BAC) and alcohol toxicity. Roux-en-Y gastric bypass and sleeve gastrectomy, in addition, alter gastric or intestinal anatomy to substantially increase peak and total BAC and the length of time required for ethanol clearance. High BAC may: 1) have toxic effects on the liver, nervous system, heart, muscle, GI tract, 2) cause hypoglycemia, 3) increase expression of MEM and production of oxidative species and carcinogens, 4) block the uptake or actions of specific vitamins and minerals, and 5) provide additional calories. Regular alcohol consumption post-surgery may also increase the risk for alcohol abuse, particularly among individuals with a previous history of alcohol misuse. Conclusion Alcohol consumption, especially in the early postoperative period, may adversely affect health and life quality. Patients should be warned of potential alcohol-related health issues and provided guidelines for alcohol use. P022 Parameters Affecting Diabetes Remission in Obese Diabetic Individuals Undergoing Sleeve Gastrectomy Presenter: 1Morechai Shimonov, Co-authors: 2Julio Wainstein, 2Michael Zukerman, 3 Eyal Leibovitz

1

p00.02). Diabetes patients in remission had shorter disease duration (8.4± 7.1 years Vs. 15.4±10.0 years, p00.02), and lower frequency of hypertension and hyperlipidemia (27.3 % Vs. 63.6 % and 36.4 % Vs. 68.2 %, respectively, p0 0.02 and p00.04 respectively). No other difference was noted, including baseline BMI, sex, Diabetes control rate, diabetes treatment profile, insulin dosage, blood pressure levels, fasting insulin and C-peptide levels. Conclusion Longer disease duration and higher prevalence of CVD risk factors are associated with lower rates of diabetes remission at follow-up. P023 “Assessment of Body Composition in Morbid Obesity: a Comparative Study Between Body Impedance and Adiposity index Methods” Presenter : Santo MA Co-authors: Riccioppo D, Pajecki D, Kawamoto F, Matsuda M, Cecconello I Digestive Surgery, Hospital das Clı´nicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil Introduction Obesity has become an epidemic public health problem. A reliable method to assess body composition and monitor the effectiveness of treatments for the morbid obesity is mandatory. However, there is still controversy as to which method to use for this purpose. Two Methods are validated in the literature, bioelectrical impedance analysis (BIA) and body adiposity index (BAI). The present study compared these methodologies. Materials & Methods We evaluated 167 patients undergoing bariatric surgery, women prevailed (82.59 %), averaging 44 years-old and mean BMI of 49.48 kg/m2. Weight, height and hip circumference were measured. Body fat (BF) was calculated by BIA and BAI. The following formulas were used: BIA: BF in kg 023.25 + (0.09x resistance in ohms) + (1.00x weight in kg)(0.08xheight in cm)+(0.13x age in years). BAI: BF% of the total weight0(hip circumference in centimeters/height in meters x height in meters)-18. Results The patients had an average of 53.35 % (± 5.37) of BF according to BIA, and BAI showed 50.51 % (± 13.59) of BF. There is no difference between the two Methods (p <0,05), even when stratified by BMI (BMI<45, 4550). Essa diferenc¸a variou quando o IMC foi dividido em treˆs faixas, abaixo de 45 kg/m2 a diferenc¸a foi de 3,1 %, entre 45,1 a 49,99 kg/m2 a diferenc¸a foi de 3,78 %, acima de 50 kg/m2 a diferenc¸a foi de 1,86 %. Discussion The BAI is a simple method of implementation, low cost and effective, when compared to other Methods validated for morbidly obese patients. Conclusion BAI is an effective method to assess BF, comparable to BIA, and also proved to be effective in super obese patients. P024 Development Diabetes Mellitus and Metabolic Syndrome Thirty One Years After a Billroth IIGastrectomy Presenter : Garcı´a-Caballero M, Miralles F*, Toval JA. Co-authors: Valle M, Martı´nez-Moreno JM, Miralles F*, Toval JA, Mata JM, Osorio D, Mı´nguez A.

Pinchas Shachter,

Wolfson Medical Center, Israel

Department of Surgery. Facultad de Medicina. University Malaga. 29080Malaga/Spain. *Internal Medicine, Department. Associate University HospitalParque San Antonio. 29017-Malaga/Spain

Aim To study the parameters effecting diabetes mellitus remission among obese diabetic individuals undergoing bariatric surgery. Methods a retrospective analysis of medical charts of patients undergoing sleeve gastrectomy. Diabetes mellitus remission was defines as HbA1c level of below 6.5 % that was obtained without hypoglycemic medications. A logistic regression model was used to identify the parameters affecting remission status. Results Included were 72 patients (mean age 48.7 years, 43 % males) of which 44 patients (61.3 %) had diabetes mellitus. After 1 year of follow-up, BMI was reduced significantly by an average of 10.8 kg/m2 for all patients, with concomitant significant improvement of the metabolic profile. There was no change in the efficacy of the surgery between diabetes and non-diabetes patients. Fifty percent of the diabetes patients obtained remission at followup. The degree of weight loss was significantly greater among the diabetes patients that obtained remission, (12.9±8.1 kg/m2 compared to 8.5±2.9 kg/m2,

One of the evidence use to justify the role of bypassing the foregut to solveDiabetes Mellitus type 2 (DM2) come from some publications appearedbetween 1955 and 1981. All of them included some dozen of diabetic patients inwhose a partial gastrectomy was performed for treating peptic ulcer or gastriccancer. Remission of DM2 was informed in some cases only some days aftersurgery.On the other hand, one of the doubt we have at present related to the role ofgastrointestinal surgery in the resolution of DM2 is long term results.Recently we have lived the case of a 68 years old male patient asked for Diabetes/Metabolic Surgery that was operated 48 years before by Billroth II forpeptic ulcer.The patient have 1,70 m, 66 kg (BMI 23) and presented a DM2 insulindependentof 17 years evolution, arterial hypertension and dyslipemia.Furthermore the patient had a prostatic RTU, traffic accident with head of radiusfracture and medial supra-umbilical incisional hernia operated three times. Atpresent he is treated by inbersartan 300 mg, metformin 850 mg, ramipril 10 mg,acethyl salysilic acid 100 mg, atorvastatine 20 mg,

1378 Lercanidipine hydrochloride10 mg, insulin glargine 24 iu and insulin glulisine 9-9-9 iu.Billroth II operation differ from our current one anastomosis (omega loop) or twoanastomosis (roux-en-y) gastric bypasses in pouch size as well as in the lengthof the excluded jejunal limb. However this case showed that diabetes andmetabolic syndrome could develop after bypassing foregut. This data togetherwith other evidence (Kao et al. Surg Obes Relat Dis. 2011 Oct 30) showed thatthe resolution and /or prophylaxis of diabetes mellitus have a direct relation withthe type of gastrointestinal changes produced by surgery. P025 Sleeve Gastrectomy in combination with Duodeno-Jejunal Bypass Presenter : E.Semenov Co-authors: V.Timerbulatov, E.Semenov State Hospital, Ufa, Russia Background Sleeve gastrectomy with Roux-en-Y Duodeno-Jejunal bypass (SG-DJBP) is being performed in the world since 2007. What is its efficiency and how it impacts the concomitant diseases. Material and Methods We present results of 8 SG-DJBP procedures performed since July 2007 up to March 2012. The mean age of patients was 38,1±6,7(29-48) years, mean BMI-47,3± 6,9 kg/m2(38,9-59,8), initial weight-130,5±17,8 kg(111-159). A "Roux-en-Y" procedure was performed with a biliopancreatic loop 60 cm and alimentary loop-100 or 150m - four operations within a period of follow up control for 4 years and 8 months. 4 operations were performed with alimentary loop-180 with the follow up control up to 2 year. A bandage was placed on the gastric tube intersurgically to 4 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 53,8%EWL(48,4-64,4 %). Up to 4 years four patients could lose more than 69,2%EWL(66,2-82,2 %). and 2 patients with alimentary loop of 180 cm normalized to %EWL75,47±3,8 % in 2 years. Medical supervision of the results showed that 1 patient, suffering from diabetes mellitus type 2 had normoglycemia using no medicine. All the patients recovered from carbohydrate and lipoid metabolism. Conclusion SG-DJBP operation results in considerable weight losing, normalization of disrupted metabolism and compensation of concomitant diseases. The best results were obtained with alimentary loop of 180 cm and banded gastric tube. Though it is necessary to proceed with the medical supervision and compare the results with those of SG and BPD. P026 Effect of Bariatric Surgery on Co Morbidities Presenter: Swarna Vyas Co-authors: Ashok Jat, Shaji Poonambathayil, Vikram Sharma, Ajit Sewkani, Subodh Varshney Dept. of Surgical Gastroenterology & Clinical Nutrition, Bhopal, India Background Obesity is associated with many health problems and a higher risk of death. Obesity may be associated with conditions such as type 2 diabetes, hypertension, sleep apnoea and other comorbidities. Recently, it has been suggested that people with a lower BMI may benefit from surgery specially in Indian population. Material and Method The study was conducted at our Centre, Bhopal from May 2008 to Oct 2011. Total 172 patients underwent surgery for obesity. Results Total 172 (60 males and 112 female) patients underwent surgery, sleeve in 164 and Lap banding in 8 patients. Total follow up was between 2 months to 2 and years. Preop weight ranges vary between 76 to 252 kg and average BMI was 39.5. The average weight reductions for all patients vary between 7 to 100 kg. Among associated comorbidities DM II was present in 96 patients before surgery of which 88 (91.8 %) patients became free of OHA after surgery and in 8 patients daily OHA / Insulin requirement has decreased. Preop hypertension was present in 98 patients of which 88 (89.8 %) patients became normotensive after surgery without drugs. Sleep apnoea was present in 12 patients all benefited after surgery. Conclusion Obesity surgery achieves good weight loss, and improves obesity related comorbidities like DM, HTN and sleep apnoea in around 90 % of Indian obese population.

OBES SURG (2012) 22:1315–1419 P027 No Ring Erosion in 145 Patients After Three to Six Years Follow up with the GaBP RingTM used in the Banded Gastric Bypass. Presenter : Alex Heylen Co-authors: Monika Lybeer CHU Brugmann Brussels, Belgium Abstract Background The weight loss and weight loss maintenance are enhanced by banding the pouch in the gastric bypass operation. Surgeonfashioned bands and rings have been used to band the pouch with a reported 1-3 % incidence of erosion. Does using the prefabricated GaBP RingTM which is standardized and sterilized result in less incidence of erosion? Methods The GaBP RingTM was used in patients to band the pouch in the gastric bypass patient. The data was kept prospectively as to the incidence of ring erosion, weight loss and weight loss maintenance. A report of the review of the data after three to five years of follow-up is reported and discussed. Results The GaBPT RingTM system was used in 145 patients undergoing gastric bypass surgery, the GaBP RingTM implantation took an average of 5 minutes . The patients were followed for three to five years. There were no GaBP RingTM erosions in this series. Percentage excess weight loss , the success rate and resolution of comorbidities are similar to those reported for banded gastric bypass using the surgeon fashioned rings and bands.. Conclusion The GaBP Ring TM is a pre-fabricated, standardized and sterilized device designed specifically for use in banding the pouch in the banded gastric bypass operation. The zero incidence of ring erosion after up to five years of follow up in this series is probably due to the use of a prefabricated, standardized and sterilized device. Long term follow-up and future analysis are planned. Keywords: Banded gastric bypass; GaBP RingTM, Surgeon-fashioned rings or bands, ring erosion P028 Effects of Staple Height and Staple Line Buttressing on Resistance to Pressure in a Surgically Stapled Ileum. Presenter: Pierre Fournier Co-author: P. Montravers, G. Dufour, , C. Muller, R. Bronchard Jean-Pierre Marmuse Bichat Claude Bernard University Hospital, Department of General Surgery, Paris 7-Denis Diderot Paris, France Introduction Few studies haveevaluated the performance ofsurgical staplesparticularly in colorectal surgery. Objectives Tounderstand the appearance mechanismsof a staple linedehiscencein alinearly stapledileum, we analyzein this studythe effect ofthe height of thestaplelineandtheuse of an experimentalbuttressingtissueon the occurrenceof fistulas. Methods This isan experimental study ontheporcine model. The ileum is stapled ex vivo. Thepressurerequired to createa fistulawas assessed byblowing airin the intestineimmersed inwater.Threesuccessive experimentswere performed : one withatriplerow of staplesof the same height(white, 2.5 mm, n010;blue, 3.5 mm, n010; green, 4.8 mm, n010); one with a reinforcementtissue produced byBiosyn(blueDuet, 3, 5 mm, n012; green-Duet, 4.8 mm, n012) and onewithatriplerow of staplesof different heights(beige, 2 mm, 2.5 mm, 3 mm, n012 /purple3mm, 3.5 mm,4 mm, n012 /black4mm, 4.5 mm, 5 mm, n012). We evaluated the pressure measured in mmHgexperimentally requiredto createafistula. The dataisreported as averageandpercentage. Nonparametric testsare usedfordata analysis. Results Inthepig intestine, thepressure required to create afistulais related tothe heightof staples. Greenchargershave the worstprofile(125.2 ± 14.6 mmHg) comparedto blue chargers(149.3±25.2 mmHg) andwhite chargers(180.4±18.5 mmHg). The difference between theloadersis significant (p< 0.001). Thetissue reinforcementimproves resistance to fistulaswhatever thecharger. The difference is significant (p<0.001) between green-Duet chargerswitha pressure of141.4± 25.5and blue-Duet chargers witha pressure of209.4±7. The presenceof staplesof different heightsinthe samestitchingalso affects thepressure required to create a fistula. The difference issignificant (p< 0.001) betweenblackloaders(188.6±26.9), purple chargers (160.2 ±28.2)and beige chargers(231.6±24.9). With beige chargers, we observed no fistulas. Conclusion Staple height isa determining factor inthe emergence of afistulain alinearly stapled ileum. Low staplesheightsare more resistantto

OBES SURG (2012) 22:1315–1419 pressure.The buttressing ofthe staple lineincreases theresistance to fistulas, as well as the presence of staples ofdifferent heightsduring on the staple line Keywords: Surgical stapling, Fistulas, Experimental sciences P029 Number of Visits (But Not Adjustments) is Related to Weight Loss in Gastric Banding Patients Presenter: Ted Okerson MD FACP Co-authors: Brad Watkins MD, Christopher Cornell PhD, Ted Okerson, MD, FACP and the APEX Study Group Allergan, United States of America Introduction After care is particularly essential to ensuring successful outcomes with adjustable gastric banding (AGB). This evaluation seeks to determine if there exists an ideal number of visits and/or adjustments of an AGB to achieve optimum weight loss. Methods The APEX study is an ongoing prospective, observational study assessing weight reduction, comorbidity improvements and quality of life after implantation of the LAP-BAND AP®. This is an interim analysis of subjects (n0 395) who have completed or exited at 2 years. Results The mean number of adjustments performed over two years was 5.7+2.5, with a median of 6.0; 56.5 % of subjects required between 4 and 7 band adjustments over 2 years. The number of adjustments did not correlate with change in BMI or percent of excess weight loss (%EWL; r values of 0.03 and 0.04, respectively; p0NS for both). Respective BMI/%EWL changes in evaluable subjects with 13 visits (n 0 185), 11-12 visits (n 070), and 10 visits (n021) were -9.7/-53.3, -9.0/-48.7 and -6.7/-41.5. There was a weak, yet significant, correlation between number of visits and change in BMI (r0-0.15; p00.01) and %EWL (r00.13; p 00.03). Subjects who had 11 visits experienced significantly greater BMI changes than those with 10 visits (-9.5 versus -6.7; p 00.03). Conclusion The number of band adjustments do not predict weight loss outcomes; however, there is a relationship between number of visits and change in BMI/%EWL. Study subjects who didn’t adhere to the protocolspecified visit schedule (i.e.,<11 visits over 2 years) experienced smaller changes in BMI.

1379 P031 Roux-en-YGastric Bypass Following Orthotopic Liver Transplant Presenter: Dr Robert Dorman Co-authors: RB Dorman, A Abdusebur, FJ Serrot, B Slusarek, B Sampson, H Buchwald, JR Lake, DB Leslie and S Ikramuddin University of Minnesota Medical Center, United States of America Introduction There is little data available to assess outcomes of bariatric surgery in patients who are status-post orthotopic liver transplant (OLT). Materials and Methods The University of Minnesota bariatric surgery database was retrospectively reviewed to identify patients who had undergone OLT followed by open Roux-en-Y gastric bypass (ORYGB). Baseline characteristics were collected and outcomes reported. Student’s t-test was used for statistical analysis where appropriate. Results Six patients were identified with a mean age of 57.3 years (range 47-68 years) and mean follow-up was 44.8 months from time of ORYGB. The mean time between transplant and ORYGB was 28.7 months with a range between 19 and 38 months. Underlying liver disease was due to hepatitis C (n 04), cryptogenic cirrhosis and alcoholic cirrhosis. There were two mortalities (33.3 %) in patients with hepatitis C 9- and 6.5months following ORYGB from metastatic esophageal adenocarcinoma and multi-system organ failure, respectively. Type 2 diabetes was present in 4 patients, and it was dramatically improved in the 3 surviving patients with diabetes. Average body mass index was 33.4 kg/m2 pretransplant and was 43.9 kg/m2 (p00.03) before bariatric surgery. PostORYGB, the average BMI was 26.4 kg/m2 (p<0.001). One patient required reversal due to malnutrition. Discussion ORYGB status-post OLT results in both significant weight loss and co-morbidity resolution. Mortality is high but deaths appear unrelated to the bariatric operations. Conclusion In the largest case series to date, ORYGB following OLT appears safe during the perioperative period. The long-term benefits of weight loss in this patient population remain unknown. P032 Behavioral Modifications & Post Bariatric Surgery: Behavioral Modification Isonly Part of the Psychological Story and is not Enough ! Presenter: Connie Stapleton, Ph.D.

P030 Effect of Surgically-Induced Weight Loss in Blacks with Hypertension Presenter: Ted Okerson MD FACP Co-authors: Brad Watkins MD, Christopher Cornell PhD, Ted Okerson, MD, FACP and the APEX Study Group Allergan, United States of America Objective To determine BP control and effect of weight loss in Blacks compared to non-Blacks. Methods Subjects with hypertension with evaluable data at 2 years from the on-going APEX study, which examines the effect of laparoscopic adjustable gastric banding (LAGB) (LAP-BAND® AP) in patients with a BMI>35 on weight loss and comorbidities. Hypertension was defined as a history of hypertension or a BP of >140/90 at screening. Results 209/395 (52.9 %) met this definition. Mean age was 42.6 yr; 81.4 % were female. Control of known hypertension was similar at baseline in Black vs. non-Black: 11/21(52.4 %) and 97/181(53.6 %) respectively, although 44 % of Blacks had undiagnosed hypertension compared to 31 % non-Black. Two years after LAGB, Blacks with uncontrolled hypertension at baseline lost a mean of 20.2 % (26 kg); mean SBP (mmHg) decreased from 150.7 to 133.6(-17.1), and mean DBP decreased from 93.1 to 84.7(-8.4). Blacks with controlled BP at baseline lost 18.9 % of body weight; SBP decreased 3.4 (122.8 to 119.4) and DBP 4.1 (79.7 to 75.6). In non-Blacks uncontrolled at baseline SBP decreased 17.8(151.0 to 133.1) and DBP 7.1(89.9 to 82.7). Baseline wt(129 kg) and % change in wt(-19.7 %) was similar to the Black group. Conclusions Hypertension is common in relatively young morbidly obese individuals and more likely to be unrecognized in Black patients. However, the BP effect of LAGB-induced weight loss was equally effective in Blacks and non-Blacks, suggesting that LAGB may be considered as part of the hypertension treatment paradigm in morbidly obese subjects, particularly those with higher overall cardiovascular risk.

Surgical and other medical weight loss programs most often include a behavior modificationcomponent, which they sometimes tout as being a mental health component of the program. Unquestionably, behavior modification is essential for patients to maintain significant weight loss. Behavior modification alone, however, is but one part of the comprehensive mental health services from which post-ops would benefit. Individual and group therapy to address the myriad of issues and changes WLS patientsencounter before, during and for years after WLS could increase successful, long-term outcomes. The obese suffer from negative self-perceptions, low self-esteem (Allon, 1982), body-imagedisturbances (Stunkard & Wadden, 1992), sexual problems (Assimakopoulos et al., 2006), lessinterpersonal contact (Bocchieri et al., 2002), and poor social skills (Carr & Friedman, 2006), depression, disordered eating, social discrimination, and poor quality of life (Fabricatore &Wadden, 2006), and abuse in childhood. Much of this can be successfully treated via counselling.CBT and interpersonal therapy are effective treatments of these issues, which are interwovenwith obesity and do not go away as a result of weight loss surgery. Psychotherapy assistspatients in dealing with body image issues, and can improve self-efficacy and self-esteem, whichmay lead to sustained efforts toward healthy behaviour necessary to maintain weight lossfollowing a surgical weight loss procedure. Behaviour modification is essential. It is not enough. Many weight loss surgery patients need thebenefits of individual and group therapy as well as classes designed to assist post-ops for yearsbeyond surgery. P033 Long Term Management and Results – Mental Health Contributions to PatientSelection and Support Services Presenter: Connie Stapleton, Ph.D. Long-term results are the desired outcome following WLS for patients – and for the bariatric team. The surgeon, one member of the bariatric team, performs the actual surgery. Long-term successof the patient is the result of factors beyond the surgical procedure, and therefore, beyond just thesurgeon.

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Mental health practitioners can assist the bariatric program in obtaining positive long term resultsby teaching patients the skills to 1) make behavior changes - adopt positive eating and exercisebehaviors, 2) set healthy boundaries and improve assertiveness skills, 3) address changes incritical relationships, 4) prevent a return to unhealthy eating/other unhealthy behavior patterns, and 5) assist in working through post-surgical mental health issues. Support services that mental health practitioners can provide include:

& & & & & & & & & & & & & & &

pre-surgical evaluations, to: identify patients for whom surgery is contraindicated assist patients in planning for surgery provide patient education review patients’ motivations for surgery post-surgical services including: post-op therapy

P035 Laparoscopic Roux-en-y Gastric Bypass is Now Considered a Gold Standard in Bariatric Surgery. We Wish to Share Our Experience of Gastric Bypasses Performed in a Single Unit Presenter: Ajay Gupta Co-author: K Mahawar, A Alhamdani, M Boyle, S Balupuri, N Schroeder, PK Small Instution: City Hospitals Sunderland

individual group couples/family education self-esteem body image self-efficacy behavior modification

Long-term results may be improved by making better use of the mental health practitioners association with the bariatric program. Physicians’ time is limited and their expertise is the surgical procedure itself. Patients’ entire lives are impacted by WLS. Having mental health providers to assist them through the changes following WLS would be a tremendous benefit to the patients and would also enhance the outcome results for the bariatric center. P034 Sugammadex Allows a Fast-Track Bariatric Anaesthesia Presenter: Michele Carron Co-authors: Mirto Foletto2

between 30 and 60 min after administration, with 20 % requiring more than 60 min to recover to a TOFR 0.9. No serious adverse events or unexpected side effects were reported with either drug. Conclusions Sugammadex provided a safe and significantly faster reversal of profound rocuronium-induced NMB compared with neostigmine under desflurane anesthesia. Sugammadex may play an important role in fast-track bariatric anesthesia.

1

Bariatric Unit - Padova University Hospital, Italy1; Department of Medicine, Anesthesiology and Intensive Care, University of Padova. Italy2; Bariatric Unit, Padova University Hospital Background The laparoscopic positioning of adjustable gastric banding (LAGB) requires general anesthesia and neuromuscular blockade (NMB). It may be a short time surgical procedure and end without an adequate recovery from NMB. Acetylcholinesterase inhibitors cannot rapidly reverse profound neuromuscular block. Sugammadex is a selective relaxant binding agent for safe and quick reversal of rocuronium-induced NMB. This study compared the efficacy of sugammadex and neostigmine for reversal of profound rocuronium-induced NMB in short time bariatric surgery. Methods Forty female morbidly obese (MO) patients (BMI > 40), aged 18 years, scheduled to undergo LAGB, received fentanyl 200 g and propofol 2 mg·kg-1 for induction, followed by entropy-guided desflurane maintenance anesthesia. NMB was achieved with rocuronium 0.9 mg·kg-1 (IBW) to facilitate tracheal intubation, followed by doses of 0.15 mg·kg-1 (IBW) if required,using acceleromyographic adductor pollicis monitoring.Patients were randomized to receive sugammadex 4 mg·kg-1 (sugammadex group) and neostigmine 5 mg plus atropine 1 mg (neostigmine group) at 1-2 post-tetanic counts(profound NMB) for complete reversal of NMB (TOFR 0.9). The primary efficacy endpoint was time from start of administration of sugammadex or neostigmine to recovery of TOF ratio 0.9 before awaking the patients at the end of surgery Results No significant difference in surgical time (sugammadex group vs. neostigmine group, 27±7 vs. 25±6 min) and anesthetic drugs were registered between two groups. The mean time to reach a TOFR 0.9 was significantly shorter (p<0.0001) in sugammadex group than neostigmine group (3.1±1.3 vs. 48±18 min). The mean duration of anesthesia was longer in sugammadex group than in neostigmine group (95±21 vs. 48±7 min) (figure 1). Most sugammadex patients (90 %) recovered to a TOFR 0.9 within 5 min after administration. In contrast, most neostigmine patients (75 %) recovered

Methods A retrospective analysis of prospective database was used to study 750 patientsoperated between 2003 and 2011. Patient demographics, comorbidities, post-operativecomplications and Excess weight loss (%EWL) were studied. Results In our series the female: male ratio was 611:139, with a mean age of 44.5 ± 10 years.62 Patients had intra-gastric balloon and 60 lap bands prior to bypass. The mean follow-upperiod was 24 months. The mean pre-operative weight was 138.2 ± 24.7 Kg, BMI-50.4 ± 7.3 kg/ m2.Comorbidities included hypertension (34 %), T2DM (27.4 %), asthma (21.6 %), GORD (30.3 %),liver disease(1.7 %), arthritis(70 %), sleep apnoea (18.6 %), previous history of DVT (3.4 %),hypercholesterolaemia (24.5 %), depression (26.2 %) and PCOS (6.4 %). Postoperatively, the %EWL at 6mo, 1-year and 2-years was 54.81 ± 24.7 %, 66.97 ± 23 %, and 68.01 ± 29.59 %. Patients with BMI > 50 had significantly less weight loss at these periods(p < 0.001). At one-year, there was no significant difference in weight loss between those 60 and those 60 years old (66.6 ± 21.8 % vs. 72.8 ± 37.6 %). There was no 30-day mortality with four deaths beyond 30 days. Similarly there was no DVTwithin 30 days with 2 DVTs within one-year post-surgery (0.26 %). Other complicationsincluded bleeding (1.3 %), leaks from gastrojejunostomy (0.65 %), jejuno-jejunostomy(0.13 %),anastomotic ulceration (2.6 %), Gastro-gastric fistula (0.6 %), gastrojejunostomy stricture(1.5 %), port-site hernia (0.27 %), internal hernia (0.67 %) and nutritional failure (0.53 %). Conclusions Laparoscopic Roux-en-Y gastric bypass is a safe procedure with good outcomein high output units. P036 Implementation of New Technologies in the Monitoring of Patients of a Program of Morbid Obesity. The Wifiobese Program. Preliminary Results Preseneter: LR. Vilallonga Co-authors: J. M. Fort, O. Gonzalez, E. Caubet, A. Lecube, A. Gromaz, A. Calero, M. Armengol. Universitary Hospital Vall d Introduction In computing, the Internet of Things refers to an interconnected network of everyday objects. Why not apply this technology’s wifi to the management of our patients? Objectives To implement a scale directly on the Internet that patients would have at home and automatically send data to the surgeon that could see through the Internet, iPhone or iPad. Thus, trying to determine if: - New technologies for the control of morbidly obese patients in a referral center, before surgery to determine the time of surgery is suitable. - Scales and email can be an interesting support for the future. - The degree of patient satisfaction with wifi follow-up is superior to the traditional. Methodology Each patient has access in the house where all the weights recorded, the BMI and the percentages of lean and fat mass. Patients share their data automatically with their surgeon whenever weighed. It offers a mobile phone to patients in cases of doubt, and an email address. It keeps track of preoperative and postoperative weights and their evolution. In followup, / the patient has an emailed questionnaire to be answered according to the protocol

OBES SURG (2012) 22:1315–1419

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Results We included 10 patients in the Wifiobese program (3 men and 7 women) who have been selected in Outpatients. 21 patients were dismissed up to include 10 patients. 8 patients have already undergone surgery. All patients had wifi at home and email account. It has been tracking all patients by e-mail with results expected. Wireless monitoring of patients no surgery involved and worked fine except in one case. Patients asked by email have been satisfied on this type of monitoring staff surgeon’s assessment was successful and that the scales are not technical problems, offers the possibility of closer monitoring and higher compliance. Conclusions We belief that new technologies also run over the monitoring of our patients, we decided to implement this pilot study at our center. The degree of compliance monitoring is greater. ICT is increasingly generalize, tele-surgery, robotics but also in monitoring patients.

sexual function was quantified using the Female Sexual Function Index (FSFI) whilst male sexual function was quantified using the International Index of Erectile Function (IIEF). Results The mean age of the patients was 47 years (range 21-64) with the mean BMI of 50 (range 34 – 74). In males, 80 % were sexually active as compared with 66 % females. The mean values of both female and male sexual function scores (with the minimum and maximum potential scores) are summarised below: Females

P037 Complications of Bariatric Surgery, Experience of a Single Surgeon

Erectile Function 19(0-30)

Presenter: Jose´ Amat Co-authors: Marco Vargas, Walter Medina, Carlos Derosas Institution : Clı´nica Da´vila Introduction Bariatric surgery is not free of complications. In our country the results regarding complications have been rather heterogeneous, ranging from 2.3 % to 20 %. The aim of this study is to present the personal experience of 5 years in bariatric surgery and its results. Patients and Methods Retrospective descriptive study of personal experience in bariatric and metabolic surgery from January 2006 to July 2011. We reviewed multiple demographic variables, procedures (Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Gastric By-Pass (LGBP)) and associated complications. Results We performed LVSG 507 (59.2 %) and 348 LGBP (40.4 %), the remainder were other related procedures (total 860 cases). The mean BMI for LVSG group 36.1±3.1 kg/m2 and 41.2±5.1 kg/m2 for LGBP. There were 74 complications (8.6 %) (6.3 % of LVSG and 11.8 % of LGBP), 1.74 % were medical complications. 6,86 % were surgical complications, which 12,7 % were reoperations (1.16 % of total), 16 cases (1.8 %) had hemoperitoneum (81.3 % LVSG). 1,16 % suffer gastrointestinal bleeding (all conservative manage), 0.8 % of leakage, 3 cases required reoperation, the rest were managed with esophageal stent and CT-guided puncture or naso-jejunal sonda, 0.6 % had a gastrojejunal anastomotic ulcer (1 case perforated and reoperated at year). 0.8 % stenosis managed with balloon dilation, 0.46 % abdominal wall complications. All other miscellaneous causes. No mortality reported. Discussion This report shows the complications presented to a single surgeon, eliminating a significant bias, multiple operators. It is further noted that complications are multivariate, so the early suspicion and late follow-up of patients are essential to prevent mortality. P038Turkish Experience in Sleeve Gastrectomy Presenter: Baris D.Yildiz,M.D Institution : Ankara Numune Teaching Hospital General Surgery, Ankara, Turkey Sleeve gastrectomy has become one of the most popular techniques for morbid obesity in Turkey. I will try to give the collective results of the country’s experience in sleeve gastrectomy. I am stil collecting the results. P039 Sexual Dysfunction and the Morbidly Obese- are Men the Fairer Sex? Presenter: Sindu Parabaran Co-authors: Omar Khan, A.C.Wan, G.E.Vasilikostas, K.M.Reddy, S.Irukulla St.George’s Hospital, United Kingdom Aim The purpose of this study was to assess the prevalence of sexual dysfunction in morbidly obese patients awaiting bariatric surgery in our institute. Methods A total of 92 patients (73 F:19 M) awaiting bariatric surgery for morbid obesity completed validated sexual function questionnaires. Female

Desire

Arousal

2.6 (1.2-6) 2.4 (0-6)

Lubrication Orgasm

Satisfaction

Pain

2.6 (0-6)

3.1 (0.8-6)

3.1(0-6) 16.6 (2-36)

2.8 (0-6)

Total FSFI

Males Orgasmic Function 7 (0-10)

Sexual Desire 7 (0-10)

Intercourse Satisfaction 9 (0-15)

Overall Satisfaction 7 (0-10)

Total IIEF 44 (0-75)

As shown in the Tables, there was significant sexual dysfunction in both males and females, however this was more pronounced in females. Conclusion There is a high incidence of sexual dysfunction in our population of patients requiring bariatric surgery particularly in women. P040 The Influence of Health on Life Quality and Psychological Status of Bariatric Candidates Presenter: Cynthia K Buffington PhD Co-authors: Keith Kim MD Kerry Ferguson PhD Florida Hospital Celebration Health, United States of America Introduction Health issues associated with obesity reduce overall quality of life (QoL). In the present study, we have examined the association between poor health QofL, health status, and psychological well-being of bariatric surgical candidates. Methods The study included 104 surgical candidates (BMI047). Perceived health and other quality of life measures (social/interpersonal relationships, work, mobility, sex, self-esteem, activities of daily living, eating) were assessed by the Impact of Weight on Quality of Life (IWQOL) questionnaire. Upper (U) and lower (L) quartiles for health QoL (corrected for differences in age) were examined with regard to major health co-morbidities, other IWQOL subscale scores and items on the 7 major Millon Behavioral Medicine Diagnostic (MBMD) scales. Results Patients in the L vs. U quartiles of the QofL health subscale did not differ with regard to BMI, gender, or ethnicity but individuals in the L health group had significantly more major co-morbidities, i.e. 4.0+0.25 vs. 1.60 + 0.24, p < 0.0001). Composite QoL scores were significantly lower (p<0.01) for individuals in the L vs. U health quartile as were scores on the IWQOL subscales representing mobility, work, sex and eating. Scores on the MBMD scales that represented response patterns, negative health habits, psychiatric indicators or coping systems did not significantly differ between the U and L health quartiles. However, stress moderators (illness apprehension, functional deficits, pain sensitivity, and future pessimism) were significantly higher for individuals with L health. Conclusion Individuals who score poorly on the IWQOL health domain have more clinical health issues, increased psychological stress moderators, and reduced overall life quality. P041 The Leak Rate Following Gastro-Jejunal Anastomoses (GJA) in Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is Reduced by the Novel Suture ‘V-loc’ Presenter: A.A. Warsi, Co-authors: M. Asaria, P Vasas, M. Barecca, D. Whitelaw and V. Jain Luton and Dunstable Teaching Hospital, Luton, U.K Background There are no reports regarding use of novel suture ‘Vloc’ in GJA in LRYGB. V-loc, an absorbable, uni-directional, barbed, knotless suture is now being used in our institution.

1382 Aim Does the use of V-loc suture affect the anastomosis and outcome in LRYGB? Method Retrospective analysis of prospectively collected data on operations performed between July 2009 and November 2011. Closure of the gastro-jejunostomy defect was achieved by the use of polydioxanone, vicryl, or V-loc sutures. A methylene blue dye test was used to test the anastomoses. Data were analysed before and after the Introduction: of V-loc. Results 440 LRYGB were analysed - 244 before the use of V-loc and 196 after its use. There were 144 males and 296 females. The median (range) age was 48 (20-69). There were 36 positive dye tests (15 %) before the use of V-loc and 18 positive dye tests (9.2 %) after its use. The number of clinically significant (needing surgical or radiological intervention) leaks before and after the use of Vloc was 7 (3 %) and 0 (0 %) respectively (p00.04). Other complications included bleeding in 7, infection in 11 and acute gastric dilation in 5 patients. The median (IQR) length of stay was 2 (2-3) days. The median (range) weight was 147 kg (84-235) and the median BMI was 51 kg/m2 (3776). There were no mortalities. Conclusion There is a significant reduction in the number of anastomotic leaks and positive dye test after the use of V-loc, confirming its efficacy and safety in our unit. P042 SILS Revision Bariatric Surgery: First Reported Band to Sleeve Conversion Presenter: Dr. Rajkumar Palaniappan, Division of Minimal Access & Bariatric Surgery Apollo Hospitals, Chennai, India Abstract Background Revision bariatric surgery is an emerging procedure that typically wasperformed for inadequate weight loss, weight gain after initial loss or for complicationsfollowing primary surgery. The Co-Author has developed a single incision laparoscopicsurgery (SILS) approach to revision bariatric surgery. Method The Co-Author has performed a SILS conversion of slipped band to sleevegastrectomy on 07 July 2011, probably the first such reported case. A 38 year oldpatient weighing 139 kg without co-morbidities underwent Laparoscopic AdjustableGastric Band in 2009. With regular follow-up and band calibration, he lost 30 kg in 2 years. He had history of recent gain of 9 kg for a period of 3 months and was diagnosedwith band slippage by barium swallow in June 2011. Revision surgery was planned andthe umbilicus as the point of entry, the same operative technique and peri-operativeprotocol as laparoscopic revision was followed. Results The procedure was successfully performed by SILS technique. Operating timewas 145 min. There were no significant intra-operative error and he needed lesseranalgesics in the immediate post-operative period. The patient was discharged in 24hours. There was no postoperative complication noted during the follow-up period of 9 months with a satisfactory weight loss of 27 kg. Conclusion Single-incision laparoscopic conversion of band to sleeve is safe, technicallyfeasible, and reproducible. P043 Use of Omega Technique in Retrocolic Method of Gastric Bypass Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Institution : Homerton University Hospital NHS foundation Trust, United Kingdom Omega technique of gastro-jejunal anastomosis where a loop of jejunum is joined to the stomach pouch is commonly performed in antecolic method. The advantages of this method of constructing the antecolic gastro-jejunostomy are: 1. the ease with which the gastro-jejunal anastomosis and jejuno-ileal anastomosis could be performed 2. Prevent the joining of the wrong limbs, as the alimentary limb is measured after the Gastro-jejunal anastomosis is performed followed by jejuno-ileal anastomosis and then only the biliary limb is severed from the alimentary limb at the gastro-jejunal anastomosis. This omega technique could also be used when Gastro-jejunal anastomosis is constructed in retrocolic method when we approach suprocolically to access the infra colic compartment; the later approach is used because of the adhesions of the omentum in the pelvis from previous surgeries. I am going to show a video where this procedure is done and the steps taken to construct all the anastomoses in the supracolic compartment before the

OBES SURG (2012) 22:1315–1419 jejuno-ileal anastomosis could be taken to the infra-colic compartment and the closure of the mesocolic defect and the Peterson’s space are closed. P044 Outcomes After Laparoscopic Sleeve Gastrectomy: Weight Loss; Health Benefits and Complications Presenter : Le Grice, Co-authors: C. Smith, E; Moorthy, K; Ahmed A Charing Cross Hospital, Imperial College Healthcare NHS trust, London Background Sleeve gastrectomy is a bariatric procedure used alone or prior to duodenal switch or gastric bypass. Methods Retrospective analysis of clinic letters of 165 patients who underwent sleeve gastrectomy as their first bariatric procedure between 29/08/2007 and 16/11/2010. Five patients were excluded as pre-operative weight was not available. Results The study population comprised 110 women and 56 men, with mean age of 49 and mean pre-operative weight of 146 kg and BMI of 48. Mean weight loss was 36 kg at 1 year, 31.8 kg at two years and 36.5 kg at three years. Mean percentage excess body weight lost was 45 % at 1 year, 42 % at 2 years and 40 % at 3 years. Health benefits included improvement in mobility (n055 patients, 34 %), hypertension control (n029, 18 %), obstructive sleep apnoea (n027, 17 %), respiratory function (n019, 12 %), diabetes(n018, 11 %), joint pain (n05, 3 %) and angina (n 02, 1 %). Complications included dietary deficiency (n 028 patients, 18 %), hair loss / brittle nails (n013, 8 %), GORD (n011, 7 %), hernia (n07, 4 %), wound infection (n05, 3 %), vomiting (n05, 3 %), abdominal pain (n03, 2 %), diarrhoea (n02, 1 %), dumping syndrome (n01, <1 %), haematoma (n01, <1 %) and adhesions (n01, <1 %). There were no post operative leaks. A second bariatric procedure was indicated in 7 patients (4 %) due to post-operative weight gain (n04), inadequate weight loss (n03) and patient dissatisfaction (n01). Conclusion Sleeve gastrectomy is effective in producing weight loss and improvement in health. Complications of sleeve gastrectomy are rare and the procedure is not associated with significant morbidity P045 Laparoscopic Repair of Perforated Marginal Ulcer Following Roux-en-Y Gastric Bypass Presenter: Ido Mizrahi Co-authors: Ronit Grinbaum, Natali Loubashevsky, Natalia Simanovsky, Haggi Mazeh, Muhammad Ghanem, Ahmed Eid, Nahum Beglaibter Hadassah Mount Scopus University Hospital, Jerusalem, Israel Introduction Marginal ulceration is a known complication of Roux-en-Y gastric bypass (RYGB). Laparoscopic repair may be a feasible repair minimizing morbidity associated with a laparotomy. Case 52 years old women had undergone LAGB removal due to infected port followed 8 months later with a laparoscopic RYGB (antecolic, antegastric). Her BMI initially had dropped with the LAGB from 39 to 23 but after band removal increased to 31. She has been a smoker and was maintained on regular PPI therapy. She presented to the ER a year postoperatively with acute epigastric pain. Abdominal computed tomography revealed an abscess in the previous lesser sac and gastrograffin upper gastrointestinal series confirmed a leak at the gastrojejunostomy anastomosis. The video of the laparoscopic procedure demonstrates: 1) The difficulty of locating the lesion (perforated ulcer found at the posterior jejunal side of the gastrojejunostomy). 2) The treatment by laparoscopic oversewing and drainage. She recovered uneventfully and maintained on PPI therapy. Conclusion a laparoscopic repair can be completed safely and effectively, with minimal postoperative hospitalization, and low associated morbidity. P046 Long-Term Outcomes of Divided Gastric Bypass For Obesity: A Systematic Review Presenter: Taulee Hsieh Co-authors: Luis Zurita, Athena Bennett, Harpreet Grover, Forough Farrokhyar, Dennis Hong Institution : McMaster University, Canada

OBES SURG (2012) 22:1315–1419 Obesity has become a major burden on healthcare over the past few decades. With increasing world wide obesity rates, numerous surgical techniques have emerged, including the dividedgastric bypass. These techniques have shown promising short-term improvements in weight loss and co-morbidities. Unfortunately, published long-term data regarding such endpoints is limited and no general consensus exists regarding expected long-term outcomes of these surgeries within the bariatric community. We have carried out a thorough review of the current published literature to obtain the first systematic review on post bariatric divided gastric bypass outcomes greater than 10 years. A literature review of Medline, Embase and Cochrane databases was undertaken and 11,189 articles were identified after the initial search. Potential articles were assessed by independent reviewers. This process yielded 3 studies fitting our inclusion criteria. Due to the small number of studies, statistical analysis was carried out using weighted means. Results revealed a reduction of weighted mean preoperative body mass index (BMI) from47.5 kg/m2 ±2.0 to a postoperative BMI of 33.4 kg/m2 ±4.4 (p-value < 0.001). The weighted mean excess weight loss was 61.4%±13.5. Although these results suggest that weight reduction is sustainable in the long-term, the current study clearly indicates that there is a lack of strong evidence to support long-term outcomes following divided gastric bypass for obesity. Follow up of these patients needs to be more rigorous and comprehensive so as to better understand theseoutcomes. The use of regional and national databases is instrumental in collecting and extracting such data. P047 Fundogastroinvagination Technique By Anatomical References: A Standardized Gastric Restriction Presenter: Virgen-Ayala He´ctor Manuel Co-authors(s): Virgen-Ayala H.M.1, Gonzalez-Reyez E.2, Perez-Gonza´lez F. 2, Velasco-Gonzalez JJ 2,Dı´az-Esquivel P. 3 1

University of Guadalajara, Surgical Clinic Department, Guadalajara, Me´xico. University of Guadalajara, School of Medicine, Guadalajara, Me´xico. 3 University of Guadalajara,Bioterio, Guadalajara, Me´xico. 2

Background The diameter of the stoma and the volume of the gastric pouch are associated tothe speed and the amount of weight loss, there for, it is of clinical importance to standardize theapplication of a restrictive technique. Our aim is to present the restrictive capacity of thefundogastroinvagination (FGI) applied with anatomic references. Methods Performed in 30 ex-vivo pig stomachs. The gastric capacity was determined when thevolume of water instilled created an intragastric pressure of 10 mmHg. FGI starts with the transversal invagination of the fundus applying interrupted sutures continued with a longitudinalinvagination of the greater curvature (GC) of the stomach with two lines of continuous suture: first line at the a vascular region and the second at the bifurcation of the gastric vessels in the lesser curvature preserving the in vagination of 10 cm of the gastric antrum. The results are expressed as median, standard deviation and for the variable correlation we employed the Pearson´s r. Results The gastric capacity and the length of the GC were reduced in 91.20± 2.98 % (2703.00 ±958.47 to 234.63±113.18 ml) and 40.39±5.33 % (57.28± 5.46 to 33.99±3.08 cm), respectively. There is a significant correlation between the length of the GC and gastric capacity, before (0.66,p<0.01) and after FGI (0.63, p00.00014). No correlation was found between the percentages of invaginated CG and the volume of the gastric pouch (0.18, p00.33). Conclusions The technique of FGI applied with anatomical references induces a restriction of thegastric capacity of more than 90 % inducing a constant distal reservoir volume using combinedmechanisms of restriction and intragastric occupation. P048 Preoperative oral Endoscopy: Utility in Bariatric Surgery Presenter: Gabriel Martinez De Aragon Co-authors: Martı´nez Bla´zquez, C.; Vitores Lo´pez, J.M.; Sierra Esteban, V.; Valencia Cortejoso, J.; Esquiroz Carballo, I; Serrano Ferna´ndez, B. Hospital Universitario de Alava Txagorritxu, Spain AlphThepreoperativegastroscopy is a test included in the guide of bariatric surgery in our hospital as a routine study.

1383 To assess the profitability of this test, we studied the last 350consecutive patients who have had bariatricsurgery (302women and 48 men) between 2005 and 2011.With a BMI between 38and 61 kg/ m.88%have co-morbidities. All patients have been subjected to biopsy of the gastric antrum.175 patients have chronicgastritis, 74 hiatalhernia , 11 duodenitis, 1 moderate dysplasia, 5 intestinalmetaplasia and 84was normal. 96 patients with gastritis have positive Helicobacterpylori. In the patients with moderatedysplasia standard gastric by-pass technique was modified and wepracticeexcluded stomach resection. Patients within testinal metaplasia underwent asleeve gastrectomy, a technique that will allow us to review the stomach in the future by endoscopy. The findings justify conducting systematic gastroscopy in all patients candidates for bariatric surgery, in order to choose the best and safest surgical procedure. P049 Prospective Evaluation of 100 Patients Who Underwent Sleeve Gastrectomy for Morbid Obesity Presenter: Dr k. Lakshmi Co-authors: dr. Aswini kumar.m, dr. Ankur saxena, dr. Muralidhar, dr. Saravanan, dr. Venkat, dr. Ritesh maheshwari, dr. Samiullah, Consultant bariatric surgeon, dept of minimal access and bariatric surgery, Global hospitals, Hyderabad, India Introduction Morbid obesity with comorbidities has become a major health risk in India. India has become the diabetic hub. Bariatric surgery offers the chance of both reduction in weight and reduction in comorbidities. Methods 100 patients with morbid obesity were evaluated in a prospective cohort who underwent Sleeve Gastrectomy over a period of 4 years. Inclusion criteria were based on NIH guidelines and multidisciplinary preoperative evaluation. Height, weight, BMI, Hypertensive, Diabetic and lipid profile status were recorded. Laparoscopic Sleeve Gastrectomy over a 36 French bougie with different height staplers was done. Procedure was done either by a multi port technique or SILS port technique. Postoperative dietary progression and vitamin supplementation was as per institution protocol. Decrement in weight, BMI and hypertensive and diabetic status were recorded. Results Most of the patients were young below 40 years of age and with average BMI of 40. The weight loss achieved ranged from 20-40kgs. There was also improvement in the comorbidity status with either stoppage of medication or reduction in the dosage of medication. One patient was converted from band to sleeve. Weight regain to preoperative value was observed in one patient. One patient had to undergo feeding jejunostomy for suture line leak after which the patient recovered well. None of the patients were converted to open surgery and all patients. Few patients complained of hair loss following surgery which recovered with vitamin supplementation. Conclusion Sleeve Gastrectomy is a safe, feasible and most effective strategy for morbid obesity with advantage of comorbidity resolution with least complications. It is useful as both initial procedure for high risk patients and also as a primary procedure for weight loss and some degree of comorbidity resolution. P050 Video Showing How A Peterson’s Hernia is Recognised and Closed Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom Debate continues whether we should close Peterson’s defect or not during gastric bypass surgery. The quoted figures for Peterson’s hernia is 1-10 if the space is closed and 5 % if the space is not closed To diagnose the Peterson’s hernia is difficult though the CT may give a clue to its presence sometimes. It is important to go in by laparoscopy soon. Even if it turns out to be negative, it is better than having a dead bowel with its consequent problems. Trying to follow the alimentary limb from the gastrojejunal anastamosis may be frustrating and similarly following the biliary limb. I am going to show a video of where we show how we deal with this hernia during surgery detailing all the steps we take to trace out the hernia by following the small intestine retrogradely starting from the ileo-caecal junction. At the end we show how the Peterson’s defect being closed.

1384 P051 Gastric Bypass Appears to Have Lower Long Term Failure Rate Compared to Gastric Band in Patients with Morbid Obesity Presenter: Vittal Rao Co-author: Rupa Sarkar, Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castel Hill Hospital, Cottingham, Hull, United Kingdom Introduction Data regarding long term failure rate for patients with morbid obesity (BMI > 40) is lacking. We report the results of failure rates of patients who underwent laparoscopic gastric band (LAGB) and laparoscopic gastric bypass (LRYGB) based on more than five year follow up. Methods A retrospective database review of morbidly obese patients who underwent LAGB and LRYGB and followed up for 5 years and more was undertaken. Failure rate defined as BMI at final follow up of >35 for patients with morbid obesity was analysed. Logistic regression model using Wald chi square test was used for statistical analysis. Results 61 patients who underwent LAGB and 17 patients who underwent LRYGB were included in the study. Demographic profiles of both patient groups were comparable. Pre-op mean BMI (LAGB: 48; LRYGB:50) and mean excess body weight (EBW in Kg; LAGB:70; LRYGB:76) was recorded. Mean %EBWL and mean BMI at mean follow up (LAGB: 45 % & 38 at 83 months; LRYGB: 59 % & 34 at 68 months) was analysed. Patients who underwent LAGB seemed to have a higher failure rate than patients who underwent LRYGB (55.7 % or 34/61 vs 29.7 % or 5/17). However the difference was of borderline statistical significance (p00.061). Conclusion Long term follow up is essential to ascertain the lasting impact of different modalities of bariatric surgery before firm recommendations can be made. P052 TAP Block in Laparoscopic Bariatric Surgery – A Novel ‘semi-blind’ Technique Presenter : Dr Atul NC Peters Co-authors: Dr Yogesh Gautam, Dr Shalabh Mohan Primus Super Speciality Hospital, India The transversus abdominus plane (TAP) block is a useful adjunct to analgesia for patients of abdominal surgery. It is usually done as a blind ‘double-pop’ approach or under ultrasound guidance. We have developed a novel ‘semiblind’ technique for laparoscopic bariatric surgery and evaluated its analgesic efficacy over the first 24 hours. Methods 40 patients scheduled for bariatric surgery were selected with a BMI ranging from 35 to 50 kg/m2, ASA grade 1–2, no significant uncontrolled comorbidity, and not on any analgesic therapy. They were randomized to 2 groups. Patients in the TAP group underwent TAP block after Introduction: of the scope into the peritoneal cavity. 40 cc of 0.25 % bupivacaine was injected on each side in a semi-blind technique, while visualizing the peritoneal surface. Post-operatively, all patients were given paracetamol 600 mg I/V 6 hourly and 1 dose of ondansetron 8 mg I/V. Further doses of opioid analgesics and antiemetics were given on demand. Patients were evaluated at 2, 6 and 24 hours after surgery by a blinded assessor. Parameters assessed were pain, nausea/vomiting and sedation. Results TAP block reduced pain scores at all post-operative time points (p< 0.005). There was a significant reduction in analgesia demand from patients, and no increased incidence of nausea and vomiting – probably due to the reduced need for opiod analgesics. There were no complications attributed to TAP block and all patients reported high degree of satisfaction in pain control. Conclusions TAP block provides high quality analgesia in the first 24 hours following laparoscopic bariatric surgery, and there is a marked advantage in obese patients, due to early mobilization, less sedation and drowsiness. P053 Bariatric Surgery: A Singapore Institution’s Initial Experience Presenter: AM Oo Co-authors: A Koura, J Rao Department of General Surgery, Tan Tock Seng Hospital, Singapore

OBES SURG (2012) 22:1315–1419 Introduction Obesity is the fifth leading risk for global deaths. At least 2.8 million adults die each year as a result of being overweight or obese. In Singapore, the National Health Survey (NHS) 2010 findings indicate a 0.65 % annual increase in the prevalence of obesity over the past six years, from 6.9 % in 2004 to 10.8 % in 2010. Objectives The objective of this study is to review the initial series of bariatric surgeries done in Tan Tock Seng Hospital, Singapore’s second largest acute care general hospital with 1,400 beds. Methods and Procedures A retrospective review of patients who underwent bariatric surgeries from November 2008 to March 2012 was done using a prospectively collected database and medical records. Results Among 50 bariatric surgical patients, 34 % (n017) were male and 66 % (n033) were female. The mean age of the patients was 43 years old. The average length of stay was 4.6 days. All patients underwent laparoscopic surgeries and only 1 patient (2 %) was converted to open surgery. 52 % (n0 26) sleeve gastrectromies, 30 % (n015) Roux-en-Y gastric bypass, 14 % (n0 7) gastric band removal and gastric bypass, 2 %(n01) duodenal switch and 2 % (n01) biliopandreatic diversion. Mean operative time was 167.5 minutes. 30 days perioperative mortality rate was 2 %(n01). 30 days morbidity rate was 8 % (4 %(n02) anastomotic leak, 2 % (n01) hematamesis and 2 %(n01) wound infection. Conclusions Morbidity and mortality rates of our institution’s initial series of baritric surgeries are comparable to those reported in the literature. P056 The High Rate of Patients’ Follow-Up Loss After Laparoscopic Adjustable Gastric Banding (LAGB) in One Bariatric Center in Poland Presenter: Pawel Lech Co-authors: Maciej Michalik, Andrzej Lehmann, Michal Orlowski General and Vascular Surgery Department Wejherowo, Poland The high rate of patients’ follow-up loss after Laparoscopic Adjustable Gastric Banding (LAGB) in one bariatric center in Poland Background Althought LAGB is an established method in bariatric surgery, there is a serious problem with follow-up and control visits concerning these patients. Regular control visits are the principle of successful therapy of obesity treatment, especially after LAGB. The aim of the study was to analyze the reasons of patients’ loss from control visits. Method and Results Between 2005-2011, 229 patients underwent LAGB procedure in one surgical center. Pars flaccida technique without band fixing was used in all patients. The mean BMI was 46,5 kg/m2 and the mean age was 38,8 years. First control visit was planned after 4 weeks, then once in 3 months. We observed a high rate of patients’ loss from control visit. After 5 years, only 16 % of patients was available to complete the assessment. Conclusions The correct control visist are the principle of the effectiveness of bariatric surgery. The reasons of patients’ loss could be a long distance away from the registered bariatric center, social and economical reasons, the lack of expected weight loss and patient’s discouragement, little knowledge about the procedure, a wrong qualification for the surgery. Follow-up loss may alter the authentic bariatric sugery results. P057 Baseline Characteristics and Benefit/Risk Assessment of Elderly Obese Patients, Candidates for Bariatric Surgery Presenter: Marco A. Santo Co-authors: Denis Pajecki, Ana Lumi, Daniel Riccioppo, Thiago Otsuzi, Roberto de Cleva, Ivan Cecconello Bariatric and Metabolic Surgery Unit – Department of Gastroenterology – Surgical Division. University of Sa˜o Paulo School of Medicine, Brazil Introduction Obesity is associated with exacerbation of the age-related decline in physical function. In the elderly, obesity is associated with loss of functionality and therefore with poor quality of life and loss of independence. Bariatric surgery in elderly people is controversial. By NIH 1991 statement, 65 years old is the age limit for patients who are candidates for surgical treatment of obesity, but in developing countries, elderly is considered as the population above 60 years. Since this population is increasing, the decision of operating is becoming a frequent concern and a big challenge for bariatric

OBES SURG (2012) 22:1315–1419 surgeons. The assessment of functionality is an important issue to evaluate the risk/benefit of the operation in this population. Objective To evaluate the baseline characteristics (co morbidities, medication use) and functionality (activities of daily living –ADL and instrumental activities of daily living-IADL) in morbid obese patients, who are candidates for bariatric surgery, with 60 years or more. Materials and Methods: Subjects from the bariatric surgery program of Hospital das Clinicas were prospectively evaluated by personal interview, chart revision and application of functionality tests (Lawton, Katz). Results Twenty six patients (18 women and 8 men) have completed the evaluation. The mean age was 64.7 years, mean weight was 121,9Kg and mean BMI was 47.9Kg/m2. All patients had hypertension, 53.8 % were diabetic, 11.5 % reported previous stroke and 30.7 % had cardiac co morbidities (which included myocardial infarction, angina, heart failure and arrhythmia). Pulmonary disease was present in 27.1 % of individuals and 73.1 % had sedentary lifestyle mostly due to pain. The prescription included 7.19 medications per patient with 57.7 % reporting regular pain medication use. With respect to functionality, 30 % and 57 % had impairment in at least one ADL and IADL, respectively. Discussion This characteristics of this population demands a structured and objective plan for the benefit/risk assessment and decision on whom of those patients should be operated and who should not. The application of functionality tests in the pre-op can be useful to separate the patients who will probably benefit of massive weight loss of those who will not. Conclusion In the study population there is a high prevalence of co morbidities, functionality impairment, sedentary lifestyle and polypharmacy. P058 Are Patients with Morbid Obesity Nutritionally Healthy? Single Centre Prospective Study of 117 Patients Presenter: Vaishali Shah Co-authors: Anuja Khamkar, Shweta Khandelwal, Sneha Ratnani, Jayashree Todkar, Shashank Shah

1385 Methods IRB approval was obtained to conduct a retrospective review of medical charts of 65 patients with ASA-PS 1 or 2, who underwent transumbilical SILS gastric bypass procedure between August 2009 and September 1011. After Introduction of general anesthesia, TAP blocks were performed bilaterally (group A, n 050) under ultrasoundguided control using 30 ml of 0.25 % ropivacaine. Patients in group B (n 025) received general anesthesia without TAP block. All patients received intravenous administrations of 2 mg/kg of tramadol and 5 mg of prochlorperazine at the time of abdominal closure. Patient-controlled intravenous analgesia was performed with morphine at the setting as follows; base 0 ml, bolus 0 ml, lockout time 6 min, max 10 ml/hr. Analgesic effects were evaluated with the presence or absence of umbilical pain at the completion of general anesthesia and visual analogue pain scale (0-10) at 0, 6, 12, 24, and 48 hours after patients returned to their wards. All data were expressed as medians and ranges and statistical analysis was conducted by Fisher exact probability test and Mann-whitney’s U-test. A level of p<.05 was considered to be significant. Results All patients successfully underwent transumbilical SILS gastric bypass procedure without open conversion. No complications due to the TAP block procedures were encountered. There was no statistically significant difference in age, body height and weight, duration of anesthesia and surgery, and the doses of anesthetic and postoperative analgesic agents between the two groups. Umbilical pain at the completion of general anesthesia was significantly less frequent in Group A (3 in Group A vs. 17 in Group B) (p 0.02). Postoperative pain score was significantly lower in Group A at 0 and 6 hours after patients returned their wards. Conclusions Ultrasound-guided TAP block is useful in reducing early postoperative umbilical incisional pain in patients undergoing SILS gastric bypass procedure under general anesthesia. P060 Prediction of Weight Loss Following the Mini-gastric Bypass: Multivariate Regression Modeling with Preoperative Weight and Time From Surgery

Dr L H Hiranandani Hospital, India Introduction Morbid obesity is a disease, but whether it is associated with nutritional deficiencies in Indians, still needs to be studied. Material and Methods 117 patients visiting Laparo Obeso Centre at Dr. L H Hiranandani Hospital were evaluated prospectively during preoperative screening for bariatric surgery from 2009 Jan to 2011 Jan. Data was recorded for Height, Weight, BMI, Serum Proteins, Hemoglobin, Serum Vitamin B12 , Serum Vitamin D3 and dietary preferences - vegetarians or non- vegetarians. Results Out of 117 patients 89 patients were deficient in Vitamin B12.40 % of vegetarianmorbid obese patients had serum Vitamin B12 deficiency (less than 400 pg/ml) and 60 % of non-vegetarian morbid obese patients had serum Vitamin B12 deficiency (less than 400 pg/ ml).Out of 64 patients 60 morbid obese patients had serum vitamin D3 deficiency. Conclusion Serum Vitamin B12 and Vitamin D3 deficiencies are commonly seen in morbidly obese Indian patients. This study is important for clinicians who treat morbidly obese patients, especially bariatritians during preoperative care. P 059 The Analgesic Effects of Ultrasound-Guided Transversus Abdominis Plane Block for Pain Control After Single Single Incision Laparoscopic Surgery Presenter: Keyur Chavda MD Co-authors: Sunil Sharma MD Institution : University of Florida – Jacksonville, Florida, USA Background The benefits of laparoscopic surgery over conventional open surgery have been well demonstrated in terms of reducing morbidity, recovery time and hospital stay after gastric bypass surgery. Single incision laparoscopic surgery (SILS) is another innovation that may further improve the outcome of laparoscopic gastric bypass. A large-sized port manufactured specifically for the SILS procedure caused uncomfortable umbilical pain in a certain numbers of patients. We had been using general anesthesia with ultrasound-guided transversus abdominis plane (TAP) block for SILS gastric bypass procedure. It was aimed in this study to investigate the efficacy TAP block under general anesthesia in SILS gastric procedures.

Presenter: Robert Rutledge Center for Laparoscopic Obesity Surgery, United Staes of America Background Accurate prediction of expected weight loss following bariatric surgery would be valuable. A regression model of weight loss as a function of time from surgery and preoperative weight using data from 4,200 Mini-Gastric Bypass patients. Methods A curve fitting program was used to fit functions to of data on weight loss information on 4,200 MGB patients. Regression analysis was used to grade the curves fit to the data. Results Regression models were generated with R2 values of between 0.63 and 0.87. The equation with the highest R2 was rejected as to complex. The simple regression model: a+b*log(x1)+c*x2 where a, b and c are constants, x10months after surgery and x20weight. The weight loss following MGB was found to vary directly with the preoperative weight and with the log of the time following surgery. The R2 for this equation was 0.84. Predicted values for weight loss in a 300 lb patient having the MGB was 25 lbs at one month, 60 lbs at 3 months, 82 lbs at 6 months and 156 lbs at 5 years. Conclusion A relatively simple regression model of starting weight and log of the time from surgery allow a very accurate prediction (r200.84) of weight loss following MGB. P061 A Review of Surgical Complications Among 307 Bariatric Surgeries at a Rural Centre in India Presenter: Mahesh Rajagopal Co-authors: Mohamed Ismail, Srijith Nair, Muhamed Shereef, Hafiz Ansari Moulana Hospital, India Aim Bariatric surgery is an increasingly used method to treat morbid obesity. The mortality rate among patients undergoing bariatric operations is generally quoted as between 0.05-2.0 %. Despite evidence for improved safety with bariatric surgery, serious complications remain a concern for patients, providers and payers. The aim of this study is to review the serious surgical complications and how they were tackled. Methods This is a retrospective study in which the surgical complications after 307 bariatric surgery were reviewed.

1386 Results There were no perioperative mortalities. Two patients after gastric bypass developed bleeding from the remnant stomach which was managed by relaparoscopy and drainage. There was one case of anastamotic leak detected on computed tomogram which was managed conservatively. There was one case of anastamotic leak which required relaparoscopy and closure of the leak. There were three cases of bleeding from the stapled margin of the stomach which required relaparoscopy. There were three cases of stricture after sleeve gastrectomy which which were managed by endoscopic balloon dilatation. There was one case of twist of the afferent limb after gastric bypass which was also managed laparoscopically. Conclusion Bariatric surgeries though much safer now, are not without complications. Hence one should always anticipate these to avoid fatal results. P062 Depression Leading to Obsession with Physical Appearance and Binge Eating Disorder Presenter: Saba Jivani Co-authors: Dr Aparna Bhaskar, Dr Aditi Agrawal, Carlyne Remedios, Miloni Shah and Dr Muffazal Lakdawala Centre for Obesity and Diabetes Surgery, India Background Depression has been found to co-exist with a diversity of disorders both medical and psychiatric. Concern over body image and weight loss has now assumed an alarming proportion in India leading to psychological disturbances in an individual. Aim The study aimed to explore and compare the presence of depression in obese men and women and whether a co relation exists in the eating pattern and self-esteem. Methods The study group consisted of 200 obese patients who walked in for a pre-operative consultation at the Centre for Obesity and Diabetes Surgery (CODS) Mumbai. There were 100 males and 100 female patients. Mean BMI for males was 46.64 kg/m2 and that for females was 52.2 kg/m2. Mean age for males was 36.3 years and that for females was 32.23 years. The patients were grouped according to their score on Becks Depression Inventory II (BDI). Eating disorder was measured using the Eating Disorder Examination – Questionnaire (EDE-Q), and self-esteem was measured using the Rosenberg Self-esteem Scale. Results Females patients with a BMI>40 kg/m2 scored higher on BDI (mean 020.54) as compared to male patients (mean06.12) with matched BMI and age. Female patients showed more concern towards shape, weight and eating; scored higher restrained and had a lower self-esteem. The percentage of binging was higher in the female patients than in males. Conclusion Among female patients, higher depression and more concern towards shape, weight and eating pattern with a low self-esteem was seen as compared to male patients. Keywords: Obesity, Depression, Males, Females P063 Single Stage Sleeve Gastrectomy - Avoiding the Pitfalls. How I Do It Presenter: Upendra Marreddygari Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom In 2 Stage DS, SG is performed as the first stage of DS as a ‘pyramid’ with preservation of Antrum. If it is performed as a single stage SG, Vertical Gastrectomy involves the Antrum also to create a uniform tube of stomach – a ‘banana’. I am going to show how I do the Single Stage Sleeve Gastrectomy as the results are good without hardly any complications in our series. I will first show a clip of video how a stomach after the sleeve Gastrectomy a year before was subjected to the re-do sleeve Gastrectomy. I show here how the fundus of the stomach is left behind which is a common pitfall. I show how this is all dissected and then resected. I include the partial Antral resection. I then show how I do the SG as a primary procedure: this shows the mobilisation of stomach from pylorus to cardia on the greater curve side, taking down all the adhesions at the back of the stomach and also the fat near the fundus to show clearly the stomach and then performing the resection of the stomach on greater side from 1-2 cm from the pylorus to the Cardia leaving 0.5 cm of Fundus.

OBES SURG (2012) 22:1315–1419 P064 Reinterventions After Silicone Ring Vertical Gastroplasty Presenter: Romeo Florin Galea Co-authors: Adriana Florinela Catoi Galea, Doru Mircioiu, Robert Deac, Aurel Mironiuc, Emil Pop “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj Napoca, Romania Introduction Silicone ring vertical gastroplasty (SRVG) is one of the restrictiveproceduresfirstlyinitiatedin 1971 and has been practiced for the first time in Romania in Cluj Napoca in 1997. Material and Methods 1300 patients have been operated for morbid obesity from March 1997 until March 2012 in the Second Surgical Clinic from Cluj Napoca. Age ranged from 18 to 65 years old, 84.33 % were female and 15.6 % were male. Weight ranged between 95-270 kg with an average of 142 kg. Body mass index was between 36-80 kg/m. The gastric rings were of 5.4-5.8 cm. The superior pouch varied between 5070 cm3. Results 120 patients were lost from the follow-up program. From the 1180 patients 91.18 % had excellent results with a weight reduction between 40100 kg. An excessive weight loss was observed in 4.92 % of cases, and a weight regain in 3.9 %. Stoma stenosis were the most frequent and they were diagnosed from the first year up to the 5th year after surgery. In 50 cases of patients with stenosis we used larger rings or Gore-Tex bands. In 8 cases the patients asked for the removal of the rings. We used other rings or Gore-Tex band in 46 cases of stoma enlargement. We comment upon the failures of this method due to the hepatogastric adherences and the migration of the rings in the stomach. Conclusions The method is non-mutilating, reversible with few complications, easy to correct. It should be improved and promoted and not limited or abandoned. P065 Optimal BMI and Body Percent Fat Cut-Offs for Thai Adult Presenter: Kanokkan Tepmalai MDa,b, Co-authors: Warit Utanwutipong MD a , Jiraporn Khorana MD b , Suthep Udomsawaengsup MDa, Pungpapong Suppa-ut MDa, Tharavej Chadin MDa, Navicharern Patpong MDa. a.Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand 10330. b.Pediatric surgery unit , Department of Surgery , Faculty of medicine , Chiang Mai University , Chiang Mai , Thailand 50000 Purpose The aim of the study was to determine optimal body fat percentage (BF%) and body mass index (BMI) cut-offs for obesity to predict cardiovascular (CVD)risk factors (Hypertention , Dyslipidemia and type 2 DM) in Thai adult. Methods This cross-sectional study is comprised of 311 subjects (99 men and 212 women) from outpatients surgery unit and obesity clinic in Chulalongkorn hospital Bangkok Thailand.BF% was measured by using bioimpedance (Tanita 420).Optimal BF% and BMI cut-offs were analyzed by receiver operating characteristic (ROC) curves. Logistic regression analysis was performed to measure the association between BF% , BMI and cardiovascular risk factors. Results The CVD risk factors positive group had BMI higher than the CVD risk factors negative group (36.75 vs 28.95 kg/m).The optimal BMI cut-offs for the prediction of the CVD risk was 33 kg/m(The odds ratios(OR) was 8.56,95 % confidence intervals (CI) 4.63-15.82,p<0.00).Area under ROC curve (AUC) was 75 %.The optimal BF% cut-offs for the prediction of CVD risk was 30 %(OR were 10.88,95 % CI 2.80-42.27,p<0.00) for men and 47 %(OR 5.17,95 % CI 2.15-12.30,p<0.00) for women.AUCs were 73 % and 72 % , respectively. Conclusion The optimal BMI and BF% cut-offs for obesity to prediction of CVD risk in Thai adults were 33 kg/m , 30%in men and 47 % in women , respectively. P066 Specimen Retrieval After Sleeve Gastrectomy-Do You Always Require a Bag? Presenter: Dr. Deep Goel Co-authors: Dr. Ravindra Vats, Dr. V.P. Bhalla BLK Super Speciality Hospital, India

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Background Laparoscopic sleeve gastrectomy has now established itself as most common option for treatment of morbid obesity at least in India. For extraction of resected stomach, various techniques are used. In this article we are presenting 275 cases where extraction was done from one of the port site without any protection. Methods We performed 276 sleeve gastrectomies from June 2007 till February 2012 in our department. In all 276 cases the grasped specimen was withdrawn through 12 mm trocar site without any endobag. Port from which specimen is retrieved is flushed with 10 ml of saline and closed with port closure needle using number 1 vicryl. Result No case of wound infection was noted. We did not encounter any case of port site hernia. Conclusion Retrieval of specimen without any protection (endobag) is safe and does not result in increase would infection.

Conclusion An standard VTE prophylaxis regimen using low-molecular-weight heparin is simple and effective and was associated with a low incidence of bleeding complications

P067 Revisional Bariatric Surgery: Feasibility, Safety, Techniques, Outcomes– Tips and Tricks

This study examines the incidence and management of post-LRYGBGJS during Jan2005-Dec2011. Stomas, <10 mm & impassable were considered as strictures. The impact of surgical technique, timing on development of GJS, stricture-anatomy on treatment outcomes was analysed. Of 1379 LRYGB patients,192 (13.9 %) had endoscopy to evaluate symptoms including weight loss(n039), nausea/vomiting(n 0153), pain(n0108), dehydration(n 010), and dysphagia (n 068) odynophagia (n038). Endoscopy revealed normal surgical anatomy (n 0152;11.2 %), anastomotic stricture(n024;1.74 %), marginal ulcer (n011;0.79 %), gastrogastric fistula(n 06;0.43 %). Early symptomatic patients(3 months) are more likely to have GJS (10/15;33 % vs.14/177; 7.9 % p 0<0.005). Patients with strictures underwent 1-7 dilations(2.5 ) at 2-8 week intervals using balloon-dilators(12 to 20 mm) , in some, needle knife stricturotomy(n0 1), hydrophillic stents (n02) were utilized. Stoma size increased from 6 mm (pin hole to 10 mm) to 15.4 mm(10-19 mm). Patients requiring single dilatation(n 013;54 % ), stoma size increased to16.9 mm(1520 mm). Those requiring multiple dilatations(n010;41 %), stoma size increased from 3.4 mm (<1-10 mm) to 12.5 mm(12-18 mm). Technique of G-J closure impacted greatly on stricture development. Pure staple (n2), or suture closure(n-1) resulted in high stricture rate. In part-staple/ suture closure, longitudinal closure of end-to-side G-J with waisting at GJ caused high stricture development(n010/60;6.6 %; p00.005) compared to horizontal suture closure (n 011/1319;0.83 %). 6 patients required revision surgery; all had longitudinal closure with waisting at GJ. Overall 87 % of dilated patients had good response, with mean follow-up 13 months(6-24). Treatment-related complications included bleeding, localised perforation(radiological N-312.5 %). Fully hand-sutured and stapled G-J resulted in high stricture rate and when vertical part-staple/sutured GJ with waisting is constructed, endoscopic dilatations and some revisions were required compared to low stricture rates with part-staple-horizontal hand-sutured G-J.

Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom This is a retrospective study of prospectively collected data from 74 patients who had revisional bariatric surgery. Operative details, efficacy, safety and outcomes were analysed. In addition, we highlight the critical operative steps (video) to ensure good outcomes. From 2005 to 2011, who formerly had gastric band(42), sleeve gastrectomy(10), vertical banded gastroplasty(10), fundoplications(6), vagotomy ±gastrojejunostomy(3) and partial gastrectomy(1) had laparoscopic revision surgery, 27 underwent sleeve gastrectomy and 47 had gastric bypasses. The interval from primary to revision ranged between 6 months to 6 years. Mean age and preoperative BMI were 42 (32-64) years and 42.3 kg/m(2)(39.3 to 51.3). Median operative time and length of hospital stay were 126 (89-256) 3 (1-32) days. No deaths occurred but two had anastamotic leaks and one major bleed. EWL% was 42.21 % ±18.34 %), BMI reduction 9.4 ±6.1 kg/m(2) and percentage of weight loss 19.38 % ± 8.2 %. We highlight though a series of video clips the utility of endoscopy, intelligent port placement to avoid collateral damage, techniques to gain access into the retro-gastric space, pseudocapsule excision techniques, for VBG patients, identification of the band, delineation of the extent of the pouch, division of the stomach, and completion of the gastrojejunostomy at appropriate level, resection of gastric remnant and recognising the presence & repair of hiatus hernia. The operative video case series demonstrate clearly the critical steps involved in ensuring effective and safe revisional surgery. The data suggest that patients with inadequate weight loss after LAGB & VBG can do well after revisional surgery. P068 No Development of Symptomatic Venous Thromboembolism (VTE) in a 200 Bariatric Surgery Patients with Standard Clexane® Therapy Presenter: HJ Choi Co-authors: YJ Kim, MJ Kim, KY Hur

P069 Does the Gatro-jejunostomy Construction Technique Has Any Bearing on Development of Gastro-Jejunal Stricture (GJS) After Gastric-Bypass(LRYGB) for Obesity?:Endoscopic and Surgical Management: Presenter: Upendra Marreddygari, Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom

P070 Pre and Post Operatory Levels Of Acid Folic, B12 Vitamin and VCM in Rygbbariatric Patients Presenter: Esteˆva˜oCUBAS R, e, Co-authors: Arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Clı´nica Dr. Se´rgio Arruda, Brazil

Soonchunhyang university hospital, Korea (South) Objective To evaluate clinical efficacy of 2-week Clexane therapy for preventing VTE undergoing bariatric surgery Background Venous thromboembolism (VTE) after bariatric surgery is a significant cause of morbidity and mortality. But there was no concensus and reliable data in Korea. Methods From April, 2009 to December, 2011, we did 200 bariatric surgery (191 with primary intent, 9 with revisional intent). There were no history of VTE prior to surgery. Standard Clexane therapy was done with 4000U or 6000U SQ once daily for 2 weeks from before one day of surgery. Development of VTE was accessed by direct interview and physical examination in out-patients clinic. And that we also called to the patients for history taking Result 2 weeks Clexane therapy was completed in 193 patients. Clexane was stopped in 5 due to surgical related complication(4, bleeding, 1 reoperation due to leak) & in the other 2 due to potencially Clexane related (1, epistaxis, 1 metrohhagia), out patients were 72 % and those who could follow up by telephone were 93 % and there were any evidence of VTE.

Background Roux-en-Y gastric bypass is the most performed bariatric operation, presenting both restrictive and malabsorptive components. These might contribute to folate and vitamin B12 deficiency anemia and to erithrocyte parameter alterations. Methods We analyzed medical records from 12 patients in the period of August 2007 to September 2010 regarding to age, sex and BMI. Serum Folate (SF), Cobalamin (B12), Mean Corpuscular Volume (MCV), Hemoglobin (Hb) and Mean Corpuscular Hemoglobin Concentration (MCHC) data were divided into Pre-Operative (PRE-OP) and Post-Operative (POST-OP) and their evolution was compared. Statistical analysis, Pearson´s correlation and paired test were performed by Microsoft Access®and Graphpad Instat® softwares. Results From all patients (12), 9 were females. Average age was 36 ±7.6 (26.7-51.5) years. Pre-operative mean BMI was 42.2±4.4(36.9-50.6)kg/m2. Average follow-up period was 9.68 ± 7.5(3.9-28.9) months. PRE-OP vs. POST-OP: folic acid: 10.65 ±3(5.4-16) X 14.9±4.8(9.4- 26.8) [p00.0089]; B12: 327.67±149.6(154-660) X 522.18±243.17(282-1113) [p00.0198]; Hb: 13.64±1.45(11.6-15.6) X 13.55±1.183(11.7-15.4) [p00.8050]; MCV: 85.9±

1388 1.69(75-95) X 87.5±0.99(79.1-92.8) [p00.2474]; MCHC: 33.675±1.01(32.435.4) X 33.34±1.25(31.2-34.9) [p00.2113]. POST-OP: folic acid X MCV: r0 0.339, p00.28; B12 X MCV: r00.34, p00.27. Conclusions In the population of this study there were no significant differences between pre and post-operatory serum levels of hemoglobin, mean corpuscular volume and mean corpuscular hemoglobin concentration. We observed higher levels of folic acid and B12 after the operation. P071 Lipidic Profile After 3 Years of Roux-en-Y Gastric Bypass Presenter: Esteˆva˜oCUBAS R, e, Co-authors: Arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Clı´nica Dr. Se´rgio Arruda, Brazil Background Roux-en-Y Gastric Bypass (RYGB) is an effective surgery to weight loss in obese patients, and also has important effects in several laboratorial parameters, improving factors such as LDL, HDL, triglycerides and cholesterol. Dyslipidemia is associated with higher cardiovascular risks and other co-morbidities. Our aim is to evaluate lipidic serum levels before and after Roux-en-Y Gastric Bypass (RYGB). Methods Between January/2004 and May/2011, 123 patients, with at least 3 years of followup, were evaluated regarding sex, Mean Age (MA), Mean BMI (mBMI), Mean serum levels of HDL (mHDL), LDL (mLDL), Cholesterol (mCHO) and Triglycerides (mTRI). Paired and Wilcoxon Matched Paired tests were performed by GraphPad Instat® and Microsoft Access® softwares. Results From all patients (123), 107 (87 %) were females. MA was of 36.8± 10.4(17-67.3) years. Pre-operative mBMI was of 42.3±4.8(34.8-60.3) kg/m2. Mean follow-up was of 46.1±11.4(30.3-79.9) months. Pre-operative serum levels vs. Post-operative serum levels: mCHO: 194.7 ± 36.7(113-326) vs. 175.8±44.5(114-515) [p<0.0001]. mHDL: 47±10.5(21-84) vs. 58.3±12.6(1997) [p<0.0001]. mLDL: 115.3±35.7(10.6-226) vs. 95.7±25.7(35.6-170) [p< 0.0001]. mTRI: 145.4±58(52-335) vs. 90.9±38.7(38-239) [p<0,0001]. Pearson Correlation: mBMI vs. mHDL: R0-0.19; p00.033. mBMI vs. mLDL: R00.054; p00.55. Conclusions Decreased lipidic profile levels showed high statistical significance after 3 years of follow-up. In our sample increased values of preoperative BMI showed correlation with decreased levels of post-operative HDL. Correlation between pre-operative BMI and postoperative LDL levels showed no significance. P072 PTH and Calcium Mean Serum Levels pre and post Roux-en-Y Gastric Bypass Presenter: Esteˆva˜oCUBAS R, e, Co-authors: Arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Clı´nica Dr. Se´rgio Arruda,Brazil Background Recent researches indicated that calcium deficiency followed by a secondary hyperparathyroidism is a possible outcome of the Roux-en-Y Gastric Bypass due to its restrictive and malabsorptive components. Nonetheless, a supplementation of this nutrient after the operation might lead to normal or abnormally high levels. Methods We reviewed data of 393 patients, from January 2004 to December 2010, and studied demographic parameters, such as age, BMI and sex. We outlined specific criteria and classified them into PreOperative (PRE-OP) and Post-Operative (POST-OP). These were compared regarding to parathyroid hormone (PTH), calcium (Ca) and alkaline phosphatase (ALP). Statistical analysis was performed by Microsoft Access®and Graphpad Instat® softwares. Results From all patients (393), 338 were females. The average age was 38± 10.76(16.5-67.3) years. Pre-operative mean BMI was 41.7±4.89(33.7-60.6) kg/m2. The average follow-up was 0.31±4.67(-43.6-9.9) months. PRE-OP vs. POST-OP: PTH:45.05±20.71(3-153) X 47.57±22.35(3-236) [p00.0271]; Ca: 9.06±0.69(1.07-11.9) X 9.1±1.51(0.3-33) Conclusions We observed in the population of this study a significant statistical difference between pre and post-operative parathyroid hormone serum levels. There was not such a difference regarding to the pre and post serum levels of calcium or alkaline phosphatase.

OBES SURG (2012) 22:1315–1419 P073 Roux-En-Y Fistulojejunostomy for Post-Sleeve Gastrectomy Fistula Presenter: Pr Elie Chouillard Poissy Medical Center, Paris West, France On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, FRANCE Aim Fistula is still a concern after Sleeve Gastrectomy (SG) in patients with morbid obesity. Although the risk of fistula is relatively low (< 5 %), its treatment is long, non standardized, and complex. Surgery may be indicated in selected cases. In this study, we present ou experience with Roux-en-Y fistulo-jejunostomy (RYFJ) in selected patients with fistula after SG. Patients and Methods: Between January 2005 and December 2011, we treated 31 patients with post SG fistula. Six of these had RYFJ (VIDEO). Results 4 patients were operated laparoscopically and 2 had open surgery. No major operative incident was encountered. Mortality was 0 %. No patient was transfused. Operative duration was 160 minutes (120-330 minutes). The healing rate of the fistula was 100 %. The mean postoperative follow-up was 39 months (13-66). Four patients had chronic diarrhea. Two patients suffered from chronic pancreatic insufficiency. All patients needed vitamine and oligoelements medication. Adequate weight loss and comorbidity remission was achieved in all patients. Conclusions RYFJ for post SG fistula is a feasible and sure option. The metabolic outcome of this procedure is ill-known. P074 The Actual Rate of Hypoglycaemia Following Gastric Bypass Persenter: R.Kefurt1, Co-authors: M. Poglitsch1, C. Reiler1, A. Bohdjalian1, F. Langer1, M. Walker2, A.Tu¨rkcan1, A. Hofer2, K. Schindler2, B. Ludvik2, G. Prager1 1 2

Medical University of Vienna, Department of Surgery,\ Medical University of Vienna, Department of Internal Medicine III

Introduction The actual incidence of hypoglycaemia following Gastric Bypass (RYGB) remains a matter of controversy. The aim of this study was to determine the rate of hypoglycaemia after gastric bypass. Methods 30 morbidly obese patients (26f/4 m; mean age 45a; mean BMI 48,2 kg/m2) were screened for hypoglycaemia (< 65 mg/dl) 4 years after RYGB. Continuous Blood Glucose (BG) monitoring was performed for 5 days. BG was additionally measured 4x/day by the patient along with detailed nutrition recording. A Mixed Meal Tolerance test (MMT) was used to detect postprandial hyperinsulinemic hypoglycaemia. BG, CPeptide, Insulin were sampled at -10,0,15,30,60,90,120,180 and 240 minutes. Results One patient was excluded due to incompliance, 4 patients due to invalid 24 h continuous BG data. In a total of 29 MMTs, hypoglycaemia occurred in 13 patients (44 %). The mean peak level of insulin during MMT was 71.2 (52.8)U/ml (p00.33) and of C-peptide 9.7 (6.0)ng/ml (p00.003) for patients with and without hypoglycaemia, respectively. In 25 patients with valid continuous BG measurements, hypoglycaemia was detected in 20 patients (80 %) with 1-9 hypoglycaemic episodes within 5 days. Postprandial hypoglycaemic episodes were recorded in 14 patients (56 %), of which 4 had normal MMT. Patients without hypoglycaemic episodes during 24 h BG monitoring and on MMT showed a mean peak level of 22U/ml of Insulin and 4 ng/ml of Cpeptide in MMT. Conclusion Hypoglycaemia after gastric bypass occurred in 80 % of patients as assessed by continuous BG monitoring and in 44 % after MMT and appears to occur more often than usually reported in the literature. Applying only the MMT might underestimate the rate of hypoglycaemia. P075 Porto-Splenic Thrombosis After Bariatric Surgery Presenter: Ismael Court Co authors : Juan E. Contreras MD, Pablo Marin MD, Ismael Court MD, Jorge Bravo MD, Gustavo Czwiklitzer MD, Percy Brante MD,James Hamilton MD Section of Bariatric & Metabolic Surgery. Surgery Department. Clinica Santa Maria. Santiago Chile.

OBES SURG (2012) 22:1315–1419 Background Porto-splenic thrombosis is an infrequent complication of gastrointestinal surgery. High morbidity and also mortality can be secondary to this complication. Aim: Describe the incidence of porto-splenic thrombosis after bariatric surgery, possible risk factors and treatment. Methods Retrospective, descriptive, uncontrolled study. We reviewed the cases of porto-esplenic thrombosis after surgery, analyzing predisposing risk factors, days of hospitalization, presentation, treatment and complications. Results 500 cases of bariatric surgery, Gastric Bypass and sleeve Gastrectomy, between 2009 and 2011. Average BMI 37, mean age 44 years old. There were 9 cases (2 male, 7 female) of porto-splenic thrombosis (1.8 %). Nonspecific abdominal pain was the most frequent presentation. Diagnosis was made using CT scan in all cases. Oral contraceptives and hormone replacement therapy were the most important risk factor. Days of hospitalization: average 6 days. All the patients were treated with anticoagulants without complications. All 9 cases were studied for thrombophilia, and 5 of them had some thrombophilia undetected preoperatively. There was no mortality in this series. Conclusion Porto splenic thrombosis is an infrequent complication after bariatric surgery. The presentation is nonspecific and requires a high index of suspicion. Diagnosis can be done by CT Scan. The study of thrombophilia is necessary in all cases. There is a good response to the anticoagulant therapy. The treatment at long term can be done with oral anticoagulation and the duration of it depend to the cause of the thrombosis. P076 Standardization of Laparoscopic Sleeve Gastrectomy Increases Efficacy and Reduces Complications

1389 patients had h/o pulmonary TB in past, treated with antitubercular drugs successfully. Preop BMI of these patients were 34, 36 & 39 respectively. Patients lost approx 24, 28 & 32 kgs on follow up at 12-15 months. These three patients had complaints of severe back pain not relieved with regular treatment and physiotherapy. All patients were evaluated for Calcium and Vitamin D deficiency and were given mineral and vitamin supplements after surgery. MRI showed Pott’s spine destruction of vertebral body s/o tubercular spine, which was confirmed on FNAC. All were treated with ATT for 12 months. All regained weight 3-8 kg while on treatment, but after stopping ATT reduced 2-4 kg. of weight All are fine now. Conclusion Surgery for morbid obesity has several advantages on overall quality of life of patients, but it is not free from sequelae. Strict followup and supplements are part of post operative management of these patients.Bone disease is not uncommon complication after bariatric surgery because of Vitamin Dor calcium deficiency, However reactivation of extrapulmonary tuberculosis leading to Pott’s spine is not reported in these patients. We report three such cases. The reason for developing TB could be reactivation of TB due to immunodefeciancy state due to defeciancy of certain nutrients or due to hypochloraemia (reduced gastric acidity). P078 C-Reactive Protein (CRP) and Sialic Acids Changing After Bariatric Procedures

Presenter: Gurvinder Jammu

Presenter: Lavryk A., Co-author: Lavryk O., Dmitrenko O.

Jammu Hospital Jalandhar, India

National O.O. Shalimov Institute of Surgery and Transplantology, Ukraine

Background The purpose of the study is to demonstrate the increased efficacy in the form of excess weight loss(EWL), remission of type2 diabetes mellitus and decreased incidence of complications in the form of leaks, GERD in a standardized LSG (laparoscopic sleeve gastrectomy) procedure. Methods We report our results of LSG before and after standardizing in our series of 215 cases of LSG since January 2008 First 47 cases were done randomly and rest 168 were standardized. In initial 47 cases the transection started at a variable distance from the pylorus us, all the staples were applied tightly against the gastric bougie, fundus was resected close to angle of His, staple line was not reinforced, crura were never dissected. In a standardized procedure the first staple started at 3 to 4 cm from the pyloric antrum, all the staples were applied loosely against the gastric bougie, fundus was divided 1 cm lateral to the OG junction, staple line was reinforced and both crura were always dissected ,all the patients were given DVT prophylaxis. The bougie size in the standardized LSG was 36 F. Results In LSG done without proper standardization mean incidence of EWL varied from 30 % to 59 %,Remission of T2DM 50 to70%,leak was 2.12 %, GERD was 12.76 %, mortality was 4.2 % . After standardization (168 cases) incidence of EWL 65 to 85 %, remission of type 2 DM 70 to 90 % ,no haemorrhage,no leak, GERD markedly decreased. No DVT or pulmonary embolism seen in the standardized series. Conclusion Standaradized LSG is a safe and effective bariatric procedure.

Aim of our study was to evaluate the impact of adjustable gastric banding (AGB) and gastric bypass (GB) on CRP levels in morbidly obese patients, to reveal the correlation between body weight decrease the changes of CRP levels, to instill the presence or absence of changes in other acute phase molecules levels (seromukoid, sialic acids) after bariatric procedures. Materials and Methods Retrospectively we have analyzed 45 clinical records of patients, who survived GB, and 45 patients after AGB with 6-months of follow-up. Gender: 86 – females, 14 – males; mean age – 46,8+2,7. Mean pre-op weight was 175+8,4 kg (mean BMI - 54,8+5,9 kg/m2). The mean pre-op CRP was 89,1+1,9 mg/L. Mean sialic acids level was 3,15+ 0,8 mmole/L, mean seromukoid level – 1,5+1,2 IU. Results In 6 months we observed body weight decrease: after AGB weight was 132,6+1,5 kg, after GB – 116 kg. After both AGB and GB CRP levels significantly decreased: after AGB till 8,5+ 1,2 mg/L, after GB till 6,2+0,8 mg/L, but normal levels of CRP were still not reached (p<0,01). Between weight loss and CRP decreasing the positive lineal correlation was installed. After AGB sialic acids were 2,96+0,7 mmole/ L, seromukoid – 0,17+0,9 IU. After GB sialic acids level was 2,68+1,5 mmole/ L, seromukoid - 0,18+1,1 IU. Conclusions After both AGB and GB CRP, sialic acids and seromukoid levels significantly decreased. Received results can prove the presence of chronic pro-inflammatory process in adipose tissue and it’s decrease after bariatric procedures.

P077 Reactivation of Tuberculosis After Bariatric Surgery: A Rare Complication or Mere Coincidence Presenter: Sewkani A, Co-author: P Shaji, Jat A, Sharma V, Vyas S, Varshney S. Department of Surgical Gastroenterology, Bhopal Memorial hospital & Research Centre, Bhopal, India Introduction Morbid Obesity has its own morbidities like Diabetes, hypertension, arthritis and many more. Bariatric surgery has advantages of not only loosing excess weight of the patients but also reducing the co-morbidities associated with obesity. In the course of loosing weight, patients may experience nutritional deficiencies which may leads to secondary immunodeficiency. We have seen three cases of extrapulmonary tuberculosis in patients operated for morbid obesity. Case Reports Only 302 cases of bariatric surgeries 2008, 3 female patients (of age 36, 38 and 42 years) developed extrapulmonary tuberculosis. two

P079 Does Stitching Band Increase Slipping? Presenter: V. Frering Espace medico chirurgical de la Sauvegarde, 29 av des Sources, 69009 Lyon France Among different procedures carried out in bariatric surgery, gastric banding is useful in Europe. Slipping is the main complication. Stitching the band remains a commonly allowed attitude as a prevention of the slippage. Redo surgery or switching to gastric by pass can be more difficult with a band stitched. Aim of this work was to evaluate the interest of stitching the band. Materiel Methods From 1997 to 2006, 4047 patient had a gastric band. Band used was Midband. Were excluded redo surgery. Data were prospectively collected. There were 1998 in the Stitched group (GS) and 2049 in unstitched (GNS).

1390 The statistical study on two qualitative variables was carried out with a test Khi 2. Results Both group were comparable for age, BMI and sex Ratio. Slippage occurred in 95 (4,8 %) patients in the stitched group and in 116 (5,5 %) in unstitched group. Khi 2 : P0ns Four patients had acute slippage within 3 days after surgery. Conclusions Stitching is more complicated for redo surgery. There is no difference regarding slippage. Multicenter randomized blinded study is currently proceeding.

OBES SURG (2012) 22:1315–1419 P082 Adiposity Better Indicator of Dysmetabolism Than Obesity: A Gender Specific Study of Indian Patients Visiting Bariatric and Metabolic Clinic in Asia Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao Ruby Hall Clinic , Pune, India

P080 Surgical Pitfalls for the Novice Bariatric Surgeon

P081 Laparoscopic Adjustable Gastric Banding: Our 10-Year Experience at Alexandra Hospital/Khoo Teck Puat Hospital, Singapore

Background South Asians including Indians show early appearance of comorbidities related to obesity well before the patient is categorized as obese using the current parameter of BMI to determine obesity. There are different Methods to analyze the body composition. This study aims to understand whether BMI and body fat percent correlate with each other and what correlates better with obesity related co morbidities . Materials and Methods This is a retrospective study of prospectively collected data of patients visiting the Bariatric and Metabolic clinic in Laparo Obeso Center , India from Dec 2010 till Feb 2011. N 0358 (M: 166 : F :192 ). The data was collected in terms of demography , anthropometry and comorbidities and total body fat percent using bioelectrical impedance analysis. Unpaired t test was used for statistical analysis. Results 265 / 358 ( M:84:F:181) patients showed total body fat percent> 30 %. According to BMI , 217 / 358 ( M:89:F:128) were in the category of obesity. Mean waist circumference in females was 108.37 cm and in males was 113.07 cm. Statistically significant difference ( p <0.05)was observed in females and males in height , weight, fat percent, muscle mass , total body water percent ,bone mass ,BMI ,BMR . No statistically significant difference was observed in age and waist circumference between males and females. High fat %was noted in 94.3 % females but only 66.7 % females fell in the category of obesity as per BMI. Good correlation was found to be existing between BMI and total body fat percent in both genders in obese ( as per the BMI) group. In non obese group in males the correlation did exist but it in non obese females it did not correlate . 21 % patients had hypertension. 13 % patients had T2DM. In both diabetic and Hypertensive group a good correlation between BMI and fat percent was evident only in obese ( as per BMI ) category of patients. Conclusion BMI may not prove to be the right indicator of fatness and may fail to identify the population at risk of getting obesity related co morbidities. This is specifically true in Indian female population. Larger studies with a bigger and diverse population are needed to prove the efficacy of body composition analysis over BMI alone to identify the population at risk.

Presenter: Kee Yuan Ngiam, Co-authors: Ganesh Ramalingam, Anton KS Cheng,

P083 LSG IN SO(BMI>50): ? stand alone procedure:OUTCOME AT 3 YEARS

Khoo Teck Puat Hospital, Singapore

Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao

Presenter: Ashish Dey Co-authors: Tarun Mitttal Vinod K Malik Sir Gangaram Hospital, New Delhi, India Laparoscopic Bariatric Surgery has seen an unprecedented upsurge across the world as the epidemic of obesity continues to grow. More and more surgeons have started to train and develop skills to be able to master the procedures so as to deliver results with minimum morbidity and mortality. Apart from an institution based multidisciplinary and intensive care support it requires, it is important for a novice surgeon to know precisely the finer technical points of these procedures, as even small technical mistakes can lead to devastating results. Leading Bariatric surgeons across the world do a number of Bariatric procedures with subtle variations in technique. It is important to have a comprehensive knowledge of their steps and accept what appears to give the best results and supported by published medical evidence. Today’s internet based disbursement of medical knowledge along with the benefits of intra operative recording and repeated viewing of surgical procedures has made dispensing and critical analysis of surgical knowledge much easier. Through this presentation I would like to present the technical difference in techniques of the most commonly performed bariatric procedures by the leading surgical experts across the world. We also present experience of our first 50 bariatric cases with a limited follow up of an average 1.2 years. We would also like to initiate a healthy debate on the mistakes we have done in these first few cases and how could we have done things differently.

Background From 2001-2011, we have performed 371 laparoscopic adjustable gastric bandings for morbidity obese patients in Singapore. We describe the weight change, resolution of co-morbidities, complications and rate of follow up over this period to determine if gastric banding is effective in inducing and maintaining weight loss. Methods Patient data was prospectively collected and the patients were followed up at the Weight Management Clinic. Patients who have been lost to follow-up were actively contacted by telephone and electronic means. The weight reduction/regain after surgery, resolution of co-morbidities, complications and follow up rates are reported. Results 371 patients had undergone laparoscopic adjustable gastric banding over a 10-year period. The average age was 35 years old. 47.3 % were Chinese compared to 25.3 % Malays, 21.2 % Indians and 6.6 % other races. The mean pre-op weight and BMI was 115.1 kg and 42.0kgm -2 . Post operative weight, percentage excess weight loss and BMI over 10 years were plotted comparing patients in the different obesity classes (I – III) demonstrating a plateau in weight loss from the 3 rd year. There was an overall improvement in diabetes, hypertension and obstructive sleep apnoea. 32 % of patients developed complications with 2 mortalities. 61.9 % were band related and the rest due to the tubing and port. Follow up rate was 21 % at 5 years. Conclusion LAGB is a viable bariatric operation with short-term weight loss and improvement in comorbidities. Nevertheless, these patients need lifelong monitoring for complications and regular follow up.

Ruby Hall Clinic , Pune, India LSG (Laparoscopic Sleeve Gastrectomy) is an effective bariatric procedure. After standardization of the technique & bougie size ,it is proving itself as a stand alone procedure . This study aims at the effectiveness and safety of LSG in super obese(SO) patients at the end of 3 yrs. We performed 500 bariatric operations between 2004 to 2008. This is a retrospective study of prospectively collected data regarding the superobese post LSG patients at the end of 3 years with regards to weight, BMI and co-morbidities. N036.BMI distribution: 17 (50 to 60 kg/m2), 17(60 to 80 kg/m2) and 2 above 80 kg/m2 . The average length of hospital stay was 3.4 days. No intra operative complications were encountered. Postop gastrograffin swallow for all showed no signs of leak or obstruction. All patients had a regular follow up. The mean % EWL was 72.6 % at the end of one year and 64 % at the end of 3 years.All patients had more than 3 associated comorbidities and all showed improvement. Diabetes/Glucose Intolerance resolution/ improvement in 30 /30 , obstructive sleep apnoea reversal in 12 /12, improvement in joint pains in 18/22. The results for SO patients undergoing LSG are encouraging even at 3 years postop. In experienced hands ,the post op course was uneventful .It is an effective & safe weight loss procedure in SO Indians and may not demand immediate second major weight loss operation.

OBES SURG (2012) 22:1315–1419 P084 To Study the Prevalence of Metabolic Syndrome and Central Obesity in Patients Admitted In Intensive Care Unit (ICU) in Tertiary Care Center in India: To Help Formulation of Risk Reduction Strategies. Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao

1391 P086 Does Adjustible Gastric Band Play Any Role Of Effective Bariatric Operation? Analysis of Outcomes of 100 AGB Operations Peformed at A Single Indian Center Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao Ruby Hall Clinic , Pune, India

Ruby Hall Clinic , Pune, India Background South Asians including Indians around the globe have highest rate of CAD (coronary arterial disease ). There would be around 62 million patients of CAD in India by 2015 and out of these 23 million would be pts lesser than 50 yrs of age. An estimated loss of 9.2 million productive Yrs of life in 2000 is expected to rise to 17.9 million yrs in 2030.The rising need of ICU beds and the cardiovascular diseases in Indian population belongs to the rise in the incidence of Metabolic Syndrome and central obesity. Metabolic Syndrome is becoming highly prevalent in India due to many reasons, like genetic predisposition, environmental and behavioral factors leading to central obesity. This all result in rise in cardiovascular diseases in the affected population. Method and Material This is a single centre observational study to evaluate the incidence of Metabolic Syndrome and central obesity in patients admitted in ICU in tertiary care center in India. The prospectively collected continuous data during the period from Dec 2010 till Feb 2011 was analyzed according to the different parameters of Metabolic Syndrome. Total 670 patients were admitted in ICU during this period (Males - 414 and Females - 256) with their average age being 56.05 years and mean duration of stay 8.23 days. Results The preliminary analysis shows that the Central Obesity was seen in 64.6 % of total patients (Females 66.1 % ,Males 63.6 %). Hypertension was seen in 54.9 % of total patients (Females 63.7 % , Males 49.4 %). Diabetes Mellitus was seen in 38.7 % of total patients (Females 43.7 % ,Males 35.6 %). Dyslipidemia was seen in 74.6 % of total patients (Females 75.4 % ,Males 74.2 %). 28.8 % of the total number of patients had any two of the comorbidities and 31.57 % of the total number of patients showed presence of minimum three comorbidities. Conclusion To alleviate the incidence of cardiovascular diseases in Indian population and to reduce the morbidity and mortality in ICU, the treatment strategies need to focus on effective control of central obesity and metabolic syndrome. P085 Plicated Band Works Better Than Adjustible Gastric Band Alone Presenter: Dr J S Todkar, Co-authors: S S Shah , P Shah , Neeta Sawant , Ayesha Rehman , Neha Singour , Amruta Bhalerao Ruby Hall Clinic , Pune, India Background AGB (laparoscopic adjustable gastric band) is a standard bariatric operation providing the unique advantage of outcome oriented adjustability. It is safe and reversible procedure with minimum anatomical dissection, low perioperative morbidity and proven long term results in selected candidates. But has a real challenge of compliance of the patient specially when patient can’t eat and remains hungry.LGCP (laparoscopic greater curvature placation) is an emerging bariatric operation with promising short term results .The durability of the effect is yet to be proven.Like AGB it is feasible and safe operation working through weight loss and restriction of food intake. They don’t influence energy expenditure and have modest effect on glucose metabolism.In our small series of patients done at Laparo Obeso Center , Pune , India we observed a better satiety score in LGCP patients than the AGB patients. Methods We combined these two operations with the aim of achieving better satiety score , better control of hunger and ultimately effective food restriction than can be achieved through each surgery alone. N:7 M: F :1:6age range :30 to 62 yrs (avg. 35.8 yrs ) BMI range:32.5 to 48 kg/m2 (avg. 36.3 kg/m2) eight range: 74 to 116 kg (avg.91.3 kg) All patients had at least one obesity related co morbidity other than obesity. Results Avg. Wt loss at 1 and 3 months: avg 9 kg , 12 kg resp .All patients showed a significant improvement in the co morbidity status.No adjustment for the band was needed till the 3 mths postop.

AGB is known as a bariatric operation with proven efficacy and safety in selected group of patients. In Indian patients metabolic disorders prevail even at mild degrees of obesity . This is the retrospective study of analysis of outcomes of AGB in 100 patients at a single center in India. The outcomes are studied in regards to EWL , Co morbidity resolution , the complications and the challenges. This study will give us insight about the role of AGB in Indian patients. P087 Establishing a Bariatric Center – the Criticality of a Mental Health Component Presenter: Connie Stapleton, Ph.D. Beyond identifying the relatively small percentage of patients presenting clear mental healthcontraindications for weight loss surgery, the mental health practitioner in a bariatric center playsan integral role in patient care, before and after WLS.Exemplary bariatric programs need mental health practitioners to provide patients the skills to 1)permanently adopt positive eating and exercise behaviors, 2) set healthy boundaries and learnassertiveness, 3) address changes in critical relationships, 5) prevent a return to unhealthyeating/ other unhealthy behavior patterns, and 6) assist in working through postsurgical mental health issues (“suicide is higher among bariatric surgery patients than other severely obeseindividuals.” [Adams TD, et al., N Engl J Med 2007]), all in an effort to optimize post-surgicalsuccess. “Bariatric surgery requires a dramatic alteration in eating behavior… In light of the demands of thepostsurgical regimen and the life changes consequent to major weight loss, discussion of patientexpectations and consideration of the individual goals and interpersonal milieu are indicated….We recommend that the surgical team routinely monitor all patients after surgery for the onset orrecurrence of eating, mood, or substance use problems, as well as other psychiatric symptoms…Careful attention to the psychiatric and psychosocial status of bariatric surgery patients is likely toenhance individual well-being and minimize the potentially negative impact on postoperativeweight loss.” (Marcus, MD, Kalarchain, MA., & Courcoulas, AP. Am J Psychiatry 2009) This talk focuses on the criticality of expanding the mental health component in all bariatriccenters, to include pre- and post-op efforts. P088 Experience in Laparoscopic Sleeve Gastrectomy in Patients with BMI Less Than 35 in Antofagasta Clinic Presenter: Rodrigo Villagra´n, Co-authors: Angelo Bizjak, Carlos Flores, Gino Bizjak, Marisol Yan˜ez, Paulina Fuentes, Gloria Bustos, Sofia Araya Institute : Clinica Antofagasta, Chile Introduction The sleeve gastrectomy is increasing indication for the treatment of obesity and its comorbidities. Their results have extended the indication to groups with lower BMI associated with comorbidities as a single procedure Objective To evaluate postoperative weight loss, safety of the procedure and surgical complication rate of laparoscopic sleeve gastrectomy performed at Antofagasta Clinic. Methods We report a case series, prospective study not randomized of obese patients with BMI less than 35 who underwent Laparoscopic Sleeve Gastrectomy as a definitive surgical treatment, performed by the same surgeon between november 2009 and march 2012. Variables we analyzed were age, sex, preoperative and postoperative weight, height, BMI, preoperative and postoperative presence of comorbidities and perioperative complication rate. The variables described was tabulated in Microsoft Excel. Results The group comprises 75 patients, 16 men (21 %) and 59 women (79 %), with an average age of 31,4 years (16-53), an average weight of 87 (68-106) and an average BMI of 33 (30-35).

1392 It showed a decrease in average BMI by 5 points and 71 % of excess weight in 6 months and 89 % at 12 months. Among the most frequent comorbidities presented include insulin resistance (78 %), hepatic steatosis (44 %), dyslipidemia (53 %), hypertension (12 %) and diabetes (10 %) There was no mortality in this series. There were no leaks, no stenosis. Were followed at 6 and 12 months. Conclusions Laparoscopic sleeve gastrectomy is a safe procedure with low complication rate and its a effective treatment for grade 1 obesity. Increased monitoring is needed P089 Experience in Laparoscopic Sleeve Gastrectomy in Antofagasta 355 Cases. 12 Months Follow Up Presenter: Angelo Bizjak Co-authors: Rodrigo Villagra´n,, Carlos Flores, Gino Bizjak, Marisol Yan˜ez, Paulina Fuentes, Gloria Bustos, Sofia Araya

OBES SURG (2012) 22:1315–1419 operative complications : one mortality due to Myocardial Infarct on day 5 ,no bleeding /pulmonary/wound complication. %EWL is 62 % at the end of one year.One patient needed band removal for erosion ,two patients had nutritional complications in the form of protein , vit B12 defficiency and was corrected conservatively. Conclusion This shows that bariatric surgery in elderly is safe and effective.This is the first study of outcomes of Bariatric surgery in elderly Indians. P091 Preliminary Results of Sleeve Gastrectomy Performed in a Multidisciplinary Environment Presenter: Kim Tang2 Co-authors: Michele Van Vuuren1, Michelle Graham1, Shirley Lockie1, Phil Lockie1 Brisbane Institute of Obesity Surgery, Brisbane, Australia, 2Ipswich General Hospital, Ipswich, Australia

1

Institute : Clinica Antofagasta, Chile Introduction It has been demonstrated the favorable impact of Laparoscopic Sleeve Gastrectomy in the treatment of obesity as a definitive treatment. Objective To evaluate postoperative weight loss, safety of the procedure and surgical complication rate of laparoscopic sleeve gastrectomy performed at Antofagasta Clinic. Methods We report a case series, prospective study not randomized of obese patients who underwent Laparoscopic Sleeve Gastrectomy as a definitive surgical treatment, performed by the same surgeon between november 2009 and march 2012. Variables we analyzed were age,sex,weight,height,BMI,presence of comorbidities and perioperative complication rate. The variables described was tabulated in Microsoft Excel. Results The group comprises 355 patients, 92 men (26 %) and 263 women (74 %), with an average age of 35 years (15-66), an average weight of 102,3 kg (77-142) and an average BMI of 38,5 (30 - 56). It showed a decrease in average BMI by 9,2 points and 68 % of excess weight in 6 months and 79 % at 12 months Among the most frequent comorbidities presented include insulin resistance (69 %), hepatic steatosis(47 %), dyslipidemia(45 %), hypertension(22 %) and diabetes(11 %) There was no mortality in this series. There were no leaks, no stenosis. There were 5 cases of hemoperitoneum(1,4 %), 3 of whom were treated medically without transfusion, only 2 patient required reoperation a few hours after surgery, progressing favorably and discharged on the third day both. Were followed at 6 and 12 months. Conclusions Laparoscopic sleeve gastrectomy is a safe procedure with low complication rate and it is a effective treatment for obesity. Increased monitoring is needed P090 Surgical Wloss in the Elderly: Is It Worth the Risk? Presenter: Dr J S Todkar, Co-authors: S S Shah, P Shah, Neeta Sawant, Ayesha Rehman, Neha Singour, Amruta Bhalerao Ruby Hall Clinic , Pune, India Background Bariatric surgery after 60 yrs age is regarded unsafe for morbidity / mortality concerns. This study aims at evaluation of Bariatric surgery in elderly . Methods This is Retrospective analysis of prospectively maintained continuous database regarding safety, operative morbidity and outcome in elderly. Since 2004 , 500 patients underwent bariatric surgery at Laparo-Obeso Center , 69(M:F035:34) above the age of 60 yrs .The BMI distribution : 35 to 40 kg/ m2 (28), 40 to 50 kg/m2(29), 50 to 60 kg/m2 (10 ),above 60 kg/m2(2). The distribution per type of surgery :Adjustable Gastric Banding : 17,Intragastric Balloon : 1 ,Laparoscopic sleeve gastrectomy: 41,Laparoscopic roux -en -y gastric bypass:10. Results Pre operative risk profile :Obstructive sleep apnoea: 12 ,Diabetes:49 , Hypertension : 49 ,Dyslipidaemia : 61 ,Joint pains : 65 , liver cirrhosis :2 , congestive cardiac failure : 2, chronic renal disease : 1 . Hospital stay : 3.5 days avg , operative time :90 min avg ,30 days readmission :zero.Post

Bariatric surgery patients have a high prevalence of mental health disorders. There is also a high prevalence of abnormal eating behaviour, in particular pre surgical binge eating. Binge eating remits for the first 612 months post surgery and preoperative binge eating does not predict poorer weight loss within the initial 6-24 months post surgery. However in the longer term, patients with preoperative binge eating behaviours are at higher risk of redeveloping problematic eating behaviours. These problematic eating behaviours are associated with a higher risk for weight regain. The practice utilizes a structured program of pre and postoperative intervention in an effort to mitigate the re-emergence of abnormal eating behaviours and maximise long term weightloss. Methods All patients have an initial consultation with the surgeon, psychologist and dietician. Patients have a second dietician and psychology appointment prior to surgery with two further appointments after surgery, on weeks 2 and 8. Patients have optional access to an exercise physiologist and a psychologist facilitated monthly patient support group. A standard sleeve gastrectomy is performed using a 38 F bougie. Results 138 consecutive cases between Oct 2007 and Oct 2011 performed by a single surgeon were evaluated. 32 % patients had a history of depression. Mean age of patients was 44.22, mean BMI pre-op was 43.49.Mean percentage of excess weight loss (%EWL) were: 47.62 % at 3-4 months (n051), 66.95 % at 56 months (n037), 79.47 % at 10-12 months (n035), 84.80 % at 13-18 months (n024), 93.97 % at 19-25 months (n018) and 91.75 % at 26- 48 months (n018). Conclusion Preliminary results suggest that sleeve gastrectomy performed with a structured program of psychological and dietetic support may help to maximize long term weightloss following sleeve gastrectomy. P092 Emergency Laparoscopic Gastric Band Removal in Late Pregnancy Presenter: 1. Adamo M, 2.M ElKalaawy,1. Co-authors: A Rotundo, M ElKalaawy, M Banks, K Dawas, M Hashemi, M Mughal, A Jenkinson, M Adamo 2. M ElKalaawy, A Rotundo, R Batterham,Y University College Hospital, London and Medical Research Institute, Alexandria. Egypt Background Adjustable gastric band (AGB) is the commonest bariatric procedure that has been performed to date. Many gastric band patients are female in child bearing age and successful pregnancies have been described after the procedure. AGB has been reported to carry up to 15-20 % long term complication rate requiring emergency removal; hence complications seen during pregnancy are becoming more frequent. We report two cases of emergency laparoscopic AGB removal during pregnancy. Methods Two pregnant patients presenting with acute recurrent obstructive gastric symptoms 3 years post ‘successful’ AGB inserted elsewhere. Gestational ages were of 24 and 28 weeks. Symptoms were nausea, dyspepsia, abdominal pain and frequent vomiting. Both patients reported the vomiting as “different” from the hyper emesis experienced during their first trimester. Patients’ care was shared with obstetric team in our newly started service for women who underwent bariatric surgery. Investigations (Endoscopy and MRI scan) were useful but not diagnostic. Laparoscopy revealed posterior AGB slippage with acute pouch dilatation in both patients and AGB was removed. Both patients had immediate improvement after AGB removal and carried out pregnancies successfully.

OBES SURG (2012) 22:1315–1419 Conclusion

& & &

Frequent vomiting in late pregnancy could be caused by AGB slippage MRI scan and endoscopy are valuable diagnostic tools in pregnancy, but operative interference should be based mainly on clinical assessment. AGB can be removed laparoscopically even in late pregnancy.

P093 Weight Loss and Metabolic Improvement Using a Swallowable, Volume-Titratable Gastric Balloon System

Presenter: Martinez A., MD; Co-authors: So M., MD; Miranda G., MD; San Miguel L., MD; Chavez C., MD; Ortiz A., MD Obesity Control Center, Tijuana, Mexico A three month feasibility study was conducted using a novel gastric balloon design (Obalon Therapeutics Inc., San Diego, California). The balloon is swallowed in a gelatin capsule and remotely inflated with gas to 250 cc without endoscopy. Additional balloons could be swallowed and inflated to increase total resident volume during the treatment period based on patient satiety and weight loss response.Two men and eight women with a mean baseline BMI of 33.5±3 kg/m2, weight of 92.3 ± 8.8 kg, and excess weight of 23.0± 7 kg received a single 250 cc balloon to start. All patients received a second balloon during the second month and two patients received a third balloon in the third month. Mean excess weight loss at the end of 12 weeks was 34.5 ±16.9 %kg, mean weight loss was 7.9 +4.4 kg, and mean reduction in BMI was 2.9 ±1.6 kg/ m2. All ten patients completed the study duration without any unexpected or serious adverse events. There was no vomiting or nausea reported and no requests for early removal.In addition to weight loss, there was a favorable trend toward improved metabolic value. Fasting glucose was reduced 12.1+27.8 mg/dl,total cholesterol fell 24.5+ 27.6 mg/dl and triglycerides declined 30.8 + 65.9 mg/dl. One patient, who had elevated baseline fasting glucose of 177 mg/dl, total cholesterol of 280 mg/dl and triglycerides of 281, lost 13.9 kg (56.5 % EWL) during the treatment period and reduced fasting glucose to 85 mg/dl (-86 mg/dl), total cholesterol to 202 mg/dl (-78 mg/dl) and triglycerides to 98 (-198 mg/dl) . The swallow and inflation of the balloons averaged 5 minutes. Balloons were removed via endoscopy using standard tools under light conscious sedation and averaged 10 minutes. No ulcers, erosions or irritations were observed at removal.Conclusion: This feasibility study demonstrated favorable tolerability and safety for up to three swallowable gas-filled gastric balloons added progressively with encouraging weight loss and metabolic improvement. The ability to easily add balloon volume appears to improve treatment and tolerability. The results of this study are consistent with the outcomes from two previous studies using this novel gastric balloon system with shorter placement durations of one and two months. P094 Laparoscopic and Endoscopic Management of Gastro-Gastric Fistula After LRYGB for Morbid Obesity

1393 BMI (47.6 kg/m2 vs. 50.4 kg/m2) but significantly less excess weight loss 1 year after surgery (44.7 % vs. 60.7 % P0.03). In one patient, GGF developed within 14 days, another patient developed it within 6 weeks rest were detected 4.5 to 9.4 months after surgery. Three underwent endoscopic cauterisation, debridement and clipping, two had laparoscopic division of fistula and omentoplasty and one other patient in addition had resection of the fundus of the remnant stomach. Smaller-diameter fistulas can be successfully managed by endoscopic therapy. If endoscopic therapy fails, large-calibre fistula can be managed laparoscopically by division of fistulous tract with omentoplasty with or without partial resection of remnant stomach. Omentoplasty to pouch may minimise the chances of GGF after gastric bypass. P095 Effective Dietetic-Led Follow Up Program With No Surgeon Visits Following Laparoscopic Adjustable Gastric Banding Presenter: Adrian Brown, Co-authors: Wendy Todd, Rishi Singhal, and Paul Super Upper GI and Minimally invasive unit, Heart of England NHS Foundation Trust, Birmingham, UK Background A multidisciplinary team approach following bariatric surgery is essential for effective weight loss. Follow up protocols vary for bariatric surgery patients. With long-term follow-up, the number of patients per surgeon increases exponentially. We evaluated the role of a dietetic-led approach with no surgeon follow up visits. Weight loss results in this program have been evaluated at 12 months. Methods A retrospective review of the database of 28 private bariatric patients underwent Laparoscopic Adjustable gastric band (LAGB) between September 2010 and March 2012. Patients completed a 12 month dietetic-led program. A standardised protocol of one contact on ward prior to surgery and six postoperative appointments were offered with no surgical appointments. Each patient was given comprehensive written information and visits focussed on behaviour change while only having between two to three radiological band adjustments depending on band size. Results 28 patients (3 males and 25 females) commenced the follow up protocol with 20 completing for a period of 12 months. The mean appointments per patient were 6.2. The mean preoperative weight and BMI was 109.0±17.5 kg and 41.6±5.6 kg/m2 and at 12 months mean weight and BMI was 86.3±18.4 kg and 33.3±.6 kg/m2. The overall mean excess percentage BMI loss at 12 months was 56±26.9 %. Conclusions A follow up program led by a specialist dietitian and minimal band adjustments is an effective way to manage patients after LAGB and produce good weight loss outcomes. There is clearly no requirement for surgeon follow up to produce effective outcome. P096 Biliopancreatic Diversion (BPD/DS) Durable and Effective Bariatric Procedure with Manageable Morbidity Presenter: Upendra Marreddygari Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Institution: Homerton University Hospital NHS foundation Trust

Presenter: Upendra Marreddygari Co-authors: Kesava Reddy Mannur Adam Goralczyk Kalpana Devalia Homerton University Hospital NHS foundation Trust, United Kingdom We present six cases of Gastro-gastric fistula (GGF) and detail the management algorithm, including endoscopic, and laparoscopic interventions. Data of 1300 patients undergoing LYGBP consecutively from Jan 2005 to January 2011 from the prospectively maintained database was analysed for development of GGF. Patients who developed GGF were compared with those who did not using Student’s t-test. Six patients (.46 %) were diagnosed with GGF. They presented with nausea, vomiting, abdominal pain, bloating and weight regain. CT scan detected GGF which were confirmed by endoscopy. The interval between initial LRYGBP and GGF diagnosis was 14 days to 9.2 months. Patients who developed GGF compared with those who did not, had similar age range (42.4 years vs. 41.2 years), operative times (72 minutes vs. 68 minutes) and preoperative

Introduction Biliopancreatic diversion with duodenal switch(BPD/DS) is one of the most effective procedures for hyperobese(>60BMI) patients. A retrospective case review of 71 patients undergoing DS between 2005 to 2011 after LSG was undertaken. Methods Mean follow up was 28.8±21.4 months (1–5 yrs). Age was 48± 6.3 years (range 26-64). The interval between the 2 procedures was 22 ±7.8 months(9-40). At LSG, the median weight and BMI was 181±42.36 kg (125-366) and 65.57 kg/m(2)(48-116.8 ). At LBPD/DS, the mean weight and BMI, was 146.9 ±29.45 kg(105-256 kg ), 51.39±8.6 kg/m(2 (38.06-81.94). Comorbidities include Diabetes in 51.6 %, hypertension in 68 %,OSA in 52 % and hyperlipdemia in 74 %. Results The mean operative time for DS was 143±35.6 minutes(125-205). One person died, 2 had bowel perforations, 1 bleed. The mean hospital stay for LSG and DS was 3.2±1.4 days(2-10) & 3.03±1.6( 2-10) At follow-up, mean weight, BMI, and percentage of excess weight loss(EWL) (compared with the pre-LSG weight) was 112.4±30.24 kg(72-200), 39.29 ±9.7 kg/m (2)(27.42-63.84), and 58.9 %±20.9 %(32.04-99.15). Further analysis revealed

1394 EWL was 38 % at 9 months(n071), 58,4 % at 15 months(n071) & 83.34±2.4 at 31 months(n 030). Resolution of DM, Hypertension and sleep apnoea occurred in 89.3 %, 64 % and 96 %. Lengthening of common channel was undertaken for problematic diarrhoea. Nutritional deficiencies (vitB12, A, D & iron deficiency in 25 % 25 % & 54 % & 29.03 %) were easily manageable. Conclusion Our results indicate that 2 stage DS is a safe and underutilized bariatric procedure with very low morbidity and easily manageable nutritional deficiencies. P097 Techniques of Laparoscopic Sleeve Gastrectomy: How I do it VIDEO Presenter: Jendana Chanyaputhipong1, Co-authros : Ruben Poopalalingam2, Shanker Pasupathy1 1

Department of General Surgery, Singapore General Hospital, Singapore Department of Anesthesiology, Singapore General Hospital, Singapore

2

In our tertiary hospital, we have performed over 100 bariatric surgery cases. The commonest type of batriatric surgery performed is laparoscopic sleeve gastrectomy. The standardized perioperative and operative techniques, including theater setup, patient positioning, port placement, landmark identification, actual surgery performed, and tips and tricks of tissue handling and solutions to overcome common but potentially difficult situations, are presented. Mean operative time and surgical outcome are also presented. P098 Valproic Acid Dosage in the Post Bariatric Surgery Patient Presenter: S. Wolter1 Co-authors: A. Dupree1, N. Sauer2, J. Stenzig3, Y. Vahist1, J. Izbicki1 O. Mann1 1. Department of General-, Visceral- and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Germany 2. Department of Internal Medicine III, Section Endocrinology, University Medical CenterHamburgEppendorf, Germany 3. Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Medical treatment of the bariatric patient bears different difficulties. Especially drug absorption anddosage finding remain unclear after Roux-Y-Gastric Bypass. Only few studies and some case reportsinvestigated the impact of a functional shortened bowel and even lesser in the bariatric patient. Asdata on specific medication is limited, further studies are needed to determine the influence of bariatricsurgery on these drugs and the implication for medical treatment of the bariatric patient with comorbidities.We present a case of a 44 year old female with a BMI of 54 kg/m2 undergoing Laparoscopic RouxYGastricBypass (LRYGB). The patient has a history of epilepsy since adolescence. She reported ofmultiple seizures during previous hospital admission. The patient is on an anticonvulsive medicationwith 300 mg of valproic acid twice daily and benzodiazepines when required. Drug monitoring wascarried out 8 times a day preoperatively and on the third postoperative day to measurepharmacological absorption to determine the area under the curve. Valproatic acid is believd to affectthe neurotransmitter GABA and is widely used in the treatment of epilepsy. Drug monitoring especiallyin the initial phase of treatment is required because of the small therapeutical range. Absorption takesplace in the whole gastrointestinal tract and mainly in the jejunum. Our results showed a significantdecrease in serum levels (41,9 mg/l preoperatively vs. 31,6 mg/l postoperatively; p <0,05).We could show that valproic acid absorption after LRYGB is drastically reduced and suggest that thisdrug should be closely monitored in patients undergoing bariatric surgery. P099 Laparoscopic Reversal of Gastric Bypass to the Original Gastrointestinal Anatomy: Best Clinical Option in Select Cases?

OBES SURG (2012) 22:1315–1419 patients develop symptoms and side effects that significantly affect their quality of life. These patients are best treated by reversal of gastric bypass to the original gastrointestinal anatomy (RGBS). We describe our experience and indications. Methods A prospectively maintained database of 1321 patients between November 2004 and April 2011 was retrospectively reviewed. Fourpatients underwent laparoscopic RGBS to the original anatomy. The indication for reversal were, 1) exaggerated dumping syndrome leading to an inability to perform work as a firefighter, 2) a non healing marginal ulcer with recurrent symptoms including perforation in a young female in spite of surgical revision of the GJ , 3) post operative food intolerance and 4) short bowel syndrome following small intestine resection due to internal hernia. The procedure involved dismantling of the gastrojejunostomy and the jejunojejunostomy, reanastamosis of gastric pouch to the gastric remnant and anastamosis between the roux limb and the pancreaticobiliary limb. Results There were three females and one male (29 - 52 years). The RGBS was performed between 3 and 53 months after the original GBP. The length of stay was 2-18 days. At 12 month all four patients have returned to their pre GBP status, having returned to work and being productive members of the society. Conclusions Laparoscopic RGBS is feasible and safe and can result in pre surgery level of functionality and resolution of symptoms. P100 Acquistion of Advanced Laparoscopic Surgical Skills for Surgical Residents, A Competency-Based Simulation Training Model for Bariatric Surgery Presenter: Erwin Buckel MD Co-authors: Julian Varas M.D., Fabrizio Moisan M.D., Nicola´s Jarufe M.D., Felipe Quezada M.D., Ricardo Mejias M.D., Camilo Boza M.D. Institution:Pontificia Universidad Cato´lica de Chile Introduction Currently, there are no valid competency based training programs to develop skills necessary to perform advanced laparoscopic procedures for bariatric surgery. Aim: To present an advanced simulation training program for bariatric surgery. Methods and Procedures Six residents from our gastrointestinal surgery program were assessed throughout two training courses; A 12-session laparoscopic stapled jejuno-jejunostomy(JJO) followed by a 13-session totallymanual gastro-jejunostomy(GJO). Training was performed in two validated bench models with ex-vivo bovine bowel and hand-sewn bovine-gastric pouch. Procedures were recorded on video and analyzed by an expert using validated global(GRS) and specific(SRS) rating scales. A motion-tracking device(ICSAD) was utilized in each assessment. Trainees’ results were compared to those of expert bariatric surgeons for both models. Mann-Whitney and Kruskal-Wallis tests were used to compare nonparametrical variables within each group. Wilcoxon test was used for pre-post assessment. P value was considered statistically significant when <0,05. Results Learning curves were achieved. For the JJO model trainees improved significantly their GRS and SRS scores [12.8(11-18) vs. 23(22-25);p<0.05] and [10.6(8-14) vs. 18.4(1819);p < 0.05] respectively and significantly reduced their surgical times [17.8(14.7-22)minutes vs. 9(8-9.7);p<0.05]. Total path length(TPL) registered by ICSAD improved significantly [89(77-115)meters vs. 49(45-57); p< 0.05]. For the GJO model trainees improved significantly their GRS and SRS scores [15.4(13-18) vs. 22.8(22-24);p<0.05] and [15.8(12-18) vs. 27(25-28);p<0.05] respectively, significantly reduced their surgical times [43.6(42-47)minutes vs. 26.7(25-28);p < 0.05], and significantly reduced their TPL [205(196224)meters vs. 156(111-185);p<0.05]. Results obtained for GRS-SRS and TPL were comparable to those achieved by expert surgeons. Conclusions Trainees significantly improved their advanced laparoscopic skills to a level compared to expert surgeons in both bench models.

Presenter: Ajay Upadhyay Co-authors: Michael Hibbard, MD, Paul Suding, MD, Gregory Broderick-Villa, MD, Teresa Kim, MD

P101 Early Outcomes of Bariatric Surgery in A Multiethnic Asian Cohort

Alta Bates Summit Medical Center, United States of America

Presenter: Asim Shabbir, Co-authors: Hind Khalifa Al Majrafi, Zhou Huijun, Litang Chen, Lomanto Davide,so Bok Yan Jimmy

Background Laparoscopic gastric bypass surgery (GBS) in most patients leads to a successful outcome with an acceptable morbidity. However, some

National University Hospital, Singapore

OBES SURG (2012) 22:1315–1419 We report the outcomes of 74 patients who underwent either laparoscopic sleeve gastrectomy (n056) (LSG) or gastric bypass (n018) (LRYGB) for morbid obesity and co morbidities between Jan 2008 – March 2012 at our institution. Methods A prospective database of consecutive bariatric patients was reviewed for outcomes. Results The mean age of our patients is 41 years (18-63) with 41(55 %) women & 33(45 %) men. The cohort consists of Chinese 29(39 %), Malay 23(31 %), Indian 21(29 %) and other ethnicities1 (1 %) patients respectively. The pre-operative BMI for the LSG was 42.79 kg/m2 (32.969) and for LRYGB 42.62 kg/m2 (33.6-49.5). The total operating time are 123 & 209 minutes for LSG & LRYGB.Both groups had <10mls blood loss. The only patient with a complication was in LRYGB with bleeding requiring surgical hemostasis. The median LOS was 3.5 & 5.5 days for LSG and LRYGB. The %EWL is 43.99 %(0.51-99.48) in LSG at 7 months(0.27-30.03) compared to LRYGB 45.38 %(1.8-97.34) at 10 months(0.5-32). Early remission of diabetes is seen in 40 % in sleeve group Vs 88.9 % in the LRYGB group, remaining 60 % in LSG had improved or stable T2DM. Other comorbidities like hypertension, obstructive sleep apnea and joint pains also showed early trends towards improvement. Conclusion Our results show that through a multidisciplinary team effort bariatric surgery can be performed safely with effective weight loss in the early post operative period in a multiethnic Asian population. Early remission of diabetes is akin to other larger studies. P102 Routine Use of Upper Gi Endoscopy in Sleeve Gastrectomy Presenter: Dr Ravindra Vats Co-authors: Dr V P Bhalla and Dr Deep Goel, Dr Chetan Merchant, Dr S Majumdar, Dr S Khanna Department of Gastrointestinal, Bariatric and Minimal Access SurgeryBLK Super Speciality Hospital, New Delhi. India Aim Laparoscopic sleeve gastrectomy has become a viable option for treatment of morbid obesity. Sleeve is constructed by firing the stapler 5 cm proximal to the pylorus. In most of the centers bariatric surgeons fire the stapler over a bougie ranging from 32 to 40 Fr gauge. Average weight loss reported in most of the series published is 50-55 % of extra body weight. In this article besides other advantages of using upper GI endoscope we compared the weight loss when sleeve is created by firing stapler over a endoscope which is 28 Fr gauge. Material and Methods In our series of 276 cases of laparoscopic sleeve gastrectomy we have used bougie in 15 cases and upper GI endoscope in 261 cases for the construction of sleeve. Per-operatively leak from the staple line was tested by insufflating air from gastroscope and also by injecting methylene blue. Inner lining of staple line was examined for any intraluminal bleed. In one patient injury was noted in the lower part of esophagus while doing leak test through bougie. Result Creation of sleeve over upper GI endoscope (28 Fr ) is safe and gives us opportunity to examine intraluminal suture line. Average weight loss ranges from 70-78 % of the extra body weight when endoscope of 28 french is used to create sleeve with 3 to 5 year of follow up. P103 Port Infection – A Hidden and Avoidable Cause of Port Rotation Presenter: Rishi Singhal Co-author: Josephine Neale, Paul Super Upper GI and Minimally invasive unit, Heart of England NHS Foundation Trust, Birmingham, UK Background Laparoscopic adjustable gastric (LAGB) is one of the most prevalent procedures in the surgical treatment of obesity but uptake is perhaps limited due to complications requiring re-operation. Many of these complications are port related. We thus examined our series for the cause and etiology of port rotation. Methods Between April 2003 and December 2011, more than 5000 patients underwent LAGB at our unit. Data collection included demographics, body mass index and weight both preoperatively and every year successively as well as all re-operations. All cases included port suture fixation to the fascia with at least three non-absorbable sutures.

1395 Results The median follow-up was 4 years. To date 18 patients have been reoperated for port rotation. All patients were swabbed for microbiology at the time of reoperation. In 8 of the cases the fixation sutures had cut out of the fascia and were still attached to the port. 7 of these patients had positive bacteriology for infection. The remainder were found to have had sutures which were not attached to the port and presumed to have failed due to operative technique. Conclusion Port placement, although a simple part of the procedure can be a cause for much morbidity. Elimination of any twist of the tubing at the time of port anchorage, and failure to adequately suture to the fascia is no doubt a major and obvious cause of port rotation. However, port infection or subclinical colonisation of the port is probably an important and perhaps avoidable cause of port rotation. P104 Factors Predictive of Unsuccessful Discharge Within 23 Hours of Laparoscopic Roux-en-Y Gastric Bypass Presenter: Menon A, Co-authors: Al-Rashedy M, Thawdar P, Akhtar K, Senapati PS, Ammori BJ Department of Obesity and Metabolic Surgery, Salford Royal Hospital, Salford, United Kingdom Introduction Although several studies have shown ambulatory surgery (23 hour stay) to be achievable in the large majority of patients undergoing laparoscopic adjustable gastric banding (LAGB), there is less evidence demonstrating this following laparoscopic Roux-en-Y gastric bypass (LRYGB). This study aims to identify factors associated with failure of ambulatory LRYGB. Methods A retrospective analysis was performed on patients undergoing LRYGB between October 2008 and January 2012 at our institution. A multivariate logistic regression model was constructed to identify factors predicting success or failure of discharge within 23-hours of surgery. Patient demographic factors, preoperative body mass index, medical comorbidities, and operating time were used as independent covariates. Results: are presented as odds ratios (OR) and 95 % confidence intervals (CI). Results Some 468 patients underwent LRYGB during the study period. The 23-hour discharge rate was 24 %, and this did not significantly change during the first three years of the analysis period. Multivariate analysis identified type-2 diabetes mellitus (OR 2.15, 95 % [CI] 1.233.76, p 00.007) and polycystic ovary syndrome (PCOS) (OR 7.87, 95 % [CI] 1.01-61.20, p00.05) as independent predictors of unsuccessful discharge within 23 hours of surgery. Discussion Identification of factors predicting unsuccessful ambulatory stay following LRYGB may allow more efficient resource allocation and targeted measures to improve 23-hour discharge rates. The longer postoperative stay in type-2 diabetics may reflect altered postoperative glycaemic control.Adoption of standardised post-operative diabetic control regimens may help facilitate earlier discharge in these patients. P105 Weight Regain after Sleeve Gastrectomy: Restrictive Revisionary Options. Presenter: Ku¨sters S, Co-authors: Gruenneberger J, Karcz WK University of Freiburg, Germany Introduction Sleeve gastrectomy was initially performed as the first step of a two-step concept in patients planned for BPD-DS or gastric bypass. Those patients mostly were severely obese (BMI>50 kg/m2). However, since it was seen that not all of the patients need the second step, sleeve gastrectomy was more and more used as a sole bariatric operation, also in patients with a BMI< 50 kg/m2. On the other hand we see a substantial proportion of patients with insufficient weight loss or slight weight regain after sleeve gastrectomy, but contraindications for malabsorptive surgery (medication, compliance, diarrhea). For those patients we propose three restrictive revisionary operations: 1) banded sleeve gastrectomy, re-sleeve-gastrectomy and gastric sleeve plication Patients and Methods Patients after sleeve gastrectomy in our centre were included. Need for revisionary surgery due to insufficient weight loss or weight regain and type of reoperation were evaluated

1396 Results Patients with a BMI>50 received a malabsorptive reoperation significantly more often (47 %) than patients with an initial BMI>50 (16 %). However 8 patients were treated with a re-sleeve –gastrectomy, a revisionary banding of the sleeve or a gastric placation according to their sleeve volume. Contraindications for malabsorptive surgery were medication, and no complains. There were no postoperative complications in this group: Conclusion Banding of the sleeve, gastric placation and re-sleeve-gastrectomy (by Sleeve volume over 500 ml) are useful and practicable revisionary options in case of weight regain and contraindication for malabsorption. P106 Laparoscopic Gastric Plication of the Greater Curve in Patients with Obesity Class 2 and Contraindication of Pharmacologic Treatment Presenter: C. Santander (**) Co-authors: G. Astete (*), G. Arzola (**), R. Corte´s (**), V. Contreras (**), P. Carbonell (**), RGutierrez (*), P. Reyes (*), J. Smith (+), AM. Parra (+)Team of Obesity Treatment from Concepcio´n (ETO Concepcio´n), Chile(*)0Universidad Cato´lica de la Santı´sima Concepcio´n, Chile(**)0Guillermo Grant Benavente Hospital Concepcio´n, Chile(+)0Nutritionist ETO Concepcio´n Hospital Clinico Regional de Concepcion, Chile Introduction pharmacologic treatment in obesity class 2 sometimes presents cases of intoleranceand contraindications which leaves a group of patients without effective treatment. Laparoscopicgastric plication of the greater curvature has been performed in severe and morbid obesity. Wepresent our experience with this technique in patients with obesity class 2 and associatedcomorbidities. Methods Inclusion criteria: body mass index (BMI) between 28-34 Kg/m and one or more of thefollowing: immediate family history of obesity or related comorbidities, unsuccessful adequatemedical treatment, fatty liver, insulin resistance, dyslipidemia, metabolic syndrome. Surgicaltechnique performed according to reference publications consisting in a three layer plication of the greater curve and liver biopsy. Results 10 patients (all women), mean age: 37,4 years (range:18-54), mean BMI: 29,6 Kg/m. Comorbidities: insulin resistance: 90 %, fatty liver: 60 %, dyslipidemia: 40 %, metformin use: 90 %,metformin intolerance: 100 %. Previous use of sibutramin: 100 %, use of intragastric balloon in 1case. Follow up 8 to 16 months. Decrease of BMI in 100 %, with a mean postoperative BMI: 24,6Kg/m and mean loss of weight : 12,8 Kg. Pathology reports of liver steatosis in 100 % of cases. Nopostoperative mortality nor morbidity. Conclusion this restrictive technique can be considered as another alternative in obese patientswith contraindication to pharmacologic treatment, considering its very low rate of postoperativecomplications. P107 Thrombembolic Complications After Bariatric Surgery: Incidence and Prophylaxis

OBES SURG (2012) 22:1315–1419 guideline providing exact inforation conserning dosage and duration of thrombophrophylaxis after bariatric surgery. Conclusion Although beeing a relatively rare event, thrombembolic complications are severe, sometimes fatal. With a weight adjusted dosage of nadroparin, the thrombembolic complication rate was< 0,1 %. However, detailed guidelines concerning phrophylaxis after bariatric surgery are urgently needed. P108 Quality of Life Analysis After Laparoscopic Gastric Bypass in Morbidly Obese Adults in Chilean Population Presenter: V. Torres (*), Co-authors: M. Rı´os (*), C. Santander (***), G. Astete (**), G. Arzola (***), R. Corte´s (***), V.Contreras (***), P. Carbonell (***), R. Gutierrez (**), P. Reyes (**), J. Smith (+), AM. Parra (+) Team of Obesity Treatment from Concepcio´n (ETO Concepcio´n), Chile(*) Universidad del Desarrollo Concepcio´n, Chile(**)0Universidad Cato´lica de la Santı´sima Concepcio´n, Chile(**)0Guillermo Grant Benavente Hospital Concepcio´n, Chile(+)0Nutritionist ETO Concepcio´n Introduction One of the goals of bariatric surgery procedures is to improve quality of life (QoL) inmorbidly obese patients. We evaluated QoL after laparoscopic Roux-en-Y gastric bypass(LRYGBP) using two different instruments in chilean population. Methods A cross-sectional study was conducted on 52 morbidly obese adults between 1 and 3 years after LRYGBP using two instruments to measure QL: the Bariatric Analysis of ReportingOutcome System (BAROS) and the SF-36. The analysis was performed according to gender. Results 52 adults, all intervened by the same surgical team; 40 females (77 %) and 12 males.BAROS score by gender (F/M) 37,5/58,3 % excellent, 27,5/ 16,6 % very good, 27,5/16,6 % good,7,5/8 % fair and 0/0 % failure, without significant differences according to gender. Global scores inSF-36 showed 100 % without limitation, 100 % without problems at work, 100 % always had vitality,without differences according to gender. Women tended to accept the surgical procedure betterthan men. There were significative and substantial improvements in every aspect evaluated byboth measure instruments after LRYGBP. Conclusion LRYGB improves QoL in morbidly obese adults and its evaluation should be used asa measure of the success of this procedure. P109 Laparoscopic Conversion of a Failed Gastric Bypass to a Banded Micro-Pouch Roux-en-y Gastric Bypass. Technical Aspects Presenter: Khaled Gawdat Co-authors: Ahmed Osman, Basem Elshayeb Ain-Shams school of Medicine, Egypt

Presenter: Kuesters S, Co-authors: Gueneberger J, Karcz WK. University of Freiburg, Germany Introduction Complication rate after bariatric surgery is usually low with a <5 % rate of severe complications. Thrombenbolic complications include deep vein thrombosis which can be asymptomatic and pulmonary embolism which can be fatal for the patient. Since obesity is a risc factor for thrombembolic complications, the prophylaxis of those is of extreme importance for bariatric and metabolic surgery. Patients and Methods Prophylaxis and incidence of thrombembolic complications in the Centre for Obesity and Metabolic Surgery at the University of Freiburg, Germany was retrospectively evaluated. A literature search was performed to obtain data about incidence of thrombembolic complications after bariatric surgery and evelaute existing data concerning dosage of prophylaxis in obese patients. Results In the Centre for Obesity and Metabolic Surgery at the University of Freiburg, Germany, >1000 bariatric procedures were performed between 2007 and 2011. Patients were treated with a weight adjusted dosage of nadroparin until hospital discharge. There was only one postoperative thrombembolic complication. Literature search revealed a thrombembolic complication rate of <1 %, there is no strong evidence that weight adjusted dosage is superiour. There is also no

Background Weight recidivism or weight loss failure is not infrequent in the long term after standard gastric bypass. Pouch and stoma dilatation accounts for increasing solid food consumption and explains the failure in some of the cases. Revision of failed gastric bypass procedures is usually a difficult task and results are not always satisfactory. Banded micro-pouch Roux-en-Y gastric bypass is a restrictive form of gastric bypass that combines a small pouch size with external pouch restriction and is used both as a primary and as a revisional bariatric procedure. Aim of work a video presentation showing the technical aspects of laparoscopic revision of open and laparoscopic gastric bypass procedures into a banded micro-pouch Roux-en Y gastric bypass. Materials and methods of 243 laparoscopic revisional bariatric procedures carried out in our series, 27 procedures were performed for revising failed gastric bypasses. Banded micro-pouch Roux-en-Y conversion was elected for patients that progressively consumed more solid food over time. Results: the video demonstrates the technical aspects and steps of the laparoscopic conversion to Banded micropouch Roux-en-Y gastric bypass after both open and laparoscopic gastric bypass. Conclusion laparoscopic bariatric intervention after failed gastric bypass is technically difficult but feasible procedure. Appropriate revisional procedure design is very important to prevent a second failure.

OBES SURG (2012) 22:1315–1419 P110 Laparoscopic Roux-en-Y Gastric Bypass with Resection of the Distal Remnant Stomach on a Morbidly Obese Patient with Type 2 DM Who Refused to Have A Gastric Remnant. Presenter: Jin-Jo Kim, MD Department of Surgery, Incheon St. Mary Hospital, The Catholic University of Korea, Incheon, Korea. Roux-en-Y gastric bypass (RYGBP) is the surgical treatment of choice to the morbidly obese patient with type 2 DM (T2DM) among other bariatric surgical procedures. However, cancer screening of the distal remnant stomach would be very difficult after RYGBP. This can be a very important health issue in an area where gastric cancer is highly prevalent, like Korea. Herein, the author reports a case of morbid obesity with T2DM which was successfully treated by laparoscopic RYGBP (LRYGBP) with resection of the distal remnant stomach (resectional LRYGBP). A 38-year old female patient visited our hospital with morbid obesity and T2DM which was refractory to medication. Her BMI was 40 (98 kg), the fasting blood sugar and HbA1c level were 208 mg/dL and 10.2 %. She heard from her family medicine doctor that he was about to change to insulin therapy. She needed LRYGBP for her DM control but she was worried about not being able to screen the remnant stomach. The author performed resectional LRYGBP. The whole operation took 220 min and the resection of the remnant stomach took only 23 min. The blood sugar level returned to normal from the second day after surgery without any medication. The patient discharged at 5 th postoperative day without any complication. During one and a half months of follow-up, she has lost 12 kg and her blood sugar level still remained normal without medication. P111 Indian Obese Women at Greater Risk of Depression Presenter :Saba Jivani Co-authors: Dr Aparna Govil, Dr Aditi, Carlyne Remedios Miloni Shah and Dr Muffazal Lakdawala Centre for Obesity and Diabetes Surgery, India Background Depression is commonly associated with obesity and both have major public health implications. Low mood, aloof behavior negative thoughts are common occurrence in obese individuals. Hence, it seems imperative to study how it can be treated. Aim Our study aimed to determine an association between depression and obese women. Methods A prospective study done on 200 morbidly obese who walked in for a pre operative consultation at the centre for obesity and diabetes surgery Mumbai. The assessment for depression was done using the Becks Depression Inventory II. Study group consisted of 100 males and 100 females. The mean age was 36.3 for males and 32.23 for females. Mean BMI was 45.70 for males and 38.93 for females. Results For 200 subjects the mean pre operative BDI score was 8.00 for males and 29.54 for female. Of all the percentage among male population 98 % were in mild and 2 % in moderate depression while none were suffering from severe depression. Comparatively among the females group 4 % were in mild, 21 % in moderate and 75 % were in severe depression. As evaluated the increasing range was seen in female patients. Conclusion Our study reveals a very high prevalence of depression amongst obese Indian women. Risk of moderate to severe depression was also significantly higher in obese Indian women as compared to men. Keywords: Obesity, Depression, Males, Females

1397 study examined the meaning in life in morbidly obese Indian female patients seeking treatment for bariatric surgery. Aim The study assessed the Purpose in life in morbidly obese female patients before and after a year of bariatric surgery. Methods A prospective study done on 100 morbidly obese female who walked in for a pre-operative consultation at the centre for obesity and diabetes surgery (CODS) Mumbai. The assessment for Purpose in Life (PIL) was done with the Purpose in Life scale by (Crumbaugh&Maholick, 1964). The mean age was 34 years and mean BMI was 45.79 kg/m2. Results In the study group mean PIL before surgery was 46.26±3.71 which was low. Low scores are indicative of experiencing an “existential void,” a lack of meaning or purpose in life. With sustained weight loss after a year mean PIL was 89.2±9.92 suggestive of high scores thus indicating of a greater purpose in life as compared to pre-operative status. Conclusion Along with resolution of other co morbidities like Diabetes, Hypothyroidism, Hypertension etc, there are a number of psychological disturbances seen in the patients like Depression, Stress, Body Image Dissatisfaction, Eating Disorders etc. Our study reveals, female patients show a greater purpose in life after a year of bariatric surgery. Key words: Obesity, PIL, Female P113 Body Image and Depression Among Indian females Presenter: Saba Jivani Co-authors: Dr Aparna Govil, Dr Aditi, Carlyne Remedios Miloni Shah and Dr Muffazal Lakdawala Centre for Obesity and Diabetes Surgery, India Background Depression and body image dissatisfaction are common in India obese, especially in female population. We examined the presence of depression and Body Image disturbance in women before and after a year of Bariatric Surgery. Methods A prospective study was done on 100 obese female patients at the centre for obesity and diabetes surgery Mumbai. Patients completed the Beck Depression Inventory II (BDI) for depressive symptoms and Body-Esteem Scale Questionnaire (BES) for body-image. The assessment was carried out before and after one year of bariatric surgery. The mean age was 32.23 and mean BMI was 38.93 kg/m2 . The Becks Depression Inventory II (BDI) scoring was classified as mild, moderate and severe. The Body Esteem Scale consisted of 3 factors: (1) Sexual Attractiveness (SA), (2) Weight Concern (WC) and (3) Physical Condition (PC). Results The mean preoperative BDI score was 29.54±6.22 in the study group which is very high and indicates an increase symptom of depression in morbidly obese female patients. BES preoperative score for PC was 13.33 ± 2.99, SA was 13.02 ±3.09, and WC was 11.45 ± 2.82. Lower scores are indicative of poor body image. Weight loss was associated with a significant and sustained fall in BDI score and an increase in the BES scores. Mean ±SD BDI was 8.15±2.48, greater fall in the BDI score was seen after 1 year. As for BES, PC was 57.79 ±5.71, SA was 50.63 ±5.99, and WC was 61.49 ± 4.14. The increasing body image score showed an improvement in the body image. Conclusion Obese women are at a risk of depression and negative body image. Decrease symptoms of depression and a boost to body imagewas noticed after a year of bariatric surgery. Key words: Obesity, Depression, BES, Female P114 Vitamin D Deficiency and Secondary Hyper Parathyroidism pre and post Bariatric Surgery Presenter: V. Kejriwal Co-authors: C. Remedios, M. Shah, A. B. Govil, M. Lakdawala

P112 Purpose in Life Before and After Bariatric Surgery Centre for Obesity and Diabetes Surgery and Saifee Hospital, Mumbai, India Presenter: Saba Jivani Co-authors: Dr Aparna Govil, Dr Aditi, Carlyne Remedios Miloni Shah and Dr Muffazal Lakdawala Centre for Obesity and Diabetes Surgery, India Background Meaning in life is referred to making sense, order and coherence out of one’s existence and having a purpose and striving towards a goal. The

Aim Obese patients have vitamin D deficiency and secondary hyperparathyroidism. The aim of this study was 1)to investigate prevalence of Vitamin D deficiency and Secondary Hyperparathyroidism 2)compare Vitamin D and PTH levels pre and post Bariatric surgery 3)determine correlation between Secondary Hyperparathyroidism, Vitamin D and BMI, Serum calcium, Ionic Calcium, Serum Phosphorous and Alkaline Phosphatase.

1398 Methods A retrospective analysis was conducted in 204 obese patients at CODS from Jan 2009 to Dec 2011 who underwent Bariatric surgery. Male to female ratio was 1:1.5, median age was 40 years (range 10 to 64 years), median BMI was 45.67 (range 28.3-87.13 kg/m2). 174 patients (87 %) underwent Sleeve Gastrectomy and 26 patients (13 %) underwent Gastric bypass surgery. Parathyroid hormone, 25-Hydroxy Vitamin D, Serum calcium, Ionic calcium, Serum Phosphorous, Alkaline phosphatase and BMI of these patients was evaluated before and after surgery. Secondary Hyperparathyroidism was defined as PTH 65 pg/ml, Vitamin D deficiency as 25-Hydroxy Vitamin D 30 ng/ml. Supplementation post surgery for Vitamin D was Intramuscular dose of Cholecalciferol 3,00,000 IU titrated as per deficiency. Calcium supplementation was Oral Calcium Citrate tablets 1000-1500 mg per day. Results 84.4 % of patients had Vitamin D deficiency pre-operatively as compared with 56.6 % 1-year post operative. Secondary Hyperparathyroidism in 43.84 % of the patients pre- surgery, decreased to 21.5 % post surgery. Pre and Postoperative Vitamin D levels were inversely correlated whereas PTH levels were positively correlated with Body mass index. Vitamin D deficiency and Secondary Hyperparathyroidism did not alter levels of Serum calcium, Ionic calcium, Serum Phosphorous and Alkaline phosphatase. Conclusion Our study shows a high prevalence of Vitamin D deficiency and Secondary Hyperparathyroidism pre surgery. Weight reduction through Bariatric Surgery along with calcium/Vitamin D supplementation, diet and exposure to sunlight decreased the prevalence of Secondary Hyperparathyroidism post surgery. P115 Consistent and Repeatable Results with an Ingestible Gastric Volume Reduction Device Presenter: Martinez A., MD; Co-authors: So M., MD; Miranda G., MD; San Miguel L., MD; Chavez C., MD; Ortiz A., MD Obesity Control Center, Tijuana, Mexico The Obalon Gastric Balloon is delivered in a capsule and is attached to a miniature, detachable catheter. Patients are directed to swallow the capsule with the proximal end of the catheter remaining outside of the mouth. Gastric positioning of the balloon is confirmed prior to inflation. Upon completion of the inflation, the catheter is manually detached and a single 6 gram, 250 cc gas filled balloon remains in the upper portion of the stomach. Additional balloons can be swallowed and inflated to increase total resident volume during the treatment period based on patient satiety and weight loss response. A total of 28 patients with a mean BMI 34.8 (range 27.3-49.3) were enrolled in three independent trials respectively lasting one, two and three months. Administration of all balloons took less than five minutes on average. Patients were monitored for tolerance to the balloon, complications and weight loss. Only basic nutritional information was provided. There were no unexpected or serious adverse events, the balloons were well tolerated and there were no requests for early removal.The Obalon Gastric Balloon produced consistent monthly weight loss in all three studies. Mean excess weight loss (EWL) at one month was 11.8 ± 9.7 %, 13.8 ± 7.4 % and 16.9 ± 22.7 % with one 250 cc balloon in each of the three studies. Mean EWL was 23.9 ± 16.4 % and 25.8 ± 31.5 % for the studies with two months of treatment. The treatment with a second balloon added in the second month was associated with greater weight loss as compared to the single balloon treatment. In the second study, five patients who received two balloons achieved a mean EWL of 35.9 % ± 36.9 (12.4100.4 %) at the end of two months. One subject lost 100 % of her excess weight at the end of two months.Patients in the final study had a mean EWL of 34.5 ± 16.9 % at the end of three months. All ten patients received an additional balloon during the second month of treatment and 2 patients received a third balloon in the final month.All balloons were easily removed via endoscopy using standard available endoscopic tools. The retrieval procedures were conducted under light conscious sedation and averaged less than 10 minutes per patient, including those with 3 balloons.Conclusion: The consistent data of the studies verified favorable tolerability and efficacy through progressive volume increases of up to three swallowable 250 cc gastric balloons. The corresponding study results confirma safe and repeatable method for producing statistically significant weight loss and encouragingpatient outcomes.

OBES SURG (2012) 22:1315–1419 P116 Screening H. Pylori Before Having Bariatric Surgery: It Is necessary? Presenter: Utanwutipong Warit MD Co-authors: Tepmalai Kanokkan MD, Thanavachirasin Komdej MD, Pungpapong Suppa-ut MD, Tharavej Chadin MD, Navicharern Patpong MD, Udomsawaengsup Suthep MD. Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand 10330 Backgroud Candidates for bariatric surgery are recommended to have an upper gastrointestinal screening. It effects the decision to choice the procedure. H.Pylori infection and eradication pre-operatively is one of major concerns but it is still controversial. For candidates with higher BMI tend to undergo laparoscopic sleeve gastrectomy that is still eligible for postoperative EGD in case of necessary, but the prevalence of H.Pylori contamination and its effect after sleeve gastrectomy is there is still lacking. We have conducted a study to define the benefit of routinely pre – operative EGD in our bariatric cases. Methods Candidates for bariatric surgery in Chulalongkorn Bariatric Clinic were undergone pre-operative upper gastrointestinal screening. Patient’s demographic data, BMI, upper gastro-intestinal symptoms, endoscopic findings and CLO tests were collected and analyzed. Results From August 2011 to March 2012, there were 56 morbidly obese patients underwent pre-operative EGD. Twenty-four of these patients (42.9 %) were positive for H.Pylori. All of them were obtaining H.Pylori eradication. Higher BMI group (60) and Moderate obesity group (4559.9) had the same H.Pylori positive rate of 46.7 %. For the lower BMI group (35-44.9) had lower rate of H.Pylori infection of 27.3 %. Hiatal hernia, esophagitis, ulcers and gastritis were found 5.4 %, 10.7 %, 7.1 % and 59 % respectively. Conclusion High BMI and Super morbidly obesity patients have a high incidence of H.Pylori infection, pre-operative screening and treatment still necessary in H.Pylori endemic area to prevent post operative complications related to H.Pylori. Lower BMI group had lower incidence of H.Pylori infection but because of the difficulty in evaluating post Rouxen-Y Gastric Bypass cases, H.Pylori screening is still recommended. Long term follow up after bariatric procedure is needed to define the effect of H.Pylori contamination and eradication in this specific group of patients. P117 Use of Food Record As A Self-Knowledge Promoter in Obese Patientseligible to Bariatric Surgery Presenter: CUBAS R, e, Co-authors: Arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Clı´nica Dr. Se´rgio Arruda, Brazil Introduction This study aimed to analyze the effectiveness of a program of self-knowledge as amodifier of eating behavior and subsequent weight loss in patients eligible for bariatric surgery. Methods Participants were 202 obese within two years, members of a Psychological PreparationProgram for Bariatric Surgery in a private clinic. The monitoring consisted of five weekly sessions withtopics addressed as: self-control, discipline, anxiety, eating habits, postsurgical, and especiallytechniques of self-knowledge that facilitate behavior change process. Instruments: Food Record,delivered to participants to fill out daily throughout the monitoring period, with data: time and place ofmeals, chewing time, social situation and feelings involved; Observation of behavior; and Self-reportin sessions. Results Patients demonstrated improvement in adherence to nutritional guidelines, withprogress in the times of mastication and greater discipline with schedules, speaking with greaterknowledge of the role that food plays in their lives, wish impose to the food a less emotional function,and greater selfcontrol in relation to the desire to eat. Conclusions The Food Record proved to be auseful tool to the development of eating behaviors more aware and appropriate of patients inpsychological preparation for bariatric surgery, since it allows the patients to be alert of their processand constantly reminded of their choices for change. Together with the Monitoring Group, the FoodRecord has allowed an effective and lasting change in eating behaviors and beliefs of patients,promoting satisfactory

OBES SURG (2012) 22:1315–1419 adherence and coping strategies, ensuring a higher probability of success aftersurgery. P118 Long Term Changes in Pre-Operatory Preparation And IntraOperatory Parameters For Roux-en-y Gastric Bypass – 6 Years of Practice Presenter: CUBAS R, e Co-authors:arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Institution:Clı´nica Dr. Se´rgio Arruda Introduction Adequate pre-operatory preparation for Roux-en-Y gastric bypass depends on multiple factors, including amount of acquired experience; it is also well known that a high volume of surgical procedures is a significant variable in bariatric surgery. Materials and Methods We analyzed medical records from the period of January 2004 to May 2011 of 779 patients. The same professionals performed all gastric bypasses. The following data were obtained for the whole group and also compared annually: Number of Patients per year, (NP) Percentage of Women(PW) and means of: Age(MA), preoperatory BMI(MBMI), pre-operatory Time(MPOT), Operatory Time (MOT), Incision Length (MIL); Hours of Hospitalizations in Intensive Care Unit(MHHICU); Days of Hospitalization(MDH); Percentage of Incisional Hernia (PIH). Statistical analysis was performed by GraphPad Instat® and Microsoft Excel® tests. Results From 779 patients, 84.7 % were females. MA was 37.2±10.6 years, MBMI was 41.8±4.9 kg/m, MPOT was 6±8.2 h, MOT was 2,9±0.6 h, HHICU was 24,75±4.96 h and DH was 3,38±1.48. Comparisons for 2004, 2005, 2006, 2007, 2008, 2009 and 2010: MA: 36.07±9.57x37.85±10.69x36.03± 8.92x36.85 ± 11.53x37.89 ± 10.76x38.19 ± 10.9x36.92 ± 11.19 years(p 0 0 . 6 6 3 1 ) ; N P : 3 8 x 7 9 x 11 2 x 1 2 4 x 1 4 8 x 1 4 9 x 1 3 5 ; P W: 78.37x89.74x85.58x81.3x82.99x89.86x82.08 %; MBMI: 43.34±4.52x42.04± 4.04x42.44 ± 5.18x41.83 ± 4.58x41.88 ± 4.92x41.01 ± 5.58x41.49 ± 4.94 kg/ m(p 00.1279); MPOT: 4.97 ± 6x3.94 ± 2.92x4.28 ± 6.58x6.56 ± 9.14x6.6 ± 8.71x6.36±9.4x7.45±9.18 h(p00.0143); MOT: 3.39±0.45x3.14±0.43x3.29± 0.58x2.92±0.42x2.72±0.42x2.5±0.43x2.54±0.69 h (p <0.0001);IL: 11.86± 2x11.13 ± 1.62x10.59 ± 1.8x10.43 ± 1.78x10.02 ± 1.74x10.47 ± 2.08x10.47 ± 1.88 cm(p < 0.0001);MHHICU: 24x24x24.44 ± 4.59x25.19 ± 6.08x24.68 ± 4.01x24.96 ± 4.72x25.51 ± 6.69 h(p 00.314); MDH: 3.94 ± 0.41x3.45 ± 0.55x4.02±2x3.23±0.44x3.11±0.34x3.41±2.73x3.04±0.23 days(p<0.0001); PIH: 10.81x7.69x10.81x4.87x4.08x3.37x0.74. Conclusion It was observed a statistically significant decrease in values of days of hospitalization, incision length and intra-operatory time and also an increase in pre-operatory preparation time over the period analyzed. There wasn‘t any statistically significant difference for any of the others variables.

1399 2 years. The patients were submitted to the stimuli twice, once on April 2011 and on April 2012, the results were compared. The dosage of the hormones was performed by ELISA. Results There was significant increase (p00,042) in the GLP-1 serum levels in the late postoperative dosages, especially 1 hour after the glutamine and glucose stimuli. Also the in this period, the palm oil stimulus caused significant reduction of the PYY serum levels, glutamine had significant paper on rising PYY serum levels. Conclusion The early presentation of glucose and glutamine to the ileum seems to be responsible for rising GLP-1 and PYY levels, contributing to control type 2 diabetes, palm oil seemed to keep satiety. Further investigations with larger groups may contribute to elucidate these effects. P120 Long-Term Observation After Ileal Transposition in Zucker Rats Reveals Fading Effect on Glucose Tolerance Presenter: JM Grueneberger Co-authors: T Sawczyn, J Kosmowski, S Ku¨sters, UT Hopt, K Karcz Department of General and Visceral Surgery, Surgical Metabolic and Anastomosis Research Team SMART, Albert-Ludwigs-University, Freiburg, Germany 2: Department of Physiology in Zabrze, Medical University of Silesia, Katowice, Poland Introduction Ileal transposition (IT) surgery has recently shown promising results leading to early remission of Type 2 Diabetes stimulating incretin secretion. However, it is uncertain if adaption occurs, and IT proves to be effective also in long-term follow up. Methods Male Zucker rats were divided into 2 groups (n010) undergoing either distal 25 % ileal transposition or SHAM surgery. Animals were observed for 6 months. For glucose assessment OGTT was performed after 1, 3 and 6 months. GLP-1, GIP and Insulin concentrations were determined at equivalent time points. Results IT animals initially showed no improvement of glucose tolerance. At 3 months follow up, the IT group presented with a significant amelioration of glucose tolerance in contrast to SHAM animals (AUC: SHAM 3833±1952 vs. IT 1903±709 mg/dl min, p<0.05). Most important, this effect faded in longterm observation (AUC 6 months: SHAM 4179±1516 vs. IT 4509±1003 mg/dl min, p>0.05). Glucose stimulated GLP-1 secretion was elevated significantly in IT animals at all times (SHAM vs. IT: 1 month 3.55±2.16 vs. 63.56±57.78 p<0.01, 3 months 5.47±2.21 vs. 45.56±49.05 p<0.001, 6 months 7.47±4.02 vs. 18.05±11.51 pmol/l p<0.05), however also revealing a fading pattern with gradually declining levels in long-term follow up. Conclusion Ileal transposition leads to an amelioration of glucose control stimulating GLP-1 secretion. This effect however is only temporary, therefore revealing limits of this type of operation in long-term follow up. P121 Pre and Post-Operative Diet for Hyperuricemic Patients

P119 Effect of Administration of Palm Oil, Glutamine and Glucose in Serum Levels of GLP-1, PYY, Ghrelin and Insulin in Patients Submitted to Duodenal-Jejunal Exclusion with Ileal Interpositionwithout Gastrectomy: Late Results Presenter: Guilherme Azevedo Terra, Co-author: Ramos, M.c.; Crema, E.; Takeuti, T.d.; Ribeiro, V.m.; Rodrigues Junior, V.; Terra Junior, J.a.; Silva, L.m.; Silva, A.a. Federal University Of Triangulo Mineiro, Brazil Introduction The duodenal-jejunal exclusion, changes the transit of nutrients, and is responsible for preventing the secretion of signalizers that trigger insulinic resistance in type 2 diabetes. Early presentation of nutrients to the ileum anticipates the production of GLP-1 and PYY, improving insulin action, exert proliferative and anti-apoptotic effects in pancreatic beta cells. It is believed that this type of surgery also leads to reduction of serum ghrelin, consequently reduces hunger. OBJECTIVES: To compare the serum levels of GLP1, PYY, ghrelin and insulin in the pre and postoperative period of patients with type 2 diabetes, submitted to duodenal-jejunal exclusion with ileal interposition without gastrectomy. Methods 17 patients submitted to duodenal-jejunal exclusion with ileal interposition without gastrectomy in 2010, with type 2 diabetes were followed over

Authors: C. Remedios Co-authors: M.Shah, A.G. Bhasker, M.Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Background Patients that want to undergo bariatric surgery are required to go onto a pre – operative diet which could range from 1 to 3 weeks. A high protein low carbohydrate diet is recommended during this period. However in the Indian obese population the prevalence of hyperuricemia is strikingly high and a high protein diet will only further aggravate the condition. Aim The aim of this study was to provide an overview of the nutritional management of patients that presented for bariatric surgery and were suffering from hyperuricemia. Methods This is a retrospective observational study. 408 obese patients were included. Anthropometric parameters were recorded. Uric Acid levels were measured in all patients.Patients who presented with hyperuricemia were given a modified diet. The diet excluded all non- vegetarian sources of protein but included vegetarian protein including soya based protein drinks and dairy products, plenty of fluids and increased fibre intake. Results Hyperuricemia was defined as serum uric acid levels greater than 6 mg/dl. The overall prevalence of hyperuricemia was 44 %. Mean age was

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41.59 years (range 18 to 75 years) and mean Body Mass Index (BMI) 45.58 (range 28.1 -88.2 kg/m2)Males had a higher percentage of hyperuricemia as compared to females 50 % vs 21.7 %. Conclusion Hyperuricemia is a growing concern among the Indian obese population. Bariatric surgery is the only effective and long term solution for obesity and its associated co – morbidities. Weight loss will eventually result in decreased serum uric acid levels, however pre –operatively and immediately post operatively it is important that we do not aggravate the condition.

but there were more cases of altered exams in GB (11 vs 2). Finally there were neither altered values nor differences in calcium, PTH or folic acid. Conclusion Here we show that GB and SG can develop micronutrients deficiencies even in supplemented patients. Also, Gastric bypass seem to interfere more severely than SG in Iron metabolism and B 12 vitamin levels.

P122 Does Polycystic Ovary Syndrome Impair Weight Loss Amongst Morbidly Obese Women Undergoing Laparoscopic Gastric Bypass? A Case-Controlled Study

Presenter: Nicola´s Quezada Co-authors: Ricardo Funke, Alex Jones, Julia´n Herna´ndez, Gustavo Pe´rez, Fernando Crovari, Alex Escalona, Camilo Boza.

Presenter: Menon A Co-authors: , Knight BC, Senapati S, Akhtar K, Ammori BJ.

Digestive Surgery Department, Division of Surgery. Ponthifical Catholic University of Chile. Santiago, Chile.

Salford Royal Bariatric Unit, Salford Royal NHS Foundation Trust, Stott lane, Salford. UK

Introduction Revisional surgery is expected to occur in up to 20 % of patients. Here we show our initial experience in converting 12 patients from sleeve gastrectomy to gastric bypass by laparoscopy. Methods Retrospective analysis of our database. Eleven patients were identified and post operative data were extracted. The surgical technique consisted in section of the sleeve creating a gastric pouch of 2050 ml. Then Gastric Bypass was performed in a standard way as described by Higa, with an alimentary limb of 150 cm and a biliopancreatic limb of 30 cm. Gastrojejunal anastomosis was performed manually in all cases. Results Eleven patients were identified, 10 were converted because of weight regain and 1 because of sleeve complication (sleeve torsion with chronic vomiting and undernutrition).There were 9 female and mean age was 40± 5 years. Initial BMI was 35 ±4 Kg/m2. Mean operative time was 120±17 min. Hospitality stay was 2.5±0.4 days. There were neither complications nor mortality in this series. Conclusion Here we show that convertion from sleeve gastrectomy to gastric bypass by laparoscopy is feasible with no complication in this series. Long term follow up is required to know the results in terms of % of excess weight loss and comor bidities resolution.

Introduction Polycystic ovary syndrome (PCOS) has a prevalence of up to 30 % in morbidly obese premenstrual women, and is associated with poor excess weight loss (EWL) following gastric banding. However, its influence on EWL following laparoscopic gastric bypass (LGBY) remains unclear. Methods Patients with PCOS were identified from a prospectively maintained bariatric database over a 3-year period. Amongst patients who underwent LGBY, those with PCOS were matched with non-PCOS women (controls) on a 1:2 ratio with respect to age, body mass index (BMI), diabetes and time elapsed since surgery. Primary outcome measure was %EWL. The data shown represent median or percentage. Results There were no conversions to open surgery amongst 35 women with PCOS and 70 controls who underwent LGBY. The groups were comparable for age (37.5 vs. 37.7 years), preoperative BMI (48.7 vs. 47.2 kg/m2), and duration of follow up (23 vs. 25 months). There were no deaths during the follow up period. The %EWL amongst PCOS women was comparable to controls at 3 months (24 % vs. 28 %, p0 0.2), 6 months (46 % vs. 48 %, p00.9), 12 months (66 % vs. 67 %, p0 0.5), and 18 months (67 % vs. 73 %, p00.2). Conclusion Laparoscopic gastric bypass achieves satisfactory EWL in morbidly obese women with PCOS that is comparable to the EWL observed in women without PCOS. P123 Micronutrients EvolutionTwo Years After Bariatric Surgery. A Comparisson Between Laparoscopic Sleeve Gastrectomy vs Laparoscopic Gastric Bypass

P124 Sleeve Gastrectomy Conversion to Gastric Bypass by Laparoscopy. Initial Experience in 11 Cases

P125 Laparoscopic Sleeve Gastrectomy: One and Three Year Results: in Indian Population Presenter: Sandeep Aggarwal1, Co-authors: Akshat Wahal1, Santosh Anand 1, Mahesh C Misra1, Richa Jaiswal2,Lokesh Kashyap3Departments of Surgical Disciplines1, Dietitics2 and Anaesthesiology3 All India Institute of Medical Sciences, New Delhi, India

Presenter: Nicola´s Quezada Co-authors: Alex Jones, Carlo Marino, Julia´n Herna´ndez, Aron Kuroiwa, Alex Escalona, Gustavo Pe´ rez, Fernando Crovari, Ricardo Funke, Fernando Pimentel, Camilo Boza. Digestive Surgery Department, Division of Surgery. Ponthifical Cattholic University of Chile. Santiago, Chile Introduction It is well known that bariatric surgery is associated with micronutrients deficiencies over time, but there are scarce reports of this problem in literature. Aim To report the evolution of micronutrients deficiencies 2 years after surgery in a supplemented population comparing Sleeve Gastrectomy (SG) vs Gastric bypass (GB). Methods Retrospective analysis of our database. We analyzed %EWL and postoperative lab (CBC, Iron Profile, Calcium, Intact PTH, Folic Acid, B12 Vitamin) was measured at 6, 12 and 24 months post op. All patients were advised to take oral vitamin supplements and received B12 supplementation at least annually. Results 100 patients were identified in both groups. Mean Age was 42±10 in SG group and 41±11 in GB group. Initial BMI was 36 in both groups. %EWL was as follow (GB vs SG): : Month1: 29±13vs30±13, Month6: 80±25vs80± 20, Month12: 100±22vs90±30, Month24: 100±30vs100±18 (p>0.05). There were no differences in mean hematocrit evolution, but there were 24 anemia in GB and 20 in SG. Iron profile did not show differences, but GB group had 13 altered exams vs 7 in SG. There was no difference in B12 vitamin evolution,

Background The incidence of obesity is steadily rising and is a major public healthissue in India. Although the prevalence of obesity is low, the absolute number ofmorbidly obese patients is significant considering the huge population of India. Laparoscopic Sleeve Gastrectomy (LSG) is getting popular as a stand-alone surgicaloption for weight loss. At All India Institute of Medical Sciences (AIIMS), New Delhi,LSG has been used as the primary procedure for majority of the patients requiringbariatric surgery. We report on the 1 and 3 year results including complications of this procedure in Indian population. Methods 180 patients underwent LSG at All India Institute of Medical Sciences (AIIMS),New Delhi from January 2008 to March 2012. Indications for this procedure weremorbidly obese [body mass index (BMI)>40 kg/m2] or severely obese patients (BMI>35 kg/m2) with co-morbidities.Data was collected prospectively and included age,gender, initial body mass index (BMI) and co-morbidities. The sleeve was created over a 36-Fr gastric calibration tube with preservation of 5-cm of gastric antrum. The patients were followed up at 3- monthlyinterval for the first year and then yearly. Follow-up parameters included weight, BMI, excess weight loss (%EWL), impact of co-morbidities and complications. A quality of life analysis was done at the end of 1-year using BAROS questionnaire. Results This series comprised 119 females and 61 males with a mean age of 39.7 years (range, 17-65). Mean preoperative weight was 124 kg (range, 78235), and mean pre-operative BMI was 47.3 Kg/m2 (range, 32.5-81). 60 patients (33.3 %) were super-obese. The mean operating time was 90 minutes (range, 70-280). All cases were completed laparoscopically.The

OBES SURG (2012) 22:1315–1419 percentage excess weight loss at three, six and twelve months was 41.8 %, 57.5 % and 70 %. The %EWL at 2 years and 3 years was 85 %. The mean post operative BMI at 3, 6 and 12 months was 37.2, 35.1 and 32.3. The mean post-operative BMI in patients who have completed 3-years was 30.3 Kg/ m2 Three patients (1.6 %) had a leak from the staple line. All three patients were managed conservatively. Other postoperative complications included one case each of stricture, bleeding requiring re-exploration, deep vein thrombosis and delayed gastro-cutaneous fistula, all of which were managed appropriately. There was one peri-operative mortality. Two patients required conversion to gastric bypass after 1-year. Type II diabetes mellitus resolved in 77 % and improved in 23 % of the diabetics. Hypertension resolved in 75 % and improved in another 25 % of patients. Sleep apnoea resolved in all patients. All the patients showed a good to excellent result on evaluation by Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire. Conclusion LSG has been effective in providing significant weight loss with a relativelylow complication rate, in addition to a beneficial impact on comorbidities. It has yieldedexcellent short-term results. Although long-term results are necessary to determine thedurability of the procedure, LSG appears to be a safe and highly effective option for treatingthe morbidly obese in the Indian population.

1401 We present our experience of 10 patients with ventral hernias undergoing sleeve gastrectomy. The Ventral hernias of all patients were diagnosed preoperatively. Our policy is to leave alone small ventral hernias that are asymptomatic and go ahead with the sleeve gastrectomy. Patients who have lost sufficient weight can undergo abdominoplasty with simultaneous repair of their hernial defect later. We have managed 5 patients in this manner. In patients symptomatic of their hernias, small defects less than 5 cm were repaired by primary sutured repair in 4 patients. In 1 patients with symptomatic ventral hernia larger than 5 cm, a limited conversion over the hernia allowed for reduction of the contents and permitted us to complete the procedure. At a mean follow up of 1.2 years none of our patients had complications related to their ventral hernias. Our experience with biological meshes in such situations are limited. P128 Clinical Result 5 Years After Gastric Banding on 78 Patients Aged Over 55 Presenter: V.Frering, Co-authors: E.Fontaumard, Y.Matussiere Espace me´dico-chirurgical de la Sauvegarde Lyon

P126 Vertical Gastrectomy as a Definitive Procedure in Superobese Patients. Our Outcomes One Year After the Surgery Presenter: Dr. Torres JP. Co-authors: Dr. Max Torres, Dr. Torres A, Dr. Torres JP, Md. Andrade A. Centro de Cirugı´a Baria´trica y Metabo´lica “Gastromed”, Ecuador Introduction Superobesity, defined as a body mass index (BMI) of 50 or more, is usually associated withsignificant comorbidities that produce limitations to undergo bariatric procedures because of theirmetabolic conditions. Therefore treatment is performed in two times: first vertical gastrectomy,getting the patient to lose some weight and improving functional status for definitive surgery(gastric bypass or biliopancreatic derivation), reducing risks. ObjectiveThis studie evaluates the efficacy of gastrectomy as a definitive treatment for patients with superobesity. Materials and Methods This is a retrospective, observational, descriptive study of patients with superobesity (BMI>50), ina period of three years (2007-2010). Vertical gastrectomy was performed by three 12 mm ports andtwo 5 mm ports, using Endo-GIA to create a gastric tube on a gauge of 36 Fr catheter. Results Operative time, complication rate, hospital stay, BMI, excess weight loss and appetite wereevaluated in 46 patients, 76.7 % women, 23.21 % male, with a mean age of 30.5±10.5 years andmean preoperative BMI of 62.4 kg/ m2. The average operating time was 110 minutes, with ahospital stay of three days. The fluid intake was started 6 hours post-operation. All patients reporteda significant loss of appetite. The follow-up was made up to one year postoperatively. Conclusion Although the number of patients is relatively small, the results of this study indicate thatlaparoscopic gastrectomy is effective in reducing weight, and is an acceptable surgical option forpatients with superobesity, however more patients are needed to evaluate the long-term efficacy. P127 Ventral Hernia in Patients Undergoing Sleeve GastrectomyThe Technical Pearls Presenter: Tarun Mittal Co-authors: Ashish Dey Vinod K Malik Sir gangaram hospital, New Delhi, India It is not uncommon for patients undergoing bariatric surgery to have an associated ventral hernia. There is no consensus as to the proper method of dealing with such hernias while attempting bariatric procedures in these patients. Ventral hernias can be left alone or repaired simultaneously, but in these high risk groups the surgical procedures have to be tailored individually. It is important to have a comprehensive knowledge of techniques that gives the best results supported by published medical evidence. Through this presentation I would like to present our experience of dealing with ventral hernias in patients undergoing sleeve gastrectomy.

Background Gastric banding is one of the main treatment in morbid obesity. The aim of the study was to assess result on patients aged over 55 years old, five years after this surgery Methods In this retrospective study, 78 patients (12 men, 66 women) were operated from January 2005 to December 2006, withlaparoscopic adjustable gastric banding (Mid band ® ). Mean age was 58,6 years (range 55-69), mean weight was 111,6 kg (range 86 -157 ), and mean body mass index was 43,3 kg/m2 (range 35,1-62,4). Clinical results were collected during follow-up. Results Average comorbidity rate for each patient was two. There were no death. Five years after the surgery, mean excess weight loss is 60,5 %. Lost of follow-up is 14,1 % . Six patients had redo surgery mainly because of reflux. Out of them, 4 patients had gastric bypass for correction. Conclusion Gastric banding is safe and allows an effective weight loss in morbidly obese patients aged more than 55 years. The progressive weight loss by progressive adjustment can be interesting to prevent sarcopenia. P129 Laparoscopic Roux-en-Y Gastric Bypass in Age>60: Successful Weight Loss but a Different Trend in Morbidity Resolution? Presenter: A. Suppiah, Co-authors: A. Carlisle, M. Peter, R. Sarkar, A. Carlisle, V. Rao, P. Sedman, P. Jain Castle Hill Hospital, Cottingham, HU16 5JQ, United Kingdom Introduction Laparoscopic Roux-en-y Gastric Bypass (LGBY) improves obesity-related morbidity in younger population but these benefits have not been assessed in the elderly. We investigate morbidity resolution in the elderly (age>60) undergoing LGBY and which morbidities are addressed by LGBY in this population to aid patients selection. Materials and Methods Prospective database and telephone interview of patients age>60 years undergoing LGBY between 2006-2011 with minimum 1 year follow-up. Changes in obesity-related morbidities were classified as resolved, improved or no change. Results 46 patients (37 female, 9 male) median age 62.5 (60.1 – 71) underwent LGBY with 9 %(4/46) morbidity and no mortality. Median BMI decreased (46.7 vs. 31.3) with total and excess body weight loss of 33.4 % (8-55) and 67.4 % (36-113) at median follow-up 23.2 (12-55) months. Mean morbidity per-patient decreased from 3.33 to 1.94. Obesity-related morbidity resolved in 41 %, improved in 51 % and no change in 8 %. Resolution was highest with sleep apnoea (57 %), hypertension (55.6 %), dyslipidaemia (33.3 %) and diabetes (28.6 %). Improvement (without resolution) was highest in arthritis (91.7 %), diabetes (70.1 %), dyslipidaemia (66.7 %) and hypertension (44.4 %). The least affected was cardiovascular disease/medications (20 %). Conclusion LGBY in the elderly leads to substantial weight loss and morbidity reduction. The trend in morbidity improvement suggests overlap with agerelated influences. Greatest resolution occurred in sleep apnoea /hypertension but greatest improvement in arthritis. The least improved was cardiovascular disease. Further studies are required to elicit differences between benefits in the elderly and young population to aid future patient selection for LGBY in the elderly.

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P130 Iatrogenic Lower Esophageal Leak in Laparoscopic Sleeve Gastrectomy: Poster Presentation

P132 Can Ursodiol Prevent Formation of Gallstones Post Laparoscopic Sleevegastrectomy (LSG)?

Presenter: Prof. Kiran S Co-authors: Vindal A, Chander J

Presenter: Dr Aditi Agrawal Co-authors: Dr Aparna Govil Bhasker, Dr Muffazal Lakdawala

Maulana Azad Medical Collge, New Delhi, India

Center for Obesity and Diabetes Surgery, Mumbai, India

We present a case of 30 year old female with morbid obesity who under went laparoscopic sleeve gastrectomy and developed a leak due to accidental inflation of calibration tube (36 fr bougie used to size the sleeve) at the lower end of esophagus. The leak was detected on a routine upper gastrointestinal contrast study done on the first post-operative day. Patient was managed conservatively initially on intra venous fluids and alimentation. An intercostal chest tube was placed on the second post operative day to drain any intra thoracic collection. A soft naso-jejunal tube was placed in the proximal jejunum under fluoroscopic guidance on the 6th post-operative day and the patient was started on naso-jejunal feeds. The chest and the abdominal drains were removed on the 12th post-operative day once the drainage was insignificant. A check upper GI contrast imaging done after one month showed no leak of dye at the site of injury in lower oesophagus with a free flow of dye into the jejunum, thereby suggestive of a spontaneous closure of the leak. The patient was started on oral liquid diet and after three weeks of tolerating oral feeds, the naso-jejunal tube was removed. The patient made an uneventful recovery thereafter, and is symptom free on follow up. The present case reiterates the fact that conservative management of lower oesophageal leaks is effective and enteral nutrition must be continued in such patients for better compliance and results.

Aim To determine if ursodiol can prevent formation of gallstones post laparoscopic sleeve gastrectomy. Background and Summary Cholelithaisis is a primary expression of obesity in the hepatobiliarysystem. 32-40 % of patients develop gallstones following surgically induced weight loss. In obese patientsduring weight loss cholesterol is mobilized from fat stores and bile acid secretion is decreased leading tosupersaturated bile. Biliary mucin is also increased and causes the nucleating time of gallstones toshorten. Impaired gallbladder motility also results in stasis and causes gallstone formation. Ursodiol is abile acid that dissolves gallstones by decreasing biliary cholesterol secretion to lower bile cholesterolsaturation and by decreasing biliary glycoprotein secretion to lower biliary nucleating factors. Thus weprepare that ursodiol be used to decrease the gallstone formation following bariatric surgery. Methods A randomised, double blinded prospective study was carried out at our centre between May2010 to May 2012. Patients were randomly allocated into 3 groups; Group 1 : did not receive ursodiol ;Group 2 : received ursodiol 300 mg and Group 3 received 600 mg. It was commenced 7 days post surgeryand was continued for upto 6 months. Transabdominal sonography was done pre-operatively and postoperatively at 3, 6 and 12 months or until gallstones developed. All patients with prior cholecystectomyand concomitant cholecystectomy were excluded from the study. Results Of 247 patients, 5 (2.02 %) patients had a prior cholecystectomy and 19 (7.6 %) patients underwent concomitant cholecystectomy for gallstones. Remaining 223 patients were randomly dividedinto 3 groups; group 1 had 64 (28.69 %) patients (median age -40; 28 males and 36 females), group 2 had73 (32.7 %) patients (median age -41; 33 males and 40 females) and group 3 had 61 (27.35 %) patients(median age -41; 38 males and 23 females). 12 patients were lost to follow up and had to be excludedfrom study. Of this 27(20.2 %) patients developed pruritis and had to discontinue the drug. The incidenceof Cholelithiasis significantly decreased with ursodiol. Gallstone formation was significantly less (P _0.0018, Fisher exact test) frequent with ursodioboth 300 mg and 600 mg than with placebo at 12 months,3 % versus 22 %, and 8 % versus 30 % (P _ 0.0022) respectively. Conclusion Ursodiol is effective for prevention of cholelithiasis post laparoscopic sleeve gastrectomy (LSG). In some patients allergic reaction to the drug is of concern and restricts its use inspite ofeffectiveness.

P131 Revisional Surgery After Laparoscopic Sleeve Gastrectomy Presenter: A.G. Bhasker Co-author: M. Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Bariatric surgery is an imperfect science. As the safety, durability, resolution of comorbidities rise and therate of complications decrease the procedure veers towards being an ideal procedure with good results.When the scales go the other way with a higher incidence of complications, unsatisfactory weight lossresults and inadequate resolution of comorbidities the likelihood of revisional surgery increases. Sleevegastrectomy has gained immense popularity in the Asian continent over last three to four years. Here wepresent three cases that required revision surgery after sleeve gastrectomy. Case 1 Laparoscopic Resleeve Gastrectomy32 year old male patient had undergone laparoscopic sleeve gastrectomy 2 years back. He presented tous with weight regain. Barium swallow and endoscopy revealed a large fundic pouch that was left behindin the primary surgery. A laparoscopic resleeve gastrectomy was performed. Video depicts the technicaldifficulties encountered during a resleeve gastrectomy. Case 2 Laparoscopic conversion of sleeve gastrectomy to roux en-y gastric bypass48 year old male patient was operated at another center and a sleeve gastrectomy was done. Patient presented to us with intractable reflux and excessive weight loss. Upper GI endoscopy revealed a largehiatus hernia. The video depicts the laparoscopic conversion of sleeve gastrectomy to a roux en-y gastricbypass with a complete dissection of the hiatus and crural repair. Case 3 Laparoscopic conversion of sleeve gastrectomy to duodenal switch34 year old African patient presented to us with inadequate weight loss after sleeve gastrectomy. Afternecessary nutritional guidance a duodenal switch was performed. The video depicts laparoscopicconversion of sleeve gastrectomy to duodenal switch with a hand sutured duodenoileal anastomosis. Conclusion: Proper patient selection is of profound importance in bariatric surgery. Sleeve gastrectomy must not be considered as a blanket solution for all morbidly obese patients and the technical ease of doing the procedure must not take precedence over its indications and contraindications.

P133 A Retrospective Survey of Post-op Pain and Nausea in Bariatric patients - PCA not Required but Regular Anti-emetics Recommended Presenter: A Gunasekera Co-authors: Y W Li, H Murally & C Cheruvu. Department of Anaesthetics and Critical Care, University Hospital of North Staffordshire, Stoke-On-Trent. UK Background and goal of study Pain and Nausea are both common and can be severe in the post-op period in patients having Laparoscopic Bariatric surgery. These can significantly delay recovery. The aims of our study were to determine the Morphine requirement and antiemetic usage in the first 24 after surgery. Materials and Methods We performed a retrospective analysis of case notes of patients undergoing Laparoscopic Bariatric surgery over a one year period from September 2009. The Morphine given and the antiemetic needed were obtained from the prescription charts. Results and Discussion 43 case notes were analysed. In the theatre recovery, patients were given either fentanyl or intravenous morphine if required. Postoperatively, patients were prescribed regular paracetamol, codeine phosphate and a non-steroidal anti-inflammatory drug (NSAID) if not contra-indicated. Patients were prescribed either oral or intravenous Morphine as rescue analgesia. Patients on regular morphine pre-operatively, prescribed PCA postoperatively or those who returned to theatre were excluded from further analysis. Of the remaining 38 patients, the morphine requirement during the

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24 hours after discharge from recovery showed a mean of 9 mg (range 0 36 mg) intravenous morphine equivalents. Patients were administered a combination of antiemetics intra-operatively and prescribed rescue anti-emetics post-operatively. 32(84 %) patients required further anti-emetics in the post operative period. Conclusion We feel that patients pain can be adequately controlled using regular Paracetamol, Codeine+NSAID with morphine for rescue analgesia without need for PCA. We recommend regular anti-emetics in the postoperative period as opposed to as required prescription.

developed lower esophageal leak, two of the patients who underwent LAGB presented with port site infection in the second post-operative week and one patient each in LSG and LAGB developed micro-nutrient deficiency. All of these complications were managed accordingly with patients making good recovery. Conclusion LSG AND LGB appear to effective procedures for the management of morbid obesity and its associated co-morbid condition in the Indian population with LSG being more effective in terms of achieving excess weight loss and BMI.

P134 Internal Hernia: a Life-Threatening Complication of Gastric Bypass

P136 Combined Laparoscopic-Endoscopic Assisted t-tube Insertion for the Management of Post-Laparoscopic Sleeve Gastrectomy Leak

Presenter: Santos, C Co-author: Barbosa, E., Valente,V., Dias, M.

Presenter: Jain V, Co-authors: Whitelaw D, Passafiume F., Warsi A., Barreca M.Luton

Surgery Department, Hospital Pedro Hispano, Matosinhos, Portugal Institution :Luton and Dunstable University Hospital, Luton, UK Morbid obesity is a public health problem. Bariatric procedures, are increasing as a promising option for the control of weight loss and weight maintenance. The most commonly used is the laparoscopic Roux-en-Y gastric bypass (RYGB). Internal hernia is a possible complication ofRYGB and if not recognized with prompt immediate surgical intervention, it could be a life threatening situation. The authors present the case of a female, 47 yrs, with a BMI of 45, submitted to a gastricband in 2000. One year later, her BMI was 46 and she was revised to a RYGB. In November of 2009, she was admitted to our Hospital with severe abdominal pain and septic shock. CTscan showed intestinal ischemia. At laparotomy pratically all small bowel had irreversible ischemia due to an internal hernia in the jejunojejunostomy space. The small bowel wasresected, leaving only the jejunal limb of the gastrojejunostomy, 5 cm of the terminal ileum,the duodenum and first portion of jejunum. Stomas were made and patient went to ICU. At asecond-look at 24hours, resection of the rest of the jejunum was necessary. A tubeduodenostomy and a gastrostomy were made (gastric stump was distended). In February,2010, having recovered clinically and nutritionally, she went to the OR for reconstruction ofthe digestive tract, with the following anastomosis: gastro-gastric, duodeno-jejunal andjejunoileal; we also performed a pyloroplasty and closed the gastrostomy. At the end of thesurgery, patient had 60 cm of small bowel measured after Treitz. Postoperative complicatedwith delayed emptying of the duodeno-jejunal anastomosis, causing biliary reflux, which was solved with conservative measures. At time of discharge, the patient had 3 bowelmovements/day and no relevant nutritional deficits. P135 Evaluation and Comparison of Bariatric Procedures in Obese Patients With Co-morbid Conditions Presenter: Lal Pawanindra Co-authors: Chander J, Hadke N S, Vindal A, Kiran S, Shrivastava N. Maulana Azad Medical Collge, New Delhi, India Background Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5 % of the country’s population. We report our early experience with the laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric banding (LGB) for treating morbid obesity in the Indian population. Methods This prospective interventional study included 30 patients who underwent laparoscopic bariatric procedure for the treatment of morbid obesity (20 patients underwent LSG and 10 patients underwent LGB). The present study was done to compare the efficacy of Laparoscopic Gastric Banding and Laparoscopic Sleeve Gastrectomy in the management of obese patients with co-morbid conditions. The data collected included age, gender, initial body mass index (BMI) and excess weight, the co-morbidity status, and preoperative investigations. Perioperative parameters and follow-up details. Weight, BMI, excess weight loss (%EWL), resolution of co-morbidities, and postoperative investigations were noted. Results All procedures were completed laparoscopically. Laparoscopic gastric banding procedure: Mean time duration from surgery: 347.4 days, Mean percentage of excess weight loss: 33.54.. Laparoscopic sleeve gastrectomy: Mean time duration from surgery: 348 days, Mean percentage of excess weight loss: 38.68.There was comparable resolution of co-morbid conditions in both the procedures. In our study, two of the patients who underwent LSG

Background Laparoscopic sleevegastrectomy (LSG) is one of the most common bariatric procedure performed nowadays. The most troublesome complication of LSG is gastric leak (GL). Treatment of leak can be challenging.Ttransforming it into an open fistula bymeans of T-tube insertion is considered a valuable treatment option. To minimize laparoscopic dissection at the site of the leak and facilitate T-tube insertion, we have developed a combined laparoscopic-endoscopic assisted technique. Methods From Jan 2003 to Feb 2012 we performed 175 LSGs. Mean preoperative BMI was 51.8 kg/m2 (36.5-80). Three patients (1.7 %) developed a staple line leak. Technique After minimal laparoscopic dissection of the peri-leak abscess cavity, a guide-wire is endoscopically fed across the mucosal tear into the peritoneal cavity and withdrawn through one port. A polypectomy snare is then anchored to the guide-wire and retrieved through the mouth. A 16/20Fr T-tube is secured to the snare and positioned with the two short arms in the stomach and the long arm out into the port. Two additional drains are positioned: one in each sub-diaphragmatic space. Results Patients were initially NJ fed and subsequently started on oral feeding after a mean of 11 days (+/- 6). All patients had an uneventful recovery and were discharged home with the T-tube in place. Conclusion In our preliminary experience this technique seems safe and effective in the management of GL. P137 Combined Procedure: Laparoscopic Bariatric Surgery and Ventral Hernia Repair Presenter: Dr Ashish Vashishtha Institution : Max Health Care Institute Limited, New Delhi, India The management of primary and incisional abdominal wall hernias continues to evolve from the early days of primary hernia repair.There has been exponential growth in the surgical treatment of obesity using laparoscopic and open techniques. There has subsequently been an increase in the number of patients who have had ventral hernias discovered at the time of their bariatric procedure.With improved recognition of these problems, surgeons are able to determine extent and timing of treatment, in order to minimize future patient morbidity. There has been development of synthetic meshes with a better understanding of the mechanical properties necessary for a secure hernia repair. There are also newer biomaterials that provide for tissue ingrowth and may be more resistant to infection than traditional meshes.The latest mesh technology has provided for the development and use of biologic products, which have been fashioned from either human or porcine sources. There are multiple types of these products available for use by surgeons, all sharing nonallergenic, acellular characteristics. They differ in base structure, preparation technique, and use of cross-linking. These products have been made from human dermal matrix, porcine dermis, or porcine small intestine submucosa. The potential advantage of these products over purely synthetic mesh is their ability to be incorporated into the native tissue and be replaced by the natural tissue surrounding the material. Vascular channels may facilitate the body’s ability to fight infection, making these products better than their synthetic counterparts in potentially infected or contaminated fields. With the placement of a biologically derived mesh, there were no recurrences in short-term follow up.

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Diligence in the clinical exam will minimize unanticipated problems in handling large hernias at the time of bariatric procedures. New mesh products and/or component separation techniques can allow for combining procedures so the patients will have the optimum recovery from their operation and the best chance for succeeding at their weight loss operation. Combined Mesh repair for ventral hernia can be safely combined with bariatric procedures.

Conclusion Selection of the most appropriate type of feed to provide adequate protein to promote healing but also avoid provision of excess calories is important. Patient and disease specific feeds should be administered keeping in mind the associated co – morbidities like diabetes, renal and liver disease. Nutrition support should be one of the main arms of the multidisciplinary team in order to provide the best outcome for the patient.

P138 Prevalence of Metabolic Syndrome in Obese Indians

P140 Single Incision Sleeve Gastrectomy Versus Conventional Laparoscopic Sleeve Gastrectomy – 2 years Follow Up

Presenter: M. Sancheti, Co-authors: V. Kejriwal, C. Remedios, A.G. Bhasker,A.Agrawal, M. Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai Background Obesity is an increasing health concern worldwide. The prevalence of metabolic syndrome and other co-morbidities are directly associated with increase in obesity. Aim The objective of this study was to determine the prevalence of Type 2 Diabetes Mellitus, Hypertension and Dyslipidemia the major components of Metabolic Syndrome in this obese population. Method We conducted a retrospective cross sectional analysis on 755 obese patients who presented at CODS from March 2008 to March 2012 and underwent Bariatric surgery. Anthropometric measurements, preoperative blood parameters, medications and duration of co morbidities were recorded. Results The median age of this population was 42 years (range 16 to 75 years).Their median BMI was 44 kg/m2 (range 29 - 88 kg/m2). All patients had a waist circumference (females >80 cm, males >90 cm) above cut off norms by WHO for Asians. The prevalence of all 3 components of Metabolic Syndrome was 11 %. 28 % had type 2 diabetes.69 % of these were on Oral hypoglycemic agents or Insulin or both, 31 % were recently diagnosed and not on medications. 40 % of patients were hypertensive of which 82 % were on medications. 26 % of patients had dyslipidemia of which 28 % were on medications. Conclusion The prevalence of all 3 major components of metabolic syndrome was high in this obese population.All patients had a waist circumference above cut off limits for Asians documenting Central Obesity. Routine investigative scanning for all these obese patients should be undertaken to document presence of Type 2 diabetes mellitus, Hypertension and Dyslipidemia. P139 Role of Nutritionist in the Management of Leaks Post Sleeve Gastrectomy Presenter: C.Remedios Co-author: A.G.Bhasker , M.Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India

Presenter: A.G. Bhasker, Co-authors: A. Agarwal, M. Lakdawala Centre for Obesity & Diabetes Surgery - India’s FIRST centre of excellence, Mumbai, India Background This is a prospective pilot study done to assess the outcomes and complication rates of thesingle incision sleeve gastrectomy versus the conventional 5 port laparoscopic sleeve gastrectomy at theend of 2 years. Methods A prospective comparative analysis was done of 50 patients in each arm who underwent laparoscopic sleeve gastrectomy and the single incision sleeve gastrectomy from September 2009 until April 2010. Both groups were matched for age, gender and BMI and were then randomly assigned to either group. Postoperative pain scoring was done using the visual analogue scale. Postoperative outcomes in terms of pain scores, excess weight loss, resolution of comorbidities and complication rateswere compared in both groups, at the end of 2 years. Results Operating times in both groups were comparable. Intraoperative blood loss was similar in bothgroups. VAS scoring revealed lesser postoperative pain after the first 8 hours in the single incision groupas compared to the laparoscopy group- P < 0.0001. At 2 years excess weight loss and resolution of comorbidities was comparable in both groups. There were no major complications or mortalities in eithergroup. Conclusions Single incision laparoscopic sleeve gastrectomy is a feasible surgical procedure for morbidobesity in selected individuals. When compared to conventional laparoscopic sleeve gastrectomy it hasequally effective weightloss and resolution of comorbidities. It also has the added benefits of little or novisible scarring and reduced postoperative pain. P141 Mastopexy and Breast Reduction Procedures in Bariatric Patients Improving the Longevity and Results with Biocompatible 3D Preshaped Mesh Presenter: Bianco G. MD, Co-authors: De Lorenzis G. MD, Pizzi M. MD, Pizzi P. MD Institution : University Center Eppendorf, Hamburg, Germany

Background Astaple line leak is the most feared complication post laparoscopic sleeve gastrectomy (LSG). Leaks need to be managed with a multidisciplinary approach - surgeon,gastroenterologist and nutritionist. Post a complication it is not possible to feed the patient, but maintenance of nutritional parameters is vital as these patients are known to be compromised nutritionallyand further healing maybe hampered. Aim The aim of this study is to provide an overview of the nutritional management of patients who were diagnosed with a leak post LSG. Methods This is a retrospective study of patients who were managed for leaks post LSG. Anthropometric measurements and serumalbumin, serum iron, vitamin B12 and vitamin D3, measured pre – operatively were evaluated. 3 patients were diabetic, 1 hypertensive and 1 had sleep apnea and 2 were on medication for GERD. The type of feed, route of feeding (oral or tube feeds), frequency of feeds, fluid intake and maintenance of nutritional parameters have been studied and reported. Results We managed 9 patients that were diagnosed with leaks post LSG. Median age was 31 years (range 21- 50 years) and median BMI 44.485 kg/m2 (range 34.84 - 52.88 kg/m2).Patientswere fed via a naso – jejunal tube or orally after placement of an endolumenal stent.Patients were tube fed for 35 weeks and givenhypocaloricbolus feeds. The dose and rate of feeding was adjusted according to patient tolerance. Multivitamin, calcium, iron, vitamin B12 and vitamin D3 were simultaneously supplemented as required.

Background After massive weight loss, one of the stigmas that afflict women is the remaining deformity of thebreasts which become ptotic, with an absent upper pole or massive hypertrophy, combined with a suprasternal notch-tonipple distance of more than 30 cm. Breast ptosis is a result of weight loss associated to weakening and lengthening of the supporting structures . The discovery in 1997 of the ligamentous suspension system gave rise to the concept that reconstruction of this anatomical structure was needed to ensure a sustained postoperative result especially in post bariatric patients with skin of poor quality. Methods A mesh implant was developed to replace the supportive function of failed ligamentous suspension in 54 post bariatric patients. Indications are breast ptosis and breast hypertrophy with ptosis Results A total of 54 patients were treated with the longest follow-up of 34 years. In no case was recurrent ptosis observed. Physical and x-ray examinations were still possible. Satisfactory breast shape, nipple projection, and upper breast fullness was obtained. Conclusion The reinforcements with the Internal Bra System were designed to obtain a longer-lasting shape and to prevent recurrent ptosis. The procedure is ideally suited for post bariatric patients with ptotic breasts and an adequate amount of breast tissue. These procedures are safe, without serious complications and with good functional and esthetic results.

OBES SURG (2012) 22:1315–1419 P142 Bipolar Spectrum Disorders in Severely Obese Patients Seeking Bariatric Surgery Presenter: Leorides Severo Duarte Guerra Co-author: Guerra LSD; Santo MA; Wang YP

1405 P144 Neurological Complications After Weightloss Surgery Presenter: Dr Sanjay Patolia Co-authors: Dr Hetal Patolia,Dr Mandeep kapadiya,Dr devendra chauhan Asian Bariatrics & Cosmetics, India

Institute of Psychiatry, University of Sa˜o Paulo Medical School, Sa˜o Paulo, Brazil Background Obesity and bipolar disorder have been one of the major challenges to medicine. The obesity epidemic has gained global dimensions and bipolar disorder has been diagnosed with an increasing frequency. In recent years, studies have showed the correlation between these pathologies. Objective The objective of this research is to raise the frequency of bipolar spectrum disorder in patients with morbid obesity undergoing bariatric surgery. Studies indicate a high number of psychiatric disorders after surgery and bipolar disorder that appears with significant frequency. Method Patients with morbid obesity who are waiting Bariatric Surgery, has been submitted to specific questionnaires for psychiatric diagnosis (N 400): SCID (Structured Clinical Interview for DSM-IV Axis I Diagnosis), HCL (Maniac Symptons Cheklist), MDQ (Mood Disordens Questionnarie ), MADRS ˚ sberg Depression Rating Scale-SIGMA ) e M-A QoQLII (Montgomery_A (Moorehead-Ardelt Quality of Life Questionnaire II) Preliminary results The preliminary results with 240 patients indicated that bipolar disorders was found in 77 (37,08 %) severely obese patients seeking to the bariatric surgery, with the highest prevalence rates for Other Bipolar Disordes (OBD) 20 %. Comorbidity with the binge eating disorder (BED) was observed in 27,92 %. The generalized anxiety disorder and social phobia was presented in 18 %, followed by alcohol abuse 10,42 %. Conclusions These results suggest that bipolar spectrum illness, is very commom in severly obese subjects, in particular the hypomaniac condition characterized by overactivity. The rates prevalence of bipolar spectrum in morbid obesity intensifies the link between mood disorders and obesitiy and encourages further research. P143 Gastric Plication– A Good Indication for Better Results in the Laparoscopic Treatment of Incisional Hernias in Morbid Obese Patients

Introduction Though Bariatric surgery merits over medical treatment for morbid obesity, it can lead to nutritional deficiencies and neurological complications.Our study aims to point the incidence and type of neurological complications of Bariatric surgery in INDIAN population.A specific protocol has been designed at our center for early detection of developing neurological symptoms. Material and Method A retrospective study was carried out between periods of January 2006 to December 2011 with evaluation of total 222 patients.Screening questionnaire was filled up during the follow up visits or telephonic conversation or email. Results The incidence of neurological complications was 34 patients (15.31 %).Clinical pattern of neurological deficits were Poly and mono neuropathy, radiculoplexopathy, myelopathy, Encephalopathy, Myopathy, behavioral changes etc.Higher incidence was observed in women, rapid weight loss, prolonged food intolerance, excessive weight loss, lake of compliance with supplementations and dietary guidelines, pure vegetarian population and alcohol addicts irrespective of pre op BMI and associated co morbidities. Discussion Neurological complications following Bariatric surgery are mostly due to nutritional deficiency, altered metabolism for fats and carbohydrates, altered immune response, compression of nerves.Complications may develop days to years after surgery.Any part of neuraxis from brain, cerebellum, spinal cord, nerves to muscle can be involved in complications. Early detection requires high suspicion and strict vigilance during follow ups especially in the high risk group. Parentral supplementations offer more reliability. Conclusion Bariatric surgery can cause neurological complications in high risk group. Out of these complications, few are life threatening, majority results in permanent disability and only few recovers fully if managed timely. P145 Removal of Resected Stomach Following Sleeve Gastrectomy

Presenter: C. Duta, Co-authors: A. Dobrescu, D. Barjica, C. Lazar, C. Tarta, F. Lazar

Presenter: Ravi Date Co-author: Sarah J Walton

UMF Timisoara, Suirgical Clinic 2, Romania

Lancashire teaching Hospitals NHS Trust, United Kingdom

Background Since the first paper published by Talebpour in 2007 of this new procedure for treating morbid obese patients, several studies show that the short-term results were acceptable. In 2010 we started to perform this new technique as an alternative bariatric procedure to sleeve gastrectomy. In this study we present our experience with vertical gastric plication, focusing on the effectiveness and complications in the management of morbid obese patients with incisional hernias. Methods Starting 2010 we perform 25 laparoscopic gastric plication in patients with a mean age of 41.4 years (25 to 54) and a mean BMI of 45 kg/ m2 (41 to 53). We used five-port approach (three 10 mm, two 5 mm) in the same position as for sleeve gastrectomy. In five cases we perform this procedure in patients with concomitant incisional hernia. We started with three trocars in the left part of the abdomen and we perform an laparoscopic adesiolysis. After that we put the trocars for gastric plication and in the end we put a mesh for treating the abdominal defect. Results All 5 procedures were completed laparoscopically. Mean operative time was 90 min (60 to 110 min) and mean hospital stay was 48 h (24 to 72 h). Patients returned to their regular activities at an average of 7 days (4 to 9) following surgery. No intra-operative complications occurred. Excess weight loss (EWL) after 1 month was 25 % (20 % to 30 %), 3 months was 35 % (28 % to 47 %) and after 6 months was 48 % (41 %-57 %). Conclusions This new procedure has the same result of weight loss as others with minimal risk of complication and very low cost, especially in developing countries. The lack of gastric resection or intestinal bypass and the lack of the use of prosthetic materials are the major advantages of the technique that influenced the patients’ decisions. We think that for obese patients with incisional hernia the laparoscopic approach is a very good indication and in these patients and a concomitant gastric plication is very useful to get better results due to weight loss. Longer follow-up and prospective comparative trials are needed.

Introduction Laparoscopic sleeve gastrectomy is a procedure, which can be done as a stand-alone bariatric procedure for the treatment of obesity, or as the first stage in a two-stage duodenal-switch procedure. In a laparoscopic sleeve gastrectomy, removal of the resected stomach remnant can be tricky. We present a technique, which makes this removal of the stomach remnant easier. Method After the stapled sleeve gastrectomy has been completed, 12 mm working port on left side is removed and an Endocatch II laparoscopic retrieval bag (Tyco Healthcare, Norwalk, Connecticut, USA) is inserted through this port site. The resected stomach is placed in the bag, with one end of the stomach held at the mouth of the retrieval bag with grasper. The drawstring of the retrieval bag is then closed, with the end of stomach still pouting through the mouth of the closed retrieval bag. The retrieval bag is pulled out gradually, thus bringing the retrieval bag opening onto the abdominal wall with the end of resected stomach still within the retrieval bag drawstring. The retrieval bag is then opened after catching the stomach end with artery forceps. Gentle traction on the resected stomach portion will then allow easy removal of the resected stomach. This technique ensures that the resected stomach is drawn out easily in a linear manner. Conclusion The technique described here is a simple modification, using established equipment to aid the final part of the operation. Usually, a 15 mm LUQ port is required, but a 12 mm can be used with this technique, which is cheaper and does not necessarily require closure of rectus sheath. P146 Is There is a Right Way to Start Bariatric Surgery ? Presenter: Bekavac-Beslin M. University Clinical Centre “Sisters of Mercy”, Croatia (Hrvatska)

1406 Considering the fact that there are no explicit instructions about which bariatric surgical procedure would be appropriate for starting bariatric surgery there are some controversies about the choice of bariatric procedure for the newly formed bariatric team. After forming the multidisciplinary team, fellowship experience, supervised trainings, and mastering the technical skills in open and laparoscopic bariatric surgery the question arises in front of the new team and a decision has to be made: “Which bariatric procedure will be the first one ?“ For the surgical team with previous long term experience in abdominal surgery the decision could be to perform the Scopinaro procedure for the super obese patient with metabolic syndrome. For the surgical team with long term experience in advanced laparoscopic surgery the decision for the first bariatric procedure could be laparoscopic gastric banding. For the surgical team without laparoscopic skills the idea of starting bariatric surgery with a visiting expert and assisting in laparoscopic bypass operations could also be the way of starting bariatric surgery. Even today when bariatric surgery is a part of the daily routine in operating theaters around the world there still are regions where bariatric surgery is in the initial stages or even before the beginning. Advice and standpoints about the first bariatric procedure to be planned for treating the morbid obese patient would be of great value and guidelines or recommendations by leading societies for bariatric and endoscopic surgery would be precious to the new surgical teams starting with bariatric surgery. P147 Impact of Gastrointestinal Surgery on Glycemic Control in a Diabetic Non-obese Animal Model. Preliminary Results Presenter: Hans Eickhoff Co-authors: Ana Guimaraes, Paulo Roquete, Carlos Vaz Obesity Center, Hospital Santiago, Setubal & Obesity Center, Hospital da Luz, Lisboa, Portugal Introduction Bariatric surgery favors the improvement of metabolic control in obese patients with type 2 diabetes (T2D) or impaired fasting glucose reducing insulin resistance and, possibly, modulating digestive peptides. The role of gastrointestinal surgery in lean patients with T2D remains yet to be defined. In a non-obese animal model of T2D, we studied the hypothesis that sleeve gastrectomy (SG) and gastric bypass (GB) could improve the glycemic control in lean diabetic animals. Methods 19 Goto-Kakizaki (GK) rats, a non-obese model of T2D obtained by selective reproduction, were randomly submitted to SG (9 animals) or BG (10 animals) under anesthesia with ketamine and chlorpromazine. Untreated GK rats and non-diabetic Wistar rats served as controls. Venous blood for determination of glycemia and glycated hemoglobin was obtained from the tail vein before and 4 weeks after treatment. Results Fasting glycemias of GK rats were significantly higher than those of Wistar rats, before and after treatment. Occasional glycemias in GK rats submitted to SG or GB were significantly lower than in the remaining GK rats (106±30.2 mg/dl – SG and 129±39.1 mg/dl – GB versus 154±54.3 mg/dl). Glycated hemoglobin in treated GK rats was also significantly improved, either in comparison to pre-operative values or to GK rats submitted to sham surgery or non-operated controls (p<0.05). Conclusion Sleeve gastrectomy and gastric bypass improve the control of occasional glycemia and glycated hemoglobin in non-obese diabetic rodents. The determination of digestive peptides could further support the applicability of these findings in non-obese patients with T2D.

OBES SURG (2012) 22:1315–1419 Material and Methods We have operated on and followed-up 10 patients having the criteria of BN. Initial preoperative weight was 53-178 kg, BMI – 19,9–51,2 kg/m2. Five patients had BMI>35 preoperatively, 3 had BMI<35 but were morbidly obese in the past, 2- have never been obese. 7 patients underwent BPD or BPD/DS, 3- Sleeve Gastrectomy (SG). Follow-up periods - 9 months – 9 years. Results All patients demonstrated complete cessation or significant improvement with bulimic attacks. Weight loss was very good but never reached undesirably low level. Patient’s satisfaction was high. Conclusion BN is a condition treatable by surgical Methods: SG might be a reasonable first-step approach in the less than morbidly patients. In the morbidly obese patients with BN BPD or BPD/DS are effective in the long-run. P149 Selective Endoscopy for Patients Undergoing Bariatric Surgery Presenter: Gurdeep Bahra Co-author: Dr. Ankit Desai Dr. Devinder Bansi Mr. Ahmed Ahmed Charing Cross Hospital, United Kigdom Introduction Some Co-Authors suggest the routine use of endoscopy in patients undergoing bariatric surgery in order to detect asymptomatic hiatal hernias, oesophagitis and gastric ulcers. Our unit uses selective endoscopy. The current study analyses the indications and findings of upper GI endoscopy in pre-operative bariatric surgery patients. Methods A retrospective analysis of all bariatric surgery patients referred for Upper GI endoscopy at Charing Cross Hospital from 01.01.2009 to 30.10.2011 was done. During this time period, 1093 bariatric surgery cases were performed. These consisted of 542 laparoscopic gastric bypasses, 220 laparoscopic gastric band insertions, 223 laparoscopic sleeve gastrectomies and 108 revisional bariatric procedures. The Endoscopy units electronic database of oesophagogastroduodenoscopies (OGDs) performed in that time period was analysed to determine how many bariatric surgery patients underwent OGDs pre-operatively and for what indication and with what result. Further sub-analysis was performed for each operation type. Results 147 OGDs were done on a total of 116 bariatric surgical patients, with 23 patients having had more than one OGD each. Of these 147 OGDs 44 were pre-operative. 13 (29.5 %) OGD referrals were made to investigate anaemia, 12 (27.3 %) for pre-surgical screening to investigate existing symptoms of gastric ulceration, and 9 (20.5 %) to investigate abdominal pain. The remaining referrals were made for interventional gastric balloon insertions and removals (6013.6 %) and to investigate symptoms of reflux (306.8 %) and dysphagia (102.3 %). The majority of patients (50 %) were referred prior to having a roux-en-y gastric bypass operation. Most of the pre-operative OGD findings were normal (16036.4 %), but gastritis (6013.6 %), hiatal hernias (6013.6 %), gastric ulceration (204.5 %), oesophagitis (102.3 %) and duodenitis (102.3 %) were noted. Of the 13 patients referred with anaemia, 9 (69.2 %) had normal mucosa on OGD, but of the 12 patients who had pre-surgical screening 7 (58.3 %) were found to have abnormalities, including a fundic gland polyp and antral erosions. Conclusion: Using a selective referral process, only 4 % of all bariatric surgery cases performed required pre-operative endoscopy. The commonest indication for OGD pre-operatively was anaemia and the commonest pathology found was mucosal inflammation (gastritis, oesophagitis and duodenitis). P150 The Influence of Permanent Stress on Development of Obesity

P148 Surgical Approaches in the Patients with Bulimia Nervosa Presenter: Yury I. Yashkov, MD, PhD

Presenter: JElena Margolina (1) Co-authors: Maksim Margolin (1), Eriks Klesmits Curikov (3).

(2)

, Uldis Teibe

(3)

, Jevgenij

The Center of Endosurgery and Lithotripsy (CELT), Moscow, Russia 1

Background Bulimia nervosa (BN) is a kind of eating disorders, characterized by consumption of huge amounts of food during discrete periods. Patients with BN demonstrate “purging” behavior to prevent weight gain: self-caused vomiting, laxatives, enemas. These habits may prevent patients from development of morbid obesity (MO), but may themselves become an excruciating condition, difficult for conservative treatment. BN is sometimes considered as a contraindication to bariatric surgery but surgery may be an effective option.

– Baltic Centre for Research and Treatment of Obesity, Riga, Latvia, – Department of Interior Health Centre, Riga, Latvia; 3 – Riga Stradins university, Riga, Latvia

2

Background Some of remarkably influencing factors on development of obesity are miscellaneous alterations of person’s psychological status including influence of various psychologically traumatic events. The aim of the study is to evaluate the influence of permanent stress on development of obesity in employees of Department of Interior of Latvia.

OBES SURG (2012) 22:1315–1419 Methods Examination of 420 employees (policemen, firemen, borderguards – all men) within yearly medical check-ups. Changes of BMI depending on age and lenght of service in comparison with control group were evaluated. Results Employees of control group had increased weight (BMI from 25 to 30) in 34,5 % of cases, but policemen in 45,9 %, firemen in 50,7 % and border-guards in 49,2 % of cases. 19,5 % of control group employees had obesity. The obesity rates in policemen were – 30,3 % and 2,9 % of them had morbid obesity. The obesity rates in firemen were – 22,9 % and 2,6 % of them had morbid obesity. The obesity in border-guards was common in 28,6 % of cases. In the group of policemen employees with length of service less than 10 years had obesity in 16,1 % but employees with length of service more than 15 years – 36,7 %. In the group of firemen the same parameters were – 10 % and 31 % and in the group of border-guards – 14,3 % and 29,4 %. Conclusions According to results of the study permanent stress (irregular meals, non fixed working hours with twenty-four hour duties, emotional and mental overwork) may influence the development of obesity in employees of law protecting instances. P151 Randomised Controlled Trial Comparing Three Methods of Liver retraction in Laparoscopic Roux-en-YGastric Bypass Presenter:Rajat Goel Co-authors: Asim Shabbir, Chi-Ming Tai, Alvin Eng, Hung-Yen Lin, Su-Long Lee, Chih-Kun Huang

1407 (15 Sleeve gastrectomy and 15 Roux-en-Y gastrojejunal bypass). All patients were performed a preoperative Gastric scintigraphy with marked food (Tc99) at a dose of 2 mCi. It filled the estimated gastric emptying time at the initial small intestine and then calculates the curve activity/time of emptying. Also, we will determine plasmatic levels of GLP-1 and Ghrelin. Results 30 morbidly obese patients (90 % ♀ - 27, and 10 ♂ - 3). Average BMI 48.4±(36-62 kg/m2). Diabetes mellitus type 2 in 10 patients (33.3 %), hypertension in 14 patients (46.7 %). T1 scintigraphy (first emptying the small intestine) 15.37 ±11minutes.Emptying time curve according to activity/time: 134.27± 65 minutes. There is a significant difference in the emptying of patients with a higher comorbidity, whether hypertensive or diabetic patients (111.11 ± 51minuts) than those without a higher comorbidity (174.27 ± 46 minutes) p<0.05. We could not find any significant correlation with gastric emptying, age and with BMI. Discussion In this study we observed a significant accelerated emptying specifically for patients with diabetes mellitus and/or preoperative hypertension. This reaffirms the hypothesis of a possible lack of regulation of GLP-1 in the morbid obesity before surgery. The expected increase of GLP-1 after surgery might also help to normalize gastric emptying. Evaluating the results at 6 and 12 months of the intervention, the study will be completed regard to the influence of surgery on gastric emptying according to the technique performed and the hormone levels of GLP-1 in particular. References Horner KM, Byrne NM, Cleghorn GJ, Na¨slund E, King NA. The effects of weight loss strategies on gastric emptying and appetite control. Obes Rev. 2011 Nov; 12(11):935-51.

E-Da Hospital, Kaohsiung, Taiwan ROC Aim To compare novel liver retraction techniques with traditional mechanical liver retractor in a Randomised controlled trial. Methods 60 obese patients (26 M/34 F), underwent LRYGB between January to July 2010 were randomised to either of 3 groups (n020), Nathanson liver retractor: (Group I), Liver suspension tape: (Group II) and V shaped liver suspension technique: V-LIST, (Group III). Data regarding demographics (age, sex, Body Mass Index), Liver function test (LFT) just before surgery, immediate post-op, 18 hours, 1st week and 1st month after surgery, operative data, and Visual analogue scale (VAS) for pain at post op day (POD) 1 and 2 were analysed. Results There was no significant difference between groups in preoperative LFT, operative data, except group III took significantly longer time for liver suspension than group I and II (p00.01, p00.03). VAS in group II was significantly less at POD 1 (p00.04) as compared to group I. There was significant rise in Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) in group I at 18 hours as compared to group II (p<0.01, p00.02) and III (p< 0.01, p00.01) and at 1 week in comparison to group II (p00.04, p00.04) and AST levels alone in immediate postoperative period in comparison to group III (p00.04) respectively. Conclusion Nathanson liver retractor causes more liver dysfunction, in comparison to V-LIST and liver suspension technique and causes more post-operative pain than liver suspension technique. Both V-LIST and Liver suspension tape have short learning curve and have their implications in Single port surgery

P153 Pre and Postoperative Sweet Craving and Weight Loss Success of Restrictive and Malabsoprtive Procedures Presenter : Cynthia Buffington PhD Co-author: Keith Kim, MD Florida Hospital Celebration Health, United States of America

Presenter :Arantxa Cabrera Co-authors: Arantxa Cabrera, Fa` tima Sabench, Merce` Herna´ ndez, Santiago Blanco, Margarida Vives, Antonio Sa´nchez, Daniel del Castillo

Introduction Sweet food eating/craving is believed to reduce surgical weight loss with restrictive procedures. This report describes our findings on the association between sweet craving pre- and postoperatively and weight loss following the adjustable gastric band (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGBP. Methods The study population included 194 bariatric surgical patients. Sweet craving was assessed by questionnaire before surgery and at average follow-up of 29, 34, and 25 mo following the AGB, SG and RYGB. Pre- and postoperative sweet craving was examined relative to maximal and current weight loss. Results Prior to surgery, 53 % of our bariatric candidates were sweet cravers. Preoperative sweet craving, however, had no significant (p>0.05) effect on weight loss with the AGB, SG, or RYGB. With the AGB, the incidence of sweet craving (45 %) remained unchanged postoperatively, and postoperative sweet craving had no effect on weight loss success. With SG or RYGB, the incidence of sweet craving was markedly reduced postoperatively (52 % to 30 % and 59 % to 27 % for the SG and RYGB, respectively). Unlike the AGB, sweet craving following SG or RYGB significantly (p<0.01) reduced weight loss success. Conclusions Our findings suggest that sweet craving before surgery is not a predictor of surgical weight loss. Postoperative sweet craving does not affect weight loss with the AGB but significantly reduces weight loss success following SG or RYGB. Mechanisms underlying these findings will be discussed and the results reviewed relative to the findings of others who have studied the effects of sweet craving/eating on surgical weight loss.

University Hospital of Sant Joan. Faculty of Medicine. IISPV.Rovira i Virgili University, Spain

P154 Diabetes Mellitus, Morbid Obesity, Renal Function pre Y post Metabolic Surgery

Introduction In morbidly obese patients we can observe an alteration of gastrointestinal motility respect to non obese patients, but their meaning is not entirely known, showing controversial results with Gastric scintigraphy. This emptying may be accelerated, normal or even delayed, indicating that other factors may be involved in this variability. Moreover, intestinal incretines (GLP-1 and GIP) are working together to reduce postprandial hyperglycemia inhibiting gastrointestinal motility and gastric emptying. GLP-1 is considered the most effective of them. Material and Methods We study in preoperative and preliminary form, a series of 30 morbidly obese patients undergoing surgical treatment of their obesity

Presenter: Vicente Silvestre1 Co-authors: Mario Ruano2, Elena Aguirregoicoa2, Laura Criado2, Yolanda Duque, L2, A´ngel Marco3, Gonzalo Garcı´a-Blanch1

P152 Analysis of Gastric Emptying in Morbidly Obese Patients Candidates for Bariatric Surgery: Preliminary Results

.- Department of General and Gastrointestinal Surgery; 2.- Department of Biochemistry;3.- Department of Endocrinology Hospital Universitary of Mo´ stoles. Mo´ stoles. Madrid (Spain)

1

Introduction In Spain there are 3 million patients with diabetes mellitus type 2 (DM2), in 20%of them this condition causes chronic renal failure (CRF). The

1408 relationship between morbidobesity (MO) and DM2 is well known is also demonstrated the usefulness of metabolic surgeryfor the treatment both entities. The objectives of this study are: 1) analyze pre-surgery anthropometric measures andbiochemical parameters of renal function in patients with OM, DM2 and CRF; 2) evaluatechanges produced after surgery and 3) its evolution in the medium and long term. Material & Methods Retrospective analysis of data from 326 patients with OM and DM2 andCRF operated in our hospital. The median age was 41.8 years (range: 19-62). before surgeryand 6, 12, 24, 60 and 120 months after it, we collected anthropometrics measures and serumlevels of serum creatinine and albumin, creatinine clearance, albumin/creatinine index,microalbumin in urine (MAU) and glomerular filtration rate (GFR). Results Before surgery found that the mean (SD) body mass index was 47.5 (5.5) and thewaist circumference 127.3 (17.0) with elevated levels of creatinine, MAU and diminished ofcreatinine clearance and GFT. After surgery and during the first 6 months begin to descendrates of BMI, WC an d r egu larized the alte red level s. At 1 20 month s, th e B MI corresponding tooverweight, abdominal obesity disappears and improves renal function. Discussion and Conclusions The decrease in antropohometric measures and theimprovement of renal function show the effectiveness of metabolic surgery will reduce risk ofdiabetic nephropathy.

OBES SURG (2012) 22:1315–1419 difficulties with this method, we compare some non-invasive markers for identification of severe/advanced fibrosis and cirrhosis. Materials & Methods We studied 638 patients undergoing bariatric surgery. Among them, 83 patients underwent liver biopsy. The laboratory data were obtained from medical records, and calculated the following markers: AAR, AP index, APRI, CDS and HALT-C. Using biopsies, performed in part of the serie (n084), as a control group, statistical analysis was performed to identify the best method and cutoff values. Results The more accurate method was APRI, with a cutoff value of 0.6 (sensitivity and specificity, CI, PPV and NPV were calculated). In the group of patients who underwent biopsy, 5 had advanced fibrosis or cirrhosis (6.02 %) and 25 some degree of fibrosis (30.12 %). Discussion In the population studied, the percentages of fibrosis / cirrhosis, and some degree of NAFLD are compatible with literature data. The APRI index would be useful as a predictor in all cases of advanced fibrosis/cirrhosis in this serie. Conclusion Regarding the markers studied, the APRI was the best method to predict advanced liver disease. Thus, it can apparently be used as a screening method for performing liver biopsies. P157 Intragastric Air Balloon : Preparatory Use of the Operation of Laparoscopic Gastric Bypass

P155 Sleeve Gastrectomy as a Revisional Procedure For Failed Gastric Banding

Presenter: Giovanelli Alessandro Co-authors: G. Ravasio , L. Bertolani, S. Ebalginelli, E. Russo, R. Lutti; A. Giovanelli

Presenter: Marcos Berry, MD; Co-authors: Lionel Urrutia, MD; Patricio Lamoza, MD; Ricardo Rossi,MD

National Institute for Obesity Surgery Entries (INCO), Clinical Institute Sant, Italy

Institution: Bariatric Surgical Unit, Clinica Las Condes, Santiago-Chile

P156 "Evaluation of Noninvasive Methods for Preoperative Diagnosis of Advanced Liver Fibrosis or Hepatic Cirrhosis in Morbid Obesity"

Context the literature data show a mortality rate of> 2 % in patientsundergoing Gastric Bypass with BMI>50, but also that the mortality rate is reduced to <1%if BMI <50. A preparatory approach was therefore proposed, consisting of placing theIntragastric air balloon to reduce the body weight of patients undergoingGastric Bypass with BMI> 50. Methods in a multicenter study involving four centers in Italy,195 patients were analyzed.73 among them had a BMI > 50, and subsequently to treatment with intragastric balloon,were submitted to Gastric Bypass. The balloon was inserted in both general anesthesiaand sedation, and inflated with 800 ml of air. A correct positioning of the device wasobtained in all cases. All patients maintained good conditions during the entire treatmentperiod. The great majority of the balloons was removed after 6 months under generalanesthesia or sedation. Results we showed a good tolerability of the device, with a percentage ofremoval before the 6th month of 2.7 %, for psychological intolerance. The weight lossobtained was satisfactory with an average PEWL of 27 %. Adverse events were:gastric problems (ulcers, bleeding, erosions) 5.2 %, vomiting lasting over 3 days4.5 %, addominalgia 2.6 %, epigastralgia 4.3 %.The mortality after Gastric Bypass was 0. Conclusions the weight loss obtained after 6 months treatment with intragastric air balloonhas reduced the BMI of patients younger than 50, in 65 % of cases. The procedure wasproved to be safe and well tolerated, and can be considered as an effective preliminarytreatment in patients with high surgical risk affected by super-obesity, and candidates tomajor surgery. Patients will then acquire preoperatively a new lifestyle that results inweight loss and eventually in the reduction of BMI. This allows the patient to get to themajor bariatric intervention, in particular the Gastric Bypass, with a lowered percentage ofconversion to laparotomy, a lowered percentage of intraoperative complications andreduced mortality.

Presenter: Santo MA Co-authors: Riccioppo D, Pajecki D, Kawamoto F, Matsuda M, Cecconello I

P158 Easy Technique For Conversion From Failed Biliopancreatic Diversion to Gastric Bypass

Digestive Surgery, Hospital das Clı´nicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

Presenter: Felipe de la Cruz Vigo Co-authors: I. Osorio, P. Go´mez, A. Pe´rez, C. Min˜ambres, M. Gutie´rrez, E. Bra, J.I. Martı´nez, J.M. Canga, J.L. de la Cruz Vigo

Introduction Laparoscopic sleeve gastrectomy(LSG) has been recognized as a beneficial treatment option for obesity and associated morbidities.Revision of a failed laparoscopic adjustable gastric banding(LAGB) has become a common situation in bariatric surgery and the ideal procedure to be offered is under debate. We evaluate the results of a one stageprocedure,with conversion of a LAGB to a LSG after failed LAGB as a revisional procedure for inadequate weight loss and/or complications after LAGB, analyzing operative time,hospital stay,%EBMIL,and morbimortality. Material and Methods A prospective case series of 44 obese patients with a prior LAGB,who later underwent a one stage LAGB removal and LSG, between June 2007 and June 2011.Careful take down of the fundus wrap and removal of the peri-band capsule were completed prior to the LSG. Results 44 patients,17 male and 27 female, mean age of 43.6 years(2062),were operated.Mean operative time was 96 minutes(90-180).Median hospital stay was 3 days.Mean preoperative BMI was 34.9. At a mean follow-up of 16 months(6-34),mean BMI was 29.6 and the mean %EBMIL was 76.9 %. Three patients(6.8 %) presented postoperative morbidity: dysphagia in one patient,which was resolved with an endoscopy;persistent fever in another patient,who underwent a negative laparoscopy;and a perigastric haematoma in a third patient which was managed non-operatively.There were no leaks and there was no mortality. Discussion LSG as a revisional surgery for a failed LAGB can be performed safely as a one stage procedure by experienced bariatric surgeons, and is effective as a weight loss procedure.Further follow-up is necessary to establish its long-term efficacy.

Introduction Currently obesity is an epidemic in Western society, with significant increase in prevalence. There are several comorbidities such as systemic hypertension, insulin resistance, dyslipidemia and NAFLD / NASH (Nonalcoholic Fatty Liver Diasease / Non alcoholic steatohepatitis). The liver biopsy is the gold standard for diagnosis of this condition. Due to several

12 de Octubre University Hospital, Spain Introduction Biliopancreatic bypass is considered to be the most effective bariatric surgical technique in weight loss results. In the counterpart it has some risk of

OBES SURG (2012) 22:1315–1419 malnutrition and other alimentary deficiencies. Sometimes, weight loss regain and nutritional problems are associated and the surgical technique must be revised. We report three patients converted from biliopancreatic to gastric banded bypass. Materials and Methods Patient 1: %1 years old woman with arterial hypertension and atrial fibrillation. A Scopinaro biliopancreatic bypass was performed in 1998 and a shortening of the common limb in 2002 because weight regain. After seven years follow-up, the patient was progressively gaining weight and developed ferropenic anemia. Patient 2: 57 years old woman. Scopinaro biliopancreatic bypass in 1999. During all the follow-up she suffered from anemia and poor weight loss. Ten years after surgery she needed hospital and ICU admission for severe malnutrition and hepatic failure, being treated with parenteral nutrition. Patient 3: 41 years old woman with Larrad biliopancreatic bypass performed abroad in 2004. Besides unsatisfactory weight loss, she had severe anemia and diarrhea with a giant ventral hernia. To all three patients, the technique performed was excision of the remaining stomach, making a pouch on the lesser curve on a 34Fr tube in continuity with the previous gastro-enteric anastomosis. A 6,5 cm perimeter polypropylene mesh band was placed around the pouch. A side to side anastomosis was performed between the alimentary limb, at 150 cm, and the biliopancreatic limb, at 40 cm. Ventral hernias were resolved. Results All three patients got a significant weight loss, improved their anemia and their nutritional status. Their chronic diarrhea disappeared. Conclusions Conversion of a mainly malabsortive technique must be done to a mainly restrictive one. Conversion to gastric bypass must be offered to patients with biliopancreatic bypass complications. The technique performed to our patients, with only one side to side digestive anastomosis is safe and effective.

1409 peptide has been reported as a predictor for T2DM remission after bariatric surgery. Our objectives were to analyze the role of post-OGTT C-peptide as the predictors for diabetes remission. Methods From September 2008 to January 2011, a total of 33 (22 females and 11 males) consecutive morbidly obese (BMI30Kg/m2 ) patients between the ages of 20 and 58 years with type 2 diabetes mellitus (T2DM) enrolled in a surgically supervised weight loss program with at least 1 year follow-up were examined. Among them, 25 patients received LRYGB, while the other 8 patients received LMB. 75-g-OGTT (oral glucose tolerance test) was performed in these patients before bariatric surgery. Plasma glucose, insulin and C-peptide levels were checked before and 30, 60, 90 and 120 minutes after 75-g-OGTT. Results One year after gastric bypass surgery, 20 patients (60 %) out of a total of 33 patient had a remission of their T2DM (HbA1c<6.5 % without pharmacologic therapy). Logistic regression confirmed the fasting C-peptide, and 60’, 90’, 120’ C-peptide after 75-g-OGTT were the predictors for diabetes remission (P<0.05). But the 30’ C-peptide after 75-g-OGTT was not significant. And no difference was found in the predictive values between the fasting Cpeptide, and 60’, 90’, 120’ C-peptide after 75-g-OGTT. Conclusions In the study, we found that fasting C-peptide, and 60’, 90’, 120’ Cpeptide after 75-g-OGTT were the predictors for diabetes remission. But the post-OGTT C-peptide seemed not better than the fasting C-peptide to predict the remission of T2DM after bariatric surgery. P161 Routine Oversewing of the Vertical Staple Line is Unnecessary in Vertical Sleeve Gastrectomy Presenter: Helmuth T. Billy, Ventura Advanced Surgical Associates, United States of America

P159 The Gastric By pass; How I do it? Presenter: Fabrizio Bellini Co-authors: Pietro Pizzi Bariatric and Metabolic Surgery, Desenzano Hospital, Italy Introduction Obesity is a multifactorial disease and none of the known operations can cure everybody, because each procedure has an effect on only a few of the many causative factors of obesity.We consider LRYGBP the ideal surgical approach for obesity since it works on different causative factors.The Roux configuration is well established,but many technical aspects vary between surgeons.Wepresent our experience,protocols and technique. Materials and Methods From January 2007 to January 2012 we have performed 250 LRYGBP in a way we call “simplified technique”. The results are analyzed in a retrospective manner. The surgeon is on the right of the patient. All the anastomosis are performed in the supra-mesocolic floor.The GJ anastomosis is on the posterior wall of the pouch with Endo-GIA+running suture.The JJ is LL with Endo-GIA + running suture.The jejunal partition is performed at the end of the procedure, getting therefore the possibility to test both the anastomosis. Non-closure of defects. Results Weight loss over time and complications were recorded retrospectively.No mortality.No intraoperative complications,1 early jejunal leak due to manipulation,1 trocar access abscess, 5 postoperative late anastomotic ulcers.No internal hernia.EWL at 4 years:71 % Discussion and Conclusion The ideal operation to control obesity has not yet been defined.Laparoscopic RYGBP is not a simple operation, but is an advanced surgical procedure that requires skill and laparoscopic experience. Nevertheless the choice of a “simplified” and really reproducible way to reach our target is mandatory. The protocol and operative technique we are rigorously following is much reproducible and with low rate of complication. P160 Pre-operative Plasma C-peptide Level in OGTT Predict the Remission of Type 2 Diabetes After Bariatric Surgery Presenter :Keong Chong Co-authors: Wei-Jei Lee, Kong-Han Ser, Yi-Chih Lee, Shu-Chun Chen, JungChien Chen Min-Sheng General Hospital, Taiwan Background C-peptide is a surrogate marker for insulin release. Its level depends on plasma glucose level and also insulin resistance. Fasting C-

Methods and Procedure 50 consecutive patients underwent laparoscopic sleeve gastrectomy. The vertical staple line was created using a 60 mm stapler. Choice of staple cartridge was at the discretion of the surgeon. In all cases compression of the tissue was enhanced by utilizing a 15 second pause between application of staple lines. Staple line reinforcement was not utilized. Staple lines were not oversewn. All patients were admitted for observation. All patients underwent postoperative barium swallow studies. All patients had 19 french Blake drains placed at the time of surgery. Results Average length of stay was 2 days. There were no leaks. 16 patients required ligation of isolated individual bleeding vessels in the staple line. 3 patients required fibrin glue tissue sealant to address persistent oozing from the staple line. Mean operative time was 82 minutes. Conclusions Oversewing of staple lines does not need to be a routine part of sleeve gastrectomy. Ligation of individual bleeding vessels can be utilized selectively. Elimination of oversewing did not result in staple line disruption or leak. Routine use of oversewing of the vertical staple line in sleeve gastrectomy is not necessary. P162 Intestinal and Gastrointestinal Hormones, Morbid Obesity and Metabolic Surgery Presenter: Vicente Silvestre1 Co-authors: Mario Ruano 2 , Elena Aguirregoicoa 2 , Laura Criado 2 , Yolanda Duque L 2,A´ ngel Marco3 , Gonzalo Garcı´a-Blanch 1 1

.- Department of General and Gastrointestinal Surgery; 2.- Department of Biochemistry; 3.- Department of Endocrinology

Hospital Universitary of Mo´stoles.Mo´stoles. Madrid (Spain) Introduction The high prevalence of morbid obesity explains the increasingly frequent use ofmetabolic surgery for treatment. Numerous Methods exist for its realization; however,laparoscopic techniques can cause alterations in intestinal and gastrointestinal hormonessecretions. The objectives of our study are: 1) evaluate prior to surgery the plasmatic levels ofsome of these hormones; 2) analyze postsurgery changes in their levels and differences werefound to use one or another procedure and 3) its evolution in the medium and long term. Material & Methods Retrospective evaluation of data from 360 patients with morbid obesityoperated in our hospital (255 by gastric bypass, 60 by gastroplasty and 45 by gastric sleeve).The median age was 39.7 years (range: 16-

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63). Before surgery and 1, 6, 12, 24, 60 and 120 months after it, we collected anthropometrics measures and plasmatic levels of intestinal (GUT)and gastrointestinal (GI) hormones. Results Before surgery all patients show values of body mass index for morbid obesity gradeIII and 120 months later values are relegated to overweight, disappearing visceral obesity.Before surgery we found high levels of cholecistokinin and inhibitory gastric polypeptide inpatients with diabetes mellitus; other hormone levels are within their references ranges. Aftersurgery and during the first month, there are important differences in these levels according tothe procedure used. Discussion and Conclusions Alterations in plasmatic levels of GUT and GI are more markedand takes longer to regularize in the procedures that combine restriction with malabsorption.

She underwent a gastric bypass and 15 months later, her BMI went down to 29.8 kg/m2, she was off medication for the first time in her life, with an overall improvement in all parameters characterizing Wilson’s disease - 24 hour urinary copper excretion levels, serum cerruloplasmin levels, and low normal copper content in liver biopsy. An exhaustive review of literature failed bring up any reference to bariatric surgery in a case of Wilson’s disease and to the best of our knowledge this is the first reported case. The patient’s remarkable reversal can probably be attributed to the malabsorption of copper from the proximal GI tract which is bypassed in RYGB – an unexpected yet welcome benefit of bariatric surgery.

P163 Nutritional State, Morbid Obesity and Metabolic Surgery

Presenter: Belgin Susleyici Duman Co-author: Fatma Kaya Dag˘ ıstanlı, Meliha Koldemir, Kag˘ an Zengin, ¨ ztu¨rk, Mustafa Tas¸kın Figen Esin Kayhan, Penbe C ¸ ag˘atay, Eren Tas¸kın, Melek O

Presenter: Vicente Silvestre1 Co-authors: Mario Ruano 2 , Elena Aguirregoicoa 2 , Laura Criado 2 , Yolanda Duque L 2,A´ ngel Marco3 , Gonzalo Garcı´a-Blanch 1 1

.- Department of General and Gastrointestinal Surgery; Biochemistry;3.- Department of Endocrinology

P165 Effects of Resistin Gene Expression Over Adiposity

Marmara University, Faculty of Science and Arts, Department of Biology, ˙Istanbul, Turkey

2.

- Department of

Hospital Universitary of Mo´stoles.Mo´stoles. Madrid (Spain) Introduction In Spain according recent estimates of the World Health Organization (WHO)15.6 % of men and 15.4 % of women suffer morbid obesity (MO). Bariatric surgery is the mostcommonly employed therapy in these patients. However, this surgery is associated withsignificant nutritional abnormalities. The objectives of the present study are: 1) evaluate beforesurgery the alterations in plasmatic levels of nutrients in MO patients; 2) analyze changesproduced after surgery and 3) its evolution in the medium and long term. Material & Methods We have retrospectively evaluated the data from 360 MO patientsoperated in our hospital. The mean age was 38.6 years (range: 1662). Before surgery and 6,12, 24, 60, and 120 months after it we collected anthropometric measures and the plasmaticlevels of nutrients. Results Before surgery the mean (SD) values of body mass index (BMI) were 46.4 (6.5) andwaist circumference (WC) 119.6 (18.4). We found decreased plasmatic levels of proteins,potassium, iron, zinc and vitamin D3, that increase or decrease during the first 6 months aftersurgery. During this time rates BMI and WC begin to decline. Between 24 months after surgerythe values of nutrients reach reference ranges; situation which is maintained at 60 and 120 months. In this period rate BMI correspond overweight and abdominal obesity disappears. Discussion and Conclusions The results suggest the usefulness of metabolic surgery fortreatment of morbid obesity, but require strict control biochemical of patient’s prior surgery andfor long periods. P164 Gastric Bypass in a Patient of Morbid Obesity with Wilson’s Disease – An Unexpected Benefit of Bariatric Surgery in Metabolic Liver Disease Presenter: Dr Shalabh Mohan Co-authors: Dr Atul NC Peters, Dr Yogesh Gautam Inst of Bariatric and Minimal Access Surgery, Primus Super Speciality Hospital, New Delhi Non alcoholic steatohepatitis (NASH) and progression to liver disease and cirrhosis is an increasingly common disorder as the incidence of obesity increases across the world. Apart from obesity, there are several other metabolic diseases causing NASH – Wilson’s disease being one of them. It is a rare autosomal recessive disorder characterized by an abnormal gene expressing protein ATP7B – an important regulator of copper metabolism. This leads to accumulation of excessive copper in the body tissues – notably liver, brain and kidneys. Treatment is directed towards blocking copper absorption from the duodenum and proximal small bowel, and chelating the excess copper stores on the liver. We present an unusual case of a young lady with morbid obesity (BMI – 54.1 kg/m2) who suffered from Wilson’s disease since childhood. She was on trientene hydrochloride – a copper chelating agent, and ursodeoxycholic acid.

Background Resistin is an inflammatory biomarker from macrophages modulating insulin actions. The aim of this study was to demonstrate site-specific adipose tissue resistin gene expression differences in individuals with and without type 2 diabetes. The relationship between conventional drug therapy and adipose tissue resistin expression was also determined. Methods Paired omental and subcutaneous adipose tissues were excised during elective surgery from morbidly obese (n010) and obese (n05) patients. Resistin mRNA gene expressions were determined by qPCR. All the tissue sections also were analyzed for their resistin and CD68 protein expressions by immunohistochemistry. Results Omental and subcutaneous adipose tissue resistin expression levels were not found to differ significantly among morbidly obese and obese study groups. The omental adipocytes resistin expressions were found to increase with macrophage number both in the omentum and subcutaneus fat. The omental and subcutaneous resistin expressions were found to be in positive correlation. As the omental adipocytes radius decreased, the macrophage number increased in subcutaneous fat. In the omentum the adipocytes diameter and areas increased, in correlation with macrophage number. The antidiabetic drug use was found to increase adipocyte size both in the omentum and subcutaneous fat. Conclusions The higher resistin gene expression in the omental fat may induce the increase in size and number of adipocytes, thus leading to elavation in omental fat mass. P166 Comparison of Direct and Indirect Measurements of Intra Abdominal Pressure in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery – A Prospective Controlled Clinical Study Presenter: Ahmad Mahajna, M.D Co-authors: Michal Mekel M.D, Bishara Bishara, M.D, Ahmad Assalia, M.D Department of General Surgery , Rambam Medical center and The Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel Objective to confirm the correlation between intra-abdominal pressure (IAP), gastric pressure (GP) and urinary bladder pressure (UBP) in morbidly obese patients (BMI>40) at normal and elevated levels of IAP in two positions, supine and 45 degree anti-trendelenburg. In addition, to examine the effect of increase in IAP and change in position on hemodynamic and respiratory parameters in those patients. Methods and Patients A prospective controlled clinical study including fourteen morbidly obese patients aged>18 years with BMI>40 who underwent laparoscopic bariatric surgery was conducted. Results In supine position; while a direct IAP of 7.8 mmHg was measered, pressure of 10+ 1.2 mmHg and 10+ 1.1 mmHg were measured in the stomach and the bladder, respectively. Increase of IAP to 15 mmHg resulted in increase of the GP and the UBP to 17 + 1.1 and 14.8 + 1.4 mmHg, respectively. Similar results were measered after tilt of 45 degrees anti-trendelenburgposition. In supine position increase in IAP to 15 mmHg, resulted in rise in mean inspiratory pressures (MIP) and peak inspiratory pressures (PIP) from 11+

OBES SURG (2012) 22:1315–1419 0.5 mmHg and 27 + 0.3 mmHg to 12.5 + 0.7 and 31 + 0.6 mmHg (p < 0.05)mmHg, respectively. After tilt of 45o similar increase of IAP resulted in rise of PIP from 24+1.1 mmHg to 28+1.2 mmHg (p00.05) Conclusions we found that baseline IAP is high in morbid obesity patient and we achieved a good correlation between the direct IAP measured by laparoscopic insuflation route and urinary bladder and gastric measured pressures in morbidly obese patients at normal and elevated levels of IAP. change of the patients position from supine position to 450 anti-trendelenburg position causes decrease of the mean and peak inspiratory pressures while increasing the tidal volume. P167 Accuracy of Intravenous Contrast-Enhanced Computed Tomography Scan for the Diagnosis of Internal HerniaafterGastric Bypass Presenter: Nicola´s Quezada Co-author: Alex Jones, Carlo Marino, Julia´n Herna´ndez, Aron Kuroiwa, Alex Escalona, Gustavo Pe´ rez, Fernando Crovari, Ricardo Funke, Fernando Pimentel, Camilo Boza. Digestive Surgery Department, Division of Surgery. Ponthifical Cattholic University of Chile. Satiango, Chile Introduction Acute Small bowelobstruction (ASBO) has a frecuency of 2-10 % aftergastric bypass and internal hernia through open mesentericdefectsisthe principal cause. The diagnosis of ASBO isclinicalbut CT scan can be helpfull in determinigthe cause of obstruction. Aim To determine the role of iv-contrast-enhanced CT in the diagnosis of internal hernia inpatientsgoingtotheemergency department dueto ASBO. Methods A retrospectiveanalisys of 80 operatedpatientswith ASBO with CT scanperformed in theemergencysetting.Wecalculatedsensitivity, especificity, Positive and Negative PredictiveValue for the diagnosis of internal hernia, with the surgical findings as the gold standard. Results 52 of 80 patients operated had interna hernia, 26 had positive CT and 26 hadNegative CT, calculating a sensitivity of 50 %. Therewere 38 patientswithother diagnosis and CT scanreported 11 internal hernias, calculating a especificity of 60 %. Positive and negative predictive values were 70 and 30 %, respectively. Conclusions Intravenous contrast-enhanced CT has a limited role in determining internal hernia as the cause of ASBO.Thus, clinical judgment should be the principal tool in determiningto operate a patient with gastric bypass and ASBO. P168 Homocysteine After Laparoscopic Roux-en-Y Gastric Bypass – Long Term Follow-Up Presenter: Marcus Poglitsch Co-authors: Ronald Kefurt, Gerhard Prager Institution : Medical University of Vienna, Department of Surgery, Australia Background Homocysteine is an important risk factor for predicting cardiovascular diseases. However, changes in the homocysteine levels following bariatric surgery remain controversially discussed. Study design: 100 consecutive bariatric surgery patients (77 % female, 23 % male, mean BMI 48 kg/m2 preoperatively) underwent laparoscopic roux-en-Y gastric bypass between 2005 and 2006 and were retrospectively evaluated for changes in their homocysteine levels at the timepoints preoperatively, at 3, 6, 9, 12, 18, 24, 36, 48, 60, 72, and 84 months postoperatively (mean follow-up: 45 months). Results Hyperhomocysteinaemia was present in 11 % preoperatively. The mean homocysteine level was 9.6 mol/l preoperatively, 12.2 mol/l at 3, 11.5 mol/l at 6, 10.7 mol/l at 9, 10.4 mol/l at 12, 10.4 mol/l at 18, 9.2 mol/l at 24, 9.0 mol/l at 36, 9.6 mol/l at 48, 9.8 mol/l at 60, 10.0 mol/l at 72 and 12.2 mol/l at 84 months postoperatively. Applying a paired t-test revealed significantly higher homocysteine levels at 3 (p00.0001) and 6 months (p00.001) postoperatively than preoperatively. After subdividing the study population in morbidly obese (Group A, n065, BMI<50 kg/m2) and superobese (Group B, n035, BMI>50 kg/m2) these findings remained. For group A the timepoint 3 months (p00.003) postoperatively and for group B the timepoints 3 (p00.001), 6 (p00.003), 9 (p00.047), 12 months (p00.039) postoperatively were significantly higher regarding homocysteine than preoperatively.

1411 Conclusion Laparoscopic roux-en-Y gastric bypass leads to significantly higher homocysteine levels in the early postoperative period. This effect is prolonged in superobese. P169 Metformin Attenuates Hypoglycaemia Resulting From Late Dumping Syndrome Presenter: Mr girish Bapat Co-authors: Dr Shrihari Dhorepatil Dr. C. Rajeswaran Apollo- Jehangir Hospital, Sasoon Road, Pune, India & Mid Yorkshire NHS Trust, Halifax road, Dewsbury, UK Introduction Dumping syndrome is a recognised side-effect following gastric bypass surgery. The anatomical rearrangement following surgery, disrupts stomach storage function, emptying mechanism, and physiological production of gastrointestinal and pancreatic hormones in response to oral intake. Late dumping syndrome occurs 1-3 hours after meal. This is due to hyperinsulinaemic response due to rapid absorption of simple carbohydrates in the proximal small bowel resulting in late hypoglycaemia. Methods We present three patients who underwent Roux-en-Y gastric bypass for morbid obesity. They presented with severe late dumping syndrome. They continued to be symptomatic with change in eating habits and low glycaemic index food. They were therefore treated with metformin. There was a significant reduction in the incidence of reactive hypoglycaemia associated with dumping syndrome. Discussion Metformin is a biguanide used in Type2 diabetes. It acts primarily by decreasing hepatic gluconeogenesis, suppressing appetite, increasing fatty acid oxidation, enhancing insulin sensitivity and peripheral glucose uptake. Effects of metformin on the intestine are less known. Evidence from the animal studies indicate that metformin, delays intestinal glucose absorption, increase anaerobic glucose metabolism in the intestine preventing hyperglycaemia. The precise mechanism by which metformin ameliorates the degree of symptomatic hypoglycaemia experienced by our patients remains unclear. It may be due to metformin related reduction in the insulin surge. It is possible that a combination of its action in the intestine and/or its earlier plasmatic peaks, likely to occur in the accelerated gastric emptying may contribute to reduced postprandial hyperglycaemia. This results in lowering the exaggerated hyperinsulinaemic response seen in late dumping syndrome. Conclusion Metformin can be an alternative therapeutic option, in patients with refractory symptoms on standard treatment or who cannot tolerate somatostatin analogues. However, randomised, prospective trials are required to clarify its value in dumping syndrome. P170 Breaking the Link Between Cancer and Obesity with Surgery Presenter: Cynthia Buffington PhD Co-authors: Keith Kim, MD Florida Hospital Celebration Health, United States of America Introduction Cancer is the leading cause of death worldwide. The risk for and mortality from specific types of cancer are significantly increased with obesity, particularly morbid obesity. In this literature review, we examine the link between cancer and obesity and the salutary benefits of bariatric surgery on cancer and obesity-associated causes. Methods A literature review was performed on: 1) epidemiological findings of cancer risk and mortality with increasing BMI or abdominal fat, 2) clinical data pertaining to metabolic/hormonal conditions of obesity that contribute to cancer initiation, growth and progression, and 3) studies of the effects of bariatric surgery on cancer occurrence and mortality. Results Obesity and abdominal fat distribution are associated with an increased risk for and mortality from various types of cancer, including colorectal, endometrial, postmenopausal breast, esophageal, gallbladder, kidney, pancreatic, liver, thyroid, ovarian, non-Hodgkin’s lymphoma, multiple myeloma, leukemia, and possibly prostate. Epidemiological studies find that surgical weight loss significantly reduces the incidence of cancer by more than 30 % and lowers cancer-related mortality by as much as 60 %. Surgery-induced reduction of cancer occurrence and mortality result, in part, from the improvement or resolution of metabolic/hormonal conditions responsible for cancer

1412 initiation, growth and development. These include: insulin resistance, hyperinsulinenmia, elevated IGF-1, altered sex hormone metabolism, chronic inflammation, leptin, low adiponectin, plasminogen-activator inhibitor 1, oxidative stress, low AMPK, more. Conclusions Obesity is linked to cancer via a number of obesity-related hormonal/metabolic conditions involved in cancer initiation and progression. Bariatric surgery improves or resolves these conditions along with highly significant reduction in cancer risk and mortality. P171 Improvement in Glucose Metabolism After Bariatric Surgery in Patients with BMI>35: Comparison of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy Presenter: Dr.Mohamed Ismail (1) Co-authors: Dr.Sreejth Nair (2) Dr.NM Mujeeb Rahman (3) Dr.Mahesh Rajagopal (4) Dr.Mohammed Shareef (5) Dr.Hafees Ansari (6) Chief Surgeon, Moulana Hospital Perinthalmanna, Kerala, Asst. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna,Kerala2,4,5,6 – Consultant Surgeons, Dept. of GI, Bariatric & metabolic Surgery, Moulana Hospital, Perinthalmanna, Kerala3- Asso. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna, Kerala Aim The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. However diabetic patients with BMI >35 were also found to have control of diabetes after sleeve gastrectomy Method In a retrospective study 69 patients with BMI >35 underwent either of the two procedures. There 30 patients in the Laparoscopic Sleeve Gastrectomy arm (LSG) and 39 patients in the Roux en Y Gastric Bypass (RYGB) arm.The primary outcome was remission of T2DM (fasting glucose <126 mg/dL and HbA1c <6.5 % without glycemic therapy). Secondary measures included loss of weight and resolution of metabolic syndrome. Results The resolution of diabetes in both arms were comparable with about 95%resolution in both arms. Conclusion Both LSG and RYGB are effective surgeries in the treatment of diabetes mellitus in obese patients with BMI>35

OBES SURG (2012) 22:1315–1419 P173 Laparoscopic Adjustable Banded Sleeve Gastrectomy As A Primary Procedure For The Super-Super-Obese (Body Mass Index>60 kg/m) Presenter: Dr. F. Goudsmedt Co-author: Dr. F. Akin, Dr. A. Warsi, Dr. S. Van Cauwenberge, Dr. B. Dillemans Institution :AZ Sint-Jan Brugge-Oostende AV, Belgium Introduction Isolated laparoscopic sleeve gastrectomy is increasingly being used for the treatment of morbid obesity. However, doubts still persist regarding long-term weight loss and complications. Whether the aetiology of failed excess weight loss is the result of an inadequate sleeve or attributable to dilatation of the sleeve is still unclear. Materials and Methods In an effort to prevent gastric dilatation and increase gastric restriction to promote further weight loss in the long term; we performed a combined procedure of laparoscopic adjustable banding with sleeve gastrectomy. The patient was a 39-year-old woman with a life-long history of obesity and a BMI of 79.8 kg/m2. The surgical technique of the laparoscopic adjustable banded sleeve gastrectomy is described with a video presentation. Results There were no immediate complications. At 1 year follow-up the patient’s BMI dropped to 54.4 kg/m, and the band was inflated. Three months after inflating the band, the patient’s BMI went down to 50 kg/m. At this time the patient experienced mild reflux complaints. At 2 year follow up, 1 year after inflating the band, the patient was doing very well. De reflux complaints were significantly reduced, vitamin B12 level remained stable with oral substitution. Most importantly further weight loss was achieved resulting in a BMI of 47 kg/m (40.7 % weight loss). Discussion The laparoscopic adjustable banded sleeve gastrectomy as a primary operation is a feasible procedure leading to promising weight reduction. To provide definitive conclusions regarding the long-term benefits and complications, more patients with a long-term follow-up are necessary. P174 Early Dumping Syndrome in Adults and Adolescents Following Roux-en-Y Gastric Bypass: Validation of the Dumping Symptom Rating Scale Presenter: Anna Laurenius Co-authors: Torsten Olbers, Ingmar Na¨slund, Jan Karlsson

P172 Early Results of Metabolic Surgeries in Patients with BMI <35 at Rural Indian Hospital

Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden

Presenter: Dr.Mohamed Ismail (1) Co-authors: Dr.Sreejth Nair (2) Dr.NM Mujeeb Rahman (3) Dr.Mahesh Rajagopal (4) Dr.Mohammed Shareef (5) Dr.Hafees Ansari (6)

Introduction There is a lack of prevalence data on the early dumping syndrome (DS) and of Methods that can measure and discriminate between different symptoms of the DS. Material & Methods A self-assessment questionnaire, the Dumping Symptom Rating Scale (DSRS), was developed.The aim was to measure the severity and frequency of nine dumping symptoms and to evaluate the construct validity of the DSRS. 47 adults and 82 adolescents completed the DSRS preoperatively and postoperatively at one and two years. Cognitive interviewing was performed. Reliability and construct validity was tested. Effect sizes of changes were calculated. Results Patients found the questionnaire relevant. A high proportion of the respondents reported no trouble at all (floor effects) for most symptoms. However, 12 % stated quite severe problems or worse for fatigue and half of these were so tired that they needed to lie down after meal. Also, 9 % of the adolescents indicated quite severe problems or worse of nausea. The internal-consistency reliability was adequate for both the severity (0.81-0.86) and frequency (0.760.84) scales. Test-retest reliability for items of the severity and the frequency scalesranged from 0.34-0.94 and0.27-0.94, respectively. Effect sizes were small since subjects experienced symptoms already preoperatively. Conclusion Although a largepercentage of subjectsstatedno ormilddumpingsymptoms, a small groupof Roux-en-Y gastric bypass patientshadpersistentsymptoms, in particular of postprandialfatigue,need tolie down, and nausea. The Dumping Symptom Rating Scale can be used as a screening tool to identify these patients.

Institution :Chief Surgeon, Moulana Hospital Perinthalmanna, Kerala, Asst. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna,Kerala 2,4,5,6 – Consultant Surgeons, Dept. of GI, Bariatric & metabolic Surgery, Moulana Hospital, Perinthalmanna, Kerala 3- Asso. Prof. Dept. of Surgery, MES Medical College, Perinthalmanna, Kerala Aim To assess and compare the results of four surgeries- Laparoscopic sleeve gastrectomy (LSG) , LSG+Standard ileal interposition, LSG+Diverted ileal interposition and LSG+Duodeno jejunal bypass,in the control of type II diabetes mellitus. Method In a prospectively controlled trial 29 patients suffering from Type II diabetes mellitus were subjected to one of the four metabolic surgeries. The trial was registered at the national clinical trial registry of India (CTRI/2010/ 091/002938). The patients were selected for the surgery after preoperative special investigations like serum C-peptide, serum Insulin, Anti-islet cell antibody, Anti GADA antibody, HbA1c.Only patients with BMI<35 were included in the study. Results Out of the 29 patients 20 patients (70 %), were off diabetic medications,5 patients (17 %) were on decreased dose of insulin , 3 patients (10 %) were on oral hypoglycemic and in one patient there was no response after the surgery. Out of 8 patients with more than one year follow-up 5patients (62.5 %) were on remission. Conclusion Our preliminary observations demonstrated the feasibility, safety, and efficacy of these novel surgical procedures in type 2 diabetes. Further long-term data from more patients are necessary to confirm these findings.

P175 Initial Results at a Bariatric Certified Excellence Center Presenter: Hyun Jung Choi Co-authors: Yong Jin Kim Soonchunhyang university hospital, Korea (south)

OBES SURG (2012) 22:1315–1419 Background The aim of Bariatric Surgery Centers of Excellence (BSCOE) is to standardize surgical outcomes among different bariatric groups, creating safety measures and efficiency standards. The Obesity Clinic at the ABC Medical Center represents the first regional center of training and consultancy for novel Bariatric surgical groups. In this context, our results must adjust to international standards and at the same time represent a reference for the development of bariatric surgery in our country. The aim of the study is to analyze our initial surgical outcomes as Bariatric Surgery Center of Excellence. Patients and Methods The prospectively constructed data base and the medical records of all patients undergoing to bariatric surgery were reviewed. Demographics, surgical details, results and complications were analyzed. Results There were 400 patients, 340 primary bariatric procedures and 60 revisional surgeries, 188 females and 212 males with a mean age of 40.2± 11.8 years (r015-74). Mean BMI was 41.8±6.7 kg/m2 (r022–71.7). Principal operation was RYGBP in 329, gastric sleeve in 11 patients and there were 60 cases with any type of revisional surgery. There were 3 conversions to open surgery (one in primary surgeries) and 11 cases of initial open surgery (no one in primary surgeries). Twenty two patients presented major surgical complications and 9 re-operated cases (three in primary surgery) Overall hospital stay averaged 2.5 days (r 01-30) and mean global surgical time averaged 149 minutes(r 075-480). There was no mortality in this study. Conclusions Our initial results are comparable to BSCOE´s references. P176 International Bariatric Club – a Worldwide Web Educational Medium for Bariatric Surgeons Presenter: Tomasz Rogula Co-authors: Haris Khwaja, Marius Nedelcu, Mervyn Deitel, Philip Schauer International Bariatric Club, Cleveland Clinic, Ohio, USA The International Bariatric Club (IBC) is a free, non-profit making organisation established in 2008 with currently over 500 members. It is open to all bariatric surgery/medicine professionals and is easily accessible via the internet to registered participants. The club through its social media page, website, live webinars and non-virtual meetings promotes and exchanges knowledge, ideas and experiences related to the pre-operative, intra-operative and post-operative care of the bariatric patient with bariatric professionals throughout the world. Bariatric surgery videos relevant to the management of intra-operative and post-operative complications can be uploaded as well as promotion of the monthly webinar in association with WebEx conferencing. The webinars provide an opportunity for all members of the IBC to listen and/or see a high quality presentation by a national/international expert in bariatric surgery with the chance to ask questions to the speaker. These lectures are also recorded and so can be watched anytime. Global non-virtual activities include promotion and involvement in national and international meetings relevant to bariatric & metabolic surgery. Currently, efforts are being concentrating on maintaining the high standard of monthly Webinars with an increasing number of live webinars from the operating theatre. The IBC website launched in March 2012 allows any bariatric professional easy access to the latest IBC activities, video library and newsletter. We believe the activities of IBC represent the future of global education and its activities are likely to be mirrored in other medical specialities. P177 Evaluation of Personality Disorders in the Relationship with Food: A Selection Strategy For Surgery Bariatic Presenter: Antoniomaria Salzano Co-authors: Bartolo Cassaglia, Maria Elena Giuliano, Pietro Maida Institution :Ospedale Evangelico Villa betania, Italy Introduction Many people live with pain and depression the relationship with her image. When your perception does not match with the image of the body you want, you potentially generate feelings of frustration and dissatisfaction related to specific personality traits may be translated into form spsicopatologich. The contrast ratio of the individual against his own body image is a feature of eating disorders and obesity phenomenon, is very important to consider this phenomenon also from a psychological point of view(Obesity

1413 psychogenic), which is to be understood as the "condition in which food is to represent: a strategy to alleviate anxiety and depression every day and one way to resolve frustrations and disappointment” a noun of the emotionalaffective loneliness; autoconsolatorioan act in front of a feeling of emotional abandonment and rejection by the outside world. Therefore, the weight increase of the weight, leads many obese subjects to request to be subjected tobariatric surgery, considered by them as the only form of effective treatment that allows a reduction of body weight. Materials and Methods The research sample, recruited in the three-year periodbetween2009 and2012, is composed of 228 subjects suffering from morbid obesity (BMI between 35 and70), candidates for bariatricsurgery. Patients appear to be178 women and 50 men (Table 1) with a mean age of the men of29.88(SD9:59) and women of31.81(SD8.70). The hypothesis of the study is to explore and address the ’presence of a personality disorder in relation to’ existence of DCA and organize a possible intervention strategy and/or psychotherapeutic treatment. Particular attention has been devoted to analyzing the personality traits and specific food issues. Specifically, the age of obese men ranges from a minimum of 18 years to a maximum of 55. Their average age was 29.88 (SD9:59), while the age of the obese women and from 15 up to56 years. Their average age is31.81 (d.s 8.70). Toolsusedfor the survey are: - The SCID-II (First, Spitzer, Gibbon, Williams, Benjamin Smith, 1997), ie the structured clinical interview for Axis II disorders of DSM-IV (personality questionnaire): -EDI-2 (Garner, 1990), used for the evaluation of the multidimensional psychological characteristics relevant to anorexia and bulimia. Results The analysis statistics of the data has been carried out using statistical program SPSS version 17,0 for Windows. Al fine to estimate which personality features were mainly present in the men and in the women of the present study, it has been carried out an analysis of the frequencies on the scores brought back from every participant on the scales of the SCID-II Moreover in order to examine the existing relation between personality features and problematic foods, it has been carried out an analysis of the Variance Univariata (ANOVA), in which it has been independent variable mail like (YOU) the features of personality of the SCID-II expressed on two levels: presence/ absence; while variable employee (the VD) are given from the scales of the EDI-2. The analyses have been separately lead for the obese subjects females and males. P178 Obesity Psychology and Food: an Integrated Team Approach Presenter: Antoniomaria Salzano Co-authors: Bartolo Cassaglia, Maria Elena Giuliano, Pietro Maida Ospedale Evangelico Villa betania, Italy Introduction Obesity has been recognized on the list of diseases and has been called a chronic multifactorial multigene component which environmental factors can intervenire to determine the clinical expression. Therefore the issues related to dysfunctional eating habits were the subject of several studies and researches in the field of psychology that have attempted to identify personality traits and relational styles linked to a dysfunctional eating behavior. Materials and Methods Our study aims to understand and monitor the different psychological factors that contribute during the whole procedure, surgical therapy. The clinical intervention is organized and structured in two phases. The first is dedicated to the evaluation of the psychodiagnostic pcs., The second focused on the emotional content in order to increase the index of psychological well-being. PHASE I Psychodiagnostic assessment involves the administration of: § SCID - II (clinical questionnaire for axis II disorders of DSM-IV); § CDQ - Self-Assessment Questionnaire; § Eating Disorder Inventory EDI-2 - 2. The clinical interview is aimed at assessing the psychological motivations, awareness and information of the route surgical treatment. PHASE II After surgery, the pc. followed, with a specific protocol of psychological intervention in the outpatient clinical psychology. them instruments used to monitor the mental state of the pieces are: § S.T.A.I. is a tool for the detection and measurement of anxiety; § CDQ IPAT depression scale. This scale assesses a personality disorder, depression, which most often comes in disguised form

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§ PHQ (Questionnaire on psychological well-being) In addition there is a therapeutic course dedicated to contain and manage any psychopathological dynamics. Conclusions So far they have been reviewed more than 150 patients, of whom a majority said, at a distance of time, become unable to manage effectively and peacefully winning the weight loss achieved through surgery. The excitement of losing weight quickly leave the place with the difficulty of being able to keep the pounds lost. This difficulty is due to the maintenance of a dysfunctional approach to food, especially mental in nature. The justification related to weight control is reflected in a context that is pursued with great difficulty, thereby demonstrating the need to accompany the piece with a supportive psychotherapy during the long process of post-operative. The psychotherapeutic approach, in addition to ensuring the containment of the anxieties and frustrations related specifically to the relationship with food, must focus on the management of certain problem areas that have often emerged from the interviews and scores on the instruments used. In particular, the stretch passive-aggressive, obsessive-compulsive and paranoid personality are some of the most easily seen in obese patients. The study found that the desire to regain a better body image is associated with feelings of inadequacy and social dissatisfaction, feelings occurred more often among young pcs.

mean age of 48.5 and mean BMI 47.37; 17 DS with mean age of 47.8 and mean BMI 47.43; and 13 VG with mean age of 44.46 and mean BMI 50.72. The variables were age, BMI and BMI Excess Loss, biochemical determinations were calcium, PTH, 25-hydroxyvitamin D and IGF-1. All these results were compared between baseline and one year after surgery and analyzed with bone mineral densitometry one year after surgery. Results The PTH, 25-hydroxyvitamin D and IGF-1 determinations prior and one year after surgery were no significant differences (p00.36, p00.37 and p0 0.77 respectively). The prevalence of osteopenia was 10.3 % in BPG, 26.7 % in DS and 14.3 % in VG but there were no statistical differences between surgical techniques. Conclusion Comparing BPG, DS and VG we found no significant differences in bone mineral density one year after surgery and baseline. The distributions of patients with normal and pathological densitometry were similar in all three groups. We found no correlation between surgical technique and levels of calcium, PTH, calcidiol or IGF-1.

P179 The Impact of Satiety Hormone on Weight Loss with the EndoBarrier

Presenter: M. Korenkov1 Co-authors: J. Heimbucher2, S. Saad3, H. Zuehlke4

Presenter: C. de Jonge Co-authors: S.S. Rensen, F.J. Verdam, R.P. Vincent, S.R. Bloom, M.A. Ghatei, W.A. Buurman, C.W. le Roux, N.D. Bouvy, J.W.M. Greve

1

Maastricht University Medical Center, Netherlands Background Bariatric procedures that exclude the proximal small intestine lead to significant weight loss. Satiety hormones such as Glucagon-like peptide-1 (GLP-1), peptide YY (PYY), ghrelin, and leptin are thought to play a major role in this process by slowing gastric emptying and reducing food intake. The EndoBarrier, a novel endoscopic duodenaljejunal bypass liner (DJBL), has been shown to be effective in treating obesity. We investigated the effect of DJBL treatment on hormones that play a role in satiety in relation to weight loss. Methods Seventeen obese patients (BMI 30-50 kg/m2) with type 2 diabetes mellitus received the DJBL for 24 weeks. GLP-1, PYY, and ghrelin levels were analyzed after a standardized meal before implantation of the device as well as, 1 and 24 weeks post-implantation. At these time points, fasting leptin levels were also analyzed. Results Twenty-four weeks post-implantation, patients had lost 12.7±1.3 kg (p< 0.01). As early as one week after implantation, post-prandial GLP-1, PYY, and ghrelin levels were increased (GLP-1: 4,440±249 vs. 6,407±480pmol/L/min, PYY: 2,584±154 vs. 4,084 ±418pmol/L, ghrelin: 7,881±1,783 vs. 11,042± 1,807 pg/mL/min, all p<0.05). Fasting leptin levels decreased reaching statistical significance at week 24 (98.4±16.5 vs. 83.1±16.7 ng/mL, p<0.05). Conclusions DJBL treatment appears to cause weight loss by affecting satiety via triggering of the ileal-brake, as indicated by the increase of GLP-1 and PYY levels. Fasting levels of the adipose derived satiety hormone leptin reduce after implantation of the DJBL. Interestingly, ghrelin levels increase, likely due to reduced caloric intake. P180 Bone Mineral Density in Bariatric Surgery. Comparative Study of Gastric Bypass, Duodenal Switch and Vertical Gastrectomy Presenter: Amador Garcı´a Ruiz de Gordejuela Co-authors: Jordi Pujol Gebelli, Anna Casajoana Badı´a, Almino Ramos, Manoel Galvao, Gustavo Rodrigues, Alfredo Sadowski Institution: Hospital Universitari de Bellvitge, Spain Introduction Morbid obesity is associated with a decrease of 25hydroxyvitamin D concentration and increase of parathyroid-hormone (PTH). These metabolic disorders can be aggravated by malabsorptive/mixed bariatric techniques. The objective was to compare changes in bone metabolism and bone mineral density after gastric bypass (RYGP), duodenal switch (DS) and vertical gastrectomy (VG). Methods A descriptive study of our prospective database. The subjects were 70 women, and the IBM of 45-55Kg/m2. There were 40 RYGP with

P181 “Classification of Intraoperative Status of Difficulty as a Component of Individual Based Metabolic Surgery”. Experience of Four German’s Clinics

Department of General and Visceral Surgery, Teaching Hospital University of Goettingen, Eschwege, Germany 2Department of General and Abdominal Surgery, Marienkrankenhaus Kassel, Kassel, Germany 3Department of Abdominal and Thoracic Surgery, Teaching Hospital University of Cologne, Cologne, Germany 4Department of General, Visceral and Abdominal Surgery, Evangelisches Krankenhaus Wittenberg, Lutherstadt, Germany It generally is surprising that there is an ubiquitous risk classification of anaesthesiology risk (ASA), but no equivalent exists in surgery. We propose to classify patients according to intraoperative difficulty (I to IV) as: I. - ideal cases (i.e. easy to operate, no problems), II. - not quite ideal cases (some minor difficulties may occur), III. - problematic cases (difficult to operate, some operative techniques are considerably more difficult than others), and IV. - very difficult cases (every operative step is difficult). This classification was validated in four German’s clinics and can be used for pre- and intraoperative assessment of patients. We define also the difficult surgical situation as every intraoperative surgical problem, which increases the likelihood of intraoperative and postoperative complications. In a difficult surgical situation, the surgeon gets into dilemma whether to continue the intended operation “at all costs” or to deviate from the initially planned surgical procedure to some alternative technique or procedure. Choosing the first option can increase the risk of intra- and postoperative complications. The consequence of the second alternative might be a lower risk of short-term complications but at the expense of worse results in the long-term. The dilemmatic nature of the difficult surgical situation has motivated us to discuss the following aspects: Standards in laparoscopic surgery, the deviation from standards, the role of experts, and the focus of research. We also propose the establishment of a registry of difficult surgical situations including the possibilities to deviate from the standard. Scientific analyses of such registries should focus on patients with apparent modifications in treatment (“process deviations”), but might also look at those with surprisingly good or bad results (“outcome deviations”). This will help to explore possible alternatives to the standard therapy and to assess their effectiveness in specific subgroups. P182 Three Year Experience of the Diagnosis and Management of Pouch Dilatation and Slippage After Laparoscopic Adjustable Gastric Banding in a Cohort of 126 Morbidly Obese Korean Patients Presenter: Seong Min Kim Co-authors: Jung Nam Lee, Woon Kee Lee Department of Surgery, Gil Medical Center, Gachon University of Medicine, Incheon, Korea (South) Purpose Pouch dilatation and band slippage are known as the most common long-term complications after laparoscopic adjustable gastric banding

OBES SURG (2012) 22:1315–1419

1415

(LAGB). The aim of the study is to present our experience of diagnosis and management of these complications. Material and Methods From March 2009 to March 2012, we have performed LAGB on 126 morbidly obese patients. Pars flaccida technique with anterior fixations of gastric fundus was routinely used. All band adjustments were performed under fluoroscopy. We analyzed the incidence, clinic-radiologic findings, management, and revisional surgeries. We further presented the outcome of gastric plication techniques as a preventive measure of these complications. Results Among the 126 patients, 14 patients (11.1 %) were diagnosed to have pouch dilatation/band slippage. Four patients had concentric pouch dilatation, which was corrected by band adjustment only. Ten patients had eccentric pouch dilatation associated with band slippage. Among the ten patients, there were three posterior slippages which were corrected by reoperation. There were seven anterior slippages with eccentric pouch dilatation. Three were early anterior slippage which was conservatively managed. Two were acute anterior slippage. One of them underwent a band replacement. Two were chronic anterior slippage. One of them underwent a band replacement. The 27 patients with gastric plication did not present eccentric pouch dilatation with band slippage during the follow-up period. Conclusion The incidence of pouch dilatation with/without band slippage in our study was 11.1 %. The management should be individualized according to the clinic-radiologic patterns in these patients. Gastric plications below the band might prevent these complications.

in order to mimic the effect of duodenal exclusion of the roux-y-gastric bypass. After successful animal studies an open labeled, prospective, single-arm, non-randomized multicentre study for diabetic obese patients was created. At baseline the patients mean age was 46.6 years, mean BMI was 43 kg/m and mean HbA1c was 8.4 %. During the one year follow up there was neither mortality nor major morbidity nor device depending severe adverse events occured. Nine out of the twelve patients were included in the analysis. The mean HbA1c dropped by 1 % and the fastening blood glucose reduced by 20 % after the 12 months follow up. The increase of postprandial blood glucose is slower under DES than at baseline marginal not significant (p00.061). Cardiovascular parameters (HDL and triglycerides) were improved. There was a EWL of 8 % at the end of follow up. DES is a feasible and safe technique with positive effect on dmt2, body weight and other cardiovascular parameters in diabetic obese patients.

P183 Preoperative Fat-Free Mass: Major Predictive Factor of Weight Loss After Gastric Bypass

Introduction Singapore is a Southeast Asiancity-state off the southern tip of the Malay Peninsula with population of 5.1 million; this country hosts three major ethnic groups including Chinese (77 %), Malays (14 %) and Indians (8 %). The aims of this study are to determine the role of ethnicity in post bariatric weight loss, diabetes control and their outcome. Method All patients who underwent laparoscopic sleeve gastrectomy and gastric bypass from September 2008 to January 2011 were included in this study. Clinico-pathological variables were obtained from bariatric database. Criteria for consideration of surgery includes body mass index (BMI) more than or equal to 37.5 without any co-morbidities or above 32.5 with obesityrelated complications. Results Forty six percent of our patients were Chinese with Malays and Indians account for 27 % each. Malays had highest average preoperative BMI (51.21 kg/m2) and body weight (131.6 kg). Indians lost most weight in 12 months follow-up with 27 % absolute weight lost followed by Chinese (25 %) and Malays (23 %). In term of type II diabetes resolution, Chinese and Malays mean plasma glucose normalized in 3 months follow-up and remain normal at 12 months. On the other hand, Indians mean plasma glucose raise after 6 months to abnormal level at 12 months follow-up. Discussion The reasons for different outcome post bariatric surgery are complex and likely involve an inter-play between genetics, cultural influence and the environment. Understanding these influences and their interaction will allow us to provide a more personalized care for the obese patient.

Presenter: ROBERT Maud (1) Co-authors: Pelascini Elise (1), Disse Emmanuel Laville Martine (2), Gouillat C (1)

(2)

, Poncet Gilles

(1)

,

Department of bariatric and digestive surgery, Edouard Herriot Hospital, Lyon, France, Lyon 1 University, Department of nutrition and endocrinology, Lyon Sud Hospital, Lyon, France, Lyon 1 University Introduction Eight to 40 % of failures are observed after gastric bypass (GBP). The aim of our study was to analyze the predictive factors of weight loss at one year so as to select the best candidates for this surgery and reduce the failures. Material and Method We included 73 patients treated by laparoscopic GBP. We retrospectively analyzed the predictive factors of weight loss in kg as well as excess weight loss in percentage [EWL%] at one year. The population was divided into thirdsso as to compare the sub-group with the highest weight loss, with the sub-group with the least satisfactory results. Results The significantly predictive factors of a better weight loss in kg were: male, higher initial weight (144 kg versus 118 kg, p 00.002), a significant early weight loss and a higher preoperative percentage of fatfree mass (FFM%) (p00.03). A higher FFM% was also associated with a better EWL% (p00.004). The preoperative FFM (in kg) was the principal factor accounting for the weight loss at 1 year regardless of age, gender, height and initial BMI (p<0.0001). There was a better correlation between FFM and weight loss (spearman test, p00.0001) than between initial BMI and weight loss (p00.016). We estimated weight loss at 1 year according to initial FFM using the formula: 0.5 kg of lost weight per kg of initial FFM. Conclusion The initial FFM appears to be a decisive factor in the success of GBP. Thus the sarcopenic patients would appear to be less suitable candidates for this surgery. P184 Can Duodenal Electric Stimulation Cure DMT2 in Diabetic Obese Patients? Report of First In Human Study Presenter :Philipp Busch Co-authors: Jens Aberle, Anna Dupre´e, Stephanie Gros, Radwan Khawaled, Jakob R. Izbicki, Oliver Mann University Medical School Hamburg, Germany Bariatric surgery achieves the best results in weight control and in dmt2 especially for duodenal excluding procedures. A duodenal electric stimulation-system (DES) for laparoscopic implantation was developed

P185 Bariatric Surgery in Multiracial Community Presenter: Chin Hong Lim Co-authors: Pasupathy S, Eng K.H, Tham K.W, Ganguly S, Wong W.K Singapore General Hospital, Singapore

P186 Bariatric Surgery versus Conventional Therapy in Obese Korean Patients: Multicenter Retrospective Cohort Study Presenter: Joong-Min Park1 Co-authors: Yong-Jin Kim2, Seong-Min Kim3, Do-Joong Park4, Sang-Kuon Lee5, Sang-Moon Han6, Jin-Won Kwon7, Kyung-Won Shim 8, Yeon-Ji Lee 9, Yoon-Seok Hur 10 1

Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea2Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea 3Department of Surgery, Gachon University College of Medicine, Incheon, Korea 4Department of Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea 5Department of Surgery, Catholic University of Korea College of Medicine, Seoul, Korea 6 Department of Surgery, CHA University School of Medicine, Seoul, Korea 7National Evidence-based Healthcare Collaborating Agency, Seoul, Korea 8Department of Family Medicine, Ewha Womans University College of Medicine, Seoul, Korea 9 Department of Family Medicine, 10Department of Surgery, Inha University College of Medicine, Incheon, Korea

1416 Background Since the first bariatric surgery in South Korea was performed in 2003, the effect of bariatric surgery has not been compared with non-surgical treatment in South Korea. The purpose of this study was to evaluate the effectiveness and safety of bariatric surgery in severely obese Korean people comparing with conventional non-surgical treatment. Methods We used the retrospective cohort design using medical chart review. The surgery group included 261 subjects who underwent bariatric surgery at seven Korean tertiary medical centers consecutively from Jan 2008 to Feb 2011. The conventional group included 224 subjects who were treated by weight control medication and lifestyle modification therapy during the same periods. Results BMI level was higher in surgery group (mean BMI±SD was 39.0 ±6.2 vs. 34.3± 3.8). The prevalence of diabetes was more frequent in surgery group (39.1 % vs. 12.9 %). The change in weight (%) from baseline at 18 month was significantly higher in surgery group (22.6 %) than conventional therapy group (6.7 %). This pattern was consistent with other outcomes of weight loss such as%EWL and %EBMIL. While 57 %, 47 %, and 84 % subjects recovered from diabetes, hypertension, and dyslipidemia in surgery group, 10 %, 20 %, and 24 % subjects recovered in conventional group respectively. In surgery group, 51 subjects (19.5 %) in surgery group reported 61 complications (23.4 %). Conclusions Bariatric surgery in South Korea had significant effectiveness for weight loss and the recovery from co-morbidity such as diabetes, hypertension, and dyslipidemia when compared with conventional medical therapy with reasonable complication rate. P187 Rapid Improvement of Triglyceride but not Nonesterified Fatty Acid Metabolism May Contribute to Rapid Improvement of Glucose Homeostasis After Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Presenter: Simon Biron Co-authors: Plouude E, Caron-Dorval D, Richard D, Carpentier A, Lebel S, Hould F, Marceau S, Lescelleur O, Biertho l, Moustarah Laval University. IUCPQ (Laval Hospital), Canada Rapid improvement of triglyceride but not nonesterified fatty acid metabolism may contribute to rapid improvement of glucose homeostasis after biliopancreatic diversion with duodenal switch (BPD/DS). Biron S, Plourde CE, Caron-Dorval D, Richard D, Carpentier AC Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Que´bec, Universite´ Laval, Quebec City, Que´bec, Canada BPD/DS is an efficient treatment for severe obesity and type 2 diabetes (T2D). Diabetes remission is reached in over 95 % and improved glucose homeostasis occurs early after surgery. Incretin has been proposed as the major antidiabetic mechanism. However, we found improved NEFA tolerance in response to i.v. lipids occurs after weight loss induced by BPD/DS. The aim was to determine whether improved postprandial NEFA and TG tolerance could also be a mechanism of rapid improvement of glucose after BPD/DS. We recruited 18 patients eligible for BPD/DS; 9 T2D and 9 non-T2D. Patients ingested a standard breakfast test before and on day 3, 4 and 5 after surgery. Blood samplings were taken at fasting and every 30 minutes during 3 h after the meal test to measure glucose, insulin, C peptide, NEFA, TG, GLP-1 and GIP. We quantified energy intake (EI) before and on first days after surgery. Postprandial glycemias was almost normalized in T2D at day 3 and continued to improve up to day 5. EI (2610 kcal/d) dropped in the first day after surgery (84 kcal/d) and increased to day 4 (465 kcal/d). Fasting and postprandial NEFA increased to similar levels in both groups (P00.001). Fasting TG tended to increase in nonT2D subjects and decreased gradually in subjects with T2D (time x group interaction P00.03). Postprandial TG excursion was reduced in both groups (P00.004). Thus, rapid improvement of TG, but not NEFA metabolism, may contribute to early improvement in glucose homeostasis in T2D after BPD/DS.

OBES SURG (2012) 22:1315–1419 Background Surgical management of high-risk morbid obese patient is associated with high morbidity and mortality. We evaluate laparoscopic gastroileal bypass as treatment of high-risk morbid obese patients. Methods 14 high-risk morbid obese patients with gastroileal bypass were prospectively analysed. They had respiratory failure and at least 2 other major comorbidities classified 3-4 inAmerican Society of Anesthesiologists classification (ASA). We perform the gastric reservoir and a gastrointestinal anatomosis with 300 cm of common channel. In a second time we´ll do the proximal loop section and made the ileum anastomosis in 100 cm untill caecus, completing the biliopancreatic diversion. During at least a period of twelve months the patients are evaluated every three months. Results Between April 2004 to 2011, 14 patients (71.4 % female), with average age 50.21 and body mass index 47.13 (44.8-58.3). 35 % of patients were older than 60 years old. The average surgery time was 37 minutes and mean hospital stay 6.42 days, mainly due to the comorbidities management. Early postoperative complications were a heart failure, an urinary infection and a hemoperitoneum. None of them were reoperated and there were no mortality. Mean BMI in 3, 6, 9, 12, 18, 24, 36, 48 and 60 months were 36.3; 33.8; 32.7; 31.6; 30.3; 29.9; 30.2; 29.1; and 28.4 respectively. Conclusions Gastroileal Bypass is a simple, fast and safe technique very suitable in high-risk morbid obese. Weight loss results and significant reduction of major obesity-related comorbidities show this technique as a definitive one, without requiring the second time of biliopancreatic diversion. P189 Patient Support Program in Soonchunhyang Bariatric Surgery Center Presenter: SY Kim Co-authors: HJ Choi, YJ Kim, MJ Kim, KY Hur Metabolic and Bariatric surgery center, Soonchunhyang University hospital (Korea-South) According to the 2011 statistical community health care research which was done by the Ministry of health and welfare showed population rate of obesity (BMI>25) were increased from 22.5 % to 23.3 % with a year in Korea. In this manner, morbid obese patients are increasing steadily not even worldwide but in Korea. There is no doubt to take care a patient by using a variety of supportive program after the bariatric surgery. Therefore, I want to introduce our SCH supportive programs. SCH bariatric surgery center has been started at 2009 and more than 300 patients are participate in our follow up supportive programs. Every patient has to be involved by our diet progress programs. The dietitian and coordinator RN helps patients to progress diet step by step. Intensive cooking class is for a month before surgery patients practicing liquid and soft diet such as protein shake, lentil soup, tofu and beans. In this class the dietitian and coordinator RN offer a personal consultation and make individual diet table. Alternative cooking class is for every other a month after patient focusing variety of high protein recipes. By offering easy cooking high protein recipes, patient can be well managed from malnutrition. These cooking classes occur twice a month. In addition, we have a regular presentation for general obesity people and preoperative patient and give a brief lecture to them what the Laparoscopic Rouxen-Y gastric bypass and the Laparoscopic sleeve gastrectomy are in every month. So people can know the exact information about bariatric surgery. Providing variety of supportive program for the bariatric patient can’t be underestimated by living better quality of life and adjusting a new life style after the surgery. P190 Obesity in Asia & India - Demographics, Cost and Strategies Presenter: Sumeet Shah Max Super Speciality Hospital, India

P188 Effectiveness of Laparoscopic Gastroileal Bypass (first stage of biliopancreatic diversion without gastrectomy) as an Alternative Technique in Patients with Hight Risk in Mordid Obesity Presenter: J. Joaquı´n Resa Co-authors: Mo´nica Valero, Javier Lagos, Elena Gonzalvo, Jose Luis Garcı´a Calleja, Jose AntonioFata´s Royo Villanova Hospital, Spain

While there is a rising burden of Obesity all across the world, especially in the west, it is even more alarming in Asia and India particularly. The main reason is that countries in this part of the world are facing a dual burden of communicable and nutrition related non communicable diseases. China and India together, have currently nearly half the diabetic population in the world. By 2030, it is estimated that India will be the Diabetes capital of the world. The dual nature of disease burden can have a crippling effect on economy. There is already a high incidence of CAD and CKD in India. The government is not

OBES SURG (2012) 22:1315–1419 geared up to look after this huge segment of urban population. Even though, bariatric surgery is a valid solution for the morbidly obese, the insurance companies in India are not covering weight loss surgery. Thus it means a huge out of pocket expense for the suffering population. India did just close to 4000 bariatric operations in year 2011 compared to nearly 120,000 in USA. The metabolic nature of disease is also different in Indian population as there is high risk of co morbidities at a lower BMI. The problems magnitude has to be understood, assessed, necessary measures taken and future strategies devised to combat the epidemic of Obesity and Type 2 diabetes mellitus.

1417 The commonest sites of bleeding were

& & & &

High gastric vessels cases-3 % Splenic capsular tear -2 % Serosal vessels or stomach wall -13 % Staple line bleeding -82 %

Presenter: HJ Choi Co-authors: YJ Kim, MJ Kim, KY Hur

The methodsemployed for controlling bleeding included gauze compression, clips, and placement of suture at the bleeding point. In 3 patients who had serious bleeding, 3 patients required blood transfusion. In one patient along with the sleeve splenectomy was done as bleeding was from the splenic capsule tear. 2 patients required blood transfusion with re-exploration. In one patient source of bleeding was not found. Since blood was coming from splenic bed splenectomy was done but patient died on 2nd post-op day due to ARDS. Other patient had bleeding from staple line which was controlled by clipping the bleeding point. A correlation was sought of bleeding with BMI

Metabolic and bariatric surgery center, Soonchunhyang University hospital, Seoul, Korea

Serial No

BMI

No of patients

Percentage

1

35-40

None

0

2

40-45

None

0

3-

45-50

2

0.72 %

4

50-60

1

0.36 %

P191 Laparoscopic Roux-en-Y Gastric Bypass in Elderly (>50) Obese Koreans

Objective To evaluate the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in elderly obese patients. Background Bariatric surgery, especially RYGB has shown to have efficacy and safe with good results especially considering resolving of co-morbidities worldwide. But there is controversy of performing RYGB in elderly patients. Because of an increased morbidity in older patients, there is concern that they may not tolerate the operation well and does not have efficacy as younger individuals. Methods We evaluated eighty seven patients who had undergone RYGB using prospectively collected database from January, 2011 to March, 2012. This was retrospective study. We had done a comparative analysis of operation times, hospital stay days, postoperative complications on sixty nine patients who are younger than 50 years old (younger group, YG) and eighteen patients older than 50 years old (older group, OG). The data was statistical analyzed using SPSS 14.0 for windows (Kruskal Wallis test & Fisher exact test). Results The mean age of the younger group was 35 (18-49) and the older group was 56(50-63). The sex of both group had no difference. (p>0.05) Preoperative weight and body mass index (BMI) of both group had no significant difference (YG vs OG, 98 kg vs 93 kg, 37 kg/m2 vs 37 kg/m2 p>0.05). The older group had more diabetes, dyslipidemia, and degenerative joint disease significantly (p<0.05) than younger group. The operation time and intra-operative bleeding was 139 min (80-250) and 163 ml (0-600) in YG, 134 min (100-220) and 150 ml (20-500) in OG (p<0.05). The complication was 3 patients (4 %) in YG and 1 patient (6 %) in OG (p<0.05). The days of hospital stay and re-admission was 2.4 days (1-12) and 3 cases (4 %) in YG and 2.9 days (1-7) and 1 case (6 %) in OG(p<0.05). Conclusions Laparoscopic Roux-en-Y gastric bypass is effective and safe for older bariatric patients. However, more long term follow up data were needed. P192 Avoiding Bleeding in Sleeve Gastrectomy: How We Do It? Presenter: Dr. Deep Goel Co-authors: Dr. Ravindra Vats, Dr. V.P. Bhalla BLK Super Speciality Hospital, India Background Laparoscopic sleeve gastrectomy is now becoming more popular as a single stage treatment option for morbid obesity. The commonest complication of the procedure is bleeding during or early in the post-op period. Aim To retrospectively study the pattern of bleeding as a complication in our series of 276 cases and highlight the impact of steps taken to minimize this complications of sleeve gastrectomy. Patients and Methods Laparoscopic sleeve gastrectomy was done in 276 cases from June 2007 to February 2012. The standard procedure described by Ren etal was followed with some modifications. A harmonic energy device was used in all cases with high definition video imaging. Unusual intra-op bleeding requiring blood transfusion occurred in 1/276 (0.36 %) patients. Reexploration for reactionary bleeding detected in the immediate post-op period was seen in 2/276 (0.72 %) cases. Death due to bleeding was recorded in one patient. Pattern of bleeding is encountered requiring something more then harmonic coagulation was studied.

We are also particular in preparing the patients pre-operatively by optimizing hypertension and sleep apnea by medical management. All stapling is performed using 60 mm Endo GI stapler, holding initial compression for minimum of 50 seconds before firing and 20 seconds of compression after firing. Conclusion Serious Bleeding is a common complication of sleeve gastrectomy. We encountered this complication 1.08 % of cases. Careful meticulous dissection, use of HD aids to improve visualization and liberal use of metallic clips, intra-corporeal suturing has kept bleeding rates within acceptable standards. P193 Thinking About the Occurrence of Fistulas and Dehiscence in a Sleeve Gastrectomy: An Experimental Study of the Resistance of the Linear Gastric Stapling Presenter: Pierre Fournier Co-author: P. Montravers, G. Dufour, , C. Muller, R. Bronchard Jean-Pierre Marmuse Bichat Claude Bernard University Hospital, Department of General Surgery, Paris 7-Denis Diderot Paris, France Introduction Few studies have evaluated the surgical stapling particularly in colorectal surgery. Objectives Tounderstand the appearance mechanismsof adehiscenceof thestaplelineduring asleeve-gastrectomy, we analyzethe effect ofthe staple heightandtheuse of atissuereinforcementon the developingofexperimentalfistula. Methods This isan experimental study ontheporcine model. Thesleevegastrectomy were performedex vivo. The pressurerequired for the development ofafistulawas assessedby blowingair into thegastric tubeimmersedin water. Thefirstexperiment compares8sleeve-gastrectomies performedwiththe use of greenstaplechargers(three rows of 4.8 mm clips) over the entire length of the staple line and 8withthe joint use ofgreen chargersfor the lower half of the staple lineandbluechargers(threerows of 3.5 mm staples)forthe upper half ofthestaple line. Thesecondexperiment uses thesame sequencewithareinforcementofBiosyn(a thin, transparent and absorbable film) in 3sleevegastrectomies performed with green chargers(three rows of 4.8 mm staples) and 4sleeve-gastrectomies performedwithgreenandblue chargers (three rows of 3.5 mm staples). Thethirdexperiment uses thelatest generationTri-Staple comparing5 sleeve gastrectomies performed withblackchargers(three rows of staplesof different widths :4 mm, 4.5 mm and 5 mm) and the joint useof black and purple chargers(three rows of staplesof different widths :3 mm, 3.5 mm and 4 mm). Theoutcomeis determined with the pressure (measured in mmHg) experimentally requiredto createafistula. Data is reportedasmean andpercentage. Nonparametric testsare usedfordata analysis.

1418 Results Whateverthe experiment, fistulas occur at the upper part of thestaple linein over 80 % of cases. Experiment1 showsthat the occurrenceof a fistularequiresgreater pressurein groupswith joint use of greenandblue chargers (mean 0122.4 mmHg(108.4, 136.5)) comparedto the group ofgreenloaders(mean 094.2 mmHg(84.2, 104.3)) with a high significance (p 00.0017). Experiment 2 showssimilar results although a higherpressurewas required with the joint use of greenandblue chargers (mean 0 189 mmHg(174.5, 203.5)) than with only green chargers (mean 0 152.3 mmHg(134.1, 170.5)); the difference is alsosignificant. Experiment3 shows no significant difference (p 00.62)betweenblackchargers (m 0130.3 mmHg(119,141.6)) and joint use of black and purple chargers(m0134 mmHg(121.7: 146.3)). Conclusion Staple height isa determining factor inthe emergence of afistulaonanexperimentalsleeve-gastrectomy. Low staplesheightsare more resistantto pressure.The buttressing ofthe staple lineincreases theresistance. Keywords: surgical stapling, gastric fistula, experimental sciences, sleeve gastrectomy P194 Laparoscopic Gastric Plication- Our Case Series Presenter: Sarfaraz Baig Co-authors: Dr B Ramana Bariatrics and Metabolism Initiative, India Introduction Gastric plication is a new bariatric procedure evolved primarily by surgeons eager to dispense with the staplers and hence making it cost effective. There is paucity of literature from India to evaluate this procedure. Methods Between 2009 to 2012, we (two surgeons) performed 32 cases of Gastric Plication in a single center. The steps of the procedure was standardized as two to three rows of sutures in the greater curve keeping a 36 Fr bougie in place. The BMI of the patients ranged from 36 to 44 with a median of 39. The female to male ratio was 26:6. We evaluated the results of these patients retrospectively after a follow up of 6 to 36 months. Results There was no mortality in our series. The complication rate was 3 out of 32. One was a leak, another intractable vomiting due to stricture and the third was dysphagia due to ball valve obstruction of the GE junction by the plicated mucosa. The leak was managed by reoperation – drain and FJ whereas the latter two were managed by endoscopy. The excess body weight loss ranged from 30 %- 55 % with a follow up which ranged from 6 to 36 months. There was resolution of OSA, OA, HTN in most patients in our series. Conclusions Gastric Plication is a relatively new procedure showing promise. More evaluation is needed to position this procedure in the bariatric armamentarium. P195 Comparison Between Two Methods of Evaluation Of Renal Functionbefore After Roux-en-y Gastric Bypass in Morbidly Obese Patients Presenter: Esteˆva˜oCUBAS R, e, Co-authors: Arruda Slm, Watanabe A, Medeiros Rs, Barbosa Ps, Ugarte Mfs, ´ jo Ms, Neves Cv, Milhomem Pd, Quirino Kp, Mensorio Ms melendez-araU Clı´nica Dr. Se´rgio Arruda, Brazil Background Studies showed results that correlates the Excess Weight Loss (%EWL) with improvement of renal function. Renal impairment in obese patients is related to glomerular hyperfiltration leading to Focal Segmental Glomerulosclerosis and Chronic Renal Disease. Cockcroft-Gault formula is a simple and fast tool to evaluate Glomerular Filtration Rate. Methods Between January/2004 and May/2011, 313 patients were evaluated after one year of Roux-en-Y Gastric Bypass(RYGB) regarding Mean Age (MA), Mean pre-operative BMI (MBMI), Mean %EWL (M%EWL) and Glomerular Filtration Rate. We evaluate the GFR by Cockcroft- Gault (GGFR) formula adjusted for obesity(corrected weight for BMI of 25 kg/m) and by abbreviated MDRD formula (MGFR). Statistical analysis was performed by GraphPad Instat® and Microsoft Excel® tests. Results From all patients (313), 273 (87,2 %) were females. MA was of: 37.4± 10.7(17-67.4) years. MBMI was of 42.16±4.8(33.7-66.2)kg/m. Mean follow-up was of 17.25±10.38(33.7- 66.2) months. M%EWL was of: 80.09±19.9(10.7145.03)%. Pre-operative vs. Postoperative: Creatinine: 0.78±0.15(0.48-1.4) vs. 0.73±0.15(0.39-1.6); p<0.0001. GGFR: 109.1±26.7(12.8-217.9) vs. 116.9 ± 29.2(37.7-219.4)ml/min/1.73 m; p < 0.0001. MGFR: 124.22 ± 29.4(10.1-

OBES SURG (2012) 22:1315–1419 208.6) vs. 135.45±34.3(47.2-267.11) ml/min/1.73 m; p<0.0001. GGFR vs. MGFR: Pre-operative: 109.1±23.7(12.8-217.8) vs. 124.2±29.4(10.1-208)ml/ min/1.73 m; p<0.0001. Post-operative: 116.9±29.6(37.7-219.4) vs. 124.2± 29.4(10.1-208.6)ml/min/1.73 m; p00.0003. Pearson Correlation: %EWL vs. Post-operative GFR by: (1)GGFR: (r)00.21; (r)00.04; p00.0002. (2)MGFR: (r)00.13; (r)00.01; p00.01. Conclusion Our sample had decreased creatinine serum levels and improvement in GFR calculated by both methods after RYGB. The Cockcroft-Gault formula adjusted for obesity underestimates the GFR when compared with MDRD formula. Increased %EWL rates showed correlation with improvement of post-operative Glomerular Filtration Rate by both methods (Cockcroft-Gault and abbreviated MDRD). P196 Gastric Bypass is a Cost Saving Procedure: Results from a Comprehensive Markov Model Presenter: Gil Faria Co-authors: John Preto, Eduardo Lima da Costa, Ana Beatriz Almeida, Jose´ Costa Maia, Joa˜o Tiago Guimara˜es, Conceic¸a˜o Calhau, Anto´nio Taveira-Gomes Department of Surgery, Faculty of Medicine, University of Porto, Portugal Background Obesity is growing public health problem in industrialized countries and is directly and indirectly responsible for almost 10 % of all health expenditures. Bariatric surgery is the best available treatment; however associated with important economical expenditures. So, cost-effectiveness analysis of the available surgical options is paramount. Methods We developed a Markov model for 3 different strategies: Best Medical Management, Gastric Band and Gastric Bypass. The Markov model was constructed to allow for the evaluation of the impact of several obesity-related co-morbidities. The results were derived for a representative population of morbidly obese patients (through a second-order probabilistic Monte-Carlo sensitivity analyses to model for uncertainty) and sub-group analyses were performed for patients without co-morbidities, patients with Diabetes Mellitus, different age and BMI groups. Cost-effectiveness analysis was performed accounting for lifetime costs and from a societal perspective. Results Gastric Bypass is a dominant strategy, rendering a significant decrease in lifetime costs and increase in quality-adjusted life-years (QALYs). Comparing with Best Medical Management, in the global population of patients with a BMI> 35 kg/m^2, Gastric Bypass renders 3 extra QALYs and a cost-saving of 29.430 per patient. Younger patients, patients with a BMI between 40-50 kg/m^2 and patients without obesity related diseases are the ones with a bigger benefit in terms of costeffectiveness. Conclusion Gastric Bypass surgery increases quality-adjusted survival and saves resources to health systems. As such, it can be an important process to control the ever-increasing health expenditure. P197 Left Ventricular Hypertrophy in Obesity and Regression After Bariatric Surgery. Influence of Prediabetes Presenter: Sabrina Chiheb Co-authors: Camille Cussac-Pillegand, Isabelle Sagnet-Pham, Patricia Poignard, Antonio Valenti, Isabela Banu, Christophe Barrat, Marinos Fysekidis, Emmanuel Cosson, Paul Valensi Department of Endocrinology-Diabetology-Nutrition, Jean Verdier Hospital AP-HP. CNRH-IdF, Paris-Nord University, Bondy, France Aims to evaluate in obese patients the role of prediabetes in left ventricular hypertrophy (LVH) and in the changes of LV mass after surgery. Methods Echocardiography was performed in 107 obese patients and 69 could be analyzed (34 diabetes or obstructive sleep apnea, 4 poor quality imaging): 55 women, 35.6±11.1 years-old, BMI 43.3±4.8 kg/m, blood pressure 121/71 mmHg. Each patient had an oral glucose tolerance test (OGTT). Results 32 % of the patients had prediabetes, 50 % insulin resistance (HOMAIR>3), 9 (13 %) LVH. LV mass correlated with fat-free mass (p<0.001), waist/ hip ratio (p<0.001), fasting (p00.015) and 2 h-OGTT glucose (p00.045). In multivariate analysis LV mass was associated with 2 h-OGTT glucose. LV

OBES SURG (2012) 22:1315–1419 mass was higher in patients with prediabetes and/or insulin resistance (p0 0.013). Echocardiographic parameters were again measured in 26 patients6 to 50 months (mean 17.6) after bariatric surgery (modulable banding gastroplasty 52 %, sleeve-gastrectomy 33 %, by-pass 15 %), with a weight loss of 22.8 % and disappearance of 50 % of prediabetes. LV mass changes correlated with body weight changes (p00.04), LVH disappeared in 4/8 patients. Among the patients who increased their LV mass, 50 % were prediabetic preoperatively whereas all the patients who reduced their LV mass (-14 % in means) were normoglycemic (p00.03). In multivariate analysis, LV mass changes were associated with both body weight changes and glycemic status at inclusion. Conclusion Prediabetes is a determinant of LV mass and its post-surgical change. Weight loss after surgery is associated with LV mass decrease only in patients with a normal glucose tolerance before surgery. P198 Understanding Obesity Phenotypes: CT Findings Correlate with Metabolic Syndrome Presenter: Gil Faria Co-authors: John Preto, Eduardo Lima da Costa, Ana Beatriz Almeida, Jose´ Costa Maia, Joa˜o Tiago Guimara˜es, Conceic¸a˜o Calhau, Anto´nio Taveira-Gomes Institution :Department of Surgery, Faculty of Medicine, University of Porto, Portugal Background Obesity is the most important risk factor for metabolic syndrome and metabolic diseases. However, a significant number of obese patients do not express overt metabolic disease. Understanding which patients develop metabolic syndrome, might render novel insights of the pathophysiology of this disease. Methods We recruited a random selection of 97 patients proposed for bariatric surgery between January and December 2010. A pre-operative CTslice at L4-L5 level, was performed to measure visceral fat and hepatic attenuation. Fatty liver disease was considered for attenuations lower than 50HU and visceral obesity was defined at the sample median (210 mm^3). Results Most patients were female (86.6 %), with a mean age of 42 years and a BMI of 45.6 (kg/m2). Diabetes mellitus was present in 30 % of the patients, high blood pressure in 53 % and metabolic syndrome in 64 %. The mean fasting glucose was 98 mg/dL and HOMA-IR was 2.47. Hepatic attenuation median value was 52.4 and the median visceral fat area was 210 mm^3. Patients with metabolic syndrome had lower hepatic attenuation values (median 49 vs 55HU; p 0.02) which translates higher fatty infiltration and had more visceral adipose tissue (296 vs 224 mm^3; p 0.001) but not overall adipose tissue (928 vs 941 mm^3; p0.3). By conventional measures (BMI – 45.7 vs 45.4 kg/m^2; p0.75 - and waist circumference – 125 vs 123 cm; p0.60), patients with metabolic syndrome were not different from patients without. Patients in the upper half of the visceral fat distribution had higher triacylgliceride levels (144 mg/dL vs 111 mg/dL; p0.004) were more likely to have high blood pressure (68 vs 39 %; p0.005) and T2DM (43 vs 18 %; p0.036). There is a significant correlation (coeff – 0.429; p0.001) between visceral fat area and visceral adipocyte mean area. Patients with fatty liver disease had higher levels of CRP (13.6 vs 7.5 mg/dL; p0.028) and were more likely to have high blood pressure (71 vs 47 %; p0.07) and T2DM (46 vs 26 %; p0.01). The prevalence of metabolic syndrome in patients with these two findings was 91 % while it was 65 % and 47 % for patients with one or none of these findings (p0.05) Conclusion CT scanning findings seem to measure 2 important pathways leading to metabolic syndrome: adipose tissue hypertrophy and hepatic fatty infiltration. According to these findings the putative role of inflammation seems to be mediated by liver fat infiltration. P199 Revisional Bariatric Surgery: Two-Stage Laparoscopic Sleeve Gastrectomy (LSG) as Revision After Laparosopic Adjustable Gastric Banding (LAGB) Failure Presenter: Silecchia G.1, Greco F.2, Perrotta N.3, Puzziello A.4, Rizzello M.1, Dobrescu A.5, Cavallaro G.1, De AngelisF.1, Iorio O. 1, Colozzi S.1.

1419 1Dept of Medico-Surgical Sciences and Biothecnologies, Division of General Surgery, “Sapienza”University of Rome - Italy 2 Surgical Division, Civita Castellana Hospital (VT-Italy) 3 Surgical Division, Villa d’Agri Hospital (PZ-Italy) 4 Surgical Department, University “Magna Grecia” (CZ-Italy) 5Second Surgical Department, “Victor Babes” University of Timisoara – Romania Background LSG has been recently proposed as a revisional procedure after LAGB removal for insufficient weight loss/regain or major complications. The safety, effectiveness of LSG and the timing of the procedure are still controversial. The aim of this paper was to evaluate the safety and efficacy of two-stage LSG, as a revisional surgery. Methods 42 patients have been evaluated. All procedures were completely laparoscopically :

& &

first stage, band removal ; second stage, LSG (intent as definitive surgery).

The patients were divided in two groups: 1) 25 patients with insufficient weight loss (EWL <25 %) or long term weight regain (BMI>35) and/or food intolerance with intact anatomy (failure group); 2) 17 patients with acute or chronic band complications requiring band removal (complications group). Results The mean interval between implant and removal of the band was 63.2 months for group 1and 36 months for group 2. LSG was performed after a mean interval of 5.1 months (range 1-21 months) in the group1 and after 29.2 months (range 2-72 months) in the group 2. No conversion to open surgery was required, no intraoperative bleeding or postoperative leaks occurred for both groups. After 12 months the mean EWL was 60.3 % and 63.5 % in group 1 and group 2 respectively. Improvement of co-morbidities was observed in12 of 19 patients in group 1 and 9 of 14 in group 2. Conclusion LSG could be an effective alternative to LRYGB which has been proposed as “first choice” revisional procedure after a band removal. Key Words: revisional bariatric surgery, laparoscopic sleeve gastrectomy, gastric banding P200 Quality of Life After Laparoscopic Roux-en Y Gastric Bypass in the Elderly (Age>60): Are Older Patients Happier? Presenter: A. Suppiah, Co-authors: A. Carlisle, M. Peter, R. Sarkar, A. Carlisle, V. Rao, P. Sedman, P. Jain Castle Hill Hospital, Cottingham, HU16 5JQ, United Kingdom Introduction Elderly obesity-related morbidity is increasing but LGBY is not routinely performed in this group. We have reported the safety of LGBY and substantial weight loss with morbidity reduction age >60 but there are no reports on Quality of Life. We report QOL following LGBY in the elderly (age >60) population. Materials and Methods All patients with LGBY between 2006-2012. Postal questionnaires and telephone interviews for pre- and post-LGBY scores (1-10) for confidence/self esteem, activity, social, work, sex, eating and mobility. Patients were also asked to rate the domains or order of most improved, and if they would recommend LGBY to friend/family. Results 46 patients (37 female, 9 male) median age 62.5 (60.1 – 71) underwent LGBY with median excess weight loss of 67.4 %(36-113) at 23.2(12-55) months follow-up. Mean post-LGBY QOL scores were significantly higher than pre-LGBY scores in all domains. The order of categories from most to least improved are: Physical activity (8.3 vs. 2.5), confidence/self-esteem (8.4 vs. 3.1), social ( 8.2 vs. 3.7), work (7.5 vs. 3.4), eating ( 7.4 vs. 3.3) and sex (4.9 vs. 2.9). Domain rated by patients as most “improved” was physical activity (98 %) and self-esteem (94 %) and least in work(78 %) and sex(63 %). Overall, 95 % “would have LGBY again” and 92 % “would recommend to friends/family”. Conclusion LGBY has substantial QOL benefits in the elderly which should be taken into account in offering LGBY to these patients. The domains considered most improved are physical activity and self-esteem and least improved are eating and sex.