8th Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders

O-001

Fast track surgery program (FTS) in bariatric surgery, Is it safe?

Abdelrahman M Galal^{1, 2, 3, a)}, Evert-jan Boerma^{1, 3, b)}, Sofie Fransen^{1, 3, c)}, Berry Meesters^{1, 3, d)}, Steven Olde Damink^{4, e)}, Jan willem Greve^{1, 3, f)}

¹⁾Department of Surgery, Metabolic and Bariatric surgery unit, Zuyderland Medical Center, Heerlen, Netherlands; ²⁾General surgery department, Sohag university hospitals, Sohag University, Sohag, Egypt; ³⁾Dutch Obesity clinic south, "Nederlandse Obisitas kliniek ZUID", Heerlen, Netherlands; ⁴⁾Surgery department, Maastricht university, Maastricht, Netherlands

^a)abdrhmangalal@yahoo.com

^b)e.boerma@zuyderland.nl

^c)fransensofie@hotmail.com

^d)b.meesters@zuyderland.nl

^e)steven.oldedamink@maastrichtuniversity.nl

^f)j.greve@zuyderland.nl

Objectives: Evaluate the safety of FTS program in patients undergoing primary and revision bariatric surgery; identify the factors that may limit early discharge in both groups.

Methods: Retrospective review of 547 consecutive morbid obese patients who underwent bariatric procedures between January 2016 - July 2017. Fast track protocol is applied on all patients. Target discharge after one-night stay. The primary end point length of stay (LOS) in hospital. The secondary end points frequency of hospital contact, readmission and reintervention within 30 days after surgery.

Results: Primary (n=475); banded bypass (BRYGB, 78.1%), sleeve gastrectomy (10.9%), gastric band (5.1%), non-banded RYGB (3.8%), one-anastomosis gastric bypass (1.9%), BPD (0.2%). Mean age (±SD) 44.7 ±11.2 years and BMI mean (±SD) 43.7± 6.1kg/m2. Revision procedures (n=72); gastric band to adjustable BRYGB (41.7%) and to non-adjustable BRYGB (40.3%), Mason to BRYGB (11.1%), one-anastmosis bypass to BRYGB (1.4%), Sleeve to BRYGB (2.8%), sleeve to SADI (1.4%), band to sleeve (1.4%). Mean age (±SD) 47.5± 9.1 years and BMI mean (±SD) 38.4 ± 6.95 kg/m2. Total 30-day readmissions in primary and revision were 32 (6.7%) and 5 (6.9%). Total re-interventions 14 primary (2.9%) and 2 revisions (2.8 %). One case mortality due to neglected port-site hernia.

Mean LOS in primary patients was 1.32± 0.98 and 1.56 ± 1.6 for revision. Successful discharge at same day 7 (5 primary and 2 revision), one night 474 (420 primary and 54 revision). After one-night discharge, Incidence of contact to the hospital, readmission and reintervention were 25.7%, 6.9%, 1.9%, in the primary group and 27.8%, 5.6%, 0% in revision respectively. There were no statistically significant differences in incidence of contact to hospital, readmission and reintervention between primary and revision patients discharged after one-night . Extended LOS after primary procedures was significantly affected by gender, diabetes and associated non-bariatric intervention.

Conclusion: The FTS is safe in both primary and revision surgery with no statistically significant difference in clinical outcomes.

O-002

Bariatric surgery related complications during pregnancy

Martine Uittenbogaart^a), Danielle Bonouvrie^b), Arijan Luijten^c), Francois van Dielen^d), Wouter Leclercq^e)

Obesity Centre Máxima, Máxima Medical Centre, Eindhoven, Netherlands

^a)m.uittenbogaart@mmc.nl

^b)d.bonouvrie@mmc.nl

^c)a.luijten@mmc.nl

^d)f.vandielen@mmc.nl

^e)w.leclercq@mmc.nl

Introduction: Significant weight loss following bariatric surgery in female patients leads to an improvement of fertility as well as a reduction of obesity related complications during pregnancy. However, certain bariatric surgery related complications, such as internal herniation or symptomatic chole(cysto)lithiasis, may occur during the course of the pregnancy and might result in severe maternal and fetal morbidity or even mortality.

Methods: An overview of all cases in the past five years of bariatric complications during pregnancy in our medical centre, which is both a centre of excellence for bariatric surgery as well as the tertiary referral centre for high risk pregnancies. Description of several illustrative cases with up-to-date and relevant literature on the topic and video clips of a laparoscopic correction of an internal herniation in a pregnant patient.

Results: Approximately twenty cases of either internal herniation or symptomatic chole(cysto)lithiasis during pregnancy in patients with a history of bariatric surgery presented at our centre in the last five years. Whereas ultrasonography might aid the diagnosis in case of gallstones, in internal herniation negative imaging, preferably MRI without contrast, does not exclude the diagnosis and diagnosis should mainly rely upon clinical assessment. A delay in diagnosis, unnecessary imaging studies and suboptimal timing of possible surgical intervention should be avoided to prevent serious maternal and fetal morbidity and mortality.

Conclusion: In case of a pregnant patient with abdominal complaints and a history of bariatric surgery, one should always consider the possibility of late complications of bariatric surgery, besides obstetric complications. Early diagnosis and treatment by a specialized multidisciplinary team – consisting of bariatric surgeons, perinatologists and neonatologists – are of the utmost importance for the safety of both mother and child.

O-003

Trocar site hernia in bariatric surgery- an underestimated problem. A qualitative systematic review

Ioannis Karampinis^{1, a)}, Eliette Lion¹⁾, Maurizio Grilli²⁾, Georgi Vassilev¹⁾, Steffen Seyfried¹⁾, Mirko Otto^{1, b)}

¹⁾General, Thoracic, Vascular and Transplant Surgery, Mannheim University Medical Center, University of Heidelberg, Mannheim, Germany; ²⁾Bibliothek, Mannheim University Medical Center, University of Heidelberg, Mannheim, Germany

^a)ioannis.karampinis@umm.de

^b)mirko.otto@umm.de

Introduction: Efforts are being made to keep morbidity associated with bariatric surgery as low as possible. The incidence of trocar site hernias in bariatric surgery has been reported between 0.5 and 3%. However, the best available evidence comes from trials retrospectively analysing prospective databases, thus including only patients who have been operated for or have been highly symptomatic due to the trocar site hernia after a laparoscopic bariatric procedure. We performed a systematic review of the literature to identify the incidence of trocar site hernia after minimal-invasive, multiportal bariatric surgery.

Materials and Methods: Medline, Current Contents, The Cochrane Library, Embase, Cinahl, ClinicalTrial.gov, WHO ICTRP and the Web of Science Core Collection Index were searched up until September 2017. Search strategies included proper combinations of the MeSH terms ‘laparoscopy’, ‘bariatric surgery’, ‘trocar/port’ and ‘hernia’. Search was not limited by publication type and there were no restrictions on language. The review was registered in PROSPERO (ID 85102) and was performed according to the PRISMA guidelines.

Results: The primary research identified 1669 records. Pearling of the references revealed 83 additional records. 192 full-text articles were assessed for eligibility and 68 were finally included. 61 were retrospective analyses, 5 prospective cohort studies and 2 randomized controlled trials. Hernia incidence range was 0-39.3%. 17 trials reported systematic closure of the fascia and 4 trials no closure. Data availability did not allow pooling in order to calculate relative risk. Two trials were identified which systematically examined all operated patients for trocar associated hernias using sonography and CT-scan. The reported incidence was 15.4 % and 39.3 % respectively. In those trials only trocars bigger than 10mm were systematically closed.

Conclusion: Trocar site hernia is clearly an underestimated complication of minimal-invasive bariatric surgery. High-quality trials are not available to allow a precise calculation of the incidence. Furthermore, risk factors for developing a trocar site hernia in bariatric surgery have not been systematically analysed yet. Prospective studies on this field are necessary.

O-004

Tailored Laparoscopic OAGB as an anti-diabetic procedure in BMI (30-35

Ahmed Elsobky

General surgery department, Ain Shams Univerisity, Cairo, Egypt

ahmedelsobky90@gmail.com

Background: Type 2 diabetes mellitus has become an epidemic health problem with significant impact on morbidity, mortality and health care resources. The medical therapy for T2DM still leaves many patients exposed to the complications of this disease. The American Diabetes Association stated that Bariatric surgery may be considered for adults with BMI > 35 kg/m2 and type 2 diabetes, especially if the diabetes or associated co morbidities are difficult to control with lifestyle and pharmacologic therapy. The aim of this study is to evaluate the efficacy and safety of tailored lap One Anastomosis Gastric Bypass (OAGB) in T2DM patients with BMI 30–35 kg/m2.

Methods: The data of 450 patients who underwent tailored Lap OAGB from December 2012 to December 2015 at our hospital were reviewed. Mean age was 47 years, mean preoperative BMI was 32.9 kg/m2, mean preoperative weight was 91.7 ± 20.3 kg, 58% were women.Preoperative data including glycosylated hemoglobin, fasting plasma glucose, 2 h postprandial glucose, c-peptide (fasting and postprandial) and lipid profile were compared with data collected at 1, 3, and 6, 12, 24, 36 postoperative months.

Results: All procedures were completed laparoscopically.fter 3 years of tailored lap OAGB, 78% of patients stopped treatment, 11% of patients shifted to oral hypoglycemic or reduced the dose of oral hypoglycemic and 11% reduced the insulin dose.Excessive weight loss occured in 8 patients(1.7%),5 of them managed conservatively and 3 cases required conversion of the procedure.

Conclusion:The tailored lap MGB leads to resolution of T2DM in 78% of patients with BMI (30-35)kg/m2, with reasonable accepted excess weight loss. The best results are obtained in patients with few years of diabetes, without or with short term use of insulin treatment, high C-peptide levels and higher preoperative weight.

References

1. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21: 1414-31.

2. 4. American Diabetes Association. Executive summary: standards ofmedical care in diabetes—2011. Diabetes Care. 2011;34 Suppl 1:S4–10.

3.Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and metaanalysis. Am J Med. 2009;122(3):248–56. e5.18.

4.Garcia-Caballero M, Tinahones FJ, Cohen R. Diabetes Surgery. Madrid 2010. McGraw Hill/Interamericana de España, S.L. 2010, pp. 1-387.7.

5.Lee W-J, Wang W, Lee Y-C, Huang M-T, Ser K-H, Chen J-C. Effect of laparoscopic Mini Gastric Bypass for Type 2 Diabetes Mellitus: Comparison BMI > 35 and < 35 kg/m2. J Gastrointest Surg 2008; 12: 945-52.

6. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004; 351(26):2683–93.

7. Laville M, Disse E. Bariatric surgery for diabetes treatment: why should we go rapidly to surgery. Diabetes Metab. 2009;35(6 Pt2):562–3.

8.Pories WJ, Macdonald KG, Flickinger EG et al (1992) Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg 215:633–64223.

9.Reis CE, Alvarez-Leite JI, Bressan J, et al. Role of bariatric–metabolic surgery in the treatment of obese type 2 diabetes with body mass index <35 kg/m2: a literature review. Diabetes Technol Ther. 2012;14(4):365–72.16.

10.Dixon JB, Chuang LM, Chong K, et al. Predicting the glycemic response to gastric bypass surgery in patients with type 2 diabetes. Diabetes Care. 2013;36(1):20–6.5.

11.Rubino F, Gagner M, Gentileschi P, et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weightregulation and glucose metabolism. Ann Surg. 2004;240(2):236–42.

Acknowledgement: I appreciate for our faculty and my colleagues that share me the production of that work.

O-005

Shortening the biliopancreatic limb length could prevent undernutrition risk while maintaining glucose homeostasis improvement: demonstration in a rat model of one anastomosis gastric bypass

Matthieu Siebert^{1, a)}, Lara Ribeiro-Parenti^{1, 2, b)}, Nathalie Kapel^{3, c)}, Anne Couvelard^{1, 4, d)}, Simon Msika^{1, 2, e)}, André Bado^{1, f)}, Maude Le Gall^{1, g)}

¹⁾Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France; ²⁾General and Digestive Surgery, AP-HP, Hôpital Bichat Claude Bernard, Paris, France; ³⁾Functional Coprology, AP-HP, Hôpital Pitié-Salpêtrière-Charles Foix, Paris, France; ⁴⁾Pathology, AP-HP Hôpital Bichat Claude Bernard, Paris, France

^a)matthieu.siebert@inserm.fr

^b)lara.ribeiro@aphp.fr

^c)nathalie.kapel@aphp.fr

^d)anne.couvelard@aphp.fr

^e)simon.msika@aphp.fr

^f)andre.bado@inserm.fr

^g)maude.le-gall@inserm.fr

Background: The one anastomosis gastric bypass (OAGB) is associated with similar metabolic improvements and weight loss than the Roux-en-Y gastric bypass. However, this bariatric procedure is still controversial; suspected to result in undernutrition and at potential risks of biliary reflux leading possibly to esophageal or gastric cancer. Reducing the size of the biliopancreatic limb in this surgery could be essential to maintain positive outcomes and prevent side effects.

Methods: Wistar rats were operated on OAGB with a short (15cm OAGB-15, n=13) or a long (35cm OAGB-35, n=13) biliopancreatic limb or sham surgery (n=8). Body weight and food intake were monitored weekly over 30 weeks and rats underwent oral glucose and insulin tolerance tests after 10 and 28 weeks. Macronutrient absorption was determined by fecal analyses. After sacrifice, histology was performed on formalin-fixed esophagus and gastro-jejunal anastomosis. Statistical analyses used non-parametric ANOVA tests.

Results: Compared with sham rats, OAGB-15 and OAGB-35 rats reduced their food intake but only during the first 4 weeks. Fecal losses of calories were greater after MGB-35 than after MGB-15 or sham surgery but malabsorption tend to decrease overtime. Consequently, OAGB-35 rats displayed a significant reduced weight over 30 weeks whereas OAGB-15 rats cached up sham weight after 12 weeks. All OAGB-operated rats displayed an improved glucose tolerance and better insulin sensitivity compared to sham rats, these effects were independent of rat weight and maintained after 28 weeks.

Conclusions: In rats, a long biliopancreatic limb led to a major nutrient malabsorption. However glucose homeostasis was similarly improved in OAGB-15 and OAGB-35 rats suggesting that shorting the biliopancreatic limb can improve metabolic parameters without major influence on weight. The impact of biliopancreatic limb length on esophageal or gastric lesion in the long term is currently under investigation and will also be presented.

Acknowledgement: We thank Chelsey Chachoute and Nicholas Nguyen for their experimental help. This work was supported by Inserm and University Paris Diderot. MS and LRP received fundings from Fondation pour la Recherche Médicale, MS received a prize from Association Francaise de Chirurgie. MLG received fundings from Société Francophone du Diabète, SFNEP and Institut Benjamin Delessert.

O-006

Incidence of secondary hyperparathyroidism after biliopancreatic diversion with duodenal switch for morbid obesity: an underestimated phenomenon

Philipp C. Nett^a), Yves M. Borbély^b), Gabriel Plitzko^c), Dino Kröll^d)

University Obesity Centre of Berne, University Hospital of Berne, Berne, Switzerland

^a)philipp.nett@insel.ch

^b)yves.borbely@insel.ch

^c)gabriel.plitzko@insel.ch

^d)dino.kroell@insel.ch

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is considered to be one of the most effective bariatric procedures resulting in a sustainable long-term weight loss and a high remission rate of obesity-related comorbidities. Besides its excellent long-term outcome, BPD-DS can lead to severe diarrhea and micronutrient deficiencies in the long-term based on the malabsorptive character of the procedure. Therefore, the risk for secondary hyperparathyroidism due to malabsorption needs to be determined in this population.

Setting: University Hospital, Switzerland.

Methods: Data from all 246 patients undergoing BPD-DS between January 2001 and December 2011 were prospectively collected. Life-long micronutrient supplementation consisted according to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines of a multivitamin-mineral supplementation on a daily base covering 200% of the daily value. It contained 2’000 IU of vitamin D₃, and 2’400 mg of calcium.

Results: Of all 246 patients, 195 (79.3%) had at least 5 years of follow-up. The majority of the procedures were laparoscopic. Almost all patients (168/195; 86.2%) underwent a concomitant cholecystectomy. Mean age and BMI were 42.8±9.2 years and 48.3±9.1kg/m², respectively. Average follow-up time after BPD-DS was 85.8±35.9 months. Of 195 patients, 102 (52.3%) showed laboratory signs of a secondary hyperparathyroidism during the follow-up. Although vitamin D levels improved with increased vitamin D₃ supplementation in 2007, the rate of secondary hyperparathyroidism increased.

Conclusion: Despite routine postoperative calcium and vitamin D₃ supplementation, secondary hyperparathyroidism is common after BPD-DS. These rates suggest current supplementation guidelines are not sufficient in preventing secondary hyperparathyroidism. Further work is needed to better define the sequelae of long-term hyperparathyroidism.

O-007

The impact of bariatric surgery on gut microbiota, diabetes remission and metabolic profile of morbidly obese patients: a comprehensive meta-analysis

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{1, 2, b)}, Eleni Sioka^{1, 2, c)}, Christina Chatedaki^{3, 2, d)}, Alexis Svokos^{4, e)}, Konstantina Svokos^{5, f)}, George Tzovaras^{1, 2, g)}, Dimitris Zacharoulis^{1, 2, h)}

¹⁾Department of General Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece; ³⁾Department of Microbiology, University Hospital of Larissa, Larissa, Greece; ⁴⁾Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, United States

⁵⁾Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)konstantinasioka@gmail.com

^d)chatechristina@yahoo.gr

^e)alexis.svokos@gmail.com

^f)konstantina.svokos@gmail.com

^g)geotzovaras@gmail.com

^h)zachadim@yahoo.com

Background: Obesity is associated with insulin resistance (IR), glucose intolerance and alterations in various metabolic factors. Bariatric surgery contributes to improved glycemic control as a result of weight loss, calorie restriction, along with increased insulin sensitivity and secretion.

Objectives: We aim to review the available literature on obese patients treated with different bariatric procedures, in order to assess their effect on gut microbiota, metabolic profile and diabetes remission.

Methods: A systematic literature search was performed in PubMed, Cochrane library, along with Scopus databases, in accordance with the PRISMA guidelines. Random-effects or Fixed-effects statistical model was used appropriately. Between-study heterogeneity was assessed through Cochran Q statistic and by estimating I². A p value of less than 0.05 was set as the threshold indicating a statistically significant result.

Results: Twenty-two studies (562 patients) met the inclusion criteria. This study points to significant amelioration of postoperative levels of glucose (WMD: 0.92 [95% CI: 0.83, 1.01]; p<0.00001), insulin (WMD: 8.84 [95% CI: 8.31, 9.37]; p<0.00001), triglycerides (WMD: 0.22 [95% CI: 0.14, 0.30]; p<0.00001), total cholesterol (WMD: 0.24 [95% CI: 0.18, 0.30]; p<0.00001), LDL (WMD: 0.20 [95% CI: 0.10, 0.30]; p<0.0001), HDL (WMD: -0.11 [95% CI: -0.13, -0.09]; p<0.00001], HOMA-IR (WMD: 0.15 [95% CI: 0.11, 0.19]; p<0.00001), food intake (WMD: 812.20 [95% CI: 765.42, 858.99]; p<0.00001, diabetes remission. Branched chain amino acids (BCAAs) decreased, while trimethylamine-n-oxide (TMAO), glucagon-like peptide 1, 2 (GLP-1, GLP-2) and peptide YY (PYY) increased postoperatively. Metabolic variables were similar between sleeve gastrectomy (SG) and roux-en-y gastric bypass (RYGB), except from insulin which was increased in patients treated with SG (WMD: -6.78 [95% CI: -11.06, -2.50]; p=0.002). Postoperative gut microbiota was similar to that of lean and less obese objects.

Conclusion: Well-designed, randomized trials are necessary to further assess the host metabolic-microbial cross-talk after bariatric procedures.

O-008

SOMATOTROPIC AXIS (GH/ IGF-1) VARIATIONS AFTER BARIATRIC SURGERY IN MORBIDLY OBESE NONDIABETIC PATIENTS

Maria E Barmpari^{1, a)}, Christos Savvidis^{1, b)}, Maria Natoudi²⁾, George Zografos³⁾, Emmanouil Leandros³⁾, Konstantinos Albanopoulos^{3, c)}

¹⁾Department of Endocrinology and Metabolism, "Hippokration" General Hospital of Athens, Athens, Greece; ²⁾2nd Department of Surgery, Henry Dunant Hospital Center, Athens, Greece; ³⁾Laparoendoscopic Unit- 1st Propaedeutic Department of Surgery, "Hippokration" General Hospital – University of Athens, Athens, Greece

^a)barbari_maria@yahoo.com

^b)csavvidis@med.uoa.gr

^c)albanopoulos_kostis@yahoo.gr

Background: Obesity suppresses growth hormone secretion and Insulin-like Growth Factor-1 (IGF-1) production in morbidly obese nondiabetic patients with consequent variations in their lipid profile.

Objective: The aim of this prospective, clinical study was to determine the variations of somatotropic axis (GH/IGF-1) in morbidly obese nondiabetic patients, after laparoscopic sleeve gastrectomy (LSG) or laparoscopic one anastomosis gastric bypass (LOAGB).

Patients and Methods: 123 morbidly obese nondiabetic patients (68.3%women) with a body mass index (BMI) 47.61± 6.54 Kg/m² were followed prior to, 1 and 6 months after LSG (66.7%) or LOAGB (33.3%). Weight loss (expressed as percent excess weight loss, EWL%), waist and hip circumference, serum GH, IGF-1 adjusted with age, Cholesterol, HDL-C, LDL-C, Triglycerides, Very Low Density Lipoprotein (VLDL), were analyzed.

Results In the first month after LSG or LOAGB the mean BMI was 42.68± 6.46kg/m² (p<0.001) and 43.25± 6.79 kg/m² (p<0.001), respectively. Serum levels of GH were significantly increased (p<0.05) with no significant changes in serum IGF-1 levels. There was a significant reduction in all serum lipid levels. The increased serum levels of GH were negatively correlated with BMI, waist and hip circumference, independently of the bariatric surgery performed. After six months from bariatric surgery the mean BMI was 34.38± 6.43kg/m² (p<0.001) and the mean excess weight loss was 52.76± 13.81Kg. Independently of the bariatric surgery performed, there was a significant increase in GH levels (p<0.001) with a consequent reduction in all serum lipid levels except from HDL-C. In patients performed LOAGB, variations in GH levels were positively correlated with excess weight loss and serum cholesterol levels.

Conclusions Weight loss after six months from bariatric surgery in morbidly obese nondiabetic patients seems to improve GH secretion and consequently lipid parameters in morbidly obese nondiabetic patients without the requirement of pharmacologic therapy.

O-009

OMEGA LOOP GASTRIC BYPASS TWO YEARS FOLLOW UP –WEIGHT LOSS, EARLY AND LATE COMPLICATIONS

Eliezer Avinoah

surgery A, soroka medical center, faculty of health sciences, Ben gurion university, beer sheva, Israel

avinoahe@gmail.com

Most bariatric surgery are gastric restrictive while the omega loop is unique by its both restrictive and malabsorptive effects. We describe our clinical experience with 112 patients more than two years after omega loop gastric bypass.

Patients and methods: We performed the omega loop gastric bypass dividing the stomach upon 32 fr. Tube, distal to the crow foot vessels, creating like golf stick gastric pouch. All operations were totally stapled. 20 first gastro-jejunosotomy were performed end to side by circular stapler 21mm, while the rest by linear stapler 60mm. in both methods the intestinal stapler fenestrations were closed by transverse stapled lines. The mean age of the patients was 38±11 and BMI 42±6.

Results: All operations were laparoscopically performed without conversion to open surgery. 26 Patients after previous banding (23%)were performed in one stage. Two to three years after surgery mean BMI 26±4 with good quality of life(BAROS). Four (3.5%) patients had early stapled line intraperitoneal bleeding. Two (1.7%) had acute bleeding due to gastric ulcer. Three patients (2.6%) had leak from gastroentrostomy, reoperated during the first 48 hours after surgery. Six patients (5.3%) had malnutrition, developed between six to nine months after surgery three had reverse operations.

Conclusions: Omega loop is very efficient operation. Its long stapled line demands careful observation and low threshold for reoperation when leak or bleeding is suspected. Malnutrition is relatively significant occurrence and surgical correction is needed.

O-010

Banded versus non-banded Roux-en-Y gastric bypass for morbid obesity: A meta-analysis

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{2, 1, b)}, Konstantina Svokos^{3, c)}, Alexis Svokos^{4, d)}, Eleni Sioka^{1, 2, e)}, George Tzovaras^{1, 2, f)}, Dimitris Zacharoulis^{1, 2, g)}

¹⁾Department of General Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece; ³⁾Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States; ⁴⁾Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, United States

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)konstantina.svokos@gmail.com

^d)alexis.svokos@gmail.com

^e)konstantinasioka@gmail.com

^f)geotzovaras@gmail.com

^g)zachadim@yahoo.com

Background: We aim to review the available literature on obese patients treated with banded (BRYGB) or non-banded roux-en-y gastric bypass (NBRYGB), in order to compare the clinical outcomes and intraoperative parameters of the two methods.

Methods: A systematic literature search was performed in PubMed, Cochrane library and Scopus databases, in accordance with the PRISMA guidelines.

Results: Eight studies met the inclusion criteria incorporating 3,899 patients. This study reveals similar rates regarding the incidence of anastomotic leaks (OR: 0.67 [95% CI: 0.24, 1.92]; p=0.46), wound infections (OR: 1.57 [95% CI: 0.50, 4.94]; p=0.44), pulmonary embolism (OR: 0.60 [95% CI: 0.02, 17.59]; p=0.77) and obstruction (OR: 1.23 [95% CI: 0.29, 5.25]; p=0.78). In addition, the incidence of vomiting (OR: 1.66 [95% CI: 0.60, 4.62]; p=0.33), along with the incidence of other complications (OR: 0.67 [95% CI: 0.33, 1.35]; p=0.26) were comparable. Furthermore, the mortality rate was similar in both groups (OR: 1.00 [95% CI: 0.14, 7.14]; p=1.00). The remission rate of type 2 diabetes (OR: 0.72 [95% CI: 0.33, 1.57]; p=0.40), hypertension (OR: 0.85 [95% CI: 0.37, 1.92]; p=0.69), dyslipidemia (OR: 2.68 [95% CI: 0.75, 9.64]; p=0.13), gastroesophageal reflux (OR: 1.86 [95% CI: 0.66, 5.28]; p=0.24) and obstructive sleep apnea (OR: 1.11 [95% CI: 0.34, 3.64]; p=0.86), along with the % excess weight loss (% EWL) at 1 (OR: 1.01 [95% CI: -3.20, 5.21]; p=0.64) and 2 years (OR: 6.25 [95% CI: -1.39, 13.88]; p=0.11) postoperatively were comparable between patients treated with either approach. However, BRYGB was associated with increased %EWL at 5 years postoperatively.

Conclusion: Well-designed, randomized controlled studies, comparing BRYGB to NBRYGB, are necessary to further assess their clinical outcomes.

O-011

OUTCOMES 15 YEARS AND BEYOND FOLLOWING ADJUSTABLE GASTRIC BANDING FOR MORBID OBESITY: HIGH BAND FAILURE RATE WITH SAFE REVISIONS

Catherine Tsai^a), Jörg Zehetner^b), Ulf Kessler^c), Hans Merki^d), Rudolf Steffen^e)

Visceral Surgery, Clinic Beau Site, Bern, Switzerland

^a)catherine.tsai.md@gmail.com

^b)Joerg.Zehetner@hirslanden.ch

^c)ulf-kessler@hotmail.com

^d)h.merki@ggp.ch

^e)rudolf.steffen@bluewin.ch

Introduction: Surgical treatment of morbid obesity has changed over time, with gastric banding having encouraging early results after its introduction over two decades ago. We present our outcomes of up to 20 years follow-up after Swedish adjustable gastric banding (SAGB).

Methods: This is a retrospective review of patients receiving SAGB between 1997 and 2002 at a bariatric surgery center in Bern, Switzerland. Patients with a minimum of 15 years of follow-up in the same center were included. Patient characteristics, comorbidities, revision surgery, and weight trends were analyzed.

Results: A total of 387 patients with SAGB were identified, of them 294 patients completed at least 15 years (mean 16.9, range 15-20) of follow-up (76.0%). There were 240 (81.6%) females and 54 (18.4%) males. Mean pre-operative age (years) was 40 in females and 41 in males. Mean pre-operative BMI (kg/m²) was 43.2 in females and 43.3 in males. Pre-operatively, 18 (6.1%) of patients had diabetes, 61 (20.7%) had hypertension, and 23 (7.8%) had dyslipidemia. There were no deaths nor major complications (bleeding, infection, re-operation) within 30 days. Within 15-20 years after SAGB, 239 (81.2%) of patients underwent revisional surgeries (median 3, range 1-4) either due to band-related complications (4.8%) or severe esophageal dilation with or without sufficient weight loss (95.2%). 193 (55.4%) of patients were converted to Roux-en-Y gastric bypass (RYGB), 9 (6.8%) to biliopancreatic diversion, 11 (3.7%) to duodenal switch, and 10 (3.4%) to sleeve gastrectomy. 15 (5.1%) patients received repeat SAGB, 3 (1.0%) had SAGB removal only, and 24 (8.2%) had no further intervention. There were no deaths after revisional surgery. At 19 years after SAGB, mean % excess BMI loss was 65.0% for all patients, 63.4% in patients converted to RYGB, and 80.4% in patients without further intervention (Figure 1).

Conclusions: Few patients have optimal outcomes after SAGB and predictive selection criteria are lacking. The vast majority of SAGB surgeries fail even with close structured follow-up. Conversions to other procedures can be done safely.

O-012

Vertical sleeve gastrectomy or Roux-en-Y gastric bypass? A Systems epidemiology approach for bariatrics personalized treatment

Styliani Geronikolou^{1, a)}, Konstantinos Albanopoulos^{2, b)}, Dennis Cokkinos^{1, c)}, Athanassia Pavlopoulou^{3, d)}, George Chrousos^{4, e)}

¹⁾Clinical, Translational, Experimental Surgery Dpt, Biomedical Research Foundation of the Academy of Athens, Athens, Greece; ²⁾First Department of Propedeutic Surgery, Hippokrateion Hospital, National and Kapodistrian University of Athens, Athens, Greece; ³⁾Izmir International Biomedicine and Genome Institute (iBG-Izmir), Dokuz Eylül University, Izmir, Turkey; ⁴⁾First Dpt Paediatrics, Aghia sophia Hospital, National and Kapodistrian University of Athens, Athens, Greece

^a)sgeronik@bioaacdemy.gr

^b)albanopoulos_kostis@yahoo.gr

^c)dcokkinos@bioacademy.gr

^d)athanasiapavlo@gmail.com

^e)chrousog@mail.nih.gov

Background: Obesity, a chronic disease of outmost increasing prevalence with distinct public health, economic and social consequences, is one of the main alarming targets set by World Health Organization. On the other hand, P4 (Predictive, Preventive, Personalized and Participatory) Medicine’ s main goals are to quantify wellness and demystify disease. In pathogenic obesity case (in need for surgical intervention for losing weight), biology and physiology mechanisms are, still, under investigation, whereas, after operation wellness needs further consideration.

Aim: To advance the insight of the severe obesity pathogenesis and contribute to a P4 medicine model for bariatric surgeons as well as obesity- focused scientists.

Methods: We profited from major Systems Epidemiology tools such as: a. literature review of epidemiological, experimental (both translational and of surgical techniques) studies, b. meta-analysis of retrieved epigenetic effects, c. evaluation of bias, d. interactions networking. PRISMA protocol was applied in a meta-analysis focused on Gastric Bypass Roux-en-Y (RYGP) and Vertical Sleeve Gastrectomy (SG) surgical techniques. The analysis studied valid and independent predictors of cardiovascular, neurohormonal/metabolic functions (HOMA-IR, HRV) with Hedge’s g effect size by CMA software. The interactions among obesity-related gene or gene products were studied through STRING v10 (Szklarczyk et al., 2015), with a high confidence interaction score of 0.7-0.97.

Results: The meta-analysis showed that insulin resistance decreases after RYGP, whereas, the vagal tone increases only after SG. The constructed interactome involves 54 nodes of gene- gene products of known and/or predicted interactions.

Conclusions: Systems epidemiology methods unlock “black boxes” in daily surgeon’s practice, integrating sparse or conflicting information from various scientific fields (-omics, clinical/experimental data): (i) RYGP is suggested for patients with glycemic and/or hypertension profile, whereas, SG for cardiovascular patients (ii) these methods activate different mechanisms (iii) the constructed interactome (obesidome) links gut hormones with inflammation and the autonomic nervous system, stress and homeostasis systems, genetic factors (iv) leptin, insulin, CRH, POMC are major “hubs” for the obesity (v) Bariatrics’ personalized treatment era emerges.

References

Chrousos,G.P. 2009.Stress and Disorders of the Stress System. Nature Reviews Endocrinology 5: 374–381.

S Geronikolou, A Pavlopoulou, G Chrousos, The interactome of obesity: Obesidome, Advances Medicine & Biology, 2017, doi: 10.1007/978-3-319-57379-3_21.

S Geronikolou, K Albanopoulos, G Chrousos, D Cokkinos, Evaluating the Homeostasis assessment model insulin resistance and the Cardiac Autonomic System in bariatric surgery patients: a meta-analysis. J Advances Medicine & Biology, 2017 doi: 1007/978-3-319-56246-9_20.

Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet [Internet] (0). Available from: http://www.sciencedirect.com/science/article/pii/S0140673614604608

Becker, D.A., L.J. Balcer, and S.L. Galetta. 2012. The Neurological Complications of Nutritional Deficiency Following Bariatric Surgery. Journal of Obesity 2012: 608534.

Han, L., L. JI, J. Chang, J. Wen, W. Zhao, H. Shi, L. Zhou, Y. Li, R. Hu, J. Hu, and B. Lu. 2015. Peripheral Neuropathy is Associated with Insulin Resistance Independent of Metabolic Syndrome. Diabetology and Metabolic Syndrome 7: 14.

Singh, A.K., R. Singh, and S.K. Kota. 2015. Bariatric Surgery and Diabetes Remission: Who Would Have Thought It? Indian Journal of Endocrinology Metabolism 19: 563–576.

Cohen, D. 1988. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ.

Hedges, L. 1981. Distribution Theory for Glass’ Estimator of Effect Size and Related Estimators. Journal of Educational Statistics 6: 107–128.

Borenstein, M., L. Hedges, J. Higgins, and H. Rothstein. 2009. Introduction to Meta-Analysis. John Wiley & Sons Ltd: West Sussex, UK.

Matteoli, G., and G.E. Boeckxstaens. 2013. The Vagal Innervation of the Gut and Immune Homeostasis. Gut 62: 1214–1222.

Szklarczyk, D., A. Franceschini, S. Wyder, K. Forslund, D. Heller, J. Huerta-Cepas, M. Simonovic, A. Roth, A. Santos, K.P. Tsafou, M. Kuhn, P. Bork, L.J. Jensen, and C. Von Mering. 2015. String V10: Protein-Protein Interaction Networks, Integrated Over the Tree of Life. Nucleic Acids Research 43: D447–D452.

Snitker, S., I.Macdonald, E.Ravussin,and A. Astrup. 2000. The Sympathetic Nervous System and Obesity: Role in Aetiology and Treatment. Obesity Reviews 1: 5–15.

O-013

One-anastomosis gastric bypass versus sleeve gastrectomy for morbid obesity: a meta-analysis

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{2, 1, b)}, Alexis Svokos^{3, c)}, Konstantina Svokos^{4, d)}, George Tzovaras^{1, 2, e)}, Dimitris Zacharoulis^{1, 2, f)}

¹⁾Department of General Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece; ³⁾Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, United States; ⁴⁾Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)alexis.svokos@gmail.com

^d)konstantina.svokos@gmail.com

^e)geotzovaras@gmail.com

^f)zachadim@yahoo.com

Background: Laparoscopic sleeve gastrectomy (LSG) is a standalone bariatric procedure that has gained increased popularity among bariatric surgeons and morbidly obese patients. One-anastomosis gastric bypass (OAGB) has been proposed as an alternative approach in order to succeed sustainable weight loss.

Objectives: We aim to review the available literature on obese patients treated with OAGB or laparoscopic sleeve gastrectomy (LSG), in order to compare the clinical outcomes and intraoperative parameters of the two methods.

Methods: A systematic literature search was performed in PubMed, Cochrane library and Scopus databases, in accordance with the PRISMA guidelines.

Results: Seventeen studies met the inclusion criteria incorporating 6,761 patients. This study reveals increased %EWL at 1 year postoperatively in OAGB group (WMD: -6.52 [95% CI: -11.65, -1.40]; p=0.01). However, %EWL after 2 years was similar between the two groups (WMD: -16.78 [95% CI: -38.92, 5.37]; p=0.14). Hypertension (HTN) remission was increased in patients treated with OAGB (OR: 0.67 [95% CI: 0.49, 0.90]; p=0.008). Resolution of dyslipidemia was also increased in OAGB group (OR: 0.32 [95% CI: 0.19, 0.56]; p<0.0001). The postoperative obstructive sleep apnea syndrome (OSAS) remission was similar between the two modalities (OR: 0.48 [95% CI: 0.21, 1.09]; p=0.08). In addition, patients treated with OAGB procedure presented shorter mean hospital stay (WMD: 1.29 [0.45, 2.12]; p = 0.002), along with lower rate of revisions (OR: 6.18 [95% CI: 2.09, 18.26]; p=0.001) and mortality (OR: 10.52 [95% CI: 1.24, 89.20]; p=0.03). The incidence of leaks (OR: 2.95 [95% CI: 0.81, 10.81]; p=0.10) and intra-abdominal bleeding (OR: 0.95 [95% CI: 0.43, 2.11]; p=0.90) was similar between the two approaches.

Conclusion: Well-designed, randomized controlled studies, comparing LSG to OAGB, are necessary to further assess their clinical outcomes.

O-014

One Anastomosis Gastric Bypass versus Roux-en-Y-Gastric Bypass as primary bariatric procedures: Mid-term results with 622 cases from a single institution

Karl Peter Rheinwalt^{1, a)}, Marcia Viviane Rückbeil^{2, b)}, Tom Florian Ulmer^{3, c)}, Sebastian Kolec^{1, d)}, Martin Hemmerich^{1, e)}, Andreas Plamper^{1, f)}

¹⁾Bariatric, Metabolic and Plastic Surgery, St. Franziskus Hospital Cologne, Cologne, Germany; ²⁾Institute for Medical Statistics, University Clinics Aachen, Aachen, Germany; ³⁾General, Visceral and Transplant Surgery, University Clinics Aachen, Aachen, Germany

^a)karlpeter.rheinwalt@cellitinnen.de

^b)mrueckbeil@ukaachen.de

^c)fulmer@ukaachen.de

^d)sebastian.kolec@cellitinnen.de

^e)martin.hemmerich@cellitinnen.de

^f)andreas.plamper@cellitinnen.de

Background: Mini-Gastric-Bypass/One-Anastomosis-Gastric-Bypass (MGB/OAGB) became a standard bariatric procedure, but Roux-en-Y Gastric Bypass (RYGB) still remains the most frequently performed gastric bypass operation. Comparative studies are rare.

Methods: Prospectively collected data from primary gastric bypass patients between July 2006 and November 2017 were analyzed retrospectively using ANCOVA and Logistic regression. Total-body-weight-loss (TBWL) after 3 years was defined as primary outcome. Secondary outcomes were duration of operation, perioperative and late postoperative complications and comorbidity-remission.

Results: 325 MGBs (mean age 42.6±11.4 years, 74.5% females) were significantly higher in preoperative BMI (53.7±6.5 kg/m² vs. 44.56 ±3.7 kg/m²) and in prevalence of comorbidities than 297 RYGBs (mean age 41.1±10.0 years, 80.5% females). Mean duration of operation was 80.4±20.4 minutes (min) in MGB and 104.7±31.1 min in RYGB (p<0.0001). Intraoperative complications (4.6% resp. 8.8%), re-laparoscopy (0.6% resp. 0.7%), leakage (1.2% resp. 1.7%), internal hernias (IH) (0.3% resp. 4.0%), marginal ulcers (3.1% resp. 5.4%) and insufficient weight loss at 3 years (4.0% resp. 5.4%) were less frequent in MGB than in RYGB (ns). Follow-up-rates at 1 and 3 years declined from 74.4% to 44.5% (MGB) resp. 76.2% to 50.9% (RYGB) (ns). Comorbidity-remission and TBWL 3 years postoperatively (MGB: 36.2±9.2%, RYGB: 33.7±8.7%; p=0.3236) were comparable. Anastomotic stenosis (1.9% resp. 14.1%) and dumping-syndrome (3.4% resp. 6.7%) were significantly less frequent in MGB.

Conclusions: 3 years postoperatively, TBWL and comorbidity-remission were comparably favorable for RYGB and MGB. But by regarding shorter operation times (p<0.0001), less frequent postoperative stenosis (p<0.0001) and dumping-syndrome (p<0.02) and a 13fold lower IH-rate (ns) we consider MGB as the preferable primary gastric-bypass-procedure.

O-015

Evolution of comorbidities at 1, 2 and 5-years follow up after sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB) and One-anastomosis gastric bypass (OAGB): A comparative study

Jaime Ruiz-Tovar^a), Miguel Angel Carbajo, Lorea Zubiaga, Jose Maria Jimenez, Maria Jose Castro, Alfonso Solar

Surgery, Centro de excelencia para el estudio y tratamiento de la obesidad, Valladolid, Spain

^a)jruiztovar@gmail.com

Introduction:It has been widely demonstrated that malabsorptive bariatric techniques achieve better comorbidities resolution rates tan mixed techniques, obtaining the restrictive procedures the worst results. This improvement of comorbidities is mostly associated with weight loss, but there are also other neuro-hormonal mechanisms involved. The aim of this study is to compare the long-term remission of comorbidities after SG, RYGB and OAGB.

Patients and Methods: We performed a prospective randomized study of patients with indication of bariatric or metabolic surgery undergoing SG, RYGB and OAGB. Analyzed variables were the resolution rates of diabetes mellitus (DM), hypertension (HTA) y dyslipidemia (DL) at 1, 2 and 5 years after surgery.

Results: 600 patients were included, 200 in each group. There no significant differences in age, comorbidities or anthropometric measurements preoperatively between groups.

One year after surgery, the remission rate of DM after SG was 86.9%, after RYGB 89.8% and after OAGB 94% (p=0.305).Remission rate of HTA after SG was 78%, after RYGB 84.3% and after OAGB 90% (p=0.027).Remission rate of DL after SG was 41.4%, after RYGB 80.3% and after OAGB 100%(p<0.001).

2 years after surgery, the remission rate of DM after SG was 85.2%, after RYGB 91.5% and after OAGB 95% (p=0.038). Remission rate of HTA after SG was 75.6%, after RYGB 84.3% and after OAGB 86% (p=0.100).Remission rate of DL after SG was 38.6%, after RYGB 78.9% and after OAGB 100%(p<0.001).

5 years after surgery, the remission rate of DM after SG was 82%, after RYGB 86.4% and after OAGB 96% (p=0.007). Remission rate of HTA after SG was 63.4%, after RYGB 73.5% and after OAGB 84%(p=0.006).Remission rate of DL after SG was 28.6%, after RYGB 71.8% and after OAGB 100%(p<0.001).

Conclusions:OAGB achieves better long-term resolution rates of DM, HTA and DL that SG and RYGB. Though inferior than OAGB, RYGB reaches acceptable improvements of comorbidities. The worst results are obtained after SG, especially with very low resolution rates of dyslipidemia.

O-016

Lack of Uniform Definition of Success, Failure and Weight Regain After Primary Roux-en-Y Gastric Bypass and Gastric Sleeve

Danielle Bonouvrie^a), Martine Uittenbogaart^b), Arijan Luijten^c), Francois Van Dielen^d), Wouter Leclercq^e)

Bariatric Surgery, Maxima Medical Center, Veldhoven, Netherlands

^a)danielle.bonouvrie@mmc.nl

^b)m.uittenbogaart@mmc.nl

^c)A.luijten@mmc.nl

^d)F.vandielen@mmc.nl

^e)w.leclercq@mmc.nl

Introduction: increases in availability of long-term follow-up data have led to more knowledge about the proportion of patients with 1) insufficient weight loss and 2) weight regain after bariatric surgery. However, the definitions of these outcomes lack consensus which makes it impossible to compare the literature. For this study, we intended to obtain knowledge about all the different definitions used in the literature.

Materials and Methods: the online database MEDLINE was searched for literature with a publication date between 01-07-2014 and 01-07-2017 concerning 1) adult patients who received a primary Roux-en-Y Gastric Bypass or a primary Gastric Sleeve and 2) the outcomes weight loss success, weight loss failure and/or weight regain. Articles were screened on title and abstract before inclusion.

Results: the search identified 650 articles of which 113 articles met the inclusion criteria. 47 out of 113 articles mentioned weight loss success of which 40 described a clear definition. Percentage excess weight loss > 50% was the most frequent described definition. 67 out of the 133 articles mentioned weight loss failure of which 40 described a definition, in total 27 different definitions. Weight regain was mentioned in 78 articles, but only twenty authors gave a definition. Striking is that in only 6.2% of the definitions resolution of comorbidities is included. There was no difference in definitions between RYGB and SG and also not between different nationalities. Another notable finding was that weight loss failure was often combined with the terminology of weight regain as an indication for revisional bariatric surgery.

Conclusion: this study shows that the recent literature regarding definitions of weight loss success, weight loss failure and weight regain remains highly inconsistent; only in 50% of the articles a definition is given and the dissimilarity between the definitions is wide. To address this problem and to be able to compare the literature international consensus is required, which our research team intend to produce in the following months using the Delphi method.

O-017

Standardized peri- and postoperative treatment protocol in insulin dependent type 2 diabetes patients undergoing Roux-en-Y gastric bypass surgery

Laura Deden^{1, a)}, Edo Aarts^{1, b)}, Ignace Janssen^{1, c)}, Eric Hazebroek^{1, d)}, Frits Berends^{1, e)}, Hans de Boer^{2, f)}

¹⁾Bariatric surgery, Rijnstate hospital and Vitalys obesity clinic, Arnhem, Netherlands; ²⁾Internal medicine, Rijnstate hospital, Arnhem, Netherlands

^a)ldeden@rijnstate.nl

^b)eaarts@rijnstate.nl

^c)ijanssen@rijnstate.nl

^d)ehazebroek@rijnstate.nl

^e)fberends@rijnstate.nl

^f)hdeboer@rijnstate.nl

Background: Shortly after Roux-en-Y gastric bypass (RYGB) surgery, insulin requirements decrease rapidly. Therefore, patients with insulin dependent type 2 diabetes mellitus (T2DMi) have increased risk for hypoglycemia. A standardized insulin reduction protocol, aiming to maintain blood glucose level (BGL) between 5 and 15 mmol/l, was developed and evaluated on safety and efficacy. At the day of surgery (D0), daily insulin dose reduced by 75% and long acting nighttime insulin was replaced by glimepiride, atministered at 20.00h. After discharge, the second after surgery (D2), glucose control was monitored by phone, until final consultation after three monts (M3).

Methods: From D0 until M3, BGL outside the range of 5 to 15 mmol/l were analyzed. Also, the postoperative change in anti-diabetics and T2DM regulation was evaluated.

Results: 154 patients were included. At D0, D2 and the first week after discharge 2%, 4% and 7% of all BGL-measurements were <5 mmol/l, and 13%, 3% and 2% were >15 mmol/l. Three patients had hypoglycemia (<3.5 mmol/l) during admission and thirteen at home; none needed treatment. Mean preoperative insulin dose was 130±80 IU/day and decreased to 37±1.9 IU/day on D0. Insulin was discontinued permanently in 8% of the patients at D0, in 18% at discharge and in 82% during follow-up. At M3, insulin treated patients used 30±4.2 IU/day. 28% and 46% of the patients still used SU-derivate and metformin, respectively. Fasting BGL and HbA1c had decreased significantly, respectively from 11.3±0.29 to 8.4±0.24 mmol/l and from 70±1.4 to 54±1.0 mmol/l (P<0.01). Largest reduction in anti-diabetics and improvement in glycemic control were observed in patients with lowest preoperative insulin doses.

Conclusion: Immediate insulin dose reduction of 75% with rapid response monitoring is safe and effective in the large majoriy of patients with T2DMi undergoing RYGB surgery. Hypo- and hyperglycemia were prevented and treatment was further reduced or discontinued rapidly.

O-018

Have National Institute for Health and Care Excellence (NICE) Guidelines for people with type 2 diabetes and obesity been implemented in the UK?

Roxanna Zakeri^{1, 2, a)}, Andrea Pucci^{1, 2)}, Mohamed Elkalaawy²⁾, Majid Hashemi²⁾, Andrew Jenkinson²⁾, Marco Adamo²⁾, Rachel Batterham^{1, 2, b)}

¹⁾Centre for Obesity Research, University College London, London, United Kingdom

²⁾UCLH Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals (UCLH), London, United Kingdom

^a)r.zakeri@ucl.ac.uk

^b)r.batterham@ucl.ac.uk

Introduction: Evidence for the beneficial health effects of bariatric surgery for people with obesity and type 2 diabetes (T2D) led the UK’s National Institute for Health and Care Excellence (NICE) to publish specific guidelines for people with obesity and T2D in 2014.¹ These guidelines recommended that people with BMI 35kg/m² or more and T2D (<10 years duration) should have an expedited referral for assessment for bariatric surgery. Furthermore, people with BMI 30-35kg/m² with poor glycaemic control could also be assessed for bariatric surgery.¹ These guidelines were then further endorsed by the 2^nd Diabetes Surgery Summit.² However, the impact of these guidelines upon real-world clinical practice in the UK are unclear. Thus, we examined referral demographics and surgical procedure undertaken.

Methods: Retrospective observational study of patients with obesity and T2D undergoing primary bariatric surgery (2008-2016) in a UK tertiary bariatric centre. Patient demographics, T2D history and surgical procedure were analysed in cohorts grouped by year of surgery (2008-11, 2012-14 and 2015-16).

Results: 463 patients with T2D (28.4% of all patients) underwent bariatric surgery (227 Roux-en-Y gastric bypass [RYBG], 236 sleeve gastrectomy [SG]). The proportion of T2D patients decreased over time (32.4%, 25.9%, 24.6%; p=0.008). No change in mean age or gender occurred but BMI significantly reduced with each cohort (B=-2.2, 95% CI [-2.9]-[-1.4], p<0.001). A non-significant increase in the proportion of T2D patients with BMI<35 kg/m² was also seen (3.5%, 7.4%, 10.0%; p=0.07). HbA1c at referral remained unchanged (mean 7.6±1.4%) but the duration of T2D increased (mean 4.4yrs, 5.4yrs, 6.0yrs; B=0.8, 95% CI 0.2-1.5, p=0.008). Surgical procedure switched from SG to RYGB (%RYGB 44.3, 59.3, 56.0; p=0.019) despite an overall switch from RYGB to SG (%RYGB 50.2, 45.4, 34.4; p=0.011).

Conclusion: Our findings of a reduced proportion of patients with T2D and increased T2D duration at referral suggest NICE guidelines are not being implemented. Interestingly, RYGB remains the procedure of choice for people with T2D and obesity.

References

1. NICE. Obesity: identification, assessment and management | Clinical Guideline CG189 (2014).

2. Rubino, F. et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care 39, 861–877 (2016).

O-019

Laparoscopic sleeve gastrectomy improves diabetes mellitus in the long term

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Background: Bariatric procedures can provide relief from diabetes mellitus type 2. Sleeve gastrectomy has relatively recently joined family of metabolic operations. Many studies have proved the efficiency of sleeve gastrectomy in the treatment of diabetes mellitus that surpasses medical treatment. Still, long term results are lacking in the literature.

Objectives to ascertain the efficacy of sleeve gastrectomy on diabetes mellitus at 1 year and 5 years follow up. The criteria used was dependence on medication for glucemic control at those endpoints.

Methods: 212 patients underwent LSG in the years 2009-2012 by a single surgeon. 49 were diabetics. At 1 year and 5 years follow up, we examined whether they stopped or deescalated their medication.

Results: Short term results were excellent. 35 (71%) patients stopped their treatment and 14 (29%) had their medication reduced. At 5 years 26 (53%) retained glucemic control without medication, 20 (40%) received less medication than preoperatively and 3 (7%) had returned to their preoperative status.

Conclusion: While larger series are necessary, it seems that LSG can achieve a long term control of diabetes mellitus without medical treatment or with less medication than preoperatively in the majority of patients. Whether that will affect the complications of diabetes mellitus (angiopathy, neuropathy, nephropathy etc) remains to be studied.

O-020

Roux-en-Y gastric bypass leads to superior improvements in fasting and postprandial glycemic and lipid profile than sleeve gastrectomy

Chrysi Koliaki¹⁾, Elpida Athanasopoulou¹⁾, Christos Liaskos¹⁾, Kleopatra Alexiadou¹⁾, Georgia Argyrakopoulou¹⁾, Nicholas Tentolouris¹⁾, Andreas Alexandrou²⁾, Theodoros Diamantis²⁾, Nicholas Katsilambros¹⁾, Alexander Kokkinos¹⁾

¹⁾First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece

²⁾First Department of Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece

Introduction

Bariatric surgery leads to substantial improvements in glycemia and lipid profile. The aim of the present study was to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on weight loss and glycemic and lipid profile in morbidly obese patients.

Methods

Seventy-one patients were recruited; 28 underwent RYGB (7 males, age: 38±2 years, BMI: 46.9±1.1 kg/m², mean±SEM), and 43 SG (9 males, age: 38±1 years, BMI: 50.2±1.1 kg/m², mean±SEM, p=NS for all comparisons with RYGB). They were studied preoperatively, 3, and 6 months postoperatively. On each occasion, a mixed test meal was consumed. Blood was taken before, and every 30 minutes afterwards, up to 180 minutes postprandially, for measurement of glucose, insulin, and lipids. The postprandial glucose, insulin, and triglyceride (TG) responses were assessed as area under the curve (AUC).

Results

Baseline parameters were similar between RYGB and SG. Both groups experienced comparable weight loss. Glucose AUC at 3 months was lower for the RYGB vs the SG group (16794±524 vs 19213±731 mg/dl*min, p=0.04), with a similar trend at 6 (15785±504 vs 17535±458 mg/dl*min, p=0.08). TG AUC was lower for the RYGB group at 3 (18881±1236 vs 26730±1378 mg/dl*min, p<0.001) and 6 months (15536±1130 vs 24199±1870 mg/dl*min, p=0.005). Total and LDL cholesterol levels were lower 6 months after RYGB than SG (TChol: 169±6 vs 200±7 mg/dl, p=0.02, LDL-Chol: 108±6 vs 136±6 mg/dl, p=0.035). There were no differences between groups in fasting glucose, insulin, HOMA-IR index, insulin AUC, fasting triglycerides, and HDL cholesterol at any time point.

Conclusion

RYGB leads to superior improvements in fasting and postprandial glycemic and lipid profile than SG, for the same amount of weight loss. This implies procedure-specific effects.

O-021

Time to glycemic control -- an observational study of 3 different operations

Alper Celik^{1, a)}, Sjaak Pouwels^{2, b)}, Fatih Can Karaca¹⁾, Eylem Cagiltay³⁾, Surendra Ugale⁴⁾, Ilker Etikan⁵⁾, Deniz Büyükbozkırlı¹⁾, Yunus Emre Kilic¹⁾

¹⁾Surgery, Metabolic Surgery Clinic, Istanbul, Turkey; ²⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands; ³⁾Endocrinology, GATA Haydarpaşa Training & Research Hospital, Istanbul, Turkey; ⁴⁾Surgery, Kirloskar Hospital, Bariatric & Metabolic Surgery Clinic, Hyderabad, India; ⁵⁾Biostatistics, Near East University Faculty of Medicine, Cyprus, Cyprus

^a)dokteralper@hotmail.com

^b)sjaakpwls@gmail.com

Background: Medical treatment fails to provide adequate control for many obese patients with type 2 diabetes mellitus (T2DM). A comparative observational study of bariatric procedures was performed to investigate the time at which patients achieve glycemic control within the first 30 postoperative days following sleeve gastrectomy (SG), mini-gastric bypass (MGB), and diverted sleeve gastrectomy with ileal transposition (DSIT).

Methods: Included patients had a body mass index (BMI) ≥30 kg/m^2; T2DM for ≥3 years, HbA_1C >7% for ≥3 months, and no significant weight change (>3%) within the prior 3 months. Surgical procedures performed were SG (n=49), MGB (n=93), and DSIT (n=109). The primary endpoint was the day within the first postoperative month on which mean fasting capillary glucose levels reached <126 mg/dL. Multivariate logistic regression analysis was used to identify predictors of glycemic control.

Results: The cohort included 251 patients with a mean BMI of 36.04±5.76 kg/m²; age, 52.84±8.52 years; T2DM duration, 13.09±7.54 years; HbA_1C, 8.82±1.58%. On the morning of surgery, mean fasting plasma glucose was 177.63±51.3 mg/dL; on day 30, 131.35±28.7 mg/dL (p<0.05). Mean fasting plasma glucose of <126 mg/dL was reached in the DSIT group (124.36±20.21 mg/dL) on day 29, and in the MGB group (123.61±22.51 mg/dL), on day 30. The SG group did not achieve the target mean capillary glucose level within postoperative 30 days.

Conclusion: During the first postoperative month, glycemic control (<126 mg/dL) was achieved following DSIT and MGB, but not SG. Preoperative BMI and postprandial C-peptide levels were independent predictors of early glycemic control following DSIT.

O-022

Metabolic Surgical Outcomes in a United States Appalachian Population

Makenzie Barr^{1, a)}, Melissa Olfert^{1, b)}, Lawrence Tabone^{2, c)}, Nova Szoka^{2, d)}, Stephanie Cox^{2, e)}, Cassie Brode^{2, f)}, I. Mark Olfert^{2, g)}, Laura Davisson^{2, h)}

¹⁾Davis College of Agriculture, Natural Resources, and Design, West Virginia University, Morgantown, United States; ²⁾School of Medicine, West Virginia University, Morgantown, United States

^a)mbarr6@mix.wvu.edu

^b)melissa.olfert@mail.wvu.edu

^c)letabone@hsc.wvu.edu

^d)nova.szoka@hsc.wvu.edu

^e)scox@hsc.wvu.edu

^f)cassie.brode@hsc.wvu.edu

^g)imolfert@hsc.wvu.edu

^h)ldavisson@hsc.wvu.edu

Objective: To examine demographics and surgical outcomes including: weight, body mass index (BMI kg/m²), percent excess body weight (%EBW), percent excess body weight loss (%EBWL) and laboratory values (i.e., blood glucose levels) among patients undergoing metabolic surgery in West Virginia. Methods: A retrospective electronic medical record (EMR) data extraction was performed on 588 patients receiving bariatric surgery at a large tertiary academic medical center within Appalachia between 2013-2017. Data extracted from patient EMR.. Results: The average preoperative weight of patients was 299.2±62.8 pounds (n=585) with a BMI of 48.3±8.1 kg/m² (n=584); the preoperative EBW was 144.5±53.4 pounds (n=585). Subjects with one year follow-up (n=250) had an average reduction in weight, BMI, and EBW of 95.3 pounds, 14.8 kg/m2, and 93.6 pounds, respectively. Traditionally surgical success at one year is measured with a 50% EBWL or greater. %EBWL from baseline to one year follow up was 70.0±29.5% (n=250). Matched pairs t-test analyses from pre to one-year postsurgical identified significant decreases in weight, BMI, and EBW (all p’s <0.0001). Baseline labs included blood glucose of 119.0±45.6 mg/dL, HbA1C of 6.1±1.1%, total cholesterol of 184.5±38.3 mg/dL, and triglycerides of 178.2±92.1 mg/dL. One-year postsurgical follow-up of labs included an average blood glucose decrease of 20.5 mg/dL, HbA1C of 0.4%, total cholesterol of 12.4 mg/dL, and triglycerides of 86.1 mg/dL. Correlational analyses revealed presurgical blood glucose was negatively associated with %EBWL (p=0.003). After controlling for surgery type, negative association was still found in RYGB (p=0.002). Conclusions: These findings suggest that patients completing surgery within an Appalachian region have successful surgical outcomes, as indicated by significant reductions in BMI, %EBW, and %EBWL. These reductions are comparable to and exceed national definitions of surgical success. Findings will inform both future prospective studies, along with specific interventions that are tailored to address the unique needs of this population.

O-023

Revisional surgery - Change of frequency and type revisional surgery during last 3 decades

Rudolf Weiner^{1, a)}, Sonja Chiappetta^{1, b)}, Sylvia Weiner^{2, c)}

¹⁾Obesity Surgery, Sana Klinikum Offenbach, Offenbach, Germany; ²⁾Obesity Surgery, Nordwest Hospital, Frankfurt a.M., Germany

^a)profweiner@gmail.com

^b)sonja.chiappetta@gmail.com

^c)sylvia.weiner@gmx.de

Background: Obesity surgery is not causal tretament of the disease. Failures in treatment, complications and recurrence can be indications for revisional surgery. For a long period the frequency was stable less than 6 %. In the last decade an rapid increase of revisional surgeries were seen worldwide.

Material : The personal experiences in the last 25 years were analyzed.

Period 1: Between 1993 and 2000 986 gastric banding procedures were performed. The revisional surgeries werde compared with primary procedures. Period 2: From 2000 until 2010 2.486 RNYGB, 476 Mini-Gastric bypasses (MGB), 462 BPD-DS and 64 BPD were performed as a primary procedure. Between 2001-2016 the sleeve gastrectomy became for a short period the leading procedure.

Results: In the period 1 and 2 the rate of revisions were 6,2 and 6,4 %. The band was removed and more than 2/3 a second band was implanted.

In the period 2 more than 80 % of band failures were changed to RNYGB.

The RNYGB patients had a revisonal surgery in 6,4 %, but 3 cases only with a change of the procedure. Candy cane resection, hiatoplasties and pouch resection including secondary placement of rings were dominating. In the last period the sleeve shows an rapid increase of revisions more than 16 %.

Conclusion: The indications for revisional surgeries are still under discussion. 2 Consensus conferences were not able to established guidelines. All bariatric procedures had in the past a frequency of revisonal surgery less than 7 %. With increase of the sleeve gastrectomies we saw an increase of revisional surgeries up to 16 %. With a longer follow-up of 10 years the revisions are increasing after sleeve gastrectomy (for GERD, weight regain or both.) The existing long term risk for Barrett were not respected in the moment. The regulary endoscopic control of all sleeve patients in the long term should be considered.

O-024

OAGB and its Early Compilations –Data From 921 Consecutive Operations

Yonatan Lessing^a), Niv Pencovich^b), Danit Dayan^c), Joseph Koriansky^d), Subhi Abu-Abeid^e)

General Surgery Division, Tel Aviv Medical Center, Tel Aviv, Israel

^a)ylessing@gmail.com

^b)nivp@tlvmc.gov.il

^c)danitd.75@gmail.com

^d)kuri190359@gmail.com

^e)subhia@tlvmc.gov.il

Introduction - OAGB is gaining popularity due to its safety, effectiveness, and the fact it can be used as a revisional procedure after a prior bariatric procedure ^(1-4).

Objective and Methods– To evaluate our experience and results, focusing on short-term complications. Data on 921 consecutive patients that were operated between March 2015 and November 2017 was reviewed.

Results – 463 women and 458 men were operated, with mean age of 41.6 (13-74), and mean BMI of 41.5 (22-68). All procedures were completed laparoscopically, with mean length of hospital stay of 2.1 (1-10). 714 patients (77.5%) underwent MGB as their primary bariatric operation and for 207 patients it was a revisional procedure. Of them, 131 patients underwent OAGB after Laparoscopic adjustable gastric band (LAGB), 51 after sleeve gastrectomy (SG), 11 after SRVG (Silastic ring vertical gastroplasty), and 11 more after a prior both LAGB and SG.

Short term complications, i.e. within 60 days from surgery occurred in 20 patients (1.9%), when most of them were identified during the index hospitalization, since only six patients were readmitted during the first 60 days after surgery.

Six patients suffered from anastomotic leak, among them, only one patient was reoperated, the rest were treated conservatively. Five patients suffered from post-operative bleeding. The bleeding was treated conservatively in three patients, yet for two, an early reoperation took place. Two patients were reoperated due to early bowel obstruction caused by an internal hernia. One patient suffered from an aspiration pneumonia, another suffered grade II skin burn caused by a retractor and one more patient had fever caused by an abdominal hematoma. Two patients suffered from fever, yet no cause was found.

Conclusion – Our data, of nearly 1000 patients, shows that apart of the known advantages of the OAGB, of being highly effective in terms of weight loss and comorbidity resolution^(5-6), it is also a safe operation and we predict that the OAGB popularity will continue to rise worldwide.

References

• 1. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001;11: 276-280.

• 2. Fisher BL, Buchwald H, Clark W, Champion JK, Fox SR, MacDonald KG, et al. Mini-gastric bypass controversy. Obes Surg 2001;11: 773-777.

• 3. Mahawar KK, Jennings N, Brown J, Gupta A, Balupuri S, Small PK. "Mini" gastric bypass: systematic review of a controversial procedure. Obes Surg 2013;23: 1890-1898.

• 4. Mahawar KK, Carr WR, Balupuri S, Small PK. Controversy surrounding 'mini' gastric bypass. Obes Surg 2014;24: 324-333.

• 5. Carbajo MA, Luque-de-Leon E, Jimenez JM, Ortiz-de-Solorzano J, Perez-Miranda M, Castro-Alija MJ. Laparoscopic One-Anastomosis Gastric Bypass: Technique, Results, and Long-Term Follow-Up in 1200 Patients. Obes Surg. 2016.

• 6. Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. Laparoscopic Roux-en-Y vs. mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. Obes Surg. 2012;22(12):1827-1834.

O-025

Mid- and long-term evolution of weight loss after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and One-anastomosis gastric bypass (OAGB): A comparative study

Jaime Ruiz-Tovar^a), Miguel Angel Carbajo, Lorea Zubiaga, Jose Maria Jimenez, Maria Jose Castro, Alfonso Solar

Surgery, Centro de excelencia para el estudio y tratamiento de la obesidad, Valladolid, Spain

^a)jruiztovar@gmail.com

Introduction: SG and RYGB are actually the most frequently performed bariatric techniques world-wide. Despite both techniques achieve acceptable short-term weight loss, there is increasing evidence of long-term weight regain. OAGB is a malabsorptive technique exponentially growing in the last years, given the excellent long-term results obtained in terms of weight loss, improvement of comorbidities and low postoperative complications rate.

The aim of this study is to compare the short- and long-term weight loss after SG, RYGB and OAGB.

Patients and Methods: We performed a prospective randomized study of patients with indication of bariatric or metabolic surgery undergoing SG, RYGB and OAGB. Analyzed variables were baseline weight and BMI, and postoperative weight, BMI and excess weight loss (EWL) at 1, 2 and 5 years.

Results: 600 patients were included, 200 in each group. There no significant differences in age, gender, comorbidities or anthropometric measurements preoperatively between groups.

One year after surgery, BMI after after SG was 28.9 Kg/m2, after RYGB 28.7 Kg/m2 and after OAGB 25 Kg/m2 (p<0.001),with EWL of 81.7%, 81.2% and 100.4%, respectively (p<0.001).

2 years after surgery, BMI after after SG was 28.7 Kg/m2, after RYGB 27.8 Kg/m2 and after OAGB 24.8 Kg/m2 (p<0.001),with EWL of 87%, 87.2% and 104.3%, respectively (p<0.001).

5 years after surgery, BMI after after SG was 30.8 Kg/m2, after RYGB 29.9 Kg/m2 and after OAGB 25.1 Kg/m2 (p<0.001),with EWL of 76.3%, 77.1% and 97.9%, respectively (p<0.001).

Conclusions: OAGB achieve superior mid- and long-term weight loss than the other techniques. There are no significant differences between SG and RYGB at 1, 2 and 5 years. 5 years after surgery, the patients who underwent SG and RYGB present again mean BMI in range of obesity, while after OAGB, anthropometric parameters remain in normal weight range.

O-026 Long-term follow-up of older patients with super obesity and biliopancreatic diversion with duodenal switch

Philipp C. Nett^a), Dino Kröll^b), Gabriel Plitzko^c), Yves M. Borbély^d)

University Obesity Centre of Berne, University Hospital of Berne, Switzerland, Berne, Switzerland

^a)philipp.nett@insel.ch

^b)dino.kroell@insel.ch

^c)gabriel.plitzko@insel.ch

^d)yves.borbely@insel.ch

Background: Indications and long-term outcome of biliopancreatic diversion with duodenal switch (BPD-DS) in older adults suffering from super obesity remain controversial. The aim of this study was to evaluate safety and long-term outcomes of this bariatric procedure in older patients with super obesity.

Setting: University Hospital, Switzerland.

Methods: Patients aged ≥60 years who underwent (BPD-DS) between January 2001 and December 2011 were included and had at least 5 years of follow-up. This is a single-center retrospective study of a prospectively collected database.

Results: Of all 246 patients undergoing (BPD-DS), 23 patients (9%) were older than 60 years and super-obese (body mass index; BMI>50 kg/m²). The majority of the procedures were laparoscopic with two conversions (9%) to open surgery. Almost all patients (19/23; 83%) underwent a concomitant cholecystectomy. Mean age and BMI were 62.8±3.1 years and 55.2±7.9kg/m², respectively. Average follow-up time after BPD-DS was 96.8±31.3 months. At baseline, 86% (20/23) of the patients had arterial hypertension, 74% (17/23) had type 2 diabetes mellitus, and 43% (10/23) had obstructive sleep apnea syndrome. There was no 30-day mortality. Complication rate (Dindo-Clavien category 3 and 4) was 9% (2/23): one leak that could be managed conservatively and one bleeding requiring transfusion. Mean percent excess weight loss (%EWL) at 2, 5 and 10 years after BPD-DS was 55.7±28.2, 57.3±22.1, and 51.9±31.4. Remission rates of arterial hypertension, type-2 diabetes mellitus, and obstructive sleep apnea syndrome were 22%, 47%, and 28% after 5 years, respectively.

Conclusion: BPD-DS is safe and effective in improving obesity-related comorbidities in older patients suffering from super obesity. Age alone should not preclude older patients from getting the best bariatric procedure for obesity and its related comorbidities.

O-027

Are there ideal bowel lenghts to obtain optimal weight loss after One-anastomosis gastric bypass (OAGB)?

Jaime Ruiz-Tovar^a), Miguel Angel Carbajo, Jose Maria Jimenez, Maria Jose Castro, Lorea Zubiaga, Alfonso Solar

Surgery, Centro de excelencia para el estudio y tratamiento de la obesidad, Valladolid, Spain

^a)jruiztovar@gmail.com

Introduction: One-anastomosis gastric bypass (OAGB) is a malabsorptive technique. As in all malabsorptive procedures, there is uncertainty of which is the ideal bowel length to optimize the results.

The aim of this study was to evaluate the different lengths of biliopancreatic limb and common limb performed in OAGB, analyzing the obtained weight loss.

Patients and methods: We performed a prospective observational study of 320 patients undegoing OAGB. Analyzed variables were BMI and excess weight loss (EWL) one year after surgery. Biliopancreatic (BP) and common (C) limbs length was determined and the ratios (BP/total bowel length) and (C/Total bowel length).

Results: 320 patients were included, 250 females and 70 males with baseline BMI 41.3+8.2 Kg/m2. OAGB was performed in all the cases with a mean BP limb length of 279+124.2cm and a mean C limb lenght of 227.2+23.3cm. Mean total bowel length (TBL) was 506.5 + 23.2cm. Mean BP/TBL ratio was 0.55+0.04 and mean C/TBL 0.45 + 0.04.

12 months after surgery BP limb length and BP/TBL ratio directly correlated with weight loss and EWL. C limb length and C/TBL ratio inversely correlated with weight loss and EWL.

Ideal cut-off point to obtain a BMI<25Kg/m2 was calculated with AUC for all the measures, being statistically significant for the C limb lenght (AUC 0.640; CI95%(0.571-0.709);p<0.001) and for the C/TBL ratio (AUC 0.687; IC95%(0.621-0.753);p<0.001).

For the C limb, cut-off point was established for 220cm with 75% sensibility and 65% specificity. A C limb length of 180cm achieved a BMI<25Kg/m2 in 100% of the cases.

For the C/TBL ratio, cut-off point was established for 0.44 with 78% sensibility and 68% specificity. A C/TBL ratio <0.37 achieved a BMI<25Kg/m2 in 100% of the cases.

Conclusions: C/TBL ratio is the best determination to predict the weight loss success of OAGB. We recommend a ratio between 0.37-0.44. Common limb lenght must range between 180-220cm.

O-028

Comparative evaluation of Pylorus-preserving types of Biliopancreatic Diversion (SADI’s vs. Switch)

Yury Yashkov^{1, a)}, Natalya Bordan^{2, b)}, Alexandra Malykhina^{1, c)}

¹⁾Obesity Surgery, CELT- clinic, Moscow, Russia, Moscow, Russian Federation; ²⁾Bariatric surgery, Center of Obstetrics, Gynecology and Perinatology im V.I.Kulakova, Moscow, Russian Federation

^a)yu@yashkov.ru

^b)socetanie@mail.ru

^c)sandroka@bk.ru

Aim. To compare 2-3 year results of two pylorus-preserving types of Biliopancreatic Diversion (Duodenal Switch vs SADI-s) in a prospective randomized study.

Methods. 60 patients operated between May, 2014 and June, 2015 by the same surgeon (YY) in CELT- clinic were prospectively randomized into two groups: 30 pts underwent open SADI-s (1-st group), 30- open DS (2-nd group). All operations were primary, secondary operations were excluded from the study. Both groups were comparable on age, sex, initial weight, BMI, % of comorbidities. Diabetes mellitus type 2 (DM2) was diagnosed in 9 (30%) pts in group 1 and in 10 (33%) pts in the group 2. Patients were followed-up for the period 2-3 years.

Results. Timing of operation was significantly less in SADI-s group. % EWL at 1, 2 and 3 years was the same. All pts with DM 2 had their Diabetes compensated in both groups and most pts were free of antidiabetic therapy. 30-day complication rate was 3/3% % in group 1 (one case of pneumonia and 3,3% % in group 2 (one intraperitoneal bleeding, revision). SADI-s had advantages in terms of Protein malnutrition, late small bowel obstruction. 3 pts in group 1 and 2 pts in group 2 had revisions for late postop problems during abdominoplasty. 10 % in SADI-s group had non-severe symptoms of bile reflux.

Conclusion. SADI-s has advantages over BPD/DS in terms of simplicity and less operative time. % EWL and % of compensation of DM2 is the same in each follow period within 3 years. SADI-s demonstrated less probability of excessive malabsorption but bile reflux symptoms are possible. SADI-s looks as a reasonable alternative to BPD/DS as a primary operation.

O-029

Weight regain after gastric sleeve operation: our experience with SADI- S Bypass

Vasiliki Christogianni^a), Martin Buesing^b), Panagiotis Bemponis^c), Radostina Dukovska^d)

General and Visceral Surgery, Klinikum Vest Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

^a)bchristogianni@yahoo.com

^b)chirurgie@klinikum-vest.de

^c)bebonis@gmail.com

^d)ineto@abv.bg

Introduction: The sleeve gastrectomy is an established procedure for the treatment of morbid obesity. Alongside with the gastroesophageal reflux, the regain of weight or inadequate weight loss- especially in patients with a BMI grater than 60kg/m2- are considered to be the two most frequent long term problems. The Single Anastomosis Duodenal Ileal bypass is a surgical approach with promising long term results.

Materials and Methods: In our clinic, the SADI- S procedure is, since August 2013, the established operation after weight regain or inadequate weight loss after sleeve gastrectomy. The hand sutured duodenoileal anastomosis is performed 250cm oral of the ileoceacal valve. In cases of dilatation of the Sleeve a Re- Sleeve resection or an inverting longitudinal suture is simultaneously performed. Patients experiencing GERD Symptoms due to a hiatal hernia are also treated with a posterior hiatoplasty. Patients were allowed to take fluids orally directly after the operation.

Results: 32 patients underwent a SADI-S operation. The time of the initial procedure was 8 to 48 months prior to the SADI- S operation. Simultaneously, the following procedures were performed: re-Sleeve (n=8), gastroplication (n=12), hiatoplasty (n=12), cholecystectomy (n=7). Duodenal stump leakage was in no case observed, whereas in one case a reanastomosis due to duodenalileal insufficiency was necessary. The mean hospital stay was 4 days. In the long term, all patients showed satisfactory weight loss (BMI drop 6-15 kg/m2). The GERD symptoms were reduced and in most no further PPI medication was needed. Excessive diarrhoea or flatulence were not observed.

Conclusions: The SADI- S operation is an effective procedure for the treatment of inadequate weight loss after a sleeve gastrectomy. An additional reduction of the sleeve volume can also be performed. In case of gastroesophageal reflux a hiatoplasty can also provide a relief of the symptoms. A long term follow up is necessary.

Acknowledgement: M. de la Cruz, A. Knapp, R. Riege, J.C. Halter

Klinikum Vest- Knappschaft Krankenhaus Recklinghausen, Recklinghausen, Germany

O-030

Safety and Effectiveness of One Anastomosis Gastric Bypass

Asnat Raziel^a), David Goitein^b), Nasser Sakran^c)

Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel

^a)doctor@asnatraziel.com

^b)david.goitein@sheba.health.gov.il

^c)sakranas@walla.com

Introduction: Mini gastric bypass (MGB) has been established as a safe and effective bariatric procedure.

Material and Methods: The study retrospectively reviewed and analyzed 337 MGB procedures.

Results: 337 MGB included 71% females. Mean age 45 years (18-76), mean preoperative weight 117 kg (74-214), and mean preoperative BMI 42 kg/m² (35-89).

There were 244 (72%) primary MGB (P-MGB) and 93 (28%) conversional MGB (C-MGB).

There were 114 concomitant operations: 36 removal of band, 24 cholecystectomy, 4 ventral hernia repair, 3 umbilical hernia repair and 47 hiatal hernia repair. We have found hiatal hernia in 47.2% out of 36 cases of band removal and MGB.

Early complications occurred in 13 (3.9%) patients including: 6 bleeding (1.8%), 2 leak (0.6%), 2 gastro-jejunal anastomosis obstruction (0.6%), 1 pericarditis (0.3%), 1 acute MI (0.3%) and 1 wound infection (0.3%). There was a low and comparable complication rate in both groups: 9/244 (3.7%) in the P-MGB group and 4/93 (4.3%) in the C-MGB group, p=0.8.

Late complications occurred in 8 (2.4%) patients including: 4 cholelithiasis (1.2%), 2 perforation of gastro-jejunal anastomotic ulcer (0.6%), 1 bleeding anastomotic ulcer (0.3%) and 1 trocar site hernia (0.3%).

Resolution or improvement in comorbidities was as follow: Hypertension 14/17 (82.3%), Diabetes 35/36 (97.2%), Hyperlipidemia 75/88 (85.2%), and Obstructive sleep apnea 30/31 (96.8%).

Excess weight loss (EWL) was 88% (n=61) after 12 months. C-MGB had inferior mean EWL compared to P-MGB: 70% versus 93% (p<0.01), though both groups were successful after 12 months (mean EWL>50%).

Conclusion: MGB may be considered as a safe and effective primary and conversional bariatric procedure. EWL percentage after conversional MGB is inferior to primary MGB after 12 months.

References

• 1. Patel, S., S. Szomstein, and R.J. Rosenthal, Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding). Obesity surgery, 2011. 21(8): p. 1209-19.

• 2. Nesset, E.M., et al., A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2007. 3(1): p. 25-30; discussion 30.

• 3. Gagner, M., et al., Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obesity surgery, 2002. 12(2): p. 254-60.

• 4. Inabnet, W.B., 3rd, et al., Comparison of 30-day outcomes after non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study.Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2010. 6(1): p. 22-30.

• 5. Spyropoulos, C., et al., Revisional bariatric surgery: 13-year experience from a tertiary institution. Archives of surgery, 2010. 145(2): p. 173-7.

• 6. Cariani, S., et al., Complications after gastroplasty and gastric bypass as a primary operation and as a reoperation. Obesity surgery, 2001. 11(4): p. 487-90.

• 7. Cadiere, G.B., et al., Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric bypass similar in terms of results? Obesity surgery, 2011. 21(6): p. 692-8.

• 8. Rutledge, R. and T.R. Walsh, Continued excellent results with the mini-gastric bypass: six-year study in 2,410 patients. Obesity surgery, 2005. 15(9): p. 1304-8.

• 9. Georgiadou, D., et al., Efficacy and safety of laparoscopic mini gastric bypass. A systematic review. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2014. 10(5): p. 984-91.

• 10. Wang, W., et al., Laparoscopic mini-gastric bypass for failed vertical banded gastroplasty. Obesity surgery, 2004. 14(6): p. 777-82.

• 11. Noun, R., et al., Mini-gastric bypass for revision of failed primary restrictive procedures: a valuable option. Obesity surgery, 2007. 17(5): p. 684-8.

• 12. Rutledge, R., Revision of failed gastric banding to mini-gastric bypass. Obesity surgery, 2006. 16(4): p. 521-3.

• 13. Piazza, L., et al., Revision of failed primary adjustable gastric banding to mini-gastric bypass: results in 48 consecutive patients. Updates in surgery, 2015. 67(4): p. 433-7.

• 14. Bruzzi, M., et al., Revisional single-anastomosis gastric bypass for a failed restrictive procedure: 5-year results. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2015.

• 15. Noun, R., et al., One thousand consecutive mini-gastric bypass: short- and long-term outcome. Obesity surgery, 2012. 22(5): p. 697-703.

• 16. Zingg, U., et al., Revisional vs. primary Roux-en-Y gastric bypass--a case-matched analysis: less weight loss in revisions. Obesity surgery, 2010. 20(12): p. 1627-32.

• 17. Goitein, D., et al., Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surgical endoscopy, 2011. 25(8): p. 2626-30.

• 18. te Riele, W.W., et al., Conversion of failed laparoscopic gastric banding to gastric bypass as safe and effective as primary gastric bypass in morbidly obese patients. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2008. 4(6): p. 735-9.

• 19. Chevallier, J.M., et al., One thousand single anastomosis (omega loop) gastric bypasses to treat morbid obesity in a 7-year period: outcomes show few complications and good efficacy. Obesity surgery, 2015. 25(6): p. 951-8.

• 20. Genser, L., et al., Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2015.

• 21. Chang, S.H., et al., The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA surgery, 2014. 149(3): p. 275-87.

• 22. Jacobsen, H.J., et al., Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass. The British journal of surgery, 2014. 101(4): p. 417-23.

• 23. Vasas, P., et al., Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass. Obesity surgery, 2013. 23(2): p. 241-8.

• 24. Kellogg, T.A., Revisional bariatric surgery. The Surgical clinics of North America, 2011. 91(6): p. 1353-71, x.

• 25. Brolin, R.E. and R.P. Cody, Weight loss outcome of revisional bariatric operations varies according to the primary procedure. Annals of surgery, 2008. 248(2): p. 227-32.

• 26. Tucker, O., et al., Revisional surgery after failed laparoscopic adjustable gastric banding. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 2008. 4(6): p. 740-7.

• 27. Acholonu, E., et al., Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obesity surgery, 2009. 19(12): p. 1612-6.

• 28. Fronza, J.S., et al., Revisional bariatric surgery at a single institution. American journal of surgery, 2010. 200(5): p. 651-4.

• 29. Kuesters, S., et al., Revisionary bariatric surgery: indications and outcome of 100 consecutive operations at a single center. Surgical endoscopy, 2012. 26(6): p. 1718-23.

O-031

Low Food Access Ranking among West Virginia Appalachian Metabolic Surgery Patients

Makenzie Barr^{1, a)}, Melissa Olfert^{1, b)}, Lawrence Tabone^{2, c)}, Nova Szoka^{2, d)}, Laura Davisson^{2, e)}, Stephanie Cox^{2, f)}, Cassie Brode^{2, g)}, Thomson Gross^{3, h)}, Bradley Wilson^{3, i)}

¹⁾Department of Animal and Nutritional Sciences, West Virginia University, Morgantown, United States

²⁾Department of Medicine, West Virginia University, Morgantown, United States

³⁾Department of Geography, West Virginia University, Morgantown, United States

^a)mbarr6@mix.wvu.edu

^b)melissa.olfert@mail.wvu.edu

^c)letabone@hsc.wvu.edu

^d)nova.szoka@hsc.wvu.edu

^e)ldavisson@hsc.wvu.edu

^f)scox@hsc.wvu.edu

^g)cassie.brode@hsc.wvu.edu

^h)tgross3@mail.wvu.edu

ⁱ⁾bradley.wilson@mail.wvu.edu

Background: West Virginia has the highest prevalence of obesity (37.7%) and weight related comorbidities, including diabetes (14.5%), and hypertension (42.7%) in the country. The Appalachian population has limited food access that may contribute to the prevalence of obesity and potentially mitigate treatments of obesity.

Objective: This research aimed to identify food access within a cohort of metabolic surgery patients in an Appalachian area, specifically West Virginia.

Methods: A retrospective data extraction was performed on 588 patients receiving bariatric surgery between 2013-2017. Variables collected included preoperative weight, demographics, and geographical location information. Patient geographical location for West Virginia residents (n=394) was gained from EMR demographics and entered into WV FOODLINK Food Accessibility Map. WV FOODLINK identified four variables regarding food access: (1) quantity of retailers, (2) quality of retailers, (3) income, and (4) vehicle access. Patients were given a food access ranking score (FARS) between 0 (low food access) and 4 (high food access).

Results: Patients overall were predominately Caucasian (92.1%), female (79.7%), with an average age of 45.6±11.2 years, and the majority received Roux-en-Y gastric bypass (71.6%). The average Food Access Score (FARS) for subjects was 1.66+0.73. The highest proportion of patients were located within FARS between 0 to 2 (72.6%). Those with low food access (0-2 FARS) were largely Caucasian, female, married, from outside of the closest urban area, had a preoperative average weight of 280.6+49.2 pounds, and an initial excess body weight (EBW) of 135.0+46.1 pounds. At baseline, however, weight in pounds was not significantly related to FARS (p=0.6526). At one-year postoperative follow-up, and weight change across that year, FARS was not significantly related (p=0.4168 and p=0.4675).

Conclusions: The majority of West Virginians have lower food access; thus, understanding food accessibility in this population and its relationship to weight and related outcomes will inform bariatric nutritional care pre- and post-surgery. Additional work is needed to examine specific dietary behaviors and characteristics of individuals across all sectors of food access ranking.

Acknowledgement: Funding from West Virginia University Experimental Station – Hatch WVA00689

O-032

Initial experience of endoscopic radiofrequency waves delivery to the lower oesophageal sphincter (Stretta procedure) on symptomatic Gastroesophageal reflux disease post sleeve gastrectomy

Nesreen Khidir^a), Moataz Bashah^b)

Bariatric and Metabolic surgery, Hamad Medical corporation, Doha, Qatar

^a)dr_sora4@hotmail.com

^b)mbashah@hamad.qa

Introduction: Gastroesophageal reflux disease (GERD) is major side effect occurs de novo (8.6%) or intensifies (21%) after laparoscopic sleeve gastrectomy (LSG) (1). Endoscopic radiofrequency (Stretta) for treatment of GERD is less invasive effective tool to manage GERD symptoms (2). However, stretta safety and efficacy are unknown in patients with symptomatic GERD after LSG.

Objective: To evaluate safety (complication rate) and efficacy of Stretta in symptomatic GERD post LSG (heart burn and regurgitation symptoms, quality of life and PPI dose at 0, 3 and 6 months).

Methods: Retrospective review of all patients who underwent Stretta procedure in our centre. Patients’ demographic, preoperative lower esophageal manometry, 24 h pH monitoring, endoscopic and radiological findings, GERD symptoms using GERD Health Related Quality of Life (HR-QoL) questionnaire at 0, 3 and 6 months, pre-and post PPI dose, were reviewed.

Results: Fifteen patients’ mean age of 35.9±10.7 and BMI 29.7±6.3. Pre-Stretta endoscopic reflux esophagitis found in 36.7%, barium imaging showed severe reflux in 45%, small hiatal hernia in 18.2% and no patient had sleeve migration. Mean DeMeester score of 27.9±6.7, (95%CI=24.2 —31.6). Hypotensive LES pressure, mean= 7.5± 2.7. Patients’ mean HR-Qol score dropped from 42.7±8.2 pre-Stretta to 41.8±10.2 at 6 months (P =0.8). One case (6.7%) was complicated by hematemesis, required re-endoscopy. At 6 months, 66.7% of patients were not satisfied with the results though PPI dose decreased in 27% and stopped in 20% of patients. One patient (6.7%), underwent Roux en-y gastric bypass at 8 months post-Stretta to relieve the symptoms. One patient underwent a second session of stretta procedure without improvement.

Conclusion: Stretta didn’t improve GERD symptoms in patients post LSG at short term follow up. Patients were not satisfied about the quality of life despite the decrease in PPI dose.

References

• D M Felsenreich, R Kefur, M Schermann, P Beckerhinn, I Kristo, M Krebs, G Prager, F B Langer. Reflux, Sleeve Dilation, and Barrett’s Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up. Obes Surg. 2017 Dec;27(12):3092-3101.

• R Fass, F Cahn, D J Scotti, D A Gregory. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc. 2017 Dec;31(12):4865-4882.

Acknowledgement: We would like to acknowledge professor Luigi Angrisani for his advices and valuable supervision.

O-033

Side to Side jejuno-ileal anastomosis as a revisional procedure in failed sleeve gastrectomy.

Halit Eren Taskin^{1, a)}, Elshad Rzayev¹⁾, Yasin Tosun¹⁾, Mustafa Taskin^{1, b)}, Seniyye Ulgen Zengin²⁾

¹⁾General Surgery, Istanbul University Cerrahpasa Faculty of Medicine, ISTANBUL, Turkey; ²⁾Anesthesiology, Bezmi Alem Vakif University Faculty of Medicine, ISTANBUL, Turkey

^a)eren_taskin@hotmail.com

^b)mtaskin@istanbul.edu.tr

Background: Side to side jejunoileal anastomosis (SJA) is a novel procedure used as an experimental procedure for the treatment of Type-2 Diabetes Mellitus in Low BMI patients ( T2DM). Also in obese subjects the procedure is effective combined with a classic sleeve gastrectomy both for weight loss and T2DM control. Here we evaluated the benefit of SJA as a revisional procedure in 4 patients who had underwent sleeve gastrectomy 4 years ago but returned with either weight regain and/or recurrence of T2DM.

Materials and Methods: The mean BMI of the patients were 34±4.2 kg/m². All patients underwent standart sleeve gastrectomy with 38F buji in the same institution. The mean f/u period was 24± 6 months and the %EWL after the primary surgery was 38±4.8% after the first procedure. Two patients came with diabetes recurrence. They were back to oral antidiabetic OAD drugs. All patients underwent a revisional SJA procedure and the mean f/u period was 8± 2.4 months.

Results: The patients achieved a %EWL of 22±5.2% and two patients quited the OAD. There was no major complications only a transient hypoalbunemia in one patients which was treated conservatively. The Hba1c of the diabetic patients were 4.9% and and 5.6% at the end of the f/u period. One patient experienced excess flatulance and undigestion which was resolved after 6 months.

Conclusion: Although being accepted as still experimental SJA is an safe and effective procedure for controlling T2DM in low-bmi and morbid obese patients. Recent use of it as a revisional procedure is promosing and a safe and easy alternative in setting of failed sleeve gastrectomy as a complementary revisional procedure. Further randomized studies will justify this role in the near future.

O-034

Comparative study of Medical Versus Surgical Weight Loss in Elderly: Cardiometabolic and Nutritional Changes At one Year Follow Up

Moamena El-Matbouly^a), Nesreen Khidir^b), Moataz Bashah^c), Wahiba Elhag^d)

Bariatric and metabolic Divison- General Surgery Department, Hamad Medical Corporation, doha, Qatar

^a)momenaelmatbouly@gmail.com

^b)dr_sora4@hotmail.com

^c)mbashah@hamad.qa

^d)welhag1@hamad.qa

Introduction: Bariatric surgery (BS) is effective in obese elderly. However, it is unknown if medical versus surgical weight loss in elderly have comparable safety, impact on obesity associated cardiometabolic risk and nutritional deficiencies.

Objective: Compare the medical versus surgical weight loss, complications rate, cardiometabolic and nutritional outcomes at 0 and 1 year.

Compare the impact of sleeve gastrectomy, Roux en Y gastric bypass, single anastomosis duodenal switch with sleeve and omega loop gastric bypass on weight loss results, cardiometabolic risk and nutritional outcomes at 0 and 1 year.

Method: Retrospective review of all elderly patients who were involved in medical weight loss program in bariatric medicine clinic (group A) and those who underwent BS in our center (group B) in (2011- 2016) with one year follow up.

Results: Group A, 45 patients versus 56 in group B. Mean age: 63.1±4.42 and 63.8±3.4 (P =0.25). Initial BMI 44.3±12.5 and 49±10.6 (P =0.04). Forty-eight patients had laparoscopic sleeve gastrectomy, 6 patients had Roux-en Y gastric bypass, one patient had SADI and another patient had omega loop gastric bypass. At one year Group A had EWL% 11.1±14.2 compared to 44.3±21.9 in group B (P˂0.001). Hemoglobin, hematocrit and iron levels showed better results in Group B (P= 0.029, 0.01 and 0.02 respectively), though detailed lipid profile parameters were comparable in both groups. Both groups showed drop in HbA1c (p= 0.004) and rise in Vitamin D (p=0.003) in favor of the surgical group post operatively. In the medical arm 18% of the population (8 patients) had BS at a later stage due to failure of response to medical management.

Conclusion: Surgical weight loss results were superior to medical at 1 year, though the decrease in cardiometabolic risk and the associated nutritional deficiencies are comparable.

O-035

Adjustable gastric bands - Is there time to say goodbye?

Karin Dolezalova

Bariatric and Mtabolic Surgery, OB klinika - Center for Treatment of Obesity and Metabolic Disorders, Prague, Czech Republic

karinkorm@seznam.cz

Background: Adjustable gastric banding (AGB) was among the most popular and widely adopted bariatric procedures in the past. However, conflicting AGB long-term treatment results being often reported.

More than 4.000 AGB were implanted in OB klinika, Prague in the last few decades. All patients were subjected to institutionally standardized post-op follow-up algorithm, composed of 4-5 visits during the first year, 2 visits during the second-to-fourth year, thereafter one visit yearly. Patients were encouraged to seek appointment at any point if unusual medical condition occures.

Methods: From the entire cohort of 210 AGB patients operated in 2007, 125 patients (64.3%) were available for 10 year follow-up review, 13 (10.4%) underwent band explantation during that period. 112 patients in their 10th postop. year with the band still in place were areviewed in 2017.

Results: 85.7% were female, 23.2% diabetics. Baseline weight 121.5 kg (95.0 to 186.5), At 10 years postoperatively absolute WL was -30.1 kg (-47.2 to - 15.7), BMI decreased by -10.1 kg/m2 (-11.8 to – 5.2) and % EWL reached -43.4% (-52.3% to -40.8%). T2DM resolution (HbA1c normal range (<6%), FPG <100 mg/dl) was noted in total of 14 (53.8%), improvement (HbA1c >6%, but < 6.5%, FPG 100–125 mg/dl) occured in 3 (11.5%) of diabetics ten years postoperatively. Complications (slippage/pouch dilatation) requiring re-operation (band not explanted) occurred in 5 patients (4%), 13 (10.4%) patients underwent band explantation for intolerance, migration/erosion and/or for unsatisfactory weight loss results/weight re-gain exceeding pre-op weight.

Conclusions: Regardless the overall decline in AGB implanted worldwide, long term (>10 years) treatment outcomes still fit within the frames of generally reported and accepted reasults of other, namely restrictive procedures. We appreciate the limitation of our study which is a 33.7% drop out in 10 years follow-up. It has to be stressed, that successful long-term AGB treatment outcomes require substantial patient-to-institution compliance in long-term follow-up regimen.

O-036

Gastric bypass specifically alters liver parameters as compared to sleeve gastrectomy, independently of steatosis evolution, one year after surgery

Séverine Ledoux^{1, a)}, Martin Flamant^{2, b)}, Daniela Calabrese^{3, c)}, Ouidad Sami^{1, d)}, Muriel Coupaye^{1, e)}

¹⁾Explorations Fonctionnelles - Centre de l'obésité (CINFO), Hôpital Louis Mourier (APHP) and Faculté Paris Diderot, Colombes, France; ²⁾Explorations Fonctionnelles, Hôpital Bichat (APHP) and Faculté Paris Diderot, Paris, France; ³⁾Service de Chirurgie - Centre de l'obésité (CINFO), Hôpital Louis Mourier (APHP) and Faculté Paris Diderot, Colombes, France

^a)severine.ledoux@aphp.fr

^b)martin.flamant@aphp.fr

^c)daniela.calabrese@aphp.fr

^d)ouidad.sami@aphp.fr

^e)muriel.coupaye@aphp.fr

Background: Numerous studies have shown that Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) differently affect the evolution of metabolic disorders associated with obesity. While bariatric surgery has been shown to improve non-alcoholic fatty liver disease, no study has compared hepatic parameters after both surgeries in a large cohort.

Objectives: To compare liver parameters one year after SG and RYGBP.

Methods: 207 subjects who underwent SG were compared with 326 subjects who underwent RYGBP. Metabolic parameters, liver parameters and abdominal ultra-sonography (US) were prospectively recorded before and 1 year after surgery.

Results: Before surgery, BMI (44.7±5.7 vs. 44.4±7.4 kg/m²), gender (15% men), age (43±11 yr) and metabolic parameters were not significantly different between RYGBP and SG candidates. One year after surgery, RYGBP had induced greater weight loss (31.9±7.7 vs 28.6±8.3 %, p<0.001), but BMI was not significantly different (31.2±9.0 vs. 32.2±6.8 kg/m²). Metabolic parameters improved in both groups, but fasting insulin (7.2±5 vs 9.2±8.8 IU/l, p<0.001), LDL-cholesterol (2.5±0.7 vs. 3.3±0.1 mmol/l, p<0.001), C-reactive protein (2.6±2.5 vs. 3.9±3.8 mg/l, p<0.001), and ferritin (83.4±82.6 vs. 117.6±109.4 μg/l, p=0.001) were lower after RYGBP. In contrast, alkaline phosphatase (88.2±25.2 vs. 72.9±19.8 IU/l, p<0.001) and transaminases (AST 22.2±8.4 vs. 17.3±5.9 IU/l, p=0.02; ALT 31.6±18.7 vs. 22.6±7.7 IU/l, p<0.001) were higher after RYGBP as compared to SG. The persistence of ALT > 34 IU/l (27% vs 7%, p<0.001) was independent of the persistence of US steatosis (39% vs 37%) one year after RYGB and SG, respectively.

Conclusion: Despite greater improvement of metabolic disorders, RYGP specifically alters liver parameters as compared to SG. Further studies are required to define the mechanisms that explain these differences between both surgical techniques.

O-037

Transient elastography for the assessment of NAFLD in bariatric/metabolic patients- a real life setting

Magdalena Eilenberg^{1, a)}, Melisa Arikan^{1, b)}, Florian Winkler^{1, c)}, Judith Stift^{2, d)}, Michael Trauner^{3, e)}, Petra Munda^{3, f)}, Arnulf Ferlitsch^{3, g)}, Felix B. Langer^{1, h)}, Gerhard Prager^{1, i)}, Katharina Staufer^{4, j)}

¹⁾Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria; ²⁾Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria; ³⁾Division of Gastroenterology and Hepatology Department of Medicine III, Medical University of Vienna, Vienna, Austria; ⁴⁾Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria

^a)magdalena.eilenberg@meduniwien.ac.at

^b)melisa.arikan@arikan.at

^c)n0642545@students.meduniwien.ac.at

^d)judith.stift@meduniwien.ac.at

^e)michael.trauner@meduniwien.ac.at

^f)petra.munda@meduniwien.ac.at

^g)arnulf.ferlitsch@meduniwien.ac.at

^h)felix.langer@meduniwien.ac.at

ⁱ⁾gerhard.prager@meduniwien.ac.at

^j)katharina.staufer@meduniwien.ac.at

Background: Up to 90% of patients with obesity suffer from non-alcoholic fatty liver disease (NAFLD) including the risk of liver fibrosis, cirrhosis and liver cancer. Transient elastography (TE) has shown reliable performance for the detection of advanced fibrosis and cirrhosis, but was not independently validated in patients with morbid obesity. The aim of this study was to determine TE’s accuracy in comparison to liver biopsy obtained from patients undergoing bariatric-metabolic surgery.

Methods: 173 consecutive patients scheduled for bariatric-metabolic surgery between 07/2014 and 11/2017 who underwent preoperative TE (XL-probe) and intraoperative liver biopsy were retrospectively analyzed. The ability of TE including controlled attenuation parameter (CAP) to detect significant and advanced fibrosis and steatosis was compared to liver histology using area under receiver operative characteristics curves (AUC). TE was performed during preoperative evaluation for assessment of either in a primary care or in an out-patient hospital setting. Liver histology was graded according to SAF score.

Of 173 patients (64.7% female, median age [IQR]:42.0y [33.5; 50.5], median BMI [IQR]: 44.1kg/m² [41.3; 47.7]), 60.7% (n=105) presented with non-alcoholic steatohepatitis (NASH), 27.2% with (n=47) non-alcoholic fatty liver, and 12.1% (n=21) with a normal liver according to histology. The degree of fibrosis was F0-1 in 78.0% (n=135), whereas F2, F3 or F4 was diagnosed in 13.3% (n=23), 5.8% (n=10), and 2.9% (n=5) of patients, respectively. TE delivered reliable results in 86.1%. The AUC of TE for significant fibrosis (≥F2) and advanced fibrosis (≥F3) was 0.692 and 0.659, respectively. CAP was available in 145 of 173 patients. The AUC for the detection of moderate steatosis (≥ S2), and advanced steatosis (S3) was 0.643, and 0.640, respectively.

Conclusion: TE including CAP showed only low to moderate accuracy for the detection of significant to advanced fibrosis or steatosis in a real life setting. Therefore we cannot recommend TE as a tool for routine screening in morbidly obese patients.

O-038

Sugar Detection Threshold After Laparoscopic Sleeve Gastrectomy in Adolescents

Ghalia N Abdeen^{1, 2, a)}, Alexander D Miras^{2, b)}, Carel W Le Roux^{3, 4, 2, c)}, Aayed R Alqahtani Alqahtani^{5, d)}

¹⁾Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; ²⁾Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom; ³⁾Diabetes Complications Research Center, Conway Institute, University College Dublin, Dublin, Ireland

⁴⁾Gastrosurgical Laboratory, Sweden Department of Surgery, College Of Medicine, University of Gothenburg, Gothenburg, Sweden

⁵⁾Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia

^a)Ghaliana@gmail.com

^b)a.miras@nhs.net

^c)carel.leroux@ucd.ie

^d)qahtani@yahoo.com

Background: Mechanisms preventing obese adolescents from losing and maintaining weight loss have been elusive. Laparoscopic sleeve gastrectomy (LSG) is successful at achieving long-term and maintained weight loss in patients across all age groups, including children and adolescents. Anecdotal clinical observation and evidence in rodents suggests that LSG induces a shift in preference of sugary foods. However, it is not known whether this shift is due to a change in the threshold for gustatory detection of sucrose, or whether LSG induces behavioural change without affecting the gustatory threshold for sugar.

Aims: To determine whether adolescents who undergo LSG experience a change in their threshold for detecting sweet taste.

Methods: We studied the sucrose detection threshold of fourteen obese adolescents (age 15.3 ± 0.5 years, rage: 12-18) who underwent LSG two weeks before surgery and at 12 and 52 postoperativeweeks. Matched non-surgical subjects were tested on two occasions 12 weeks apart to correct for any learning process in study subjects. Eight blocks containing seven standardized sucrose concentrations were used, with the eighth block containing pure water. Seven sucrose concentrations were used, and were tested in eight blocks with each block consisting of a random seven sucrose and seven water stimuli. The subjects were asked to report whether the sample contained water or not after they tasted 15 ml of the fluid for 10 seconds.

Results: The bodyweight of the study LSG group decreased from 136.7 ± 5.4 kg to 109.6 ± 5.1 kg and 86.5 ±4.0 kg after 12 and 52 weeks, respectively (p<0.001). There was no significant difference after surgery in taste detection threshold of patients in the study group (p=0.60), and no difference was observed comparing the taste detection threshold of the study group with the non-surgical controls (p=0.38).

Conclusion: LSG did not affect the taste detection threshold for sucrose, suggesting that the shift in preference for sugary foods may be due to factors other than fundamental changes in taste sensitivity.

O-039

How often do restrictive bariatric operations cause metabolic deficiencies?

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Introduction: Bariatric surgery has resulted in an effective, long term loss of excess weight in morbidly obese patients with a simultaneous improvement of their metabolic profile. Another aspect of bariatric surgery is vitamins malabsorption that requires administration of supplements.

Objectives: The purpose of this study is to ascertain the incidence of metabolic deficiencies after restrictive bariatric operations (gastric sleeve or plication).

Methods: Retrospective study of morbidly obese patients that underwent restrictive bariatric operations during the years 2010-2016. Levels of folic acid, B12, ferritin and serum protein were measured 3, 6 and 9 months postoperatively. 604 patients were included in the study. In cases of deficiency, supplements were administered.

Results: Out of 604 patients, 118 (19.5%) presented with low folic acid levels, 17 (2.8%) low B12, 66 (10.9%) low ferritin and 35 (5.8%) low serum protein levels. The abnormalities presented mostly at 3 months and tended to improve at 6 and 9 months. 5 cases proved refractory to folic acid administration, 4 to iron administration and 5 cases of B12 deficiency endured, 2 because of patient noncompliciance to parenteral administration.

Conclusions: Restrictive bariatric operations are followed by a drop of consumed calories and fat but also by vitamin deficiencies, especially water soluble, to a degree that requires supplementation. It is pending whether it is because of changes to the anatomy and physiology of the GI tract or because of changes in eating habits. In any case the monitoring and support of a dietician is imperative to ensure a balanced diet and a healthy weight loss.

O-040

Direct measurement of macronutrient intake and preference 1 year after Roux- en -Y Gastric bypass (RYGB)

Natasha Kapoor^{1, a)}, Conor Murphy^{1, b)}, Werd Al-Najim^{1, c)}, Neil Docherty^{1, d)}, Colm O'Boyle^{2, e)}, Helen Heneghan^{3, f)}, Barbara Livingstone^{4, g)}, Alan Spector^{5, h)}, Carel Le Roux^{1, i)}

¹⁾School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland; ²⁾Department of Bariatric Surgery, Bon Secours Hospital Cork, Cork, Ireland; ³⁾Department of General Surgery, St Vincent's University Hospital, Dublin, Ireland; ⁴⁾School of Biomedical Sciences, Ulster University, Ulster, United Kingdom

⁵⁾Department of Psychology, Florida State University, Florida, United States

^a)natasha.kapoor@ucdconnect.ie

^b)conor.murphy.8@ucdconnect.ie

^c)werd.al-najim@ucd.ie

^d)neil.docherty@ucd.ie

^e)cjoboyle@thecorkclinic.eu

^f)helenheneghan@hotmail.com

^g)mbe.livingstone@ulster.ac.uk

^h)aspector@fsu.edu

ⁱ⁾carel.leroux@ucd.ie

Introduction: Patients report food preference changes away from sweet and fatty foods after Roux-en-Y gastric bypass (RYGB). Verbal report is however unreliable. Direct measurement of food intake and preference in humans after RYGB are needed for the phenomenon.

Objectives: 1) To conduct a longitudinal self-selection buffet paradigm study coupled to direct assessment of food preferences after RYGB 2) Test blockade of postprandial gut hormone responses.

Methods: An interim analysis was performed on RYGB (n=6) and normal weight subjects (n=4). Caloric and macronutrient intake was assessed; 1 month before, 3 and 12 months after surgery. At 12 months, subjects were randomised to receive saline or octreotide to block gut hormone responses in a crossover design.

Results: In healthy volunteers, calorie intake and food preferences remained stable. In RYGB subjects calorie intake decreased by 47% vs baseline (1949±257 to 1039±101kcal, p=0.02). Percentage total carbohydrates preference was 49.1±5.2% pre and 34.2±2.9% 1 year after RYGB, p=0.05; of which sugars were 22.4±3.7% pre and 13.5±2.4% 1 year after, p=0.87; other carbohydrates were 26.7±3.5% pre and 20.7±2.2% 1 year after, p=0.10; fat was 38.3±5.2% pre and 50.4±3.1% 1 year after, p=0.49 and protein was 11.8±0.5% pre and 14.6±1.8% 1 year after, p=0.23.

Octreotide had no effect on calorie intake in either group. In RYGB subjects on the Octreotide day, total carbohydrate intake was increased by 9.9±1.7%, p=0.001 and fat intake decreased by 3.5±1.3%, p=0.04 versus saline day. No change were observed in protein, sugar or other carbohydrate preferences.

Conclusion: Direct measurement of calorie intake and macronutrient preferences is feasible in humans. Interim results suggest a reduction in total calories and preference for total carbohydrates one year after RYGB. In the context of a buffet meal octreotide did not increase calorie intake. Reanalysis is required once larger numbers of patients complete the assessments.

O-041

Impact of gut hormone FGF-19 on type-2 diabetes and mitochondrial recovery in a prospective study of obese diabetic women undergoing bariatric surgery

Martin Fried^{1, a)}, Lucia Martinez de la Escalera^{2, 3)}, Ioannis Kyrou^{2, 3, 4)}, Jana Vrbikova⁵⁾, Voitech Hainer⁵⁾, Petra Sramkova¹⁾, Milan K. Piya^{2, 6)}, Sudhesh Kumar^{2, 3)}, Gyanendra Tripathi^{2, 7)}, Philip G. McTernan^{2, 3, 8)}

¹⁾Bariatric and Metabolic Surgery, OB Clinic - Center for Treatment of Obesity and Metabolic Disorders, Prague, Czech Republic; ²⁾Warwick Medical School, University of Warwick, Coventry, United Kingdom; ³⁾Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals of Coventry and Warwickshire (UHCW) NHS Trust, Coventry, United Kingdom; ⁴⁾Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom; ⁵⁾Obesitology Dept., Institute of Endocrinology, Prague, Czech Republic; ⁶⁾Derby Teaching Hospitals NHS Foundation Trust, ., Derby, United Kingdom; ⁷⁾Department of Biomedical Sciences, University of Westminster, London, United Kingdom; ⁸⁾School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom

^a)docfried@volny.cz

Background: The ileal-derived hormone, fibroblast growth factor 19 (FGF-19), may promote weight loss and facilitate type-2 diabetes mellitus remission in bariatric surgical patients. We investigated the effect of different bariatric procedures on circulating FGF-19 levels and the resulting impact on mitochondrial health in white adipose tissue (AT).

Methods: Obese and type-2 diabetic women (n = 39, BMI > 35 kg/m2) undergoing either biliopancreatic diversion (BPD), laparoscopic greater curvature plication (LGCP), or laparoscopic adjustable gastric banding (LAGB) participated in this ethics approved study. Anthropometry, biochemical, clinical data, serum, and AT biopsies were collected before and 6 months after surgery. Mitochondrial gene expression in adipose biopsies and serum FGF-19 levels were then assessed.

Results: All surgeries led to metabolic improvements with BPD producing the greatest benefits on excess weight loss (↓30%), HbA1c (↓28%), and cholesterol (↓25%) reduction, whilst LGCP resulted in similar HbA1c improvements (adjusted for BMI). Circulating FGF-19 increased in both BPD and LGCP (χ2(2) = 8.088; P = 0.018), whilst, in LAGB, FGF-19 serum levels decreased (P = 0.028). Interestingly, circulating FGF-19 was inversely correlated with mitochondrial number in AT across all surgeries (n = 39). In contrast to LGCP and LAGB, mitochondrial number in BPD patients corresponded directly with changes in 12 of 14 mitochondrial genes assayed (P < 0.01).

Conclusions: Elevated serum FGF-19 levels post-surgery were associated with improved mitochondrial health in AT and overall diabetic remission. Changes in circulating FGF-19 levels were surgery-specific, with BPD producing the best metabolic outcomes among the study procedures (BPD > LGCP > LAGB), and highlighting mitochondria in AT as a potential target of FGF-19 during diabetes remission.

O-042

Effects of Sleeve Gastrectomy on the Expression and DNA Methylation of Human Intermediary Metabolism, Inflammation and Weight Control-Related Genes in Whole Blood

Marc Beisani^{1, a)}, Mireia Jordà²⁾, Pau Moreno³⁾, Martinez Eva⁴⁾, Tarasco Jordi³⁾, Marisa Granada⁵⁾, Manel Cremades³⁾, Stella Pappa²⁾, Manel Puig-Domingo⁶⁾, Silvia Pellitero⁴⁾, Jose Balibrea^{7, b)}

¹⁾Department of Surgery, Hospital Universitari Arnau de Vilanova / Centre de Recerca Experimental Biomedica Aplicada (CREBA), Lleida, Spain; ²⁾Program for Predictive and Personalized Medicine of Cancer, Germans Trias I Pujol Research Institute (PMPPC-IGTP), Badalona, Spain; ³⁾Department of Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; ⁴⁾Department of Endocrinology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; ⁵⁾Department of Biochemistry, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; ⁶⁾Scientific Director, Institut de Recerca Germans Trias i Pujol (IGTP), Badalona, Spain; ⁷⁾Department of Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain

^a)mbeisani@gmail.com

^b)balibrea@gmail.com

Background: Changes of gene expression and DNA methylation in whole blood after sleeve gastrectomy (SG) have not been properly investigated.

Methods: From July 2013 to June 2014, 35 bariatric patients and 33 healthy lean volunteers were recruited. Clinical, biochemical, hormonal and molecular data were obtained once on the control group and at 3 different times on the bariatric patients: before very low calorie diet, before SG and 6 months after SG. Molecular data from whole peripheral blood included expression of ghrelin (GHRL), visfatin (NAMPT), insulin receptor substrate 1 (IRS1), fat mass and obesity related gene (FTO), leptin (LEP), peroxisome proliferator-activated receptor gamma (PPARG), adiponectin (ADIPOQ), fatty acid synthase (FASN), melanocortin 4 receptor (MC4R), resistin (RETN), fas cell surface death receptor (FAS), tumor necrosis factor alpha (TNF) and chemokine (C-C motif) ligand 2 (CCL2) genes analyzed by quantitative real-time polymerase chain reaction, and DNA methylation of GHRL, NAMPT and FAS promoters analyzed by bisulfite pyrosequencing.

Results: The expression of seven genes (GHRL, NAMPT, IRS1, FTO, FAS, TNF and CCL2) was detected in blood. FTO expression in blood was higher in controls than in patients. Among patients, those with body mass index>40 had a higher baseline expression of IRS1. No changes in GHRL blood expression were detected, but all studied CpG sites in GHRL gene promoter followed a non-significant but consistent pattern of methylation/demethylation during the weight loss process. CCL2 expression in blood decreased by 50% 6 months after SG compared to pre-surgical levels. FAS expression in blood decreased after VLCD and stayed low 6 months after SG.

Conclusions: Weight loss may modify GHRL promoter DNA methylation in blood. SG induces changes in peripheral expression of CCL2.

O-043

Single Anastomosis Duodenal Ileal with Sleeve Gasterctomy versus Roux-Y Gastric Bypass: comparison of results on glycemic homeostasis and weight loss. A murine model.

Laura Montana^{1, 2, a)}, Konstantinos Arapis^{3, 2, b)}, Chirstophe Barrat^{1, c)}, Christophe Magnan^{2, d)}

¹⁾Digestive and metabolic surgery, Avicenne University Hospital Center, Bobigny, France; ²⁾REGLYS Team, Paris Diderot University, Paris, France; ³⁾Digestive and metabolic Surgery, Bichat University Hospital Center, Paris, France

^a)doc.laura.montana@gmail.com

^b)konstantinos.arapis@bch.aphp.fr

^c)christophe.barrat@aphp.fr

^d)christophe.magna@univ-paris-diderot.fr

As treatment of morbid obesity and related metabolic complications, the Single Anastomosis Duodenal-Ileal with Sleeve Gastrectomy (SADI-S) seems to offer good results. Yet, SADI-S effect on glycemic homeostasis is still unclear and comparison between SADI-S and standard bariatric procedure in terms of weight loss and resolution of type 2 diabetes (T2D) has never been reported. The aim of this study was to develop a reproducible animal model of SADI-S in order to compare weight loss and T2D resolutions after SADI-S to Roux-Y Gastric Bypass (RYGB) results. 80 Winstar male rats were submitted to a 3-months hight-fat diet promoting obesity. T2D was induced with a 35 mg/Kg intra-peritoneal injection of Steptozocine. Animals were divided in four groups: SADI-S, RYGB, Sham and Pairfed (caloric restriction diet). During a 30 days follow-up, weight, glycemia and indirected calorimetry were daily evaluated. Oral Glucose Tolerance Test (OGTT), Insuline Tolerance Test (ITT) and Intraperitoneal Pyruvate Tolerance Test (IpPTT) were performed pre- and postoperatively. A Magnetic Resonance Imaging (MRI) was completed pre- and post-operatively, to evaluate fat and lean mass. Based on these results, SADI-S was demonstrated as being superior in regard to weight-loss and glycemic control when compared to Sham and Pairfed groups (p

O-044

Monocyte subpopulations in peripheral blood are suitable for non-invasive diagnosis of NASH in patients with obesity

Katharina Staufer^{1, 2, a)}, Katharina Scheuba^{1, 2, b)}, Florian Winkler^{1, 2, c)}, Magdalena Eilenberg^{1, 2, d)}, Felix B. Langer^{1, e)}, MIchael Trauner^{3, f)}, Christine Brostjan^{2, g)}, Gerhard Prager^{1, h)}

¹⁾Surgery, Medical University of Vienna, Vienna, Austria; ²⁾Surgical Research Laboratories, Medical University of Vienna, Vienna, Austria; ³⁾Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria

^a)Katharina.Staufer@meduniwien.ac.at

^b)K@Scheuba.at

^c)n0642545@students.meduniwien.ac.at

^d)Magdalena.Eilenberg@meduniwien.ac.at

^e)Felix.Langer@meduniwien.ac.at

^f)Michael.Trauner@meduniwien.ac.at

^g)Christine.Brostjan@meduniwien.ac.at

^h)Gerhard.Prager@meduniwien.ac.at

Background and Aims: Up to 80% of patients with obesity suffer from non-alcoholic fatty liver disease (NAFLD) including non-alcoholic steatohepatitis (NASH). The present study investigated inflammatory-induced changes in monocyte-subpopulations for the non-invasive diagnosis of NAFLD, as well as the differentiation of NASH and non-alcoholic fatty liver (NAFL).

Methods: Patients with NAFLD scheduled for bariatric-metabolic surgery between 07/2015 and 05/2017, as well as healthy controls were consecutively included. The expression profile of monocyte surface markers for the differentiation of classical (CL; CD14++ CD16-), non-classical (NC; CD14+ CD16++) and intermediate monocytes (IM; CD14++ CD16+) were investigated by flow cytometry in EDTA whole blood. According to intra-operative liver biopsy patients were stratified into NAFL and NASH and disease activity was graded based on NAFLD-activity score (NAS).

Results: In total, 80 patients (m:f=34:46, median BMI: 43,8) und 27 healthy controls (m:f=15:12, median BMI: 25,0) were included. Seventy-nine percent of patients suffered from NASH, 21% presented with NAFL.

The median absolute concentration of monocyte subpopulations was significantly higher in patients with NAFLD than in healthy controls. In contrast, the relative number of monocyte subpopulations showed a significant rise of IM, as well as a significant decrease in CL in patients with NAFLD, whereas NC were equal in both groups.

Patients with NASH had significantly higher absolute IM/ml, as well as a significantly lower CL/IM ratio than patients with NAFL or healthy controls.

The absolute IM concentration was the most suitable diagnostic marker for NAFLD (AUC 0.861; cut-off>18.7; sensitivity 71%; specificity 89%). The CL/IM ratio was the most suitable marker for the presence of NASH (AUC 0.706; cut-off<20.1; sensitivity 71%; specificity 72%).

Conclusion: Monocyte subpopulations are suited for the non-invasive diagnosis of NAFLD and NASH. The inflammatory process within NASH seems to be reflected by a strong activation of monocytes which can be non-invasively and therefore repeatedly monitored in peripheral blood.

O-045

Preoperative education and informed consent in young adults undergoing bariatric surgery: patients’ perspectives on current practice

Charlotte Dohmen^a), Daniëlle Bonouvrie^b), Martine Uittenbogaart^c), Arjan Luijten^d), Francois van Dielen^e), Wouter Leclercq^f)

Bariatric surgery, Máxima Medical Centre, Veldhoven, Netherlands

^a)c.dohmen@student.maastrichtuniversity.nl

^b)danielle.bonouvrie@mmc.nl

^c)m.uittenbogaart@mmc.nl

^d)a.luijten@mmc.nl

^e)f.vandielen@mmc.nl

^f)w.leclercq@mmc.nl

Introduction: Information about the quality of the perceived education and informed consent process in bariatric surgery, especially in young adults is lacking. As part of the surgical informed consent process, preoperative education informs patients about their bariatric procedure, the perioperative risks, the results and the lifestyle adjustments needed after bariatric surgery. Afterwards, patients should be able to make an informed decision to undergo their surgical procedure. Aim of this study was to evaluate the preoperative education and informed consent process in young adults, aged 18-25 years, undergoing bariatric surgery.

Methods: 23 of the 55 young adults who underwent bariatric surgery between 2012 and 2017 at our centre were interviewed using a semi-structured interview. This interview included three sections: education of the specific informed consent domains; perioperative expectations and experiences; personal (un)certainties to undergo bariatric surgery.

Preliminary results: 23 patients were interviewed. Mean age at surgery was 23.1 ± 1.6 years and mean BMI at surgery was 42.2 ± 5.3 kg/m². All consent domains were remembered. However, 95% of the patients could not mention one or more complications. Primary success outcome for patients was not confined to weight loss, but gaining self-confidence, being able to buy clothes in a regular shop and raised fertility chances were considered more important. 37,5% of the patients had troubles dealing with their new self-image. 25% of the patients regrets the decision for the bariatric surgery.

Conclusion: The preoperative education and informed consent process is an essential step in bariatric surgery. This study provides new information on perceived education and informed consent issues in young adults. Improved preoperative education including possible scenarios after bariatric surgery to assess risks and lifetime consequences should be developed to help these patient in making a truly well informed decision.

O-046

Bariatric surgery and incidental gastrointestinal stromal tumors – a single-center study

Orestis Lyros^a), Yusef Moulla, Robert Sucher, Arne Dietrich

Division of Bariatric Surgery, Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany

^a)orestis.lyros@medizin.uni-leipzig.de

Introduction:The frequency of incidental pathology found during bariatric procedures has been estimated to be 2%. Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract and are most commonly located in the stomach. The reported incidence of GISTs during bariatric surgery is around 0.8%.

Aim:To analyze the incidence of GISTs in patients undergoing bariatric surgery and to verify whether an operation performed according to the bariatric protocol is oncologically radical.

Material and methods:A single-center retrospective study of 542 morbidly obese patients, who underwent bariatric procedures between January 2002 and October 2017 in the University Hospital Leipzig Germany, with no upper gastrointestinal tract neoplasms found during preoperative diagnostic examinations. Incidental intraoperative findings of GISTs were recorded including tumor size and localization, mitotic index and immunohistochemical analysis.

Results: Six (1,1%) patients were found to have incidental GIST. There were five (84%) women; mean age 54.6 (range 27–65), mean BMI 54,1 mg/m² (range 49-71). None of them had symptoms that served as orientation for preoperative diagnosis. Four GISTs were located in stomach vs two in small bowl; four were found during laparoscopic Roux-en-Y-gastric bypasses (LRYGBs) vs. two during laparoscopic Sleeve Gastrectomies (LSGs). No change on the initial surgical plan or aborting the procedure took place. All tumors were of low/very low risk of malignancy, with <5 mitoses/50 fields, less than 1,5 cm in diameter, and disease-free surgical margins. Cluster of differentiation CD117/CD34 were positive in 84% of the cases. None of the patients required adjuvant therapy after the surgery.

Conclusions:The incidence of unsuspected GIST in our series was higher to what has been already reported. The degree of tumor malignancy was low and resection as part of the bariatric procedure was the definitive treatment. In case of incidental GISTs during bariatric surgery, tumor resection with negative margins may be considered as complete oncological treatment if there is very low/low risk stratification of GIST’s recurrence.

O-047

Obesity as a determinant of post-operative outcome in patients following colorectal cancer surgery: a population based study (2009-2016).

Youri Poelemeijer^{1, 2, a)}, Niki Lijftogt^{1, b)}, Robin Detering^{3, c)}, Marta Fiocco^{4, d)}, Rob Tollenaar^{1, 2, e)}, Michel Wouters^{5, 2, f)}

¹⁾Surgery Department, Leiden University Medical Center, Leiden, Netherlands; ²⁾Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, Netherlands; ³⁾Surgery Department, Academic Medical Center, Amsterdam, Netherlands; ⁴⁾Medical Statistics and Bioinformatics Department, Leiden University Medical Center, Leiden, Netherlands; ⁵⁾Surgery Department, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands

^a)Y.Q.M.Poelemeijer@lumc.nl

^b)n.lijftogt@gmail.com

^c)R.Detering@amc.nl

^d)M.Fiocco@lumc.nl

^e)R.A.E.M.Tollenaar@lumc.nl

^f)M.Wouters@nki.nl

Background: Obesity is a worldwide spreading disease and therefore one of the most concerning problems in healthcare outcome and costs nowadays. The relation between obesity and treatment-related morbidity and mortality after colorectal resections is still unclear.

Study design: This study was a population based study, performed in 83 Dutch hospitals. The aim of this study was to analyse the influence of obesity on postoperative outcomes in patients after colorectal cancer resection. Data of the Dutch ColoRectal Audit (DCRA) was extracted between 2009 and 2016. Patient, tumor, treatment and short-term outcome (30 days) characteristics of colorectal cancer patients, undergoing surgical resection for primary colorectal cancer, were analysed.

Results: A total of 78,751 unique patient records were registered, resulted in 55,937 (71.0%) colon cancer and 22,481 (28.5%) rectal cancer patients. In total 50,918 (91.0%) colon cancer and 21,090 (93.8%) rectal cancer patients, of whom a computable preoperative BMI could be calculated.

Multivariate analysis, showed a highly significant increased risk in developing a postoperative complicated course for obese colon cancer patients (OR 2.01; CI 1.68-2.41) and rectal cancer patients (OR 2.12; CI 1.76-2.56). No significant differences in performance were observed between bariatric and non-bariatric hospitals in postoperative outcome of morbid obese colorectal cancer patients.

Conclusion: Obesity should be recognized as an important risk factor in the care process of colorectal cancer patients. Comorbidities related to obesity are associated with a higher postoperative morbidity in severe obese patients with colorectal cancer. No differences in performance were observed between bariatric-experienced and non-experienced hospitals.

O-048

Comparison of nutritional status and neonatal outcomes in pregnant women after Roux-en-Y gastric bypass and sleeve gastrectomy

Muriel Coupaye^{1, a)}, Hélène Legardeur^{2, b)}, Ouidad Sami^{1, c)}, Daniela Calabrese^{3, d)}, Laurent Mandelbrot^{2, e)}, Séverine Ledoux^{1, f)}

¹⁾Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de prise en charge de l’Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Colombes, France

²⁾Service de Gynécologie Obstétrique, Hôpital Louis Mourier (AP-HP), Colombes, France

³⁾Service de Chirurgie, Centre Intégré Nord Francilien de prise en charge de l’Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Colombes, France

^a)muriel.coupaye@aphp.fr

^b)helene.legardeur@aphp.fr

^c)ouidad.sami@aphp.fr

^d)daniela.calabrese@aphp.fr

^e)laurent.mandelbrot@aphp.fr

^f)severine.ledoux@aphp.fr

Background: There is a lack of evidence on whether nutritional deficiencies affect fetal growth in pregnant women who have undergone bariatric surgery (BS), notably after Roux-en-Y-gastric bypass (RYGB) and sleeve gastrectomy (SG), the two procedures most often performed.

Objectives: To compare maternal nutritional parameters and neonatal outcomes after RYGB and SG and to assess the impact of nutritional alterations on fetal growth after BS.

Methods: Women with singleton pregnancies who had at least one nutritional evaluation during pregnancy in our institution between 2006 and 2017 were included. We evaluated nutritional deficiencies according to standard and pregnancy-specific norms.

Results: There were 123 pregnancies during the study period: 77 after RYGB and 46 after SG. Weight loss was higher after RYGB than after SG (45.6±12.4 vs. 39.5±13.7 kg, p=0.02), but mean body mass index before pregnancy (30.5±5.0 vs. 31.6±6.8 kg/m²) and weight gain during pregnancy (8.4±6.7 vs. 9.5±8.1 kg) were similar. Mean birth weight (BW) was not significantly different (3026±677 vs. 3171±719 g). Mean BW Z-score (adjusted for sex and term) and incidence of small for gestational age (BW Z-score < 10th percentile) were also similar (24 vs 19% after RYGB and SG, respectively). Mean number of nutritional deficiencies during the second trimester was similar after both procedures (2.2±1.5 vs. 2.1±1.2 with specific norms). However, serum and urinary calcium were significantly lower and parathyroid hormone was significantly higher after RYGB. In the whole cohort, urinary urea (R=0.307, p=0.02) and urinary calcium (R=0.399, p=0.002), reflecting protein and calcium intake and absorption, were positively correlated to BW, in contrast to serum iron parameters (including transferrin saturation, serum iron and ferritin) that were negatively associated with BW Z-score.

Conclusion: Fetal growth restriction occurs after both SG and RYGB. Calcium and protein intake positively influences fetal growth after BS. In contrast, excessive iron supplementation could negatively affect fetal growth.

O-049

Blind loop syndrom after Roux-en-y gastric bypass

Volker Lange^{1, a)}, Oliver Stumpf^{1, b)}, Wael Eskander^{1, c)}, Anke Rosenthal^{2, a)}

¹⁾Obesity and Metabolic Surgery Center, Vivantes Klinikum Spandau, Berlin, Germany; ²⁾Obesity Outpatient Clinic Dr. Anke Rosenthal, Obesity Outpatient Clinic Dr. Anke Rosenthal, Berlin, Germany

^a)volker.lange@vivantes.de

^b)oliver.stumpf@vivantes.de

^c)wael.eskander@vivantes.de

Background: Jejuno-Jejunostomy in Roux-en-Y gastric bypass is usually performed by creating a side to side anastomosis of the alimentary and biliary limb. Depending on the operative technique the construction creates a biliary blind loop of various length. We analyzed patients who became symptomatic by this blind segment of the small bowel.

Method: A retrospective analysis of all patients who became symptomatic due to bacterial overgrowth in the blind biliary loop was performed. Symptoms were defined as long lasting diarrhea, overproduction of bowel gases with extreme bad smell, meteorism, postprandial pain in the left upper abdomen, hypoalbuminemia and edema. There was in general a combination of symptoms. In the last 3 years we analyzed the kind of bacterial contamination taken from the resected segment.

Results: Of 3853 patients who received a Roux-en-Y Gastric Bypass in our institution 12 patients (0.3 %) developed symptoms as mentioned above. All patients were treated by laparoscopic resection of the blind loop. Bacterial analysis from the resected segment was performed in most cases. In 81 patients, who needed a revisional operation after gastric bypass for other reasons we also resected long biliary blind loops. None of these patients demonstrated symptoms like the symptomatic ones. After resection of the blind segment all symptomatic patients recovered from their symptoms. An antibiotic treatment after resection was never initiated.

Conclusion: Bacterial overgrowth is common in a biliary blind loop as we saw in asymptomatic patients. Compared to symptomatic patients we could not identify special germs which might explain the symptoms. Over all a blind loop syndrome is a rare condition, which can successfully be treated by resection of the blind loop.

O-050

Transitory jejuno-gastric intussesception as a potential cause of epigastric pain and dyspepsia after the gastric bypass surgery

Yaroslav Isaev^{1, a)}, Christine Stier^{2, b)}, Sonya Chiappetta^{3, c)}, Rudolf Weiner^{3, d)}

¹⁾General surgery, Helios Klinikum, Erfurt, Germany; ²⁾Uniklinik Würzburg, Endocrinology, Endoscopy, Würzburg, Germany; ³⁾Bariatric surgery cemter, Sana Klinikum Offenbach, Offenbach, Germany

^a)doctorisaev@gmail.com

^b)dr.med.christine.stier@sana.de

^c)Sonja.Chiappetta@sana.de

^d)profweiner@gmail.com

Inroduction: In the bariatric surgery intussusception is still not a well-known postoperative complication. Since the first publication of Bozzi (1914), around two hundred cases of jejuno-gastric intussuseption have been reported, most of them – with the development of surgical complications.

Methods and results: We report about 12 cases of the transitory jejuno-gastric intussesception as a potential cause of epigastric pain and dyspepsia without an anatomic correlate after the gastric bypass (RNYGB, MGB, SADI-S) surgery for the first time. 8 patients underwent Roux-en-Y gastric bypass (RNYGB), 3 – mini gastric bypass (MGB) and one – SADI-S. The postoperative time ranged from 1 month to 9 years. Just in 2 cases the transient intussusception was the incidental finding in the asymptomatic patients. In 10 cases the patients complained epigastric pain, reflux or nausea and vomiting. In none of this cases surgery was performed.

Discussion: Thanks to the correlation of the sonographic findings with the macroscopic changes of the distal stomach we have assumed that transitory invagination can affect the microcirculation of the intestinal (gastric) wall, whereby the endoscopic findings often correspond to the clinical picture. Till present time it was believed that jejuno-gastric invagination is a rare condition that can lead to dangerous complications. Our dates necessitate to doubt it and to assume that the real frequency of the intussusceptions in fact is much higher. Obviously dangerous complications like ileus and necrosis of the intestine occur very rare. Nevertheless the endoscopic findings show that even transient intussusception can lead to macroscopic changes and can be considered as a possible cause of abdominal pain and dyspepsia. Of course it’s not clear, how far such conditions influence the quality of life of the patients and whether the surgical techniques should be changed, but these dates bring us to look at the problem from the different point of view and can be a basis for the further investigation and possible reconsideration of a present tactic.

References:

1. Smit Singla, Brandon A. Guenthart, Lauren May, John Gaughan, and John E. Meilahn. Intussusception after Laparoscopic Gastric Bypass Surgery: An Underrecognized Complication. Research Article Minimally Invasive Surgery.

2. Ajay Kohli, Lily Gutnik, Danielle Berman, and Anil Narula Jejunojejunostomy intussusception after gastric bypass: Case report of a rare but serious complication. Int J Surg Case Rep. 2017; 30: 101–102.

3. Zainabadi K, Ramanathan R Intussusception after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007 Dec;17(12):1619-23. Epub 2007 Nov 28.

4. Ali Mahmood, Nadia Mahmood and Robert B. Robinson Small Bowel Intussusception: A Dangerous Sequela of Bariatric SurgeryRadiol Case Rep. 2007; 2(1): 10–12.

5. Bozzi E. Annotation. Bull Acad Med. 1914;122:3–4.

6. Sumitoj Singh, Arvinder Singh et al. Retrograde Jejuno-gastric Intussusception. Niger J Surg. 2015 Jan-Jun; 21(1): 70–72.

7. Gokhan Cipe, Fatma Umit Malya, Mustafa Hasbahceci, Yeliz Emine Ersoy et al. Jejunogastric Intussusception: A Rare Complication of Gastric Surgery. Case Rep Surg. 2013; 2013: 838360.

8. Jha AK, Maitra S, Roy SB. Efferent loop gastrojejunal intussusception: a case report. J Indian Med Assoc. 2011 Dec;109(12):932-3.

9. Wheatley MJ.Jejunogastric intussusception diagnosis and management. J Clin Gastroenterol. 1989 Aug;11(4):452-4.

O-051

Over three years results of hiatal hernia repair with mesh in a single institution

Angelo Iossa^a), Cristian Boru^b), Gianfranco Silecchia^c)

Department of medico-surgical sciences and biotechnologies, University of Rome "Sapienza"-Division of general Surgery and Bariatric Centre of Excellence, Latina, Italy

^a)angelo.iossa@gmail.com

^b)crisboru@icloud.com

^c)gianfranco.silecchia@uniroma1.it

Introduction: The standard technique for hiatal hernia repair (HHR) is controversial and it remain debated how to treat large hiatal hernia (HH) during bariatric procedures in obese population, which have a per se negative impact on recurrence rate. The aim of the present paper was to report the long-term results of a single institution series of HHR with mesh in obese patients, evaluating the safety profile of the absorbable mesh.

Materials and methods: 90 obese (mean BMI 43,4 ± 5,65 kg/m2) patients (18 male; 72 female) treated with HHR (mean defect size 6 ± 2 cm2) with mesh (BIO-A U shaped -W.L. Gore & Associates, Inc., Flagstaff, AZ) were evaluated after a mean follow-up of 39 ± 5 months. In the 64.4% of these the HH diagnosis was made pre-operatively and eight patients were submitted to revisional bariatric surgery. The end-points evaluated were dysphagia rate (%), post-operative complications mesh related (> 30 days), GERD symptoms control (questionnaire Rome III) and endoscopic findings, recurrence (%-clinical and/or radiological). The HHR reinforced with mesh was performed with the following concomitant laparoscopic bariatric procedures: 79 sleeve gastrectomy (LSG), 7 re-LSG, 4 standard gastric bypass (GBP).

Results: No complications mesh related was registered post-operatively (> 30 days) and after long-term follow-up. 51 of 64 (79.6%) of patients affected by pre-operative GERD solved completely the problem without need of PPI therapy. The remnant 13 presented the followed symptoms: EPS (epigastric pain syndrome) (5 patients), nausea and vomit (less then 5 monthly epysode - 6 patients), atypical GERD symptoms (2 patients). Only one patient was converted to GBP (1.05%) 26 months after the primary LSG. Transient dysphagia was reported in 5%. Regarding the recurrence we observed 4 cases (4.4%): 3 radiological recurrence and 1 clinical and radiological.

Conclusions: Our results supports the use of mesh for the treatment of HH > 4 cm2 in obese patients during bariatric procedure showing excellent recurrence rate results (4.4%) and good GERD symptoms control.

O-052

Alcohol And WLS: It’s a problem the multidisciplinary team needs to address!

Connie Stapleton

Psychology, Mind Body Health Services, Inc., Augusta, United States

Cstapletonphd@gmail.com

A recent research study reported in the journal, Surgery for Obesity and Related Diseases (2017) recently reported: “Undergoing RYGB versus LAGB was associated with twice the risk of incident AUD symptoms. One-fifth of participants reported incident AUD symptoms within 5 years post-RYGB. AUD education, screening, evaluation, and treatment referral should be incorporated in pre- and postoperative care.”

• This is a shockingly high percentage of post-op patients. It is the responsibility of the entire bariatric multidisciplinary team to educate the patients about the possibility of problematic issues with alcohol following bariatric procedures.

A complex interplay exists between a person’s alcohol consumption and nutritional status,” and … alcohol and its metabolism prevent the body from properly absorbing, digesting, and using essential nutrients” and “alcoholic beverages are considered ‘empty calories.’ Therefore, any calories provided by alcoholic beverages are derived from the carbohydrates and alcohol they contain.” 2

• Nutritional deficiency is one of the concerns monitored following WLS. Patients are told to take vitamins for the rest of their lives to help ensure proper nutritional balance.

„Alcohol is actually classified as a drug and is a known depressant. Under this category, it is the most widely used drug in the world.”. 3

• We tell patients, “Don’t eat empty calories. Eat a lot of protein. Limit simple carbs and sugar. Refrain from consuming your calories from liquids.

• Alcohol contains sugar/carb laden, empty, nutrition-robbing toxic calories in liquid form.

“No one needs alcohol to live, so regardless of what you've heard or want to believe, alcohol is not essential in our diets… a glass of wine can have the same calories as four cookies.” 4

• It would be unlikely for a bariatric professional to say it’s okay to eat four cookies. However, that is what many patients are told about the use of alcohol following WLS.

Alcohol issues after WLS is problem that all of the multidisciplinary team needs to be made aware of.

References

• 1. Alcohol and Other Substance Use after Bariatric Surgery: Prospective Evidence from a US Multicenter Cohort Study. Wendy C King, Jia-Yuh Chen, Anita P Courcoulas, Gregory F Dakin, Scott G Engel, David R Flum, Marcelo W Hinojosa, Melissa A Kalarchian, Samer G. Mattar, James E Mitchell, Alfons Pomp, Walter J Pories, Kristine J Steffen, Gretchen E White, Bruce M Wolfe, Susan Z Yanovski. Surg Obes Relat Dis. Author manuscript; available in PMC 2018 Aug 1.Published in final edited form as: Surg Obes Relat Dis. 2017 Aug; 13(8): 1392–1402. Published online 2017 Mar 31. doi: 10.1016/j.soard.2017.03.021PMCID: PMC5568472

• 2. Pubs.niaaa.nih.gov. (2018). Relationships Between Nutrition, Alcohol Use, and Liver Disease. [online] Available at: https://pubs.niaaa.nih.gov/publications/arh27-3/220-231.htm

• 3. Pubs.niaaa.nih.gov. (2018). Relationships Between Nutrition, Alcohol Use, and Liver Disease. [online] Available at: https://pubs.niaaa.nih.gov/publications/arh27-3/220-231.htm

• 4. Drinkaware.co.uk. (2018). Calories in alcohol. [online] Available at: https://www.drinkaware.co.uk/check-the-facts/health-effects-of-alcohol/appearance/calories-in-alcohol

O-053

Single Anastomosis Duodenoileal bypass versus Roux-en-Y Gastric Bypass following failed Sleeve Gastrectomy: A Multicenter Cohort study

Phillip Dijkhorst^{1, a)}, Abel Boerboom^{1, b)}, Edo Aarts^{1, c)}, Ignace Janssen^{1, d)}, Eric Hazebroek^{1, e)}, Dingeman Swank^{2, f)}, René Wiezer^{3, g)}

¹⁾Department of Surgery, Rijnstate hospital/Vitalys Clinics, Arnhem, Netherlands; ²⁾Department of Surgery, Dutch Obesity Clinic West, Den Haag, Netherlands; ³⁾Department of Surgery, St. Antonius hospital, Nieuwegein, Netherlands

^a)phillip.dijkhorst@gmail.com

^b)ABoerboom2@rijnstate.nl

^c)eaarts@rijnstate.nl

^d)ignace.janssen@gmail.com

^e)ehazebroek@rijnstate.nl

^f)Dingeman.Swank@ghz.nl

^g)r.wiezer@antoniusziekenhuis.nl

Background: Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. In SG patients however, a large portion of patients show insufficient weight loss or weight regain after a few years. Studies concerning the effectiveness of revisional procedures after SG are scarce and comparisons are lacking. This study analyzes the Single Anastomosis Duodenoileal Bypass (SADI) and the Roux-en-Y Gastric Bypass (RYGB) following SG.

Methods: From 2010 to 2017, 162 patients received revisional laparoscopic surgery after SG. A SADI was performed in 61 patients and 101 patients were converted to a RYGB. Patients submitted to revisional SADI were operated to improve weight-loss. Revisional RYGB patients were operated to improve weight loss (n=61) or because of a complicated SG (e.a. stenosis or severe reflux). For this study, only RYGB patients operated to improve weight loss were included.

Preliminary results: Mean age prior to SG was 41.45 (±11.28) years, mean weight was 154.89 (±30,31) kg and mean BMI was 54.14 (±10.32). On average, patients submitted to revisional SADI were operated after 3.69 (±2.40) years and revisional RYGB after 2.58 (±1.40) years. Short-term complications (<30 days) occurred in 6.4% of SADI patients and 0% in the RYGB group. For long-term complications (>30 days), these percentages were 11.1% and 14.3% respectively. No intra- or postoperative mortality was observed. At the second operation, mean weight and BMI was 129.53 (±21.83) and 45.44 (±6.99) for the SADI group and 123.63 (±23.34) and 42.87 (±6.77) for the RYGB group. After adjustment for baseline weight, the difference in percentage total body weight loss (%TBWL) for SADI compared to RYGB at 6, 12 and 24 months was 6.7%, 12.6% and 15.6% in favor of SADI patients (all p-values <0,001).

Conclusion: More short-term complications were observed following revisional SADI when compared to RYGB, while long-term complications rates were similar. Weight loss after SADI following SG is significantly better when compared to RYGB.

O-054

Conversion of Both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass, Analysis of Short-term Outcomes

Talal Khewater^a), Nathalie Yercovich^b), Edouard Grymonprez^c), Isabelle Debergh^d), Bruno Dillemans^e)

Obesity Center, Department of Surgery, AZ Sint-Jan Brugge-Oostende AV, Campus Sint- Jan, Ruddershove 10, 8000, Bruges, Belgium

^a)dr_tka@hotmail.com

^b)natuyerco2010@gmail.com

^c)grymonprez.e@gmail.com

^d)Isabelle.debergh@azsintjan.be

^e)Bruno.Dillemans@azsintjan.be

Background: Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (RYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively).

Methods: The records of patients who underwent laparoscopic RYGB as a conversional procedure after VBG between November 2004 and December 2016 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (<30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency.

Results: A total of 305 patients (81.97% females) who underwent conversional RYGB were included. For the LVBG group (209 patients), OVBG group (96 patients), respectively, BMI was 34.48±6.39 and 37.97±6.46 kg/m² (p<0.05), the operation time was 93.59±29.66 and 118.31±37.75 minutes (p<0.05), hospitalization duration was 3.00±1.14 and 3.22±1.16 days (p=0.08), the early complication rate was 6.70% and 9.38% (p=0.41), and the reoperation rate was 2.39% and 2.08% (p=0.87). There were no major intraoperative problems. Two patients with OVBG were converted to open RYGB (2.08%). There was no mortality.

Conclusion: The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.

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O-055

Outcome of revisional bariatric surgery for insufficient weight loss after laparoscopic Roux-en-Y Gastric Bypass

Katja Allgaier^{1, a)}, Romano Schneider^{1, b)}, Martina Gebhart^{2, c)}, Truc Ngo^{2, d)}, Marc Slawik^{2, e)}, Thomas Peters^{2, f)}, Ralph Peterli^{1, g)}

¹⁾Viszeral Surgery, St. Claraspital, Basel, Switzerland; ²⁾Interdisciplinary Center of Nutritional and Metabolic Diseases, St.Claraspital, Basel, Switzerland

^a)Katja.Allgaier@claraspital.ch

^b)Romano.Schneider@claraspital.ch

^c)Martina.Gebhart@claraspital.ch

^d)Truc.Ngo@claraspital.ch

^e)Marc.Slawik@claraspital.ch

^f)Thomas.Peters@claraspital.ch

^g)Ralph.Peterli@claraspital.ch

Background: Insufficient weight loss or secondary weight regain with/without recurrence of co-morbidity can occur years after laparoscopic Roux-en-Y gastric bypass (LRYGB). In selected patients increasing restriction or adding malabsorption may be a surgical option after failed conservative measures.

Methods: Retrospective analysis of prospectively collected data from a cohort of 1150 LRYGB patients. Between 01/2009 to 12/2016, 38 patients, who had undergone revisional bariatric surgery after LRYGB for insufficient weight loss with a minimal follow-up of one year were included. After interdisciplinary evaluation patients with insufficient weight loss and signs of dumping syndrome and lacking restriction were offered a non adjustable band around the pouch (banded-group, n=22), patients with sufficient restriction, excellent compliance and adherence were offered a revision to laparoscopic bilio-pancreatic diversion (BPD-group, n=16).

Results: The revisional procedure was performed 3.0 ± 2.2 years after LRYGB in the banded-group, 6.9 ± 4.7 years in the BPD-group. Mean body mass index (BMI) at the time of the LRYGB was 43.1 ± 4.6 kg/m² in banded-group and 47.8 ± 6.4 kg/m² in BPD-group; at the time of revisional surgery 30.7 ± 5.6 kg/m² in banded-group and 41.6 ± 6.7 kg/m² in BPD-group. The mean BMI one year after revisional surgery was 29.7 ± 5.6 kg/m² in banded-group and 33.8 ± 5.2 kg/m² in BPD-group. In the banded-group, 11 patients (50.0%) needed removal of the band, two were later converted to BPD. In the BPD-group, two patients (12.5%) needed revision for severe protein malabsorption.

Conclusions: In carefully selected patients with insufficient weight loss following LRYGB, revisional procedures like banding or BPD can achieve satisfactory results concerning additional weight loss and complications.

O-056

Weight Regain After Vertical Gastric Plication: Sleeve Gastrectomy or Roux en Y Gastric Bypass as a Salvage Procedure? Analysis of the first 300 consecutive patients

Elie Chouillard^a), Elias CHAHINE^b), Nader KARY^c), Mohammad ABDULLAH AWAD^d)

Minimally Invasive Surgery Department, Metabolic Surgery Unit, PARIS WEST MEDICAL CENTER, POISSY, France

^a)chouillard@yahoo.com

^b)dr_elias_chahine@hotmail.com

^c)naderkary@hotmail.com

^d)why2424@hotmail.com

Introduction: Bariatric surgery is the best available long-term treatment in patients with morbid obesity. Vertical Gastric Plication (VGP) has been recently performed as a weight loss procedure in France. Despite its relative short-term safety and efficacy, long-term results of VGP are still controversial. The goal of this study was to assess the indications and outcome of revision for weight regain in patients with VGP.

Methods: Patients were prospectively included in a database, with regular assessment of both results, and complications, respectively. Weight regain or insufficient weight loss were initially treated conservatively in all patients after a through clinical, biological, endoscopic and radiologic assessment. If conservative treatment was unsuccessful or in case of anatomical anomaly, surgical revision was indicated.

Results: Between February 2010 and September 2017, 300 patients had VGP. Of these, 60 were lost to follow-up. The rate of patients with excess weight loss (EWL) > 50% was only 50 %. The remaining 120 patients had either inadequate weight loss (66 patients) or weight regain (54 patients) and eventually required revisional surgery. Roux en Y Gastric Bypass (RYGB) was performed in 72 patients (60 %). Sleeve Gatrectomy (SG) was performed in 48 patients (40 %). Median interval from VGP to revision was 29 months (range, 18-61). Mean operative time was 168 min (range, 100–228). Median length of stay was 3 days (range, 2–5). Major complications occurred in 6 patients (5 %) including 3 leaks fistula and one intra-abdominal abscess, all after SG.

Conclusions: VGP is associated to high rates of weight regain or inadequate weight loss. As compared to SG, RYGB seems to be a safer revisional procedure after VGP.

O-057

The failed Roux-en-Y Gastric Bypass: band or distalization?

Abel Boerboom^a), Laura Deden, Mellody Cooiman, Theo Aufenacker, Bart Witteman, Ignace Janssen, Eric Hazebroek, Edo Aarts, Frits Berends

Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands

^a)aboerboom2@rijnstate.nl

Background: Approximately 20-30% of patients fail to achieve significant weight loss or regain weight after Roux-en-Y gastric bypass (RYGB). Although some patients get back on track by additional counseling, revisional surgery is often necessary. Despite the growing number of patients with insufficient weight loss (IWL) or weight regain (WR), there is no standardized approach. This retrospective study analyzes the banded RYGB (B-GB) and the distal RYGB (D-GB) in patients with IWL or WR after RYGB.

Methods: Between January 1st, 2013 and December 31st, 2016 patients who underwent revisional surgery because of IWL, defined as a percentage excess weight loss (EWL) < 50%, or WR, defined as an increase in weight after initially successful weight loss (EWL > 50%), were included. RYGB was converted to a B-GB using a non-adjustable silicone MiniMizer ring or to a D-GB with a 100cm common channel and 300cm alimentary limb. %EWL one year after revisional surgery, starting from the initial RYGB surgery, and complications were collected and analyzed.

Results: B-GB was performed in 20 patients and 30 patient were converted to a D-GB. %EWL improved in both groups, from 28% at revision to 43% in the B-GB group and from 24% to 55% in the D-GB group. In both groups patients with WR performed better compared to patients with IWL, 62% versus 10% in the B-GB group and 62% versus 40% in the D-GB group. In four (20%) patients the MiniMizer ring was removed during the first year because of dysfagia. In the D-GB group 15 (50%) patients developed nutritional deficiencies requiring supplementation and five (17%) patients developed protein caloric malnutrition compared to 25% and no patients in the B-GB group respectively.

Conclusion: In patients with WR conversion to B-GB and D-GB resulted in similar weight loss. Banding may be preferred because of less morbidity and nutritional complications. In patients with IWL the D-GB resulted in more weight loss, although this was associated with more severe nutritional deficiencies.

O-058

Revision in 1000 consecutive Patients Who Had Sleeve Gastrectomy for Morbid Obesity in a Single Center

Elie CHOUILLARD^a), Antonio D'ALESSANDRO^b), Elias CHAHINE^c)

Minimally Invasive Surgery Department, Metabolic Surgery Unit, PARIS WEST MEDICAL CENTER, POISSY, France

^a)chouillard@yahoo.com

^b)anto.dalex84@gmail.com

^c)dr_elias_chahine@hotmail.com

Introduction: Bariatric surgery is the best available, long-term treatment for morbid obesity. Currently, laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in France. Despite its safety and efficacy, long-term complications of LSG are not rare including weight regain, insufficient weight loss, gastroesophageal reflux disease (GERD), and twisting or stenosis. The goal of this study was to analyze the pattern and short-term results of surgical revision in patients with LSG.

Methods: Revisional surgery, regardless of its motivation, was always a multidisciplinary decision after thorough clinical, biological, endoscopic, and radiological assessment. Patients who had revisional surgery were retrospectively identified and subsequently divided in 4 subgroups according to preoperative body mass index (BMI) (< or > 50 kg/m²) and the presence or not of GERD. The minimal follow up period was 12 months.

Results: Between December 2004 and September 2015, 1000 patients had LSG. 114 patients were lost to follow-up (11.4 %). The rate of excess weight loss (EWL) > 50% was 68%. Out of 886 patients, 94 had a revisional surgery (10.6%) for inadequate weight loss, GERD, or stenosis, respectively. The performed procedures included Roux en Y Gastric Bypass (60%), re-Sleeve (18%), Duodenal Switch (DS) (12%), Single Anatomosis Duodeno-Ileal Shunt (6 %), and Sero-myotomy (4%). Median interval from the initial surgery to conversion was 29 months (18-81). Median operating room time was 170 min (range, 100–290). Median length of stay was 72 hours (range, 48 – 120). Mortality was nil. Overall complication rate was 8% (8/94). The follow-up rate at 12 months was at 96 %. Satisfaction index at 12 month was 88%.

Conclusions: Revisional options after LSG are safe and lead rarely to complications. Nowadays, LSG could be considered as the first step of a potentially multi-step bariatric pathway. Longer follow-up will be needed to establish the correct algorithm of choice of the surgical option for post LSG revision.

O-059

Outcome and risks of surgical reintervention for weight regain after RYGB

Daniel Moritz Felsenreich^{1, a)}, Magdalena Eilenberg^{1, b)}, Julia Jedamzik^{1, c)}, Ronald Kefurt^{1, d)}, Michael Arnoldner^{2, e)}, Christoph Bichler^{1, f)}, Felix Langer^{1, g)}, Gerhard Prager^{1, h)}

¹⁾Department of General Surgery, Medical University Vienna, Vienna, Austria

²⁾Department of Radiology, Medical University Vienna, Vienna, Austria

^a)moritz.felsenreich@meduniwien.ac.at

^b)magdalena.eilenberg@meduniwien.ac.at

^c)julia.jedamzik@meduniwien.ac.at

^d)ronald.kefurt@meduniwien.ac.at

^e)michael.arnoldner@meduniwien.ac.at

^f)christoph.bichler@meduniwien.ac.at

^g)felix.langer@meduniwien.ac.at

^h)gerhard.prager@meduniwien.ac.at

Background and aims: Weight regain occurs after Roux-en-Y gastric bypass (RYGB) in a significant number of patients. As dietary counseling is successful in only few of them, surgical reinterventions, performed as common limb reduction (CLR), pouch banding (PB), pouch remodeling (PR) and as a combination of these procedures might be more successful. PR was defined as pouch resizing, rebuilding of the anastomosis or resection of the blind limb.

The aim of this analysis is to assess outcomes and the risks of these interventions.

Methods: In a total number of 65 patients, surgical reinterventions for weight regain after RYGB were common limb reduction (n=22), pouch banding (n=35), and pouch remodeling (n=8). Within these main groups, some patients had an additional procedure: 11 common limb reduction patients had PB, another 3 had PR and 26 of the pouch banding patients additionally had PR.

Results: In a total of 6 patients (27%) in the CLR group, severe malnutrition led to revisional surgery to increase alimentary and common limb length. 6 PB patients (17%) had to have their pouch band removed due to stenosis and vomiting. In total, 5 out of the 65 (8%) participating patients needed an additional malabsorptive procedure.

The final follow-up rate as well as data on patients’ weight development are currently being reviewed and will be presented by the time of the congress.

Conclusion: The methods of CLR, PB, PR and a combination of them may successfully induce additional weight loss, however, they may also cause the need for further surgical interventions. Thus, they should only be performed in experienced bariatric centers. A final conclusion, including a comparison of these methods based on data on patients’ weight development, has yet to be drawn.

O-060

Simultaneous conversion of gastric band to sleeve gastrectomy: an analysis of 98,298 patients from the MBSAQIP Database

Onur Kutlu^{1, a)}, Ana Cristina Rearte^{2, b)}, Nestor De La Cruz-Munoz^{1, c)}

¹⁾Bariatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States; ²⁾Family Medicine, University of Miami Miller School of Medicine, Miami, FL, United States

^a)ockutlu@gmail.com

^b)okutlu@gmail.com

^c)nedlacruz@med.miami.edu

Background: The objective of this study is to compare the outcomes of laparoscopic sleeve gastrectomy (LSG) to single-stage band removal and sleeve gastrectomy (BR/LSG).

Methods: Patients who underwent LSG and BR/LSG were identified in the MBSAQIP database. Patient characteristics (age, sex, BMI, history of cardiac disease, hypertension, hyperlipidemia, DVT, diabetes, dialysis, mobility, pulmonary embolism, smoking, steroid use, albumin, hematocrit levels) and perioperative outcomes (hospital stay, renal failure, infection, organ-space infection, MI, pneumonia, PE, sepsis, septic shock, transfusion, re-intubation, ICU admission, DVT, death, conversion to open re-operation, readmission) were recorded. Multivariable regression analyses were performed to evaluate the effect of LSG vs BR/LSG on outcomes. To analyze the outcome variables effected, factors were further investigated with binary logistic regression.

Results: 98,298 patients were identified. (93,852-95.8% LSG, 2,978-4.2% BR/LSG). Mean operative time was longer for BR/LSG (113.6 vs. 76.41 min). After correction for confounding factors; conversion to open (OR 1.931, p<0.001), re-operation(OR 1.931, p<0.001), readmission(OR 1.283, p=0.009), drain placement (OR 1.159, p=0.001), septic shock(OR 11.719, p<0.001) were higher in the BR/LSG group. No difference was seen for death, sepsis, MI, PE, renal failure, pneumonia, organ-space infection, ICU admission, transfusion and re-intubation. For septic shock, previous cardiac surgery(OR 3.541, p=0.048), age(OR 1.032, p=0.04), pre-op DVT(OR 3.803 p=0.043) were seen to be a significant factors along with BR/LSG surgery.

Conclusion: BR/LSG can be performed with low risk of adverse events. However the risk of readmission and reoperation is higher, and older patients and patients with previous cardiac surgery are under increased risk of complications.

References

1: Rebibo L, Mensah E, Verhaeghe P, Dhahri A, Cosse C, Diouf M, Regimbeau JM. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg. 2012 Sep;22(9):1420-6.

2: Dietch ZC, Schirmer BD, Hallowell PT. Simultaneous conversion of gastric band to sleeve gastrectomy is associated with increased postoperative complications: an analysis of the American College of Surgeons National Surgical Quality Improvement Program. Surg Endosc. 2017 Dec;31(12):5228-5233.

3: Sharples AJ, Charalampakis V, Daskalakis M, Tahrani AA, Singhal R. Systematic Review and Meta-Analysis of Outcomes After Revisional Bariatric Surgery Following a Failed Adjustable Gastric Band. Obes Surg. 2017 Oct;27(10):2522-2536.

4: Ramly EP, Alami RS, Tamim H, Kantar R, Elias E, Safadi BY. Concomitant removal of gastric band and sleeve gastrectomy: analysis of outcomes and complications from the ACS-NSQIP database. Surg Obes Relat Dis. 2016 Jun;12(5):984-8.

O-061

Gastroesophageal reflux disease following LSG: a prospective study.

Georgia Doulami^a), Viktoria Michalopoulou^b), Stamatina Triantafyllou, Maria Natoudi, Emmanouil Leandros, Georgios Zografos, Dimitrios Theodorou

1st Propaedeutic Surgical Department, Hippokration General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece

^a)tzinagb@yahoo.gr

^b)victoria.michal@gmail.com

Introduction: Literature is still inconclusive as to if sleve gastrectomy (SG) causes newly onset gastro-esophageal reflux (GERD) or worsens already existing GERD. This is due to the absence of prospective studies using objective assessment measures of GERD such as pH monitoring. Our study aims at assessing GERD one year post-LSG procedure for obesity.

Materials and methods: Twelve asymptomatic obese patients were studied prospectively by using 24h MIIpH pre- and 12 months post- LSG.

Results: 83.33% of patients’ one year post-LSG suffered from GERD (either newly onset or worsening of already existing). Mean DeMeester score one year post- LSG was 47, almost 2.5 times higher than the preoperative score (p=0.072). Percentage of total time with pH lower than 4 was statistically significant higher postoperatively (13.27% vs 3.87%, p=0.048).

Conclusion: This study is one of the few in the literature that measure objectively GERD post-LSG by using 24h MIIpH. The majority of patients suffer from GERD 12 months postoperatively, implying that close postoperative monitor for GERD with use of pH testing and upper gastrointestinal endoscopy in order to early diagnose GERD and identify possible mucosal injury and also a prophylactic PPI use may be of great importance.

O-062

Incidence of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy with staple line reinforcement with oversewing and staple line inversion vs buttressing material

Jaime Ruiz-Tovar^a), Carolina Llavero, Lorea Zubiaga, Jose Luis Munoz, Juan Gonzalez, Alejandro Garcia, Carlos Ferrigni, Manuel Duran, Damian Garcia-Olmo

Surgery, HOSPITAL REY JUAN CARLOS, Madrid, Spain

^a)jruiztovar@gmail.com

Background: Postoperative nausea and vomiting are relevant complications after restrictive bariatric procedures, such as sleeve gastrectomy, mainly secondary to a drastic reduction in the gastric volume. However, other causes can be related.

The aim of this study was to determine the incidence of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG), with staple line reinforcement with oversewing vs buttressing material.

Patients and Methods: A prospective randomized clinical trial of all the patients undergoing LSG was performed. Patients were into 2 groups: patients undergoing staple line inversion (Group 1) and patients undergoing staple line reinforcement with buttressing material (Group 2). Nausea and vomiting were assessed by the Postoperative Nausea and Vomiting Intensity Scale.

Results: A total of 100 females were included in the study, 50 in each group. Mean operative time was 66.1+11.6 minutes in Group 1 and 55.4+9.4 in Group 2 (p<0.001). There were no significant differences in staple line leaks and bleeds between groups.

The PONV intensity score at 6 hours was 316.4 in Group 1 and 77.1 in Group 2 (p<0.001). 24 hours after surgery, the PONV intensity score was 86 in Group 1 and 7.9 in Group 2 (p=0.022).

Conclusion: The use of reinforced cartridges in the LSG reduces the incidence of PONV during the first 6 hours after surgery.

O-063

Pushing the limits in bariatric surgery: sleeve gastrectomy for morbidly obese patients over 65 years old

Panagiotis Lainas^{1, a)}, Carmelisa Dammaro¹⁾, Martin Gaillard¹⁾, Gianfranco Donatelli²⁾, Hadrien Tranchart¹⁾, Ibrahim Dagher¹⁾

¹⁾Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, Paris, France

²⁾Department of Endoscopy, Peupliers Private Hospital, Paris, France

^a)plainas@gmail.com

Background: The number of morbidly obese elderly patients is progressively increasing worldwide, triggering an important health and financial burden for society [1]. Laparoscopic sleeve gastrectomy (LSG) is a widely accepted stand-alone bariatric operation [2,3]. Data on elderly patients undergoing LSG are scarce, with very few data on patients older than 65 years-old [4-6]. We therefore aimed to demonstrate that LSG is safe and effective in morbidly obese patients over 65 years-old.

Methods: Prospectively collected data from all consecutive patients undergoing single-incision LSG in our department until May 2016 were retrospectively analyzed. For weight loss and comorbidity evaluation, only patients with at least 1-year follow-up were included in our analysis. Quality of life (QoL) was evaluated using the French version of Short-Form 36 (SF-36) questionnaire.

Results: Fifty-four patients over 65 years-old (range: 65-75 years) underwent single-incision LSG in our department. Median weight was 119 kg, median BMI 43 kg/m². Median duration of surgery was 86.5 minutes. Two patients (3.7%) suffered a gastric staple-line leak; the first was successfully treated using a purely endoscopic approach; the second was treated by relaparoscopy and subsequent endoscopic internal drainage. Mortality was null. Median length of hospital stay was 5 days. Six, 12 and 24 months after LSG, median BMI had decreased significantly to 35, 32.9 and 30.7 kg/m2, respectively (p < 0.0001), with a mean EWL of 76.3% at 2 years. Type II diabetes, hypertension, dyslipidemia, sleep apnea and arthralgia showed statistically significant remission at one year. Six out of 8 SF-36 scale scores of QoL assessment improved significantly.

Conclusions: Our results suggest that LSG is safe and effective for patients older than 65 years-old, resulting in significant weight loss, comorbidities remission and QoL improvement. Morbidly obese patients over 65 years-old should not automatically be denied LSG. A careful patient selection after an adequate risk versus benefit evaluation by an expert multidisciplinary team is essential.

References

• 1. Gagner M, Deitel M, Erickson AL, Crosby RD (2013) Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obesity surgery 23:2013-2017

• 2. van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs SW (2014) Outcome of sleeve gastrectomy as a primary bariatric procedure. Br J Surg 101:661-668

• 3. Himpens J, Dobbeleir J, Peeters G (2010) Long-term results of laparoscopic sleeve gastrectomy for obesity. Annals of surgery 252:319-324

• 4. Burchett MA, McKenna DT, Selzer DJ, Choi JH, Mattar SG (2015) Laparoscopic sleeve gastrectomy is safe and effective in elderly patients: a comparative analysis. Obesity surgery 25:222-228

• 5. O'Keefe KL, Kemmeter PR, Kemmeter KD (2010) Bariatric surgery outcomes in patients aged 65 years and older at an American Society for Metabolic and Bariatric Surgery Center of Excellence. Obesity surgery 20:1199-1205

• 6. Ramirez A, Roy M, Hidalgo JE, Szomstein S, Rosenthal RJ (2012) Outcomes of bariatric surgery in patients >70 years old. Surg Obes Relat Dis 8:458-462

O-064

Food tolerance and quality of alimentation following laparoscopic sleeve gastrectomy calibrated with a 50-Fr bougie: Long-term results

Jaime Ruiz-Tovar^a), Carolina Llavero, Lorea Zubiaga, Jose Luis Munoz

Surgery, Centro de excelencia para el estudio y tratamiento de la obesidad, Valladolid, Spain

^a)jruiztovar@gmail.com

Background: Adjustable gastric banding and vertical banded gastroplasty are associated with the worst postoperative food tolerance of all bariatric techniques. However, food tolerance tends to improve over time.

The aim of this study was to assess food tolerance and diet quality in patients undergoing a sleeve gastrectomy, 1 and 5 years after surgery.

Methods: A prospective observational study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy was performed. Food tolerance was assessed using the Quality of Alimentation questionnaire validated in bariatric patients.

Results:93 patients were analyzed. One year after surgery, mean excess weight loss(EWL) was 81.1±8.3% and 5 years after surgery, mean EWL was 79.9±6.4%. Preoperatively, 39.8% of patients perceived their eating patterns as good or excellent, 1 year after surgery, 79.6% and 5years postoperatively, 86%. 1 year after surgery the patients reported some difficulty in tolerance of rice, pasta and red meat. 5years after surgery, these difficulties disappeared and very few patients just refer some tolerance difficulties with red meat. One year after surgery 10% of the patients reported that they suffered postprandial vomits often and 22% rarely. Five years postoperatively, only 8% of subjects describe rarely vomits.

Conclusion:After sleeve gastrectomy, the patients recognize an improvement in the quality of alimentation. During the first postoperative year, they present tolerance problems with rice, pasta and red meat, that 5 years after surgery disappeared.

O-065

Preoperative detection of sarcopenic obesity helps to predict the occurrence of gastric leak after sleeve gastrectomy

Panagiotis Lainas^{1, a)}, Martin Gaillard¹⁾, Cosmin Voican²⁾, Sophie Maitre³⁾, Gabriel Perlemuter²⁾, Hadrien Tranchart¹⁾, Ibrahim Dagher^{1, b)}

¹⁾Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, AP-HP, Clamart, Paris, France; ²⁾Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, AP-HP, Clamart, Paris, France; ³⁾Department of Radiology, Antoine Béclère Hospital, AP-HP, Clamart, Paris, France

^a)plainas@gmail.com

^b)ibrahim.dagher@aphp.fr

Background: Sleeve gastrectomy (SG) is a primary procedure for many bariatric teams worldwide [1]. Staple-line leak is the most feared complication of SG, with an incidence of 1-7% [2-4]. Sarcopenic obesity combines the risks of obesity and depleted lean mass leading possibly to an inferior surgical outcome [5]. Muscle quantification by abdominal CT-scan is an accurate technique for detecting sarcopenic patients [5]. We aimed to evaluate the existence of a link between radiologically determined sarcopenic obesity and staple-line leak risk after SG.

Methods: A retrospective analysis of a single-center prospective database was performed in consecutive patients undergoing laparoscopic SG as primary procedure. Total psoas muscles area (TPA) and total visible muscles area (TMA) were measured on axial slice at the third lumbar spine vertebra level on CT-scan performed one month before surgery. Skeletal muscular mass indexes were defined as ratio between muscular areas over square of height. Sarcopenia was defined as lowest tertile of skeletal muscular mass indexes (using TPA or TMA) in each gender. Multivariate analysis was performed to determine the main independent preoperative risk factors for staple-line leak.

Results: During the study period, 234 patients underwent laparoscopic SG. Twenty-nine superobese patients were excluded from the study. Median BMI was 40.8 kg/m² [34.2-49.6]. Nine patients (4.4%) presented a gastric leak; in 4 cases relaparoscopy was required (to evacuate and drain an abscess) with subsequent endoscopic drainage, while exclusive endoscopic management was sufficient in 5 cases. The sex-specific cut-offs for skeletal muscular mass index according to TPA were 8.2 cm²/m² for men and 6.08 cm²/m² for women; patients below these values were classified as having sarcopenia. After multivariate analysis, preoperative weight (OR=1,043) and sarcopenia (TPA) (OR=5,204) were independent predictive factors for gastric leak.

Conclusions: The present series suggests that CT-scan determined sarcopenic obesity is associated with increased risk of gastric leak after SG. This preoperatively radiological examination would be a useful clinical tool to tailor patient management according to gastric leak risk.

References

[1] Deitel M, Gagner M, Erickson AL, Crosby RD. Third International Summit: Current status of sleeve gastrectomy. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2011;7:749-59.

[2] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surgical endoscopy. 2012;26:1509-15.

[3] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Annals of surgery. 2013;257:231-7.

[4] Rosenthal RJ, International Sleeve Gastrectomy Expert P, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2012;8:8-19.

[5] Jones K, Gordon-Weeks A, Coleman C, Silva M. Radiologically Determined Sarcopenia Predicts Morbidity and Mortality Following Abdominal Surgery: A Systematic Review and Meta-Analysis. World journal of surgery. 2017;41:2266-79.

O-066

The comparative analysis of sleeve gastrectomy with and without antrumectomy

Taryel Omerov^{1, a)}, Nuru Bayramov^{1, b)}, Nadir Zeynalov^{1, c)}, Elvina Salimova^{2, d)}

¹⁾I Surgical Diseaes Department, Azerbaijan Medical University, Baku, Azerbaijan

²⁾Bariatrik-Metabolic Surgery Department, Modern Hospital, BAku, Azerbaijan

^a)taryel.omerov@gmail.com

^b)nurubay2006@yahoo.com

^c)zeynalovnadir@gmail.com

^d)e-salimova@inbox.ru

Aim of the study: To present the comparative analysis of results of sleeve gastrectomy with and without antrumectomy in super obese patients.

Material and methods: This study involves 109 obese patients(mean age 33.1 years, mean body mass index 57.5 kg/m²) who underwent a laparoscopic sleeve gastrectomy (LSG) 2012 through 2017. Changes of BMI, serum glucose, arterial hypertension, syndrome of sleep apnea and fatty liver disease have been evaluated preoperatively and 1, 3, 6 and 12 month postoperatively as well as postoperative problems according to different surgical techniques applied.

Results: 57 patients(52.3%) who underwent a standard laparoscopic sleeve gastrectomy procedure (group 1) lost 39.5±11.5 kg mean during first 6 months. We followed up those patients up to 36 months postoperatively. 52 patients(47.7%) who underwent the technique of antrumectomy with lesser stomach remaining that we applied (group 2) lost 44+13kg accordingly. Arterial hypertension, concomitant fatty liver syndrome and hyperlipidemia resolved in 61 of 64 patients within first 3 months postoperatively.

All patients who had fatty liver syndrome showed its regression within 12 months. 38 of 43 patients with type 2 diabetes mellitus had normal serum sugar level without any medication 1 month after surgery, and the rest 5 patients decreased the dosage of anti-diabetic drug during 3 months postoperatively following with stop of drug intake on the 6^th month.

Conclusion: Modified LSG procedure (sleeve gastrectomy+ antrumectomy) is more effective and fast in weight loss and improvement of concomitant diseases in super obese patients. These advantages together with the absence of malabsorption syndrome and negative effect to the vitamin balance make this modification a more reliable procedure. Consequently, LSG is believed to be a reliable method, which ensures sufficient weight loss in the treatment of obesity and super-obesity, as well as improvement in comorbidities.

Key words: Severe obesity, sleeve gastrectomy, antrumectpmy, Azerbaijan.

References

• 1. Angrisani, L., Santonicola, A., Hasani, A., Nosso, G., Capaldo, B., Iovino, P. Five-year results of laparoscopic sleeve gastrectomy: effects on gastroesophageal reflux disease symptoms and co-morbidities. Surg Obes Relat Dis. 2016;12:960–968.

• 2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. ObesSurg/ 2013;23(4): 427-36.

• 3. Felsenreich, D.M., Langer, F.B., Kefurt, R. et al, Weight loss, weight regain and conversions to Roux-en-Y gastric bypass-10-year results of laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2016;12:1651–1654.

• 4. Himpens, J., Dobbeleir, J., Peeters, G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg. 2010;252:319–324.

• 5. Hirth, D.A., Jones, E.L., Rothchild, K.B., Mitchell, B.C., Schoen, J.A. Laparoscopic sleeve gastrectomy: long-term weight loss outcomes. Surg Obes Relat Dis. 2015;11:1004–1007

• 6. Mechanick JI, Youdim A, Jones DB, et.al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by american association of clinical endocrinologists, The obesity society, and american society for metabolic &amp; bariatric surgery*. Obesity(Silver Spring). 2013;21Suppl 1:S1-S27

• 7. Sammour, T., Hill, A.G., Singh, P. et al, Laparoscopic sleeve gastrectomy as a single-stage bariatric procedure. Obes Surg. 2010;20:271–275.

• 8. Stroh, C., Köckerling, F., Volker, L. et al, Results of more than 11,800 sleeve gastrectomies: data analysis of the german bariatric surgery registry. Ann Surg. 2016;263:949–955.

O-067

Nine-Year Experience with Laparoscopic Sleeve Gastrectomy in a Tertiary Public Hospital in Greece

Angeliki Kolinioti^{1, a)}, Athanasios Pantelis^{2, b)}, Ioannis-Petros Katralis^{2, c)}, Vasilios Drakopoulos^{3, d)}, Stylianos Kapiris^{1, e)}, Dimitris Lapatsanis^{2, f)}

¹⁾3rd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece; ²⁾2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece; ³⁾1st Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)akolinioti@gmail.com

^b)ath.pantelis@gmail.com

^c)katralispetros@gmail.com

^d)vasileiosdrakopoulos@gmail.com

^e)stkapiris@hotmail.com

^f)dimitrislapatsanis@gmail.com

Background: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric operation worldwide. We hereby present the experience accumulated at our institution over a nine-year period.

Methods: Patient data were collected by retrospectively accessing electronic recordings and prospectively evaluating postoperative progress at scheduled follow-up intervals. Patients were allocated to 2 groups, depending on the extent of the gastric sleeve (Group 1: <2cm from pylorus, <1cm from the angle of His; Group 2: >4cm from pylorus, >1 cm from His). We studied the effect of LSG on excess BMI loss (%EBMIL); type 2 diabetes mellitus (T2DM); morbidity and mortality; and new-onset symptomatic GERD.

Results: From January 2009 to December 2017, 696 obese patients (68.5% females; mean age 39.7 years, range 17-69) were submitted to LSG in our center. Group 1 consists of 502 patients (72%), whereas the rest were allocated to group 2. Fifty patients (7.2%) underwent three-port LSG (vs. 5-port for the rest). No reoperations were documented in the cases not lost to follow-up. Mean pre-operative BMI was 49.2 Kg/m² (range 40-74.2). Mean 1-year %EBMIL was 81.8% vs. 62.7% for Group 1 and Group 2, respectively. Overall mortality was 0.14%. Overall complication rates between Groups 1 and 2 were 2.4% vs. 3.1% (p<0.0001), respectively (leaks: 1.2% vs. 0%, p<0.0001; major hemorrhage: 0% vs. 0.6%, p<0.0001; pulmonary embolism: 0.2% vs. 0.6%, p<0.0001). At 5-year follow-up, 93% of patients with T2DM in Group 1 vs. 87% in Group 2 (p=0.15) needed less or no anti-diabetic medications as compared to their pre-operative status. GERD was clinically significant in 17 patients.

Conclusion – The implementation of LSG in one of the country’s largest healthcare facilities proved to be safe and efficacious in its purpose as a sustainable restrictive weight-loss procedure. Technical variations had an impact on both bariatric effect and complications. Long-term amelioration of T2DM was comparable to that documented internationally, whereas symptomatic GERD was a rare but non-negligible, inherent side effect of the method.

O-068

The endoscopic-vacuum assisted closure-technique in the treatment of staple line leaks after sleeve gastrectomy.

Vasiliki Christogianni^a), Panagiotis Bemponis^b), Martin Buesing^c), Radostina Dukovska^d)

General and Visceral Surgery, Vest Klinikum- Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

^a)bchristogianni@yahoo.com

^b)bebonis@gmail.com

^c)chirurgie@klinikum-vest.de

^d)ineto@abv.bg

Introduction: A Staple line leak after a sleeve gastrectomy is a common complication. Although there are many endoscopical und surgical approaches on this matter, the endoscopic-vacuum assisted closure-technique has only been used in some cases.

Material and methods: The study group included 21 patients with early postoperative (up to 10 days) proximal staple line leaks after a sleeve gastrectomy. The diagnosis was made either after a CT scan with oral contrast or after a relaparoscopy. The time of the first EndoVAC placement, the interval of changes, frequency and duration, adjuvant measures and specific complications of the treatment were evaluated

Results: EndoVAC therapy was initiated in all cases after a previous relaparoscopy (2-10 p.o. day), lavage and drainage of the abdominal cavity. Re-endoscopy and EndoVAC changes were performed every 2-7 days. The average duration of EndoVAC therapy was 22 days (4-47 days), requiring 2-10 changes. Specific complications of the treatment were identified in 4 cases as a result of early dislocation of the EndoVAC system. Additionally, the EndoVAC system was satisfactorily tolerated by the patients and fluids (water, tea) were given orally after the second placement. The EndoVAC therapy was successfully completed in 18 cases, in 3 cases a persistent fistula was treated with a double pigtail drainage. In the long term, no stenoses were observed. In one case a recurrent abscess was treated surgically 1 year later.

Conclusion: The proximal staple line leakage after a sleeve gastrectomy requires a rapid approach. Our treatment strategy consists of an early relaparoscopy, lavage and drainage, followed by the initiation of an EndoVAC therapy in the following days. In addition, antibiotics and intensive care unit admission are almost always necessary. The duration of therapy depends on the endoscopic evaluation of the abscess cavity and the improvement of the clinical status. In the treatment of proximal staple line leaks after sleeve gastrectomy, EndoVAC therapy has proven to be very effective.

Acknowledgement

M. Büsing¹, R. Dukovska¹, K. Husemeyer¹, R. Riege¹, M Reiser²

¹Vest Klinkum- Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

²Klinikum Vest-Paracelsus Hospital Marl, Marl Germany

O-069

Results of the Crossover Group in the Randomized Controlled Multicenter MILEPOST Study for Primary Obesity (POSE) vs. Diet-Exercise alone

Karl Miller^{1, a)}, Jan Willem Greve²⁾, Jorge C. Espinos³⁾, Roman Turro³⁾, Marcus Radauer⁴⁾

¹⁾Surgical Department, Diakonissen Wehrle Private Hospital, Salzburg, Austria; ²⁾Atrium-Orbis Medical Centre, Heerlen, Netherlands; ³⁾Hospital Quirón Teknon, Barcelona, Spain; ⁴⁾Hallein Hospital, Hallein, Austria

^a)karl@miller.co.at

Background: The POSE procedure is a minimally invasive technique to treat obesity. The POSE procedure employs a peroral incisionless operating platform (USGI Medical, San Clemente, Calif) to place transmural tissue anchor plications that reduce accommodation of the gastric fundus. Additional plications are placed in the distal gastric body to delay gastric emptying. The Milepost study compared safety, satiety, and weight loss outcomes of subjects undergoing the POSE procedure plus diet and exercise to those following diet and exercise alone at one year post randomization [1]. After one year, the control subjects were offered the POSE procedure (Crossover Pose Group) and followed for an additional 12 months.

Methods: A non-blinded, randomized controlled trial was conducted in 3 EU countries. Following Ethics approval, 44 subjects were randomized (34, 77.3% female; mean age 38.3±10.7 years; body mass index, 36.5±3.4 kg/m²) to pose (n=34) or control (n=10) in 3 centers. The Control group was eligible to crossover at the end of the primary study period to the treatment group. Change in mean % total body weight loss (TBWL) was measured one year following the crossover procedure.

Results: Seven of the eight eligible control subjects elected to crossover and received the POSE procedure. One year following their crossover procedure, %TBWL for the Crossover POSE Group was 11.0% (EWL: 40.0%). The control group average %TBWL was 5.3% (EWL 18.1%) prior to crossover period. Hence an additional 5.7 %TBWL was attained, doubling their average weight loss achieved during the diet and exercise period alone. 24 month weight loss shown in Figure 1.

There were no serious adverse events related to device in the crossover group. One incident of extra gastric bleeding occurred in one of the crossover subjects, which was managed immediately during the recovery phase and resolved without long-term sequelae.

Conclusions: Dietary and lifestyle modifications alone often fail to achieve desired weight loss outcomes. POSE provides a safe and durable weight loss solution over diet/exercise alone.

References: 1 Miller K, Turró R, Greve JW, Bakker CM, Buchwald JN, Espinós JC. MILEPOST Multicenter Randomized Controlled Trial: 12-Month Weight Loss and Satiety Outcomes After POSE TM vs. Medical Therapy. Obes Surg 2017 Feb;27(2):310-322.

Acknowledgement: We would like to thank Stephanie Amlung, PhD, RN, USGIMedical, San Clemente, CA, USA for database integration and management and T.W.McGlennon, M3 LLC, Maiden Rock,Wisconsin, USA, for statistical analysis.

O-070

REVERSIBLE GASTRIC BYPASS WITH FUNDECTOMY AND GASTRIC REMNANT EXPLORATION (LRYGBfse): RESULTS AT 5-YEARS FOLLOW-UP

Giovanni Lesti^{1, a)}, Marco Zappa^{2, b)}, Ezio Lattuada³⁾, Enrico Mozzi⁴⁾, Alberto Aiolfi²⁾, Fabrizio Altorio⁵⁾

¹⁾general surgery, Private Hospital Prof. Petrucciani, Lecce, Italy; ²⁾General Surgery, Ospedale Fatebenefratelli, Erba (Monza), Italy; ³⁾General Surgery, Private Hospital San Pio X, Milano, Italy; ⁴⁾General Surgery, Istituto Auxologico IRCCS, Milano, Italy; ⁵⁾General Surgery, Private Hospital Clinica Di Lorenzo, Avezzano, Italy

^a)giovannilesti@gmail.com

^b)marcoantoniozappa@libero.it

Background: The Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold standard procedure for morbid obesity and its results are well known and largely discussed. The LRYGB is not reversible and its major limitation is the difficult exploration of the gastric remnant and duodenum. The reversible gastric bypass with fundectomy and exploration of the gastric remnant was introduced in attempt to overcome this limitation. To date, its outcomes are debated and still unclear. The purposes of this study were to describe a novel technique of gastric bypass with fundectomy and to analyze its outcomes

Material and Methods: This is a multicenter prospective study. From January 2008 to December 2015 a series of morbidly obese patients underwent the laparoscopic gastric bypass with fundectomy and gastric remnant exploration (LRYGBfse). Outcomes in term of weight loss, BMI decrease, %EWL improvement, and comorbid resolution were analyzed during follow-up.

Results: Overall, 653 patients were enrolled in the study and prospectively followed. The preoperative mean body weight and mean BMI were 133.4 ± 28.6 kg and 48.2 ± 7.8 kg/m2, respectively. No major intraoperative complications were reported. The mean postoperative in-hospital length of stay was 4 days (range 2-10), and the mean ICU length of stay was 1 day (range 1-2). Postoperative overall morbidity and mortality rates were 0.7% and 0% respectively. Overall, 229 patients completed the 5-years follow-up. Mean BMI and Excess Weight Loss (EWL%) were significantly lower compared to baseline (p <0.05). Comorbid improvement or resolution was recorded in most of the patients. Banding removal was necessary in one patient 62 months after the index operation.

Conclusions: The reversible gastric bypass with fundectomy and gastric remnant exploration is feasible and effective with durable results at 5-years follow-up. Outcomes in term of weight loss, overall complications, and comorbid resolution seems comparable to the standard LRYGB. Endoscopic evaluation of the gastric remnant with an easy access to the main duodenal papilla are unquestionable advantages.

O-071

Elipse® Swallowable Intragastric Balloon + Very Low Calorie Ketogenic Diet (VLCKD): A Novel Strategy to Optimize Weight-Loss and Minimize Side Effects

Roberta Ienca^{1, a)}, Cristiano Giardiello^{2, b)}, Rita Schiano^{2, c)}, Ilaria Ernesti^{1, d)}

¹⁾Department of Experimental Medicine, Medical Pathophysiology, food science and endocrinology section, Sapienza University, Rome, Italy; ²⁾Emergency and Metabolic surgery dept, Pineta Grande Hospital, Caserta, Italy

^a)roberta.ienca@libero.it

^b)cristiano.giardiello@pinetagrande.it

^c)rita_schiano@libero.it

^d)ilariaernesti@libero.it

Background: Eighty percent of weight loss from intragastric balloons occurs in the first half of balloon residence. Addition of VLCKD may further augment weight loss. The timing of adding VLCKD to maximize weight loss and minimize side effects, is unknown.

Aims: To investigate the optimal timing of VLCKD addition to Elipse Balloon therapy.

Methods: A prospective, randomized study was conducted in 24 obese individuals(8M/16F) receiving Elipse®, a new swallowable intragastric balloon. Patients were randomized into two groups. Group A started VLCKD at Elipse placement (4 months of VLCKD) while Group B started VLCKD three months after Elipse® placement (1 month of VLCKD); A Visual Analog Scale (VAS) was used monthly to evaluate satiety and side effects following placement.

Results: Group A mean starting weight and BMI were 108.2±19.7kg and 36.4±6.1kg/m² respectively. In Group B these were 109.7 ± 20.9kg, and 38.6 ± 6.7kg/m² respectively. After 16 weeks, in Group A mean weight loss was 12.8±3.1kg, mean %EWL was 35.2% and mean BMI reduction was 4.1±1.4kg/m². In Group B, these were 5.2 ± 2,6kg, 42% and 5.3±1.1kg/m² respectively. VAS revealed that the satiety grade at the end of each month of therapy was comparable between Group A and Group B. No serious adverse events were noted, although 3 pts in group A reported muscle cramps caused by inadequate intake of electrolytes.

Conclusion: Elipse balloon alone, without the addition of VLCKD can sustain satiety. VLCKD does not appear to enhance the efficacy of Elipse if added in the first three months as Elipse efficacy may already be maximized then. Weight loss is greater in the group that started VLCKD only in the last month of Elipse treatment. Introduction of VLCKD during the last month of Elipse therapy is enough to enhance efficacy, optimize weight loss and minimize side effects.

O-072

Modified laparoscopic Sleeve Gastrectomy combined with Rossetti fundoplication (R-Sleeve): midterm results after more than 170 procedures

Matteo Uccelli^a), Giovanni Cesana, Francesca Ciccarese, Riccardo Giorgi, Roberta Villa, Giorgio Castello, Stefano De Carli, Alberto Oldani, Adelinda Zanoni, Stefano Olmi

General and Oncological Surgery - Centre of Bariatric Surgery, San Marco Hospital - GSD, Zingonia - Osio Sotto (BG), Italy

^a)matteo.uccelli@gmail.com

Introduction: Gastroesophageal Reflux disease (GERD) can be considered strictly related to obesity. Sleeve Gastrectomy (SG) is one of the most frequently performed bariatric procedures. There is a growing concern about the relationship between SG and GERD. This study aims to assess the effectiveness, on morbid obese patients, of the combined SG and Rossetti anti-reflux fundoplication (R-Sleeve) for the treatment of GERD in obese patients before and after bariatric surgery.

Methods: From February 2016 to November 2017, 179 obese patients (134 female; 45 male) underwent R-Sleeve procedure, performed by 4 different expert bariatric surgeons.

Results: Mean age: 42.8±10.1 years. Mean BMI: 42.5±6.2 kg/m2 (range: 30-63). Patient were suffering from GERD before surgery: 124/179 (69.5%). Mean operative time: 49±19 minutes. No intraoperative complications or conversion were reported. Incidence of medical complications: 6/172 (3.4%); surgical complications: 14/172 (7.8%); gastric fistula: 9/179 (5.0%). The fistula has always arisen in fundoplication. Rate of reoperation: 11/172 (6.1%). A good sense of repletion without episodes of vomiting, nausea or dysphagia was reported at 12 months follow up from 95% of patients. 18 months after surgery, more than 95% of patients do not suffer from reflux symptoms and do not take PPI. Excess BMI loss percent (EBMIL%) at follow-up were comparable with SG.

Conclusions: R-Sleeve is well tolerated, feasible and safe procedure in obese patients with good postoperative weight loss results. We recorded an almost complete resolution of clinical signs of GERD after SG to 18 months after surgery. Genesis of the fistula is attributable to an incorrect manipulation of the stomach. This complication, different to the classic fistula after LSG, can be ascribed to an improvement of the technique and its complete standardization. Moreover, the postoperative course also in case of surgical complication was, after reoperation, comparable if not better than the postoperative SG course complicated by gastric fistula. Two monocentric prospective studies are underway to validate this technique.

O-073

Magenstrasse and Mill procedure with Nissen-Rossetti fundoplication as an alternative option for bariatric patients with gastroesophageal reflux or hiatal hernia.

Bernard MAJERUS^a), Jean-Paul HAXHE^b), Erik KOVACS

Service de Chirurgie Viscérale, Clinique Saint-Pierre, Ottignies-Louvain-La-Neuve, Belgium

^a)bernard.majerus@cspo.be

^b)jean-paul.haxhe@cspo.be

Surgery is the best option for morbidly obese patients not responding to conservative treatments. Esophagitis and hiatal hernias are frequent among obese population. Patients with morbid obesity and esophagitis and/or large hiatal hernia are best treated with gastric bypass associated with crural repair. However, some patients present contra-indications to the gastric bypass or do not accept this procedure. Sleeve gastrectomy is generally considered as contra-indicated in obese patients with esophagitis or large hiatal hernia because of the risk of worsening of gastro-esophageal reflux. The addition of a crural repair to the sleeve has been advocated in presence of a hiatal hernia, but effectiveness remains subject to debate. When gastric bypass is contra-indicated or not accepted by the patient, the addition of a Nissen-Rossetti anti-reflux procedure to the Magenstrasse and Mill intervention (MMNR), as described by Fedenko and Evdoshenko in 2007, seems interesting. From November 2015, we propose this intervention to selected patients, after multidisciplinary assessment and informed consent. MMNR is feasible and safe on a short to mid-term. Patients’ tolerance is good. Weight loss could be less important than with sleeve gastrectomy or gastric bypass. Efficiency evaluation on GERD/HH (and other comorbidities) is promising but longer follow-up is required.

References

Fedenko V, Evdoshenko V. Antireflux sleeve gastroplasty: description of a novel technique. Obes Surg. 2007 Jun;17(6):820-4

O-074 Robotic versus conventional laparoscopic minigastric bypass: is innovation always better?

Hakan Karatas^a), Suleyman Cetinkunar^b), Tevfik Tolga Sahin^c)

General Surgery, Adana City Hospital, Adana, Turkey

^a)h3301@hotmail.com

^b)slmcetin@gmail.com

^c)tevfiktolgaa@gmail.com

Aim and background: Currently we perform laparoscopic sleeve gastrectomy and laparoscopic mini-gastric bypass (MGB) at a high volume. The aim of the present study is to evaluate the efficacy of laparoscopic and robotic mini-gastric bypass (MGB) in resolution of morbid obesity and concomitant systemic diseases. In addition, we aimed to evaluate the efficacy of robotic surgery with respect to conventional laparoscopic approach.

Patients and methods: Two hundred-thirty-five patients who underwent laparoscopic or robotic MGB in our center between January 2014 to 2017 were included in the study. Patients were grouped in to robotic (RMGB) and laparoscopic MGB (LMGB) groups. Patient demographic data, laboratory tests, metabolic parameters and resolution of the systemic diseases were investigated.

Results: Mean age of the RMGB and LMGB groups were 35.3+12.4 and 37.6+9.9 years, respectively (p>0.05).In both groups 76% of the patients were female and the two groups were similar in terms of preoperative BMI, body weight and distribution of the systemic diseases (p>0.05). When each group was evaluated according to the preoperative values MGB procedure resulted in significant weight loss, reduction in BMI and resolution of the concomitant diseases such as diabetes, hyperlipidemia and etc. (p<0.05). However, the postoperative 1^st year results of LMGB were superior to RMGB in terms of weight loss, resolution of diabetes related parameters and the lipid profile of the patients (p<0.05). Although complication rate of RMGB was higher than LMGB it did not reach statistical significance (p>0.05).

Discussion and conclusion: In conclusion, MGB is an effective treatment modality for morbid obesity and related systemic diseases. Robotic approach in bariatric surgery is in the diffusion phase of popularization of technologic innovation. Learning curve may be one reason why robotic surgery results may be inferior to laparoscopic approach. We use the Da Vinci S system which is designed for the urologic applications and may be not suitable for more complex general surgical procedures. Multi-institutional large volume data are needed to confirm the results of the study.

References

Prevention and management of the global epidemic of obesity. Report of the WHO Consultation on Obesity (Geneva, June, 3–5, 1997). Geneva: WHO

• 1. Bulucu Altunkaynak B. Z., Özbek, E., Obezite: Nedenleri ve Tedavi Seçenekleri, Dicle Tıp Dergisi, 2007Cilt: 34, Sayı: 2, (144-149)

• 2. Azizi F. Bariatric surgery for obesity and diabetes. Arch Iran Med 2013;16(3):182-6.

• 3. Yurdakul, C., Bariatrik Cerrahi Sonrası Hastaların Beslenme Kalitelerinin Uzun Dönemde Klinik Ve Antropometrik Ölçümlere Etkisi. İstanbul Medipol Üniversitesi Sağlık Bilimleri Enstitüsü Beslenme Ve Diyetetik Anabilim Dalı Yüksek Lisans Tezi İstanbul 2015

• 4. Pories WJ.J Clin Endocrinol Metab. 2008 Nov;93(11 Suppl 1):S89-96.

• 5. Gözeneli, O., 2006-2012 Tarihleri Arasında İnönü Üniversitesi Tıp Fakültesi Genel Cerrahi Kliniği’nde Morbid Obezite Hastalarında Yapılan Roux-En-Y Gastrik By-Pass Ameliyatlarının Retrospektif Olarak Değerlendirilmesi. İnönü Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı Uzmanlık Tezi Malatya – 2012

• 6. Brethauer SA. Sleeve Gastrectomy. Surg Clin N Am 2011;91:1265-1279.

• 7. Sağlam, F., Güven H., Obezitenin Cerrahi Tedavisi Okmeydanı Tıp Dergisi 30(Ek sayı 1):60-65, 2014

• 8. Özger, İ. A. Fazla Kilolu ve Obez Bireylerde Duygu Değişiklikleri ve Yeme Eğilimi İlişkisinin Değerlendirilmesi. İstanbul: Haliç Üniversitesi Sağlık Bilimleri Enstitüsü, Beslenme ve Diyetetik Yüksek Lisans Tezi, İstanbul, 2012.

• 9. Aydoğan, H., Obezite Olan ve Olmayan Bireylerde Benlik Saygısı Ve Bağlanma Biçimi. Üsküdar Üniversitesi Sosyal Bilimleri Enstitüsü Klinik Psikoloji Anabilim Dalı Yüksek Lisans Tezi İstanbul, 2017

• 10. Soper NJ, Barteau JA, Clayman RV, Ashley SW, Dunnegan DL. Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy. Surg Gynecol Obstet 1992;174:114-118.

• 11. Vander Velpen GC, Shirni SM, Cuschieri A. Outcome after cholecystectomy for symptomatic gallstone disease and effect of surgical access: Laparoscopic vs. open approach. Gut 1993:34:1448-1451.

O-075

Effect of the EndoBarrier Device: a 4-year follow up of a multicenter randomized clinical trial

Yvonne Roebroek^{1, 2, a)}, Selwyn van Rijn^{1, b)}, Charlotte de Jonge^{3, c)}, Jan-Willem Greve^{3, d)}, Nicole Bouvy^{1, 2, e)}

¹⁾Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands; ²⁾NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, Netherlands; ³⁾Department of General Surgery, Zuyderland Medical Center, Heerlen, Netherlands

^a)y.roebroek@maastrichtuniversity.nl

^b)selwyn.v.rijn@catharinaziekenhuis.nl

^c)charlotte.de.jonge@mumc.nl

^d)j.greve@zuyderland.nl

^e)n.bouvy@mumc.nl

Background: DJBL treatment has been proven effective for the treatment of obesity and type 2 diabetes mellitus. However, data on the long term effect of DJBL treatment is missing. The aim of this study was to evaluate the long-term effect of the duodenal jejunal bypass liner (DJBL) on weight loss and glycemic control.

Methods: From 2010 to 2012, twenty-nine patients were treated with the DJBL at Maastricht University Medical Center and Zuyderland Medical Center Heerlen, as part of multicenter randomized controlled trial. Prior to implantation and after removal of the DJBL, all patients underwent standardized physical examination and blood sampling (HbA1c, C-peptide, total cholesterol, HDL, LDL, triglycerides). Included patients underwent standardized physical examination and blood sampling as previously performed during the initial study.

Results: Out of the twenty-nine patients fifteen patients were eligible for follow-up with a median duration of 49 months. Five patients had successfully received additional bariatric surgery and were not included in the primary analysis in this long-term evaluation of the DJBL. Four years after explantation of the DJBL median body weight in these ten patients was 95.2 kg (IQR 91.7-115.2) compared to 102.0 kg at baseline (IQR 95.0-124.4), corresponding with a median BMI of 32.2 kg/m² (IQR 30.7-33.7) compared to 32.6 kg/m² at baseline (IQR 31.9-34.0). Patients had an EWL of 11.9% (IQR -39.1-0.0) compared to baseline weight. HbA1c increased from 7.2% to 7.6% (IQR 6.5-8.0). Four years after removal of the DJBL no significant changes were seen.

Conclusions: The effect of weight reduction seems to be partially maintained 4 years after DJBL treatment compared to baseline. However, to fully determine the long term effect of DJBL treatment larger prospective studies with long-term follow up need to be conducted in the future.

O-076

Determination of underlying genetic variations in an obese cohort of more than 1000 patients and the effect of bariatric surgery.

Mellody Cooiman^{1, 2, a)}, Lotte Kleinendorst^{2, 3, a)}, Edo Aarts^{1, b)}, Frits Berends^{1, a)}, Ignace Janssen^{1, a)}, Eric Hazebroek^{1, c)}, Hans Kristian Ploos van Amstel^{4, a)}, Bert Zwaag van der^{4, a)}, Mieke Haelst van^{2, 3, a)}

¹⁾Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands; ²⁾Clinical Genetics, VU Medical Center, Amsterdam, Netherlands; ³⁾Clinical Genetics, Academic Medical Center, Amsterdam, Netherlands; ⁴⁾Genetics, University Medical Center, Utrecht, Netherlands

^a)mcooiman@rijnstate.nl

^b)eaarts@rijnstate.nl

^c)ehazebroek@rijnstate.nl

Introduction: A number of monogenic causes of obesity have been identified in humans. The most common cause of monogenic obesity is a mutation in the melanocortin-4 receptor gene (MC4R), which is part of the leptin-melanocortin pathway. Mutations in this pathway can lead to an imbalance in energy homeostasis and therefore obesity. Next generation sequencing (NGS) techniques can be used for determination of underlying genetic variations. Even so, with more knowledge on obesity associated genes and their possible influence on weight loss after bariatric surgery, it could be possible to further personalize treatment.

Methods: A custom NGS-assay aimed at enrichment of 255 known obesity genes or putative obesity candidate genes was developed. Analysis of 52 obesity associated genes was performed as a diagnostic gene panel-test by the genome diagnostics laboratory of the UMC Utrecht. Patient inclusion criteria were: redo-surgery for insufficient weight loss, BMI > 50kg/m² or childhood age of onset of obesity. Genomic DNA of 1014 patients was sequenced at > 100X median coverage, yielding a 15X horizontal gene panel coverage of >95%.

Results: Multiple known pathogenic mutations and genetic variants of uncertain clinical significance (VUS) were identified. Nine patients showed a mutation in MC4R; six of these patients underwent Roux-en-Y Gastric Bypass surgery. After two years, mean %Total Body Weight Loss (%TBWL) of 26.6 (±12.9) was achieved, compared to %TBWL of 32.6 (± 9.9) (p=0.421) in 102 patients without mutations on the gene panel matched for age and BMI.

Conclusion: Follow-up of the patients with a MC4R mutation is necessary to assess the long term effect of bariatric procedures. In parallel, analysis of all identified pathogenic mutations and VUS of the 52 obesity associated genes with their effect on weight loss will be performed. Analysis of the 203 (candidate) obesity associated genes could uncover novel genetic causes of obesity. Results from these studies can potentially be used to develop personalized treatment options in patients with morbidly obesity.

O-077

Appetite, Glycemia, and Entero-Insular Hormone Responses Differ Between Oral, Gastric-Remnant, and Duodenal Administration of a Mixed Meal Test After Roux-en-Y Gastric Bypass

Daniel Gero^{1, a)}, Robert E. Steinert^{1, b)}, Hanna Hosa^{1, c)}, David E. Cummings^{2, d)}, Marco Bueter^{1, e)}

¹⁾Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland; ²⁾Department of Medicine, Division of Metabolism, Endocrinology & Nutrition, University of Washington, Seattle, Washington State, United States

^a)danielgero.md@gmail.com

^b)re.steinert@gmail.com

^c)Hanna.Hosa@usz.ch

^d)davidec@u.washington.edu

^e)marco.bueter@usz.ch

Objective: Human studies that investigated the effect of gastrointestinal re-routing after Roux-en-Y gastric bypass (RYGB) on glycemic control used meal tests (MT) administered by mouth and by gastrostomy. Significantly higher insulin response was observed after oral route [1,2], which can be attributed to the early exposure of intestinal L-cells to undigested food (hindgut theory) or to the lack of stimulation of an un-identified duodenal anti-incretin pathway (foregut theory). Given that the intestinal hormonal response to nutrients is caloric-rate dependent, we hypostatized that the meal administration by gastrostomy might be biased by the intact pyloric function regulating gastric emptying. Therefore, we examined the appetite and metabolic responses after RYGB by three feeding routes, with an additional duodenostomy (Figure 1).

Methods: A standard liquid MT was administered orally, into the gastric remnant, or intraduodenally 6 months after RYGB in 1 patient, 2-times per each route. Changes in plasma glucose, insulin, GLP-1, GIP, PYY, and appetite were measured pre- and up to 120 minutes postprandially.

Results (Figure 2): Postprandial GLP-1 and PYY responses were similar, whereas glucose, insulin, and GIP levels differed markedly after oral vs. intraduodenal feeding. Intraduodenal feeding prompted an intermediate appetite response (i.e., between oral and intragastric). For postprandial glucose, insulin, and GIP levels, the intraduodenal route was more similar to the intragastric than oral route (30-min insulinema: gastric≈60pmol/l, duodenal≈250pmol/l, oral≈1615pmol/l). Intragastric administration did not evoke changes in appetite, glucose, or insulin; however, it slightly increased GLP-1 and PYY, and moderately increased GIP.

Conclusions: This study is the first to compare metabolic responses to MT administered by three different routes after RYGB. Findings indicate that appetite and metabolic responses depend on the route by which nutrients enter the gastrointestinal tract and that the remnant gastric emptying rate interferes with outcomes. Hence, intraduodenal meal administration should be used in future studies to circumvent this bias.

References

• 1. Pournaras DJ, Aasheim ET, Bueter M, Ahmed AR, Welbourn R, Olbers T, le Roux CW. Effect of bypassing the proximal gut on gut hormones involved with glycemic control and weight loss. Surg Obes Relat Dis. 2012 Jul-Aug;8(4):371-4.

• 2. Dirksen C, Hansen DL, Madsbad S, Hvolris LE, Naver LS, Holst JJ, Worm D. Postprandial diabetic glucose tolerance is normalized by gastric bypass feeding as opposed to gastric feeding and is associated with exaggerated GLP-1 secretion: a case report. Diabetes Care. 2010 Feb;33(2):375-7.

Acknowledgement: The Cantonal Ethics Committee of Zürich approved this study (BASEC-Nr. Req-2017-0616). We are grateful to Pelagia Kakka, architecture student at the Democritus University of Thrace, Xanthi, Greece, for creating the schematic illustration. Our gratitude goes also to Udo Ungethuem, lead laboratory technician at the Department of Visceral Surgery and Transplantation, University Hospital Zürich, Switzerland, for his important help in performing the immunoassays.

O-078

Effects of Different Metabolic States and Surgical Models on Glucose Metabolism and Secretion of Ileal L-Cell Peptides: Results from the HIPER-1 Study

Eylem Cagiltay¹⁾, Alper Celik^{2, a)}, John Dixon³⁾, Sjaak Pouwels^{4, b)}, Sergio Santoro⁵⁾, Adarsh Gupta⁶⁾, Bahri Onur Celik²⁾, Surendra Ugale⁷⁾, Muhammed Abdul-Ghani⁸⁾

¹⁾Endocrinology, Sultan Abdulhamid Han Education and Research Hospital, Istanbul, Turkey; ²⁾Surgery, Metabolic Surgery Clinic, Istanbul, Turkey; ³⁾Primary Health Care, Monash University, Melbourne, Australia; ⁴⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands; ⁵⁾Surgery, Albert Einstein Hospital, Sao Paolo, Brazil; ⁶⁾Center for Medical Weight Loss & Metabolic Control, Rowan University, Stratford, New Jersey, United States; ⁷⁾Bariatric and metabolic surgery, Kirloskar Hospital, Hyderabad, India; ⁸⁾Diabetology, University of Texas Health Science Center, San Antonio, Texas, United States

^a)doktoralper@hotmail.com

^b)sjaakpwls@gmail.com

Objective: To compare the impact of 4 surgical procedures (mini gastric bypass [MGB], sleeve gastrectomy [SG], ileal transposition [IT], and transit bipartition [TB]) versus medical management on gut peptide secretion, beta cell function, and resolution of hyperglycemia in patients with type 2 diabetes.

Research design and methods: A mixed-meal tolerance test (MMTT) was administered 6-24 months after each surgical procedure (mini gastric bypass [MGB], sleeve gastrectomy [SG], ileal transposition [IT], and transit bipartition [TB], n=30 in each group) and the result was compared to matched lean (n=30) and obese (n=30) type 2 diabetes patients undergoing medical management

Results: MGB and IT patients had a greater increase in plasma glucose concentration following MMTT than SG and TB patients. MGB patients exhibited the greatest increase in the incremental area under the curve of plasma glucose concentration above baseline (∆G_0-120) (p<0.0001). Insulin sensitivity was comparable across surgical groups, and statistically greater in surgical patients than in obese nonsurgical patients (p<0.0001). Beta cell responsiveness to glucose was greater in SG and TB than in MGB and IT patients (p<0.001) despite a smaller increase in ∆GLP-1_0-120 relative to IT. Postoperative beta cell function was the strongest predictor of hyperglycemia resolution.

Conclusions: The present study demonstrated that the level of beta cell function after bariatric surgery is the strongest predictor of hyperglycemia resolution. The study also demonstrates a disconnection between postprandial GLP-1 levels and beta cell function among the studied surgical procedures.

O-079

Reduction in Iron deficiency after Sleeve gastrectomy in women, a prospective controlled cohort study.

Simon Msika^{1, a)}, Muriel Coupaye^{1, b)}, Hervé Puy^{2, c)}, Carole Lagnel^{3, d)}, Fadia Dib^{4, e)}, Zoubida Karim^{4, f)}, Thibaud Lefebvre^{2, g)}, Marina Esposito-Farese^{5, h)}, André Bado^{5, i)}

¹⁾UpperGI and Bariatric surgery - University Paris Diderot, University Hospital BICHAT, Paris, France; ²⁾Centre National de Références des Porphyries, Université Paris Diderot, PRES Sorbonne Paris Cité, Paris, France; ³⁾Centre de Recherches sur l'inflammation Equipe "heme, fer et maladies inflammatoires, University of Rouen, Rouen, France; ⁴⁾UMR 1149/ERL CNRS 8252, Centre de Recherches sur l'inflammation Equipe "heme, fer et maladies inflammatoires, Université Paris Diderot, PRES Sorbonne Paris Cité, Paris, France; ⁵⁾Fonctions Gastro-Intestinales, Métaboliques et Physiopathologies Nutritionnelles, Equipe B.A.D.O (Bariatric surgery Alimentary Diseases and Obesity) Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, Université Paris Diderot, PRES Sorbonne Paris Cité, Paris, France

^a)simon.msika@aphp.fr

^b)muriel.coupaye@aphp.fr

^c)herve.puy@aphp.fr

^d)carole.lagnel@univ-rouen.fr

^e)fadia.dib@aphp.fr

^f)zoubida.karim@inserm.fr

^g)thibaud.lefebvre@aphp.fr

^h)marina.esposito-farese@aphp.fr

ⁱ⁾andre.bado@inserm.fr

Introduction: Iron deficiency with or without anemia needing continuous iron supplementation is very common in obese patients, particularly those requiring bariatric surgery, and may be due to an increase in serum hepcidin that decreases iron absorption. However, bariatric surgery procedures may reduce the prevalence of this iron deficiency. Our aim was to address this reduction in sleeve gastrectomy patients.

Methods: The cohort included 88 obese women (Median age 36 years, Median BMI 40.85 Kg/m2 ). 31 patients were discharged because of pregnancy (3), lost to follow-up (27), and change of surgical procedure (1). Pre-operative (E1) and one-year post-operative (E2) explorations were performed during which blood samples duodenal and fat tissue biopsies were taken. Levels of serum hepcidin (the inflammatory-induced iron regulatory peptide), the erythroid iron deficiency markers (soluble transferrin receptor (sTfR1) and Zn- PPIX), the gene expression of duodenal iron carriers (DMT1 and ferroportin) and of hepcidin in adipose tissue, and the inflammatory markers (CRP, IL-6, orosomucoïde) were measured. For all patients, iron supplementation was stopped 3 weeks before E1.

Results: Despite normal iron balance, sTfR1 and Zn-PPIX were significantly decreased at E2 compared to E1, suggestive of recovery from erythroid iron deficiency as confirmed by increased MCV and decreased reticulocytes values. Interestingly, the level of serum hepcidin was enhanced despite significant decrease of inflammatory markers suggestive of increased iron availability from absorptive cells. Indeed, increased DMT1-mRNA expression was significantly correlated with decreased body weight. Increased serum hepcidin was independent from local fat tissues production, which remained unchanged. Finally, serum levels of B12 vitamin and folate were increased, which could additionally improve the efficiency of erythropoiesis.

Conclusions: This study shed a new light in effective iron recovery pathways after sleeve gastrectomy involving: 1- suppression of inflammation, 2-improvement of iron absorption, 3- iron supply and efficiency of erythropoiesis, and finally beneficial control of iron homeostasis by hepcidin. Thus, recommendations of iron supplementation of patients after sleeve surgery may not be systematically necessary.

O-080

Sleeve gastrectomy: Does the procedure impact gut hormones or the induced weight loss does

Panagiotis Patrikakos^{1, a)}, Stylianos Kapiris^{2, b)}, Despoina Perrea^{3, c)}, Theodoros Mauromatis^{2, d)}

¹⁾Surgery, General Hospital Patra, Patra, Greece; ²⁾3rd Surgical Department, Evangelismos Hospital, Athens, Greece; ³⁾Division of Experimental Surgery, National and Kapodistrian University of Athens, Athens, Greece

^a)ppatrikakos@gmail.com

^b)stkapiris@hotmail.com

^c)dperrea@med.uoa.gr

^d)thmauro@yahoo.gr

Introduction: Sleeve gastrectomy is a well defined and established procedure in the arsenal of bariatric choices. There have been proposed many mechanisms of action as far as it concerns the mechanisms of weight loss and many studies investigate the long term metabolic outcome. With this study we prospectively investigated appetite and gut hormone changes in response to LSG in adiposity-matched non-diabetic patients.

Patients and methods: Ten morbidly obese patients programmed for LSG were chosen with an average BMI of 45Kg/m². The patients were submitted in a series of blood sampling before and after a standard meal before the LSG and the same protocol was applied 3 years later. Ghrelin, leptin ,insulin, glucose, GLP1 and blood lipids were measured.

Results: There were documented changes in des-acyl ghrelin which was reduced after LSG but acyl Ghrelin was not affected. GLP1 patterns had borderline changes in post prandial fluctuation. Glucose and insulin metabolism showed an improved profile in comparison with the pre LSG fluctuation. Blood lipid profile did not change with the exception of triglycerides values which were lower.

Discussion: LSG is an adequate procedure in terms of weight loss and induces beneficial metabolic changes as far as it concerns better glycaemic control at least in patients with pro-diabetes. But the mechanism of action seems to have stronger link to food restriction leading to weight loss than the LSG induced hormone changes.

O-081

Taste sensitivity to dietary fat before and after bariatric surgery: A cross-sectional study of oleic acid taste detection thresholds with correlation to GLP-1 profiles

Janine Makaronidis^{1, 2, 3, a)}, Cormac Magee^{1, 2, b)}, Giulia Argentesi^{1, 2, 3, c)}, Friedrich Jassil^{1, d)}, Jenny Jones^{1, e)}, Andrea Pucci^{2, 1, f)}, Andrew Jenkinson²⁾, Majid Hashemi²⁾, Mohamed Elkalaawy²⁾, Marco Adamo²⁾, Rachel Batterham^{1, 2, 3, g)}

¹⁾Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom; ²⁾University College London Hospital (UCLH) Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, London, United Kingdom; ³⁾UCLH Biomedical Research Centre, National Institute of Health Research, London, United Kingdom

^a)makaronidis.janine@doctors.org.uk

^b)cormac.magee@nhs.net

^c)g.argentesi@nhs.net

^d)friedrich.jassil.13@ucl.ac.uk

^e)jjones_dsl@yahoo.co.uk

^f)a.pucci@nhs.net

^g)r.batterham@ucl.ac.uk

Background and Aims: Taste changes and reduced preference for dietary fat are thought to be key contributors to the altered eating behavior seen following bariatric surgery and to contribute to sustained weight loss. Meal-stimulated levels of the incretin hormone glucagon-like peptide-1 (GLP-1), rise following bariatric surgery. GLP-1 has potent appetite suppressing effects and is believed to be a mediator for post-bariatric surgery weight loss. Furthermore, GLP-1 has been implicated in modifying taste. We hypothesised a link between post-surgery GLP-1 changes and reduced dietary fat preference and investigated taste sensitivity to oleic acid in the fasted and fed state, perceived hedonic value of varying fat-contents in a liquid meal and GLP-1 levels in plasma and saliva in people with obesity awaiting bariatric surgery and post-surgery.

Methods: 9 pre-surgery and 9 post-surgery individuals from a Bariatric Surgical Centre were recruited to a cross-sectional study. Taste detection thresholds for oleic acid were assessed fasted and following a 478kcal meal, using a forced choice methodology. The hedonic value of varying fat content in a meal was assessed. Serial plasma and saliva samples were collected and GLP-1 levels measured.

Results: Fasted taste detection thresholds for oleic acid were similar in the two groups (4.3 vs. 5.1mM, p=0.617). Post-meal oleic acid detection thresholds were higher in the pre-surgery group (4.3 vs. 9.1mM p=0.028) but did not change in the post-surgery group (5.1 vs. 6.6mM, p=0.541). Post-surgery meal fat-content negatively correlated with hedonic value (Spearman r=-1), no correlation was observed pre-surgery. Plasma GLP-1 levels increased post-meal with a higher meal-stimulated peak in the post-surgery group (p<0.0001), whereas salivary GLP-1 levels were unchanged by the meal. However, tasting oleic acid lead to an increase in salivary GLP-1 levels in the fasted state in both groups.

Conclusions: Our findings suggest a potential link between post-bariatric surgery changes in taste toward fatty acids, food preference away from fat-rich foods and salivary GLP-1 levels.

References

1. Haryono RY, Sprajcer MA, Keast RS. Measuring oral fatty acid thresholds, fat perception, fatty food liking, and papillae density in humans. J Vis Exp. 2014(88).

Acknowledgement: Funded by the Rosetrees Trust and the National Institute for Health Research.

O-082

Pre-operative Very Low Calory Ketogenic Diet (VLCKD) vs. Very Low Calory Diet (VLCD): Surgical impact

Alice Albanese^a), Luca Prevedello^b), Marko Markovich^c), Luca Busetto^d), Roberto Vettor^e), Mirto Foletto^f)

Bariatric Unit, Padua University Hospital, Padua, Italy

^a)alicealbanese@alice.it

^b)luca.prevedello@aopd.veneto.it

^c)marko.markovich@aopd.veneto.it

^d)luca.busetto@unipd.it

^e)roberto.vettor@unipd.it

^f)mirto.foletto@unipd.it

Introduction: Adequate accessibility to abdominal cavity is one of the major limiting factor of bariatric surgery and it is mainly due to liver steatosis and visceral obesity. Pre-operative diet may play an important role as far as patients’s fitness for surgery, post-operative outcomes and successful weight loss.

Objectives: The present study was aimed to compare surgical outcome and weight loss in two groups of patients who were offered two different pre-operative kinds of diet: Very Low Calory Diet (VLCD- 900 Kcal) and Very Low Calory Ketogenic Diet (VLCKD- 700 Kcal).

Methods: Patients candidate for Bariatric Surgery (Laparoscopic Sleeve Gastrectomy) were registered and assessed according to pre and post-diet BMI, liver steatosis (US scan), operative time, lenght of stay, drainage output, haemogloblin (hb) levels. Patients clinical features and comorbidities influenced the type of diet. T-student was used to compare the two groups of patients.

Results: From January trough December 2016, 178 patients candidates for bariatric surgery were enrolled in this study. There were 139 F and 39 M, the mean age was 43 years. In total 72 patients were on VLKCD while 106 patients on VLCD. Pre-diet mean BMI was 46 .27 ± 6.27 Kg/m2 for VLKCD group and 43 .1 ± 6.98 Kg/m2 for VLCD group, while immediately pre-op BMI were 43.89 .1 ± 5.88 Kg/m2 and 41 .88 ± 6.79 Kg/m2, respectively. Drainage output and haemoglobin levels after surgery were the only factors that resulted significantly correlated with diet induced BMI reduction ( 141.25 ± 75.82 vs 190.72 ±183. 59 ml, p= 0.032; 13.1 ± 1.2 vs 12.69 ± 1.49 g/l, p =0.04).

References

• Leonetti F et al. Very low-carbohydrate ketogenic diet before bariatric surgery: prospective evaluation of a sequential diet. Obes Surg. 2015 Jan;25(1):64-71.

• Faria SL et al. Effects of a very low calorie diet in the preoperative stage of bariatric surgery: a randomized trial. Surg Obes Relat Dis. 2015 Jan-Feb;11(1):230-7.

• Gilbertson NM.Bariatric Surgery Resistance: Using Preoperative Lifestyle Medicine and/or Pharmacology for Metabolic Responsiveness. Obes Surg. 2017 Dec; 27(12):3281-3291.

• Bourne R et al. Preoperative nutritional management of bariatric patients in Australia: The current practice of dietitians. Nutr Diet. 2017 Sep 15. Epub ahead of print

• Watanabe A, Seki Y, Haruta H, Kikkawa E, Kasama K. Preoperative Weight Loss and Operative Outcome After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2017 Oct; 27(10):2515-2521.

• Hutcheon DA, Byham-Gray LD, Marcus AF, Scott JD, Miller M. Predictors of preoperative weight loss achievement in adult bariatric surgery candidates while following a low-calorie diet for 4 weeks.. Surg Obes Relat Dis. 2017 Jun;13(6):1041-1051

• Cleveland E, Peirce G, Brown S, Freemyer J, Rice W, Lee L, Coviello L, Davis KG. A short-duration restrictive diet reduces visceral adiposity in the morbidly obese surgical patient. Am J Surg. 2016 Nov;212(5):927-930.

• Nielsen LV, Nielsen MS, Schmidt JB, Pedersen SD, Sjödin A. Efficacy of a liquid low-energy formula diet in achieving preoperative target weight loss before bariatric surgery. J Nutr Sci. 2016 May 30;5:e22.

• Ross LJ, Wallin S, Osland EJ, Memon MA. Commercial Very Low Energy Meal Replacements for Preoperative Weight Loss in Obese Patients: a Systematic Review.Obes Surg. 2016 Jun;26(6):1343-51.

• Schouten R, van der Kaaden I, van 't Hof G, Feskens PGComparison of Preoperative Diets Before Bariatric Surgery: a Randomized, Single-Blinded, Non-inferiority Trial. Obes Surg. 2016 Aug;26(8):1743-9.

• Ruiz-Tovar J, Zubiaga L, Diez M, Murcia A, Boix E, Muñoz JL, Llavero C; OBELCHE group. Preoperative Regular Diet of 900 kcal/day vs Balanced Energy High-Protein Formula vs Immunonutrition Formula: Effect on Preoperative Weight Loss and Postoperative Pain, Complications and Analytical Acute Phase Reactants After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Jun;26(6):1221-7.

• Stewart F, Avenell A. Behavioural Interventions for Severe Obesity Before and/or After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg. 2016 Jun;26(6):1203-14.

• Van Wissen J, Bakker N, Doodeman HJ, Jansma EP, Bonjer HJ, Houdijk AP. Preoperative Methods to Reduce Liver Volume in Bariatric Surgery: a Systematic Review. Obes Surg. 2016 Feb;26(2):251-6.

• .Schiavo L, Scalera G, Sergio R, De Sena G, Pilone V, Barbarisi A. Clinical impact of Mediterranean-enriched-protein diet on liver size, visceral fat, fat mass, and fat-free mass in patients undergoing sleeve gastrectomy. Surg Obes Relat Dis. 2015 Sep-Oct;11(5):1164-70.

• Santo MA, Riccioppo D, Pajecki D, Cleva Rd, Kawamoto F, Cecconello I.Preoperative weight loss in super-obese patients: study of the rate of weight loss and its effects on surgical morbidity. Clinics (Sao Paulo). 2014;69(12):828-34.

• Edholm D, Kullberg J, Karlsson FA, Haenni A, Ahlström H, Sundbom M. Changes in liver volume and body composition during 4 weeks of low calorie diet before laparoscopic gastric bypass. Surg Obes Relat Dis. 2015 May-Jun;11(3):602-6.

• Ruiz-Tovar J, Boix E, Bonete JM, Martínez R, Zubiaga L, Díez M, Calpena R; Group OBELCHE. Effect of preoperative eating patterns and preoperative weight loss on the short- and mid-term weight loss results of sleeve gastrectomy. Cir Esp. 2015 Apr;93(4):241-7.

O-083

Laparoscopic sleeve gastrectomy for morbidly obese patients under 18 years-old

Panagiotis Lainas^{1, a)}, Hadrien Tranchart¹⁾, Gianpaolo De Filippo²⁾, Georges Chahine¹⁾, Carmelisa Dammaro¹⁾, Pierre Bougneres²⁾, Ibrahim Dagher¹⁾

¹⁾Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP–HP, Clamart, Paris, France; ²⁾Department of Pediatric Endocrinology and Diabetology, Bicetre Hospital, AP–HP, Le Kremlin-Bicêtre, Paris, France

^a)plainas@gmail.com

Background: The prevalence of morbid obesity is reaching epidemic proportions worldwide, without sparing any age group. The number of morbidly obese pediatric and adolescent patients is progressively increasing [1]. In the past two decades, bariatric surgery has become an increasingly popular form for the treatment of morbid obesity. However, data on adolescent patients undergoing laparoscopic sleeve gastrectomy (LSG) are scarce in the literature, focusing mainly on patients over 18 years-old [2-4]. We therefore aimed to demonstrate the safety and effectiveness of LSG on weight loss and comorbidities resolution in morbidly obese patients strictly under 18 years-old.

Methods: Prospectively collected data from 1474 consecutive patients undergoing single-incision LSG in our department were retrospectively analyzed. Adolescent candidates for bariatric surgery were referred by a tertiary care center for pediatric obesity. For weight loss and comorbidity evaluation, only patients with at least 1-year follow-up were included in our analysis.

Results: A total of 77 adolescent patients underwent single-incision LSG. Median age of the cohort was 17 years (range: 15-18 years). Median weight was 119.5 kg (range: 86-227 kg), with median BMI of 42.3 kg/m² (range: 31.5-74.6 kg/m²). Median duration of surgery was 68.5 minutes. One major complication was recorded: a patient developed severe pneumonia that necessitated ventilatory support and intravenous antibiotics with a hospital stay of 12 days. Mortality was null. Median length of hospital stay was 4 days. Mean excess weight loss was 50.7%, 62.2%, 77.7% and 79% at 3, 6, 12 and 24 months after LSG, respectively. Improvement of type II diabetes, hypertension, dyslipidemia, sleep apnea and a statistically significant remission for arthralgia were noted 1 year after surgery.

Conclusions: LSG can be safely performed in the under 18 years-old, with good results regarding weight loss and comorbidities remission. A careful patient selection by an expert multidisciplinary team is essential. To our knowledge, this is the largest report of patients strictly younger than 18 years-old undergoing LSG for the treatment of morbid obesity.

References

• 1. Cunningham SA, Kramer MR, Narayan KM (2014) Incidence of childhood obesity in the United States. N Engl J Med 370:403-411.

• 2. Boza C, Viscido G, Salinas J, Crovari F, Funke R, Perez G (2012) Laparoscopic sleeve gastrectomy in obese adolescents: results in 51 patients. Surg Obes Relat Dis 8:133-137.

• 3. Till H, Bluher S, Hirsch W, Kiess W (2008) Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity. Obes Surg 18:1047-1049.

• 4. Nocca D, Nedelcu M, Nedelcu A, Noel P, Leger P, Skalli M, Lefebvre P, Coisel Y, Laurent C, Lemaitre F, Fabre JM (2014) Laparoscopic sleeve gastrectomy for late adolescent population. Obes Surg 24:861-865.

O-084

Bariatric surgery in the elderly: is sleeve gastrectomy a feasible option

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Introduction: Bariatric surgery improves weight loss and metabolic profile. There is reluctance in performing such operations in older patients, with the rationale that the morbidity of the procedures outweighs long term benefits.

Objectives: In this study we present the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in older patients.

Methods: 28 patients, (5 men, 23 women), aged 65-70 years (median 67) underwent LSG in the years 2010-2015 by a single surgeon. Preoperative BMI ranged 40-66 (median 48). ASA score was 3. All suffered from one or more of the following conditions: arterial hypertension, diabetes mellitus, dyslipidemia, hyperuricemia, chronic obstructive pulmonary disease (COPD), sleep apnea, chronic musculoskeletal pain. Follow up was 6-66 months (median 40). Weight loss, complications and metabolic changes were documented and the efficiency of the operation was measured with BAROS score and Moorehead-Ardelt Quality of Life Questionnaire II (QoL).

Results: There was no mortality. There was 1 major complication (severe postoperative pneumonia) and 3 minor complications (1 dehydration and 2 rhabdomyolysis). Average weight loss was 67% of excess weight. Hypertension improved in 70% of cases, diabetes mellitus in 71%, dyslipidemia in 60%, hyperuricemia in 75%, COPD in 80%, sleep apnea in 100% and musculoskeletal pain in 67%. Average QoL score was 1.6 (Good) and average total BAROS score was 5.3 (Very Good).

Conclusions: Complication rates were low. Long term results in weight loss, health improvement and satisfaction were very good and comparable to younger ages. Finally, LSG is safe and effective in carefully selected elderly patients.

O-085

Weight loss, Reduction of Comorbidities and Quality of Life after Bariatric Surgery in the Elderly

Mellody Cooiman^a), Barend Mol^a), Edo Aarts^b), Ignace Janssen^a), Eric Hazebroek^c), Frits Berends^a)

Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands

^a)mcooiman@rijnstate.nl

^b)eaarts@rijnstate.nl

^c)ehazebroek@rijnstate.nl

Introduction: Worldwide the obesogenic trend is pursuing, regardless the stage of age. Bariatric surgery (BS) show superior effectiveness in the induction and maintenance of weight loss.

According to the IFSO criteria, patients are only eligible with an age between 18-65 years. However, elderly patients may also benefit of weight loss induced by BS, especially when accompanied by improved comorbidities such as diabetes mellitus. Although concerns have been raised about the safety of BS in patients >65 years due to higher risk of morbidity and mortality, it has been suggested that BS may be considered in selected elderly patients.

Methods: All preoperative and perioperative data from morbidly obese patients aged >65 and 35-55 years, between 2010 and 2014 were retrospectively collected. Follow-up data was then gathered prospectively, by collection of (laboratory) measurements and questionnaires.

Results: 102 elderly patients (mean age 66.1) were matched to 102 adult patients (mean age 42.6), for BMI and time of surgery. 88.2% of the elderly and 75% of the adults underwent a gastric bypass (GB). Three years after GB, mean %Total Body Weight Loss was 26.9 (± 6.1) and 29.9 (±7.7) (p <0.183) respectively. The <30-days complication rate was comparable between both groups with three and two reoperations. The >30-days complications were significantly different for readmission, reoperation and cholecystectomy (p<0.01) in favor of the elderly group; total >30-days complication rate was 15% and 25.9% in the elderly and adult group respectively (p=0.066). Quality of life (SF-36) was not significantly different between the two age groups.

Conclusion: Bariatric surgery can be performed safe en effective in selected elderly patients. Short term results are comparable to age groups in which bariatric surgery is most often performed. These results suggest that bariatric surgery is a valid treatment option in selected elderly patients with morbid obesity.

O-086

Multi-centre, intraoperative micro-costing of Roux-en-Y gastric bypass, adjustable gastric banding and sleeve gastrectomy procedures for the treatment of severe, complex obesity in the United Kingdom

Brett Doble^{1, a)}, Richard Welbourn^{2, b)}, Nicholas Carter^{3, c)}, James Byrne^{4, d)}, Chris Rogers^{5, e)}, Jane Blazeby^{6, f)}, Sarah Wordsworth^{1, g)}

¹⁾Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom; ²⁾Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom; ³⁾Bariatric & Metabolic Surgery Department, Queen Alexandra Hospital, Portsmouth, United Kingdom; ⁴⁾Southampton University Hospitals NHS Trust, Southampton, United Kingdom; ⁵⁾Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; ⁶⁾Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, United Kingdom

^a)brett.doble@dph.ox.ac.uk

^b)Richard.Welbourn@tst.nhs.uk

^c)Nicholas.Carter@porthosp.nhs.uk

^d)James.Byrne@uhs.nhs.uk

^e)Chris.Rogers@bristol.ac.uk

^f)J.M.Blazeby@bristol.ac.uk

^g)sarah.wordsworth@dph.ox.ac.uk

Background: With a growing interest in comparing the effectiveness and costs of alternative forms of bariatric surgery, it is important that detailed cost information on the three main procedures used internationally are available.

Objective: To compare the per-patient, intra-operative cost of Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) and sleeve gastrectomy (SG) from the perspective of the National Health Service in the United Kingdom.

Methods: Multi-centre (two publicly-funded and one privately-funded hospital), micro-costing, using a time-and-motion study design to prospectively collect procedure times, staff involvement, quantities of equipment, instruments and consumables used for 12 patients (four RYGB, three AGB, five SG). Data were recorded from patient arrival on the day of surgery to the patient leaving the theatre recovery area and did not include pre-operative preparation prior to the day of surgery or hospital bed stay. Mean costs for each procedure are compared and differences across hospitals examined. Sensitivity analyses assess the robustness of the results.

Results: The initial analysis resulted in mean costs for RYGB, AGB and SG of £3,872, £1,916 and £3,769 respectively. Increasing seniority of staff involved in the procedures increased mean costs for all procedures by approximately £200. Reducing the list prices of consumables by 20% reduced mean costs of RYGB, AGB and SG to £3,354 (-13%), £1,687 (-12%) and £3,195 (-15%) respectively. Procedures at publicly-funded hospitals were generally more expensive due to longer procedural times when trainees were operating. Compared to costs estimates for either RYGB or AGB reported in the literature (mean £9,288) our estimates are substantially lower. Differences may be explained by the use of disparate timeframes in which costs were measured and limited application of micro-costing in existing studies.

Conclusions: Detailed costs of the three procedures will allow for precise setting of payments, appropriate budgeting by providers and support comprehensive cost-effectiveness analyses that will assess the additional costs of care, re-operations and life-long support received by bariatric patients.

Acknowledgement: This study is funded by The National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 09/127/53) for which Richard Welbourn, Nicolas Carter, James Byrne, Chris A. Rogers, Jane M. Blazeby and Sarah Wordsworth are investigators. The views and opinions expressed are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, the UK National Health Service, or the Department of Health. Jane M. Blazeby is also a NIHR Senior Investigator. Richard Welbourn declares receiving support from Ethicon Endo-Surgery for attending conferences and funding a Bariatric Clinical Fellow at Musgrove Park Hospital as well as receiving honoraria from Novo Nordisk.

O-087

Association Between Cardiorespiratory Fitness and Excess Weight Loss after Sleeve Gastrectomy

Paulina Ibacache^{1, a)}, Marcelo Cano-Cappellacci^{2, b)}, Claudia Miranda^{1, c)}, Juan Rojas^{3, d)}

¹⁾Facultad de Ciencias de la Rehabilitación, Universidad Andres Bello, Viña del Mar, Chile; ²⁾Departamento de Kinesiología, Universidad de Chile, Santiago de Chile, Chile; ³⁾Facultad de Ciencias de la Salud, Universidad de las Ámericas, Viña del Mar, Chile

^a)paulina.ibacache@unab.cl

^b)mcano@u.uchile.cl

^c)cmiranda@unab.cl

^d)jrojasm@udla.cl

Introduction: Obesity has been recognized as an independent risk factor for cardiovascular disease, associated with other comorbidities as well as with significant physical fitness deterioration[1,2]. The increase in obesity cases[3] has led to an increase in laparoscopic sleeve gastrectomy (SG)[4], with a successful weight loss and remission or improvement of comorbidities[5]. However, its impact on cardiorespiratory fitness (CRF) are yet to be determined. As CRF is an indicator of health and life expectancy[6,7], the objective of this study was to determine the impact of weight loss, after SG, on CRF.

Methods: 24 women with obesity, mean age of 36 years old and BMI of 35 kg/m² were evaluated preoperatively to a SG and then after a one and three months postoperative. Patients performed a submaximal cardiopulmonary test on a cyclo-ergometer Monark 915 E to obtain peak oxygen consumption (VO₂peak). During the test, gas exchange was measured using a Cortex Metalyzer 3B and heart rate was monitored. A gradual protocol was used, cycling at 60 rpm, starting at 0.5 Watts/kg of body weight with gradual increase of 20 Watts/2 min until the stopping criteria. Weight loss was expressed as % Excess Weight Loss (%EWL). ANOVA was used to detect statistical significance for changes in CRF and the Spearman correlation coefficient (Rho) for the association between the variables. Data was analysed using SPSS 21.0 software.

Results: The absolute VO₂peak decreased after the first (p<0.001) and third month (p=0.001) of the SG compared to preoperative evaluation. The %EWL obtained at the first post-surgical month was inversely correlated with the change in absolute VO₂peak (Rho=-0.636, p=0.001). In the same way, the %EWL at the third month was inversely correlated with the change in absolute VO₂peak (Rho=-0.490, p=0.015).

Conclusions: After SG, greater weight loss is associated with a greater reduction in VO₂ peak, suggesting the need to implement physical training programs both before and after SG.

References

• 1. Mandviwala T, Khalid U, Deswal A. Obesity and cardiovascular disease: a risk factor or a risk marker? Curr Atheroscler Rep. 2016 May;18(5):21.

• 2. Arena R, Cahalin LP. Evaluation of cardiorespiratory fitness and respiratory muscle function in the obese population. Prog Cardiovasc Dis. 2014 Jan-Feb;56(4):457-64.

• 3. Fabris R, Serra R, Vettor R. Definition, epidemiology, and social implications of obesity. In: Foletto M, Rosenthal RJ, editors. The globesity challenge to general surgery: a guide to strategy and techniques. Milano: Springer Milan; 2014. p. 1-8.

• 4. Angrisani L, Santonicola A, Iovino P, Vitiello A, Zundel N, Buchwald H, et al. Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014. Obes Surg. 2017 Sep;27(9):2279-2289.

• 5. Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol. 2017 Mar;14(3):160-9.

• 6. Laukkanen JA, Zaccardi F, Khan H, Kurl S, Jae SY, Rauramaa R. Long-term change in cardiorespiratory fitness and all-cause mortality: a population-based follow-up study. Mayo Clin Proc. 2016 Sep;91(9):1183-8.

• 7. Lee DC, Sui X, Ortega FB, Kim YS, Church TS, Winett RA, et al. Comparisons of leisure-time physical activity and cardiorespiratory fitness as predictors of all-cause mortality in men and women. Brit J Sport Med. 2011 May;45(6):504-10.

Acknowledgement: To Universidad Andres Bello, for allowing me to have its facilities and equipment for the development of this study and for the financial support provided. Also, the researchers would like to thanks to our patients who made this project possible.

O-088

Taste makes waist? The relationship between energy intake and weight loss in Dutch bariatric patients

Louella Schoemacher¹⁾, Abel Boerboom²⁾, Laura Deden²⁾, Monique Thijsselink³⁾, Edo Aarts^{2, a)}

¹⁾Wageningen University & Research, Wageningen, Netherlands; ²⁾Bariatric surgery, Rijnstate hospital and Vitalys obesity clinic, Arnhem, Netherlands; ³⁾Dutch obesity clinic, Velp, Netherlands

^a)eaarts@rijnstate.nl

Introduction: There is a large variation in weight loss outcomes between bariatric patients, possibly due to differences in caloric intake and changes in the amount physical activity. However, the association between the change in energy intake and weight loss has not yet been the subject of an extensive investigation.

Objective: To explore the relationship between long-term (≥4y) changes in dietary intake and % total body weight loss (%TBWL).

Methods: Of the 466 patients who were asked to participate, a total 135 patients were included in this study. They all underwent bariatric surgery; 54 primary Roux-en-Y Gastric Bypass, 43 redo Roux-en-Y Gastric Bypass after Laparoscopic Gastric Banding, and 38 primary Laparoscopic Sleeve Gastrectomy. Pre- and postoperative dietary intake and physical activity were collected for both a weekday and a weekend day. The main analysis was performed using linear regression and was adjusted for age at surgery, BMI at baseline, obstructive sleep apnoea syndrome, type of eating behaviour, change in physical activity and protein intake (g/kg body weight).

Results: %TBWL over time, post-operative energy intake and change in physical activity did not differ between the different procedure groups (p=0.312, p=0.988 and p=0.050, respectively). Only small, non-significant changes were observed in physical activity from pre- to postoperative. Linear regression showed that change in energy intake was related to total body weight loss for the fully adjusted model (β=-0.004, p=0.014).

Conclusion: This study showed a lower post-operative energy intake compared to pre-operative energy intake, in relation to a higher total body weight loss.

O-089

Determination of slimming effect by auricular Acupuncture stimulation -Statistical analysis of 1500 female data-

Takahiro Fujimoto

Clinic F, Director, Tokyo, Japan

fujimoto@clinic-f.com

The slimming method stimulating 6 auricle acupuncture points have a long history in Japan, putting ceramic particles to six needle points (Shin Maru MA-TF 1 Ershenmen, Stomach, esophagus A-IC6 Shidao, Cardia MA-IC7 Benmen, lung MA-IC1 Fei, endocrine MA-IC3 Neifenmi) In this study, we evaluated retrospective analysis of statistical study and correlation as to whether this method is an effective tool for slimming, and also conducted rebound follow-up survey half a year after completion of the procedure. Measurement was performed using dual frequency body composition meter. The treatment was performed for 1510 healthy females for 3months. Body weight (63.6 kg ± 10.2 → 57.3 kg ± 9.0) Body fat mass (23.8 kg ± 7.1 → 18.6 kg ± 6.4) body muscle mass (37.5 kg ± 4.1 → 36.5 kg ± 3.9) .The basal metabolic rate per kg of body weight (19.2 kal ± 1.8 → 20.2 kcal ± 1) showed a significant decrease. Between body fat percentage and visceral fat level with respect to the amount of BMI at the start had high correlation. Furthermore, analysis was performed in 5 groups according to the rate of body weight change after the end of the measurement. As a result, a correlation was found between the basal metabolic rate and the muscle mass at the beginning, and the weight loss rate depends on the initial basal metabolism It was confirmed that the higher the basal metabolic rate at the start, the greater the weight loss rate. Weight loss effects were observed in "non-obese people and healthy adult subjects by" auricle acupuncture stimulation by particles ". In addition, it was considered that the setting point of the satiety center including leptin sensitivity was reset by stimulation of the auricular acupuncture as well as improving the constitution by the change of the dietary life for 3 months because rebound was not confirmed.

References: ● Yeh ML, Chu NF, Hsu MY, Hsu CC, Chung YC:Acupoint Stimulation on Weight Reduction for Obesity: A Randomized Sham-Controlled Study. West J Nurs Res. 2015 Dec;37(12):1517-30. ● Yeo S, Kim KS, Lim S:Randomised clinical trial of five ear acupuncture points for the treatment of overweight people. Acupunct Med. 2014 Apr;32(2):132-8. ● Hsieh CH, Su TJ, Fang YW, Chou PH:Effects of auricular acupressure on weight reduction and abdominal obesity in Asian young adults: a randomized controlled trial. Am J Chin Med. 2011;39(3):433-40. ● Hsieh CH:The effects of auricular acupressure on weight loss and serum lipid levels in overweight adolescents.　Am J Chin Med. 2010;38(4):675-82. ● Shen EY, Hsieh CL, Chang YH, Lin JG:Observation of sympathomimetic effect of ear acupuncture stimulation for body weight reduction.　Am J Chin Med. 2009;37(6):1023-30. ● Hsu CH, Wang CJ, Hwang KC, Lee TY, Chou P, Chang HH:The effect of auricular acupuncture in obese women: a randomized controlled trial. J Womens Health (Larchmt). 2009 Jun;18(6):813-8.

O-090

Serum uromodulin in diabetic nephropathy

Katharina Scheurlen^{1, a)}, Adrian Billeter^{1, b)}, Victor Herbst^{2, c)}, Matthias Block^{2, d)}, Peter Nawroth^{3, e)}, Martin Zeier^{3, f)}, Beat Müller^{1, g)}, Jürgen Scherberich^{4, h)}

¹⁾Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany; ²⁾Institute for Experimental Immunology, EUROIMMUN Medical Laboratory Diagnostics AG, Lübeck, Germany; ³⁾Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany; ⁴⁾Department of Nephrology and Clinical Immunology, Klinikum Muenchen-Harlaching, Teaching Hospital of the Ludwig-Maximilians University, Munich, Germany

^a)katharina.scheurlen@med.uni-heidelberg.de

^b)adrian.billeter@med.uni-heidelberg.de

^c)v.herbst@euroimmun.de

^d)m.block@euroimmun.de

^e)peter.nawroth@med.uni-heidelberg.de

^f)martin.zeier@med.uni-heidelberg.de

^g)beatpeter.mueller@med.uni-heidelberg.de

^h)j.scherberich@web.de

Introduction: Diabetic nephropathy (DN) is the most common cause of end-stage renal disease. Since no causal therapy exists, symptomatic approaches with glycemic control, renin-angiotensin inhibition and blood pressure control are applied. Early diagnosis of DN is pivotal to prevent progression, but none of the established biomarkers reliably measure impaired kidney function in DN, especially at its early stages. This study evaluates the effect of Roux-en-Y gastric bypass (RYGB) on kidney function using serum uromodulin (sUMOD) in diabetic patients with a high risk for DN.

Materials and Methods: Fifteen obese patients with T2DM, fifteen without T2DM as well as sixteen non-severely obese patients (BMI 25-35 kg/m²) undergoing RYGB were enrolled. The control group consisted of 190 healthy subjects without diabetes. Change of sUMOD in obese patients with and without T2DM and in non-severely obese patients before and after metabolic surgery was compared with creatinine and cystatin C. Healthy subjects were used as a reference.

Results: sUMOD levels in non-severely obese diabetic patients were 140.6±80.8 ng/ml preoperatively. After RYGB, sUMOD levels in non-severely obese, in obese patients with T2DM and without T2DM significantly increased within six months (p=<0.05). In comparison to sUMOD levels of the control group, baseline levels of diabetic patients were significantly lower (p=<0.05). The levels of estimated glomerular filtration rate (eGFR) according to the MDRD-formula significantly improved postoperatively within 6 months with mean eGFR levels >89 ml/min/1,73m² (p=<0.05). Also serum creatinine levels in diabetic patients improved significantly 6 months after RYGB (p=<0.05). Mean urinary albumin-creatinine ratio was halfed postoperatively.

Conclusion: sUMOD significantly increased in non-severely obese and obese patients with T2DM undergoing RYGB, indicating a profound recovery of kidney function. The sUMOD levels in these groups were comparable to levels of healthy subjects, whereas conventional markers were in the normal range. Furthermore, sUMOD may discover impaired kidney function earlier and provide a more precise estimate of function compared to traditionally used parameters of kidney function.

O-091

Histopathology Findings in Patients Undergoing Laparoscopic Sleeve Gastrectomy

Angelo Iossa^a), Ammiel Martinez Canil^b), Daniela Caporilli^c), Francesco De Angelis^d), Gianfranco Silecchia^e)

Department of medico-surgical sciences and biotechnologies, University of Rome "Sapienza", Division of General surgery and bariatric centre of excellence, Latina, Italy

^a)angelo.iossa@gmail.com

^b)ammielmartinezcanil@gmail.com

^c)daniela.caporilli@uniroma1.it

^d)francescodeangelis7@gmail.com

^e)gianfranco.silecchia@uniroma1.it

Background: Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10 years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up.

Methods: A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed.

Results: A total of 925 patients entered the study group (mean age = 44.1 years, Females = 80.3%, BMI = 44.58 kg/m2). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively.

Conclusion: Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.

O-092

Bariatric surgery for people with intellectual disability

Julia Hilbert^a), Rami Archid^b), Daniel Wulff^c), Alfred Königsrainer^d), Jessica Lange^e)

Allgemeine, Viszeral- und Transplantationschirurgie, Universität Tübingen, Tübingen, Germany

^a)julia.hilbert@med.uni-tuebingen.de

^b)rami.archid@med.uni-tuebingen.de

^c)daniel.wulff@med.uni-tuebingen.de

^d)alfred.koenigsrainer@med.uni-tuebingen.de

^e)jessica.lange@med.uni-tuebingen.de

Objective: Obesity in patients with intellectual disability (ID) is a wellknown phenomenon. It is even more prevalent in this group than in normal population (1). Educational programs often don’t have the desired effect, so that bariatric surgery could become a part of the treatment of this population. There are only few studies investigating effects of bariatric surgery in patients with ID (2).

Methods: Retrospective review was performed on all patients with ID that underwent bariatric surgery in the University Hospital of Tübingen in the last 5 years. Informed consent was possible to give for all patients.

We examined BMI and EWL over the course of time. To measure possible deficiencies and even as a dimension to estimate compliance we screened lab results for ferritin, vitamin B12 and folic acid exemplarily after 1 and 2 years.

Results: We identified 12 patients (6 male, 6 female) with diagnosed iID. Mean BMI dropped within the first 6 and 12 months from preoperatively 53.3 ± 10.5 kg/m² to 41.0 ± 12.8 kg/m² and 33.3 ± 10.7 kg/m². Mean EWL reached within the first 6 and 12 months 52.9±17.1% and 58.0±17.9% respectively. 1 year after surgery mean ferritin was 15,7 ± 9,6μg/dl, Vitamin B12 was 27,7 ± 5,5 ng/dl and folic acid was 752,5 ± 273,8 ng/dl. 2 years after surgery mean ferritin was 6,9 ± 7,4 μg/dl, Vitamin B12 was 37 ± 10,6 ng/dl and folic acid was 450,7 ± 67,7 ng/dl. There were no statistical differences between these results and those of patients without ID.

Conclusion: Our data are promising. We could show that people with intellectual disabilities benefit from bariatric surgery. Weight loss is adequate in this population and does not differ significantly from other weight loss surgery patients. Lab results didn’t uncover more deficiencies than would be ekipxpected in the normal population, so a additional aftercare is not necessarily urgent.

O-093

The effect of bariatric surgery on direct oral anticoagulant activity of rivaroxaban after bariatric surgery: the extension study

Dino Kröll^a), Guido Stirnimann^b), Yves Borbely^c), Lorenzo Alberio^d), Philipp Nett^e)

Department of Visceral Surgery and Medicine, University Hospital of Bern, Inselspital, Switzerland, Bern, Switzerland

^a)dino.kroell@insel.ch

^b)guido.stirnimann@insel.ch

^c)yves.borbely@insel.ch

^d)lorenzo.alberio@chuv.ch

^e)philipp.nett@insel.ch

Background: Thromboembolic disease is a potentially serious complication in morbidly obese patients. This risk is further increased after bariatric surgery. Direct oral anticoagulants (DOACs) have been investigated in patients after orthopedic surgery. Data regarding the use of DOACs after bariatric surgery is still limited to the early postsurgical period. Whether long-term anatomical and physiological adaptions influence drug pharmacology is currently not known.

Objective: The aim of this study was to investigate the influence of weight loss and type of bariatric surgery on pharmacokinetic (PK) and pharmacodynamic (PD) parameters of rivaroxaban.

Setting: University Hospital.

Methods: In this single-centre study, bariatric patients received single oral doses of rivaroxaban (10 mg) six to eight months after Sleeve Gastrectomy (SG) or Roux-en-Y-gastric bypass (RYGB). PK and PD parameters were compared with values obtained before bariatric surgery.

Results: In total, 6 RYGB patients and 6 SG patients were included. Percent excess BMI loss (%EBMIL) was 71.4% (IQR 56.4, 87.9) in the SG group and 76.6% (64.5, 85.7) in the RYGB group. Post-surgical rivaroxaban areas under the curve (AUC) were comparable to those measured preoperatively: Mean preop AUC was 952.6.4 (16.8) and 922.4 (43.2) μg*h/L, respectively. There was no relevant difference between the two surgical procedures groups. In patients with RYGB, C_max was lower postoperatively (ratio 1.45), but not in patients with GB (ratio 0.99).

Conclusions: Significant weight loss 6 to 8 months after bariatric surgery did not affect AUCs of rivaroxaban (10 mg). This has been demonstrated for both subgroups, i.e. RYGB and SG. In this study population, rivaroxaban was considered safe and well tolerated.

O-094

Multipurposed Abdominoplasty after bariatric surgery

Yury Yashkov^{1, a)}, Natalya Bordan^{2, b)}, Dmitry Bekuzarov^{1, a)}

¹⁾Obesity Surgery, CELT- clinic, Moscow, Russia, Moscow, Russian Federation; ²⁾Bariatric surgery, Center of Obstetrics, Gynecology and Perinatology im V.I.Kulakova, Moscow, Russian Federation

^a)yu@yashkov.ru

^b)socetanie@mail.ru

Aim. Many patients undergoing bariatric/metabolic surgery need plastic surgery after massive weight loss. Many of them at the same time need other relevant surgery which usually are performed step-by step. The aim of this study is evaluation of long-term experience of operations simultaneous with abdominoplasty (AP).

Material. AP was performed in 242 patients within the years 1993 – 2017. 207 of them (85,9%) underwent simultaneous operations aiming to: 1) improve results of previous bariatric surgery (n-48); 2) treatment of complications and undesirable side effects of bariatric surgery; 3) treatment of incisional hernias (n-160) and other surgical diseases (gallstones, gynecolocical etc). 4) plastic surgery in other problematic zones (n-41). In some selected cases AP was done together with main bariatric operations (n-50). Different approaches and combination of operations were used depending on concrete situation.

Results. Postoperative mortality was 0. Mean postoperative stay in the clinic- 4 days (2-6) but many patients needed prolonged period for dressings for seromas. Early postoperative complication rate was 8,97% which is some more than after surgery without AP. Specific complication were: marginal skin necroses (n-5), umbilical necrectomies (n-4), hematomas (n-3), wound infection (n-7), one case of small bowel obstruction with reoperation (n-1).

Conclusions. AP which is frequently needed after massive weight loss may be successfully combined with other surgery both intraabdominal and plastic. AP is a good opportunity to improve result of primary bariatric operation by mean of additional metabolic procedure. In some selected cases AP can be successfully done together with main bariatric operation.

O-095

The Effects of Protein-Riched Diet, Performed Before Bariatric Surgery, On Losing Weight, Clinical Results And Liver Volume Reduction

N. Z. Erdem^{1, a)}, D Özelgün¹⁾, H. E. Taşkın²⁾, F. M. Avşar³⁾, M. Taşkın²⁾

¹⁾Department of Nutrition and Dietetics, Faculty of Health Sciences, İstanbul Medipol University, Istanbul, Turkey; ²⁾Department of Metabolic & Bariatric Surgery, Department of General Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey; ³⁾Department of Metabolic & Bariatric Surgery, Ankara Numune Health Practice and Research Center, Turkey Health Sciences University, Ankara, Turkey

^a)nzerdem@yahoo.com

Background: In this study, with both low energy ketogenic diet (LEKD) and mediterranean diet (MD), weight loss in morbidly obese patients planned for bariatric surgery in the preoperative period, liver volume reduction, anthropometric and clinical outcomes.

Introduction: In the preop period, weight loss was achieved by LEKD and MD. Weight loss, reduced liver size and fat percentages, motivated the patients during the preop period and prepared postoperative turnover.

Objectives: To examine the effects of two different diets on preop weight loss, anthropometric and clinical outcomes.

Methods: This prospective, randomized controlled trial was conducted in 45 patients between the ages of 18 and 65 between January 2016 and March 2017, during the preop period for 15 days. In LEKD, 10-12 kcal / kg / day of energy and 1-1.2 g / kg of protein were given using Societa Dietetica Medica® (S.D.M.RTM.) Products with ideal weights. Anthropometric measurements, medical history, biochemical findings, liver dimensions, sleep patterns, and diet-related complications were evaluated pre-demographically, pre-diet (day 0) and post-day (day 16). Kolmogorov Simirnov, Mann-Whitney U, Wilcoxon, Chi-Square, Fischer, Mc Nemar tests were used for the statistical evaluation and the SPSS 22.0 program was used for the analyzes. p <0.05 was considered significant.

Results: After the applied LEKD and MD, in order of weight; 7.3 ± 2.3 and 3.4 ± 0.8 kg in the BMI; 2.8 ± 0.8 and 1.3 ± 0.3 units, 3.4% ± 1.0% and 1.6 ± 0.3% reductions in fat percentage (LEKD more) (p˂0.05). The liver size decreased by 5.5% in the LEKD group (p˂0.05). HbA1c values in biochemical findings were significantly lower (p ˂ 0.05) in LEKD than in MD. Decreases in total cholesterol and LDL levels were detected in both dietary groups (p ˂ 0.05).

Conclusion: LEKD was found to be effective in reducing anxiety, anthropometric and clinical outcomes and decreasing liver size in patients who underwent bariatric surgery.

O-096

A structured approach to airway management in the morbidly obese patient: the experience of a high volume bariatric center at Humanitas Research Hospital (Italy)

Chiara Ferrari^a), Benedetta Basta^b), Barbara Crescimbini^c), Stefania Gherardi^d)

Anesthesia, Humanitas Research Hospital, Rozzano (Milan), Italy

^a)chiara.ferrari@humanitas.it

^b)benedetta.basta@humanitas.it

^c)barbara.crescimbini@humanitas.it

^d)stefania.gherardi@humanitas.it

We annually treat >1000 morbidly obese patients undergoing bariatric surgery according to ERAS principles.

Ventilation and intubation of these patients have always been reported challenging (1) but consistent evidence shows the benefits of a systematic approach to airway management to safely overcome these issues (2).

According with this evidence we implemented the structured protocol based on EGRI assessment in all patients as predictor of potential difficulty and routinely use of Glidescope® for intubation as described by Caldiroli and Cortellazzi (3).

To avoid interrater variability of the results and the heterogeneity in expertise, all five bariatric anesthesiologists got skilled with videolaryngoscope (> 76 intubations each) before entering the protocol (4).

45 minutes before induction patients were premedicated with dexmedetomidine continuous infusion to grant mild sedation without losing airway protection.

Difficult mask ventilation (DMV) was assessed according to Han classification.

Since July 2015 to November 2017, 2125 consecutive patients entered the protocol: mean age 41, 74% females, mean BMI 45, 13% OSAS under CPAP ventilation, 87% undergoing laparoscopic sleeve gastrectomy, 46% EGRI > 4.

100% received Glidescope® intubation, 97% at first attempt, 3% at second; CL 1 = 97%, CL 2 = 3%.

None underwent fiberoptic intubation: 1 EGRI > 7 was checked with a Glidescope® quick look under dexmedetomidine sedation without NMB.

Ventilation by face mask was easily overcome in 88% (Grade I); 9 % Grade II; 3 % Grade III and no LMA was needed.

Mean Time To Cormack (TTC) since oral blade insertion was 5 seconds (+/- 2) and the mean Total Time To Intubation (TTI) was 15 seconds (+/- 5).

TTC and TTI relate to EGRI (p = 0,007) and DMV Grade III relate to neck circumference (p < 0,0001) but both do not relate to BMI (p = 0,08).

Our experience confirms that airway of the morbidly obese patients can be safely managed with a structured approach that combines a scoring system with the routinely use of videolaryngoscope by expert operators.

References

• 1. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. De Jong A, Molinari N, Pouzeratte Y, et al. Br J Anaesth 2015; 114: 297–306

• 2. Near-zero difficult tracheal intubation and tracheal intubation failure rate with the "Besta Airway Algorithm" and "Glidescope® in morbidly obese" (GLOBE).Cagnazzi E, Mosca A, Pe F, Togazzari T, Manenti O, Mittempergher F, Raffetti E, Donato F, Latronico N. Minerva Anestesiol. 2016 Sep;82(9):966-73.

• 3. A new difficult airway management algorithm based upon the El Ganzouri Risk Index and GlideScope® videolaryngoscope. A new look for intubation? Caldiroli D, Cortellazzi P. Minerva Anestesiol. 2011 Oct;77(10):1011-7.

• 4. Defining and developing expertise in tracheal intubation using a GlideScope(®) for anaesthetists with expertise in Macintosh direct laryngoscopy: an in-vivo longitudinal study. Cortellazzi P, Caldiroli D, Byrne A, Sommariva A, Orena EF, Tramacere I. Anaesthesia. 2015 Mar;70(3):290-5.

O-097

The effect of pre-surgery information online lecture on nutrition-knowledge and anxiety among bariatric surgery candidates

Shiri Sherf-Dagan^{1, a)}, Keren Hod^{1, b)}, Limor Mardy-Tilbor^{1, c)}, Shir Gliksman^{1, d)}, Tair Ben-Porat^{2, e)}, David Goitein^{1, 3, 4, f)}, Nasser Sakran^{1, 5, g)}, Shira Zelber-Sagi^{6, 7, h)}, Asnat Raziel^{1, i)}

¹⁾Assuta Medical Center, Tel-Aviv, Israel; ²⁾Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; ³⁾Department of Surgery C, Sheba Medical Center, Tel Hashomer, Israel; ⁴⁾Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; ⁵⁾Department of Surgery A, Emek Medical Center, Afula, affiliated with Rappaport Faculty of Medicine, Technion, Israel; ⁶⁾School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; ⁷⁾Department of Gastroenterology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel

^a)shirisherf@gmail.com

^b)hodkeren@gmail.com

^c)limorm@assuta.co.il

^d)shirgliksman@gmail.com

^e)tairbp20@gmail.com

^f)david.goitein@sheba.health.gov.il

^g)sakranas@walla.com

^h)zelbersagi@bezeqint.net

ⁱ⁾asnatraziel@aol.com

Introduction: Bariatric surgery (BS) patient education best practices remain unclear. Hence, the study aims were to evaluate the effect of an information online-lecture on BS nutrition-knowledge, weight-loss expectations and anxiety among BS-candidates and to present a new valid-tool to assess nutrition-knowledge prior to BS.

Methods: An interventional non-randomized control-trial on 200-candidates for BS, recruited while attending to the bariatric committee. The first 100-consecutive patients were assigned to the control-group and the later 100-consecutive patients to the intervention-group and were asked to watch an online-lecture of 15-minutes 1-2-weeks prior to the surgery-date. All participants completed a BS nutrition-knowledge questionnaire and the state-trait anxiety-inventory (STAI) questionnaire at the bariatric-committee and once again at the pre-surgery clinic. Additionally, data on body mass index (BMI), comorbidities, surgery-type, marital-status and number of dietitian sessions were obtained from medical-records.

Results: Data for paired study questionnaires scores were available for 128-patients (n=69 and n=59 for the control-group and the intervention-group, respectively), with a mean age and BMI of 40.3±11.4years and 41.3±4.9kg/m², respectively. The BS nutrition-knowledge and the state-anxiety scores increased for both study-groups at the pre-surgery clinic as compared to the bariatric-committee (P≤0.028), but the elevation in the BS nutrition-knowledge score was significantly higher for the intervention-group (P=0.030). No within or between-groups differences were found for the trait-anxiety items score. The 'dream' and 'realistic' weight-goals were lower than the expected weight-loss according to 70%EWL for both study-groups at both time-points (P<0.001 for-all).

Conclusion: Education-intervention by an online-lecture prior to the surgery improves BS nutrition-knowledge, but not anxiety-levels.

O-098

Attendance of follow-up visits after bariatric operation within 5 years

Anke Rosenthal^{1, a)}, Oliver Stumpf^{2, b)}, Volker Lange^{2, a)}

¹⁾Obesity outpatient Clinic, Dr. Anke Rosenthal, Obesity outpatient Clinic, Dr. Anke Rosenthal, Berlin, Germany; ²⁾Obesity and Metabolic Surgery Center, Vivantes Klinikum Spandau, Berlin, Germany

^a)volker.lange@vivantes.de

^b)oliver.stumpf@vivantes.de

Background: Obesity is a chronic relapsing progressive disease. This must be kept in mind even after a bariatric operation. A continuous medical guidance and supervision of operated patients is mandatory. But the attendance of aftercare consultations rapidly decreases worldwide after the operation. We analyzed the frequency of visits over a five year period.

Method: A cohort of 385 patients operated in 2011 was followed up to the end of 2016. Patients contacts with the Outpatient Clinic were taken from the patients file. Each patient received at each visit a new date for the next control. There was no recall system.

Results: The rate of patients coming to the Outpatient center was 95% after 1 year, 85% after 2 years, 50% after 3 years, 42% after 4 years, 27% after 5 years and 18% after 6 years. The range of visits per person per year was 1-27 contacts a year. The attending patients contacted the center 5961 times. Mean attendance frequency of visits per person/year was nearly constant over the time showing 4 visits per year. We further analyzed whether there was a difference between German patients and patients with migration background ( 27% ) concerning the attendance of aftercare. There was no difference for the first 4 years, after that time Non-German patients were seen less often.

Conclusion: For many reasons patients who got a bariatric operation omit to attend the follow-up visits soon after the operation. Although patients preoperatively sign an agreement to attend life-long aftercare after the operation we have to state that they do not follow this repeated instruction. This is a worldwide phenomenon. New tools seem to be necessary to keep patients under surveillance.

O-099

Interpersonal characters among bariatric candidates compared to control group

Inbal Globus^{1, a)}, Anat Brunstein-Klomek^{2, b)}, Yael Latzer^{3, c)}

¹⁾Public Health, Haifa University, Haifa, Israel; ²⁾School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel; ³⁾Faculty of social Welfare and Health Sciences, Haifa University, Haifa, Israel

^a)inbal.balog@gmail.com

^b)bkanat@idc.ac.il

^c)latzery@gmail.com

Introduction: Studies have found that patients with Binge Eating Disorder (BED) have difficulties in their interpersonal relationship. There is limited research examining interpersonal relationships among bariatric patients. Interpersonal characters refer to a variety of abilities, including assertiveness, the capacity to initiate a conversation, the ability for emotional regulation and more. The aim of this study was to assess the differences in interpersonal characters between bariatric candidates and a control group including individuals with normal weight, overweight and obese.

Methods: A hundred and sixty six adult bariatric candidates in Israel (Mean BMI = 40.7 sd = 5.1) (mean age= 43.2; sd = 11.3) participated in the study. They were compared to 82 controls who were divided into three groups: normal weight (N= 41) (Mean BMI = 22.1 sd = 1.8) (Mean age = 41.4; sd = 9.1), Overweight (N= 27) (Mean BMI = 26.9; sd = 1.4) (Mean age = 41.8; sd = 8.03) and obese (N= 14) (Mean BMI = 34.05; sd = 4.05) (Mean age = 52.7; sd = 9.8). All participants completed surveys addressing demographic, eating disorders (EDE-Q), depression, anxiety, stress (DASS) and interpersonal characters(SAS-SR, IIP).

Results: Bariatric candidates had significantly more difficulties in “primary relationship” (intimate relationships) and were higher in being “too caring” (the tendency to put other people's needs before your own). Eating and shape concerns, as well as anxiety levels were significantly higher in the bariatric candidates compared to the other two control groups (normal weight and overweight). Weight concern levels were also found to be significantly higher amongst bariatric candidates compared to all three of the sub control groups.

Conclusion: Our findings are in line with previous studies which found difficulties with intimate relationships and nurturance among BED patients. Patients in this study are continuing follow up to assess which interpersonal skills are related to failure of bariatric surgery.

Targeting these skills among bariatric candidates before surgery may help these patients preserve the outcomes of the surgery

References

Applegate, K.L., & Friedman, K.E. (2008). The impact of weight loss surgery on romantic relationships. BariatrNursSurg Patient Car, 3, 135-141.

Duchesne, M., de Oliveira Falcone, M., de Freitas, R., D'Augustin, F., Marinho, V., &Appolinario, J.C. (2012). Assessment of interpersonal skills in obese women with binge eating disorder. J Health Psychol, 17 (7), 1065-1075.

Fairburn, C. G. (1997). Interpersonal psychotherapy for bulimia nervosa. In D. Garner, & P. Garfinkel (Eds.), Handbook of treatment for eating disorders (2nd ed.) (pp. 278-294). New York: Guilford Press.

Goble, L., Rand, C.S.W., &Kuldau, J.M. (1986). Understanding marital relationships following obesity surgery. Fam Ther, 13, 195–202.

Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal psychotherapy for eating disorders. Clin Psycho Psychother, 19, 150-158.

O-100

How to treat iron deficiencies after RYGB: outcomes of an RCT

Wendy Schijns, Abel Boerboom, Ignace Janssen, Frits Berends, Hans de Boer, Edo Aarts

Rijnstate Hospital, Arnhem, Netherlands

Background: Iron deficiency is one of the most common postoperative complications after Roux-en-Y gastric bypass (RYGB). Ferrous fumarate, ferrous gluconate and Ferinject® (iron(III)carboxymaltose) are most often used for supplementation. Worldwide there is no uniform treatment protocol for iron deficiency.

Objectives: To evaluate the effect of ferrous fumarate, ferrous gluconate and Ferinject® treatment in patients with an iron deficiency after RYGB.

Setting: Large teaching hospital

Methods: In this multicenter study 120 female patients with an iron deficiency (ferritine <20) after RYGB were included. Patients were randomized into three groups, 40 patients were treated with ferrous fumarate 200 milligram (195 mg elementary iron) orally three times a day, 40 patients were treated with ferrous gluconate 695 milligram (160 mg elementary iron) orally two times, both during three months, and 40 patients received a single dose of Ferinject® 1000 milligram intravenous. Iron and ferritin were measured 6 weeks, 3, 6 and 12 months after supplementation.

Results: After three months, 8% and 10% of the patients with ferrous fumarate and ferrous gluconate respectively were still deficient compared to 0% in the Ferinject® group. So far, 69% of the patients were followed for 1 year. In both the ferrous fumarate group and the ferrous gluconate group 17 patients, 63% and 68% respectively, experienced a (re-)deficiency during the one year follow-up compared to 9 patients (29%) in the Ferinject® group (p=0.005). In these patients (re-)treatment was necessary.

Conclusion: Ferinject® seems to be the most effective and patient-friendly treatment in patients with an iron deficiency after RYGB compared to ferrous fumarate and ferrous gluconate.

umarate, ferrous gluconate and Ferinject® treatment in patients with an iron deficiency after RYGB.

O-101

Vitamin, trace element and protein status of patients undergoing One Anastomosis Gastric Bypass

Julia Jedamzik^{1, a)}, Magdalena Eilenberg^{1, b)}, Felix Langer^{1, c)}, Michael Krebs²⁾, Gerhard Prager^{1, d)}, Daniel Moritz Felsenreich¹⁾, Tamara Ranzenberger-Haider^{2, e)}

¹⁾Department of General Surgery, Medical University of Vienna, Vienna, Austria; ²⁾Division of Endocrinology and Metabolism Department of Medicine III, Medical University of Vienna, Vienna, Austria

^a)julia.jedamzik@meduniwien.ac.at

^b)magdalena.eilenberg@meduniwien.ac.at

^c)felix.langer@meduniwien.ac.at

^d)gerhard.prager@meduniwien.ac.at

^e)tamara.ranzenberger-haider@meduniwien.ac.at

Background. Obesity is a growing problem in modern societies. Bariatric surgery is a well-established treatment modality, which leads to weight and comorbidity loss over the course of time. Nevertheless, in a significant number of patients the changes in the gastrointestinal tract result in relevant micronutrient deficiencies. One Anastomosis Gastric Bypass (OAGB) is an excellent procedure to reduce weight and comorbidities, but has yet to be evaluated for its impact on micronutrient deficiencies.

Methods. A prospectively fed database including all patients undergoing OAGB between 11/2012 and 12/2014 was retrospectively analysed. A regular follow up was carried out preoperatively as well as 3, 6, 12, 18, 24 months and yearly thereafter. Systemic levels of parathyroid hormone, vitamins (A, D, E, B12), folic acid, magnesium, calcium, iron, albumin and ferritin were retrieved and correlated with clinical parameters (excess weight loss, length of limb, sex, age).

Results. A total number of 149 patients were evaluated (female/male:109/40). In general, OAGB led to an average %Excess weight loss (%EWL) of 81% (+/-25,6%) and a median body mass index (BMI) decrease from 45.5 kg/m2 to 29.3kg/m2. Preoperative deficiencies were seen in 25-Hydroxy-vitamin D (95%), folic acid (39%), ferritin (6%), iron (16%), vitamin A (4%) and B12 (2%); no deficiencies were found in calcium, magnesium, vitamin E or albumin. In patients with long (>200cm) biliopancreatic limb a significantly lower 25-OH-vitamin D level was seen 12 months postoperatively when compared to shorter limb (≤200cm; p=0.0462). Regarding %EWL after 12 months, significantly lower serum protein levels (p=0.01) were found in patients with high (≥80%) %EWL when compared to low (<80%) %EWL.

Conclusion. OAGB is an easily feasible procedure to achieve weight loss and a reduction of comorbidities. It’s a combination of both a restrictive and a malabsorptive component leading to a reduced intake and absorption of essential micronutrients and vitamins. Therefore, a thorough pre- and postoperative screening for micronutrient deficiencies has to be carried out in order to prevent long-term complications.

O-102

Metabolic Surgeons self-assessing sexual health issues in disease management of morbid obese patients at the Austrian Congress of Surgeons, June 2017

Lucia Ucsnik^{1, a)}, Felix Langer¹⁾, Andrea Kottmel²⁾, Thomas Dorner³⁾, Johannes Bitzer⁴⁾, Bela Teleky¹⁾, Gerhard Prager¹⁾

¹⁾Dpt of Surgery, Medical University Vienna, Vienna, Austria; ²⁾Private Practice for Gynecology and Sexual Medicine, Vienna, Austria; ³⁾Center for Public Health, Medical University Vienna, Vienna, Austria; ⁴⁾Private Practice for Gynecology, Basel, Switzerland

^a)lucia.ucsnik@meduniwien.ac.at

Introduction: Bariatric Surgery does have an impact on sexual health, fertility, contraception and reproduction. Thus this issue needs to be integrated in disease-management of morbid obese patients.

Material: The integration of sexual health issues in medical routine was self-assessed by surgeons during 2 bariatric sessions at the Annual Austrian Congress for Surgeons, June 2017, via 3-parted survey on the morbid obeses patients treated, the offer for treatment, surgeon’s professional profile.

Results: 11 of 34 surgeons participated in the survey (return-rate 31,42%), 55% working at university, 36% in public hospital. 73 % of them asked up to 20% of the patients about sexual problems, 18% not at all, only 9% of the doctors 80-100% of the patients. 63% of the surgeons were asked by up to 20% of the patients on sexual dysfunction, 36,6% of the doctors weren't asked at all. The surgeons suggested the following reasons for non-addressing the topic by the patients: topics more relevant (8), lack of time (7), language-barrier (3), embarrassing topic (2), shame (1). Medical situations for bringing up the topic by the doctors were assessed: concrete diagnoses (55%), prevention (36%), andro-/menopause (36%), 27% before/after surgery. Neither public nor university hospitals had established sexual-medicine appointments. 55% of the doctors refer to gynaecologists/urologists, 36% to andrologists, 27% to psychosomatic specialists, each 18% to internal medicine (cardiology, endocrinology). No surgeon participating in this survey had further training nor expertise in the field of sexual medicine.

Conclusion: 80% of the morbid obese patients were not asked at all about their sexual health by metabolic surgons. Only 9% of the surgeons brought up the topic of "sexuality and intimacy" in 81-100% of the patients treated. Thus there's a need for raising awareness of the importance and relevance of sexual health in morbid obese patients. In surgeons, too, there's a need for special medical training in sexual medicine in order to treat morbid obese patients state-of-the art according to the WHO-concept of health.

References

Brotto L¹, Atallah S², Johnson-Agbakwu C³, Rosenbaum T⁴, Abdo C⁵, Byers ES⁶, Graham C⁷, Nobre P⁸, Wylie K⁹, “Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction”, J SexMed. 2016 Apr;13(4):538-71. doi: 10.1016/j.jsxm.2016.01.019. Epub 2016 Mar 25

McCabe MP¹, Sharlip ID², Lewis R³, Atalla E⁴, Balon R⁵, Fisher AD⁶, Laumann E⁷, Lee SW⁸, Segraves RT⁹, “Risk Factors for Sexual Dysfunction Among Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015”, J Sex Med. 2016 Feb;13(2):153-67.doi: 10.1016/j.jsxm.2015.12.015

McCabe MP¹, Sharlip ID², Lewis R³, Atalla E⁴, Balon R⁵, Fisher AD⁶, Laumann E⁷, Lee SW⁸, Segraves RT⁹, Incidence and Prevalence of Sexual Dysfunction in Women and Men: A Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015”, J Sex Med. 2016 Feb;13(2):144doi: 10.1016/j.jsxm.2015.12.034

McCabe MP¹, Sharlip ID², Atalla E³, Balon R⁴, Fisher AD⁵, Laumann E⁶, Lee SW⁷, Lewis R⁸, Segraves RT⁹, “Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015” J Sex Med. 2016 Feb;13(2):135-43. doi:10.1016/j.jsxm.2015.12.019

Hatzichristou D¹, Rosen RC, Derogatis LR, Low WY, Meuleman EJ, Sadovsky R, Symonds T.,„Recommendations for the clinical evaluation of men and women with sexual dysfunction.”, J Sex Med. 2010 Jan;7(1 Pt 2):337-48. doi: 10.1111/j.1743-6109.2009.01619.x.

Shindel AW¹, Ferguson GG, Nelson CJ, Brandes SB, „The sexual lives of medical students: a single institution survey”, J Sex Med. 2008 Apr;5(4):796-803. doi: 10.1111/j.1743-6109.2007.00744.x. Epub 2008 Jan 14.

Esposito K¹, Giugliano F, Ciotola M, De Sio M, D'Armiento M, Giugliano D, „Obesity and sexual dysfunction, male and female”, Int J Impot Res. 2008 Jul-Aug;20(4):358-65. doi:10.1038/ijir.2008.9.Epub 2008 Apr 10

Mulhall J¹, King R, Glina S, Hvidsten K, „Importance of and satisfaction with sex among men and women worldwide: results of the global better sex survey”, J Sex Med. 2008 Apr;5(4):788-95. doi:10.1111/j.1743-6109.2007.00765.x. Epub 2008 Feb 11

Hatzimouratidis K¹, Hatzichristou D., “Sexual dysfunctions: classifications and definitions.”, J Sex Med.2007 Jan;4(1):241-50.

Sadovsky R¹, Nusbaum M., „Sexual health inquiry and support is a primary care priority”, J Sex Med.2006 Jan;3(1):3-11.

Colson MH¹, Lemaire A, Pinton P, Hamidi K, Klein P., “Sexual behaviors and mental perception, satisfaction and expectations of sex life in men and women in France”, J Sex Med. 2006 Jan;3(1):12131

Heiman JR¹, „Sexual dysfunction: overview of prevalence, etiological factors, and treatments”, J Sex Res. 2002 Feb;39(1):73-8 K.L. Beier, H.A.G: Bosinski, K. Loewit, “Sexualmedizin”, Urban und Fischer, 2. Ausgabe, 2005

Musicki B¹, Bella AJ², Bivalacqua TJ¹, Davies KP³, DiSanto ME⁴, Gonzalez-Cadavid NF^5,6, Hannan JL⁷, Kim NN⁸, Podlasek CA⁹, Wingard CJ⁷, Burnett AL¹, „Basic Science Evidence for the Link Between Erectile Dysfunction and Cardiometabolic Dysfunction.“, J Sex Med. 2015 Dec;12(12):2233-55. doi:10.1111/jsm.13069. Epub 2015 Dec 8.

Tostes RC¹, Carneiro FS, Lee AJ, Giachini FR, Leite R, Osawa Y, Webb RC., „Cigarette smoking and erectile dysfunction: focus on NO bioavailability and ROS generation.“, J Sex Med.2008 Jun;5(6):1284-95. doi: 10.1111/j.1743-6109.2008.00804.x. Epub 2008 Mar 4.

Müller A¹, Mulhall JP., „Cardiovascular disease, metabolic syndrome and erectile dysfunction.“, Curr Opin Urol. 2006 Nov;16(6):435-43.

Ganz P¹., „Erectile dysfunction: pathophysiologic mechanisms pointing to underlying cardiovascular disease.“, Am J Cardiol. 2005 Dec 26;96(12B):8M-12M. Epub 2005 Jul 27

McVary KT¹, Carrier S, Wessells H., „Subcommittee on Smoking and Erectile Dysfunction Socioeconomic Committee, Sexual Medicine Society of North America.; Smoking and erectile dysfunction: evidence based analysis.“, J Urol. 2001 Nov;166(5):1624-32.

O-103

Do specialized bariatric multivitamins lower deficiencies after RYGB?

Wendy Schijns¹⁾, Lisanne Schuurman²⁾, Ignace Janssen¹⁾, A Melse-Boonstra²⁾, Frits Berends¹⁾, Edo Aarts^{1, a)}

¹⁾Rijnstate Hospital, Arnhem, Netherlands; ²⁾Wageningen University & Research, Wageningen, Netherlands

^a)edoaarts@hotmail.com

Background: One of the side effects of bariatric surgery is the risk of vitamin and mineral deficiencies. Vitamin B12, vitamin D, folate and iron deficiencies are especially common among Roux-en-Y gastric bypass (RYGB) patients.

Objective: Prospectively examine the effectiveness of a specialized multivitamin supplement for RYGB patients (WLS Forte™) on deficiencies the first three years postoperatively in a large cohort.

Setting: Large specialized bariatric hospital

Results: 1160 patients were included, 883 users and 258 who were non-users of WLS Forte™. Patient characteristics and total body weight were comparable. Higher serum concentrations of ferritin (124.7 ± 96.2 μg/L versus 106.0 ± 83.0 μg/L, p=0.016), vitamin B12 (347.3 ± 145.1 pmol/L versus 276.8 ± 131.4 pmol/L, p<0.001), folic acid (34.9 ± 9.6 nmol/L versus 25.4 ± 10.7 nmol/L, p<0.001) and vitamin D (98.4 ± 28.7 nmol/L versus 90.0 ± 34.5 nmol/L, p=0.002) were observed in users compared to non-users after one year. Less de novo deficiencies were found for ferritin (1% versus 4%, p=0.029), vitamin B12 (9% versus 23%, p<0.001) and vitamin D (0% versus 4%, p<0.001) in users compared to non-users. Two and three years after the surgery these findings remained almost identical.

Conclusions: The use of specialized multivitamin supplements resulted in less deficiencies of vitamin B12, vitamin D, folic acid and ferritin. The study clearly showed that RYGB patients benefited from the specialized multivitamin supplements and it should be advised to this patient group.

O-104

Effects of preoperative nutritional supplements enriched with Omega-3 fatty acids on postoperative pain and analytical acute-phase reactants in patients undergoing Roux-en-Y gastric bypass

Jaime Ruiz-Tovar^a), Carolina Llavero, Maria Blanca, Alejandro Garcia, Juan Gonzalez, Carlos Ferrigni, Manuel Duran, Damian Garcia-Olmo

Surgery, HOSPITAL REY JUAN CARLOS, Madrid, Spain

^a)jruiztovar@gmail.com

Introduction: Surgical damage induces a local and systemic inflammatory response, presenting clinically as pain and analytically as elevation of acute-phase reactants (White blood cell count, C reactive protein, fibrinogen,…).

Omega-3 fatty acids (O3FA) are considered immunomodulating agents, reducing the postoperative inflammatory response, and decreasing the proinflammatory mediators release. Thus, O3FA are essential components of immunonutrition (IMN). A previous study of our group demonstrated that the preoperative administration of IMN was associated with a greater preoperative weight loss, and lower postoperative pain and acute-phase reactants. The aim of this study was to evaluate the isolate effect of O3FA on these parameters in patients undergoing a Roux-en-Y gastric bypass (RYGB).

Material and methods: We performed a prospective randomized study of patients undergoing laparoscopic RYGB. The patients were randomized into 2 groups: those ones receiving hyperproteic supplements 14 days before surgery (Control group: CG) and those ones receiving hyperproteic supplements enriched with O3FA. Preoperative weight loss and postoperative pain and acute-phase reactants were assessed.

Results: 42 patients were included, 21 in each group. There were no significant differences in age, gender, comorbidities and baseline BMI. Preoperative excess weight loss was 12,6 + 7,7% in CG and 14,1 + 5,8% en O3FA (p=0,024). There was 1 complication in CG (1 jejuno-jejunal leak) and 0 in O3FA (NS). Excluding the patient who presented the complication, postoperative pain 24h after surgery, as measured by VAS, was 15 + 9,2mm en CG and 10,9mm + 4,4mm in O3FA(p=0,015). C reactive levels 24h after surgery were 7,36 + 4,22 mg/dl in CG and 2,98 + 1,1 mg/dl in O3FA(p=0,009). Glucose levels at 24h postoperatively were 121,6 + 55,3mg/dl in CG and 103,2 + 20,4mg/dl in O3FA(p=0,008). There were no significant differences in WBC and fibrinogen.

Conclusion: The use of nutritional supplements enriched with O3FA is associated with a greater preoperative weight loss, reduces postoperative pain and decreases postoperative levels of C reactive protein and glucose.

O-105 Nutritional Management of Bariatric Surgery Patients in Order to Attenuate Bone Deterioration

Tair Ben-Porat^{1, a)}, Ram Elazary^{2, b)}, Shiri Sherf-Dagan^{3, c)}, Ariela Goldenshluger^{1, d)}, Ronit Brodie^{2, e)}, Yoav Mintz^{2, f)}, Nasser Sakran^{4, g)}, Rivki Harari^{1, h)}, Ram Weiss^{5, i)}

¹⁾Department of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; ²⁾Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; ³⁾Department of Nutrition, Assuta Medical Center, Tel Aviv, Israel; ⁴⁾Assuta Medical Center, Tel Aviv, Israel

⁵⁾Department of Human Metabolism and Nutrition, Hebrew University, Jerusalem, Israel

^a)tairbp20@gmail.com

^b)ramelazary@hadassah.org.il

^c)shirisherf@gmail.com

^d)arielitaw@gmail.com

^e)Ronitu@hadassah.org.il

^f)ymintz@hadassah.org.il

^g)sakran_as@clalit.org.il

^h)rivki@hadassah.org.il

ⁱ⁾ramw@ekmd.huji.ac.il

Background: Bariatric surgery (BS) is an effective treatment for morbid obesity and its related co-morbidities but may result in a detrimental effect on bone metabolism, depending on the amount of weight loss and malabsorption of several micro and macronutrients as related to the type of the procedure. Nutritional guidelines on bone loss prevention for BS patients previously published are very comprehensive, yet there is a lack of randomized clinical trials regarding doses of micronutrients supplements required.

Objectives: To summarize the nutritional management aspects for bone health maintenance in BS patients and to address issues of safety and efficacy of nutritional supplements for BS patients.

Methods: A literature search was performed as appropriate for narrative reviews including three electronic databases.

Results: Calcium consumption post-operatively should reach 1200-2400 mg/day depending on the type of the procedure. Patients with vitamin D deficiency or insufficiency should be replete with vitamin D3 of at least 3000 IU/day and as high as 6000 IU/day, yet further studies are needed to clarify the appropriate vitamin D dosing prior to and post BS, and to shed light on their effect on bone metabolism and skeletal health in BS patients. The supplemental sources, tolerable upper intake level and potential adverse effects of excess intake should be considerate. Protein intake should reach 60 g/day and up to 1.5 g/kg ideal body weight while higher protein intake is associated to lower lean body mass loss post-operatively. Patients should be advised to incorporate moderate aerobic physical activity and strength training 2 to 3 times per week, with most benefit being derived from weight-bearing and muscle loading exercise. Additional nutrients such as zinc, magnesium and vitamin B12 may also play a role, but no studies have been carried out regarding their intake or deficiency impact on bone outcomes in BS patients.

Conclusions: Early prevention via comprehensive clinical evaluation accompanied by nutritional and medical counseling should begin pre-operatively with continued long-term monitoring post operatively.

O-106

The impact of Roux-en-Y Gastric Bypass on bone remodelling expressed by the P1NP/βCTX ratio: a single-center prospective cohort study

Daniel Gero^{1, a)}, Markus K. Muller^{2, b)}, Diana Vetter^{1, c)}, Robert E. Steinert^{1, d)}, Thorsten Hornemann^{3, e)}, Marco Bueter^{1, f)}

¹⁾Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland; ²⁾Department of Surgery, Cantonal Hospital Frauenfeld, Frauenfeld, Switzerland; ³⁾Institute of Clinical Chemistry, University Hospital of Zurich, Zurich, Switzerland

^a)daniel.gero@usz.ch

^b)markus.k.mueller@stgag.ch

^c)diana.vetter@usz.ch

^d)re.steinert@gmail.com

^e)thorsten.hornemann@usz.ch

^f)marco.bueter@usz.ch

Background: Bariatric surgery decreases bone mineral density and may thus increase the risk of fatigue fractures. P1NP (bone formation) and βCTX (bone resorption) were recently approved as reference bone turnover markers (BTM).

Objective: To assess changes in bone remodeling in severely obese patients undergoing Roux-en-Y gastric bypass (RYGB) by using a new composite biomarker, the P1NP/βCTX ratio (value<100: increased risk of fracture).

Methods: We prospectively collected blood samples preoperatively, at 1-month and at 1-year from 114 consecutive RYGB patients between 12/2012 and 04/2014. Repeated measures ANOVA and multiple regression were used for data analysis.

Results: The P1NP/βCTX ratio decreased significantly (P<0.001) from baseline to 1-month and 1-year (180±6.6, 110±4.1 and 132±5.4) (Figure 1). The 1-year P1NP/βCTX ratio did not correlate with BMI or ΔBMI, but inversely correlated with age (R=-0.23, P=0.014) and with hsCRP (R=-0.26, P=0.009), even after adjustment of age, sex, BMI and lifestyle; and linearly correlated with albumin (R=0.2, P=0.037) (Table 1). At baseline none of these correlations were detectable. Both P1NP and βCTX correlated with BMI at baseline (R=0.23, P=0.014 and R=0.25, P=0.007, respectively), but not at 1-year. At 1-year, P1NP and βCTX individually correlated with PTH levels (R= 0.22, P= 0.02, R=0.23, P= 0.015), and P1NP also correlated with Ca2+ levels (R= 0.16, P= 0.009), and inversely with hsCRP (R= -0.2, P= 0.045) and trigliceridemia (R= -0.29, P= 0.002). Vitamin D, sex hormones and fasting glycemia levels did not correlate with BTM. Missing data was minimal: serum was obtained in >94% of patients at all time-points, whereas 1-year BMI data was 100%.

Conclusion: Bone remodeling increases after RYGB with a shift towards degradation. This effect seems to be weight-loss independent and correlates with the level of systemic inflammation and nutritional state. The risk of fractures should be assessed systematically in bariatric patients and measures of prevention should be improved accordingly.

References

Figure 1. Evolution of A. BMI, B. CRP, C. Vitamin D, D. P1NP E. ßCTX and F. P1NP/ßCTX ratio from baseline to 1 and 12 months postoperatively. Four CRP values over 50mg/l at 1-month were not taken into consideration due to infectious postoperative complications.

Table1. Correlations of bone turnover markers with serum markers of metabolic syndrome, gonadic hormones and bone metabolism at 1-year postoperatively by using partial correlations and univariate linear regression models. Model 1: + gender, Model 2: + age, Model 3: + BMI, Model 4: + smoking and alcohol consumption.

*Correlation coefficient obtained by partial correlations (pearson's R) for continuous variables and univariate general linear model (adjusted R squared) for categorical variables.

PTH: parathyroid hormone, HDL: high density cholesterol, LDL: low density cholesterol, CRP: C-reactive protein

O-107

Beta cells in patients with changes in glycemic control after Roux-en-Y gastric bypass surgery, visualized by 68Ga-exendin-4 PET/CT

Laura Deden^{1, a)}, Marti Boss^{2, b)}, Hans de Boer^{3, c)}, Edo Aarts^{1, d)}, Ignace Janssen^{1, e)}, Eric Hazebroek^{1, f)}, Maarten Brom^{2, g)}, Frits Berends^{1, h)}, Martin Gotthardt^{2, i)}

¹⁾Bariatric surgery, Rijnstate hospital and Vitalys obesity clinic, Arnhem, Netherlands

²⁾Radiology and nuclear medicine, RadboudUMC, Nijmegen, Netherlands

³⁾Internal medicine, Rijnstate, Arnhem, Netherlands

^a)ldeden@rijnstate.nl

^b)marti.boss@radboudumc.nl

^c)hdeboer@rijnstate.nl

^d)eaarts@rijnstate.nl

^e)ijanssen@rijnstate.nl

^f)ehazebroek@rijnstate.nl

^g)maarten.brom@radboudumc.nl

^h)fberends@rijnstate.nl

ⁱ⁾martin.gotthardt@radboudumc.nl

Background: Remission of type 2 diabetes (T2D) occurs in >60% of patients undergoing Roux-en-Y gastric bypass (RYGB) surgery. In rare cases, hyperinsulinaemic hypoglycaemia occurs. The mechanisms behind these responses are incompletely understood, but a role for beta cell activity (BCA) and beta cell mass (BCM) is hypothesized. Studying the role of BCM in changed glycaemic control after RYGB in vivo is possible using Exendin-4, a stable analogue of glucagon-like peptide-1, that specifically accumulates in the beta cells. ⁶⁸Ga-exendin-4 PET/CT can be used to quantify BCM.

Methods: BCA and BCM were compared between patients with different responses in glycaemic control after RYGB. Five patients with complete remission of T2D (responders), five patients without complete remission of T2D (non-responders) and five patients with hypoglycaemia after RYGB were included. BCA was measured by an arginine stimulation test. Total pancreatic uptake of ⁶⁸Ga-exendin-4 was determined by quantitative analysis of PET/CT scans as measure for BCM.

Results: Patient characteristics and weight loss were comparable between the groups. BCA was significantly lower in non-responders compared to responders; the arginine stimulated acute C-peptide response was 0.4±0.2 and 0.9±0.3 nmol/l, respectively (p=0.02). Pancreatic ⁶⁸Ga-exendin-4 uptake was 26% lower in non-responders (83±58 kBq) compared to responders (111±55 kBq), although not statistically significant (p=0.088). BCA and BCM did not correlate (linear, Pearson R=0.30, p=0.40). In hypoglycaemia patients, BCM was significantly higher than in responders (191±63 kBq, p=0.032).

Conclusion: The data of this study suggest that BCM is higher in T2D patients with complete remission compared to non-responders after RYGB. BCA did not correlate with BCM. Furthermore, patients with hypoglycaemia have a higher BCM than T2D responders. In conclusion, BCM may play important role in patient's response to RYGB. Furthermore, ⁶⁸Ga-exendin-4 PET/CT is a feasible technique to measure BCM in vivo and may be applied to find underlying mechanisms in T2D and post-RYGB hypoglycemia.

O-108

Features of oral glucose tolerance test in patients with and without late dumping after Roux-en-Y gastric bypass: it’s all about speed.

Ilke Marien^{1, a)}, Eveline Dirinck^{1, b)}, Guy Hubens^{2, c)}, Luc Van Gaal^{1, d)}

¹⁾Endocrinology, diabetology and metabolic diseases, University Hospital of Antwerp, Antwerp, Belgium

²⁾Abdominal Surgery, University of Antwerp, Antwerp, Belgium

^a)ilke.marien@uza.be

^b)eveline.dirinck@uza.be

^c)guy.hubens@uza.be

^d)luc.vangaal@uza.be

Background Hypoglycemia is a well-known complication of Roux-en-Y gastric bypass (GB). This study aimed at evaluating glucose and insulin profiles during an oral glucose tolerance test (OGTT), both pre- and postoperatively, in patients with and without hypoglycemia symptoms.

Methods This retrospective study has 2 groups. The dumping group (n=27) presented with symptoms of hypoglycemia, ranging from 10 to 150 months after GB. The control group (n=99) had an OGTT 1 year after GB due to enrollment in another study, and displayed no hypoglycemia symptoms. Both groups had an OGTT pre-operatively. Blood samples were obtained for glucose and insulin at 0, 15, 30, 60, 120, 150 and 180 minutes.

Results Preoperatively, glucose and insulin were at any point similar in both groups (Fig 1). The speed glucose increased from fasting to peak and decreased from peak to minimum showed no difference between the two groups (p=0.611 and p=0.967 respectively). The speed insulin increased from fasting to peak was similar for the two groups (p=0.235); the speed insulin decreased was lower in the dumping group (p=0.003) (Fig 2).

Postoperatively, weight loss was similar in both groups (28% versus 25%, p=0.265). Glucose levels were significantly higher in the dumping group at 0, 15, 30 and 60 minutes (p<0.001 for all) (Fig 1). Insulin levels were higher at 30 and 60 minutes in the dumping group (p=0.010 for both) (Fig 1). The speed glucose increased from fasting to peak and decreased from peak to minimum was significantly higher in the dumping group (p=0.006 and p<0.001 respectively). The speed insulin increased from fasting to peak and decreased from peak to minimum was significantly higher in the dumping group (p=0.040 and p=0.014 respectively) (Fig 2).

Conclusion Assessing hypoglycemia after gastric bypass is challenging. Our study indicates that the main difference between patients with and without dumping symptoms, is the speed of glucose and insulin increment and decline during OGTT, rather than the absolute values obtained.

References

1. Emous, F. L. Ubels, A. P. van Beek. Diagnostic tools for post-gastric bypass hypoglycaemia. Obes Rev. 2015 Oct;16(10):843-56.

2. CM Craig, LF Liu, CF Deacon et al. Critical role for GLP-1 in symptomatic post-bariatric hypoglycaemia. Diabetologia. 2017 Mar;60(3):531-540.

3. Ritz P, Vaurs C, Barigou M et al. Hypoglycaemia after gastric bypass: mechanisms and treatment. Diabetes Obes Metab. 2016 Mar;18(3):217-23.

4. Patti ME, Li P, Goldfine AB. Insulin response to oral stimuli and glucose effectiveness increased in neuroglycopenia following gastric bypass. Obesity (Silver Spring). 2015 Apr;23(4):798-807.

5. Sarwar H, Chapman WH 3rd, Pender JR et al. Hypoglycemia after Roux-en-Y gastric bypass: the BOLD experience. Obes Surg. 2014 Jul;24(7):1120-4

O-109

Dumping Syndrome after Gastric Bypass: Endoluminal Revision of the Dilated Gastrojejunostomy is a Safe and Highly Effective Treatment Option

Catherine Tsai^a), Ulf Kessler^b), Rudolf Steffen^c), Hans Merki^d), Jörg Zehetner^e)

Visceral Surgery, Clinic Beau Site, Bern, Switzerland

^a)catherine.tsai.md@gmail.com

^b)ulf-kessler@hotmail.com

^c)rudolf.steffen@bluewin.ch

^d)h.merki@ggp.ch

^e)Joerg.Zehetner@hirslanden.ch

Background: Dumping syndrome is a known long-term complication of Roux-en-Y gastric bypass. Most often dumping can be avoided with dietary changes. Severe dumping syndrome is characterized by multiple daily episodes with significant impact on quality-of-life. As dumping correlates with rapid pouch emptying through a dilated gastrojejunostomy, the aim of this study was to assess endoluminal revision of the anastomosis regarding feasibility, safety and outcome.

Methods: From January 2016 to November 2017 we reviewed the electronic records of all patients with dumping syndrome undergoing endoluminal revision of the gastrojejunostomy with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details and outcome variables were recorded.

Results: There were 21 patients (M:F=6:15) treated with endoluminal revision for either dumping syndrome (n=13) or dumping syndrome and weight-regain (n=8). The median procedure time was 17 minutes (R 8-41), with a median number of 1 suture (range 1-3). There were no complications recorded within 30 days (no bleeding, no re-intervention, no infection, no dilation). All patients had treatment response, with 66.6% having resolved and 33.3% having improved symptoms. Recurrence of symptoms occurred in 6 (46.1%) of 13 patients treated for dumping only, of them 5 patients required a second Apollo intervention while 1 patient underwent laparoscopic pouch revision with placement of a silastic ring, with subsequent treatment response.

Conclusion: Endoluminal revision of the dilated gastrojejunostomy is a highly effective treatment for dumping syndrome after Roux-en-Y gastric bypass. Due to its endoluminal approach it is a very feasible and safe procedure, and effective for immediate symptom resolution in nearly all patients. In some patients repeat narrowing of the anastomosis is necessary for maintenance of symptom resolution.

O-110

Impact of implementation of an Enhanced Recovery After Surgery (ERAS) program in in laparoscopic Roux-en-Y gastric bypass: A prospective randomized clinical trial

Jaime Ruiz-Tovar^a), Carolina Llavero, Cesar Levano, Juan Gonzalez, Alejandro Garcia, Carlos Ferrigni, Montiel Jimenez-Fuertes, Manuel Duran, Damian Garcia-Olmo

Surgery, HOSPITAL REY JUAN CARLOS, Madrid, Spain

^a)jruiztovar@gmail.com

Objectives: The aim of this study was to evaluate the postoperative pain after implementation of an ERAS protocol in Roux-en-Y gastric bypass(RYGB) and compare it with the application of a standard care protocol.

Summary background data:The essence of Enhanced Recovery After Surgery(ERAS) programs is the multimodal approach and many authors have demonstrated safety and feasibility in fast track bariatric surgery.

Methods: A prospective randomized clinical trial of all the patients undergoing RYGB was performed. Patients were randomized into 2 groups: those patients following an ERAS program(ERAS) and those patients following a Standard Care protocol(SC). Postoperative pain, nausea or vomiting, morbidity, mortality, hospital stay and analytical acute phase reactants 24h after surgery were evaluated.

Results: 180 patients were included in the study, 90 in each group. Postoperative pain (16 vs 37mm; p<0.001), nausea or vomiting(8.9% vs 2.2%;p=0.05) and hospital stay (1.7 vs 2.8 days; p<0.001) were significantly lower in the ERAS group. There were no significant differences in complications, mortality and readmission. White blood cell count, serum fibrinogen and C reactive protein levels were significantly lower in the ERAS group 24h after surgery.

Conclusion: The implementation of an ERAS protocol is associated with lower postoperative pain, reduced incidence of postoperative nausea or vomiting, lower levels of acute phase reactants and earlier hospital discharge. Complications, reinterventions, mortality and readmission rates are similar to that achieved with a standard care protocol.

O-111

Gastro-esophageal reflux disease one year after one anastomosis gastric bypass

Georgia Doulami^a), Viktoria Michalopoulou^b), Stamatina Triantafyllou, Konstantinos Albanopoulos, Georgios Zografos, Dimitrios Theodorou

1st Propaedeutic Surgical Department, Hippokration General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece

^a)tzinagb@yahoo.gr

^b)victoria.michal@gmail.com

Background: One anastomosis gastric bypass (OGB) was introduced in 2001 as an alternative to “loop” gastric bypass. It was thought that it would eliminate alkaline reflux and associated esophagitis.

Objectives: Existing evidence about the postoperative incidence of gastro-esophageal reflux (GERD) following OGB is based on studies that use symptom questionnaires. The aim of our study was to study GERD 12 months after OGB by using 24h multichannel intraluminal impedance pHmetry (24h MIIpH).

Materials and methods: Morbidly obese candidates for OGB underwent 24h MIIpH prior and 12 months following their bariatric procedure.

Results: Eleven patients were included in this prospective study. Results of 24h MIIpH revealed that DeMeester score (40.48 vs 24.16, p=0.339) had an increasing trend 12 months after OGB. Acid reflux episodes decreased, whereas non-acid reflux episodes increased postoperatively, both in proximal and distal esophagus. Total median bolus clearance time and acid clearance time increased. De novo GERD developed in 2 patients (28.6%) and worsening of already existing GERD developed in all patients with preoperative evidence of GERD.

Conclusion: The use of symptom questionnaires in order to assess postoperative GERD following OGB does not accurately depict the real image. 24h MIIpH following OGB revealed an increase of total number of non-acid reflux episodes and a decrease of total number of acid reflux episodes, with longer duration of each acid reflux episode. Close postoperative follow up with reflux testing and possibly endoscopy could eliminate the risk of complicated GERD.

O-112

Long-term weight loss after Roux-en-Y gastric bypass is independant from age at baseline

Styliani Mantziari^{1, a)}, Anna Dayer-Jankechova^{1, 2, b)}, Nicolas Demartines^{1, c)}, Celine Duvoisin^{1, d)}, Pierre Allemann^{1, e)}, Pierre Fournier^{1, f)}, Michel Suter^{1, 2, g)}

¹⁾Visceral Surgery and Transplantation, Lausanne University Hospital, Lausanne, Switzerland

²⁾Department of Surgery, Riviera-Chablais Hospital, Aigle-Monthey, Switzerland

^a)styliani.mantziari@chuv.ch

^b)anna.dayer@hopitalrivierachablais.ch

^c)demartines@chuv.ch

^d)celine.duvoisin@chuv.ch

^e)pierre.allemann@chuv.ch

^f)pierre.fournier@chuv.ch

^g)michel.suter@hopitalrivierachablais.ch

Background: Several comparative studies have suggested that, despite overall satisfactory results, Roux-en-Y gastric bypass (RYGBP) was associated with less weight loss in older compared to younger patients. The aim of the present study was to analyze 10-year weight loss and metabolic results of RYGBP in a large cohort of consecutive patients in relation to patient age at surgery.

Patients and methods: Retrospective analysis of a prospectively maintained common bariatric database in two reference bariatric centers. Comparisons regarding total weight loss (%TWL), excess BMI loss (%EBMIL), serum glucose and lipid values were made using ANOVA between patients aged 39 years or less (Group A), 40 to 54 (Group B), and 55 or more (Group C).

Results: A total of 822 patients operated between 1999 and 2007 were included, 621 females and 201 males. Groups A, B, and C include 398, 337, and 87 patients respectively. Follow-up at 10 years was 75,5 %. Comorbidities were more common and length of stay longer in Group C. Group A had the highest %TWL and %EBMIL throughout the study period, but the difference was significant only until Year 6. There was no significant difference in %TWL or %EBMIL at any time point between groups B and C. As a result, BMI did not differ between groups after 10 years. 10-year lipid values did not differ between groups, but mean glycemia remained significantly higher at 10 years in Group C.

Conclusions: Results of RYGBP are better during the first 5-6 post-operative years in younger patients, but the differences fade away after 10 years. Lipid profile improvement was similar throughout age groups, whereas glycemic control remained better in younger patients. Age should not be a limiting factor for access to bariatric surgery, and notably to RYGBP, in patients with severe adiposity-related disorders.

O-113

Band and Extend? Results of 2 randomized controlled trials on RYGB improvement

Abel Boerboom^a), Wendy Schijns, Edo Aarts, Laura Deden, Mellody Cooiman, Theo Aufenacker, Bart Witteman, Ignace Janssen, Eric Hazebroek, Frits Berends

Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands

^a)aboerboom2@rijnstate.nl

Background: Despite the fact that the Roux-en-Y gastric bypass (RYGB) is performed to treat morbid obesity on a broad scale worldwide, there is no uniform technique for this operation. Banding the gastric pouch and different pouch sizes are used and investigated to improve weight loss after surgery. Following simple physical laws, banding the pouch and creating a longer gastric pouch may affect pouch dilatation and passage and therefore improve results. We present results from two randomized controlled trials (RCTs) in which the effect on weight loss of a banded RYGB (B-GB) and an extended pouch RYGB (EP-GB) was compared to a standard RYGB (S-GB).

Methods: In both studies the modified RYGB (B-GB and EP-GB) was compared with a S-GB. In each study a total of 130 patients were randomized into two groups. Subsequently, weight loss, morbidity, reduction of comorbidities, nutritional status, reflux and quality of life were measured during a follow-up of 2 years. The B-GB was created using a non-adjustable MiniMizer silicone ring and in the EP-GB a 15 cm long pouch was formed.

Results: In the 'Banded' study mean EWL after 24 months was 88% in the B-GB group versus 80% in the S-GB group (p=0.212) and in the 'Pouch' study, mean EWL was 77% in the EP-GB group versus 73% in the S-GB group (p=0.437). In four (6%) patients the MiniMizer ring was removed because of persistent dysphagia. No differences in other complications and nutritional deficiencies were found between the modified RYGB group and S-GB group in both studies.

Conclusion: Two years after surgery, no significant difference in weight loss were detected between the B-GB, EP-GB and S-GB group. Extension of follow-up of both RCTs is needed to assess if modications of the gastric pouch, such as the B-GB, may prevent weight regain in the long term.

O-114

Procalcitonin (PCT) as a marker of postoperative complications in bariatric surgery. A prospective study.

Laura Montana^{1, a)}, Jeremy Rouet^{1, b)}, Cedric Desbene^{2, c)}, Claude Polliand^{1, d)}, Nathalie Charnaux^{2, e)}, Christophe Barrat^{1, f)}

¹⁾Surgical Department, Universitary Hospital Center of Avicenne, Bobigny, France

²⁾Biochimic Department, University Hospital Center of Avicenne, Bobigny, France

^a)doc.laura.montana@gmail.com

^b)jeremy.rouet@aphp.fr

^c)cedric.desbene@aphp.fr

^d)claude.polliand@aphp.fr

^e)nathalie.charnaux@aphp.fr

^f)christophe.barrat@aphp.fr

Gastric leak is one of the most common bariatric surgery complications, reported in the 3-5% of cases after Sleeve Gastrectomy (SG) and Roux Y Gastric Bypass (RYGB). Several studies underlying importance of early detection of leak and different biological markers are proposed. The role of Procalcitonin (PCT) in bariatric surgery is not totally investigated, expecially after RYGB.

The aim of this study was to investigate the role of PCT in early detection of postoperative complications after bariatric procedures.

Beetween October 2016 and Jannuary 2017, 70 patients, 58 women (82.9%) and 12 men (17.1%), were prospectively included. Mean age was 41.9 years (21-65). Mean Body Mass Index (BMI) was 41.2 kg/m² (35-63). 24 patients were diabetics (34.2%), 26 patients (37.1%) presented hypertension and 53 patients (75.7%) presented Obstructive Sleep Apnea Syndrome. SG was perfomed in the 77.1% of cases (54 patients) and RYGB in the 22.9% of cases (16 patients).

PCT and C-Reactive Protein (PRC) were evaluated the day before operation and at the first, second and fourth postoperative day (POD). Computer Tomography (CT) scan with oral contrast administration was performed at the second POD when PRC was superior to 150 mg/ml or in the case of fever.

13 patients (18.5%) developed a postoperative complication. We recorded 2 cases of pneumopathy, 6 gastric leaks, 3 hematomas and 2 Upper Gastro Intestinal bleeding.

At second POD, patients with early postoperative complication presented PCT levels significantly higher than no complication group (p=0.009). A threshold value of 0.08 μg/l was identify detecting early postoperative complication with sensibility of 71% and specificity of 72%.

No significant difference were recorded in PRC (p= 0.097) and fibrinogen (p= 0,962) evolution. Body temperature was significantly higher (p=0.001) in early postoperative complication group. 37.7°C seems to be a threshold value detecting early postoperative complication with sensibility of 25% and specificity of 75%.

PCT seems to be usefull to detect early postoperative complication after bariatric surgery.

O-115

The influence of body weight on brain function and structure. The BARICO study: study rationale and protocol

Debby Vreeken^{1, 2, 3, a)}, Maximilian Wiesmann^{2, 3)}, Laura N. Deden¹⁾, Ilse A. Arnoldussen^{2, 3)}, Esther Aarts²⁾, Roy P.C. Kessels^{4, 5)}, Frank Schuren⁶⁾, Robert Kleemann⁷⁾, Eric J. Hazebroek¹⁾, Edo O. Aarts¹⁾, Amanda J. Kiliaan^{2, 3)}

¹⁾Bariatric Surgery, Rijnstate Hospital and Vitalys Obesity Clinic, Arnhem, Netherlands

²⁾Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands

³⁾Anatomy, Radboud university medical center, Nijmegen, Netherlands

⁴⁾Medical Psychology, Radboud university medical center, Nijmegen, Netherlands

⁵⁾Vincent van Gogh Institute for Psychiatry, Venray, Netherlands

⁶⁾Microbiology and Systems Biology Group, Netherlands Organisation for Applied Scientific Research (TNO), Zeist, Netherlands

⁷⁾Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, Netherlands

^a)dvreeken@rijnstate.nl

Background: Mid-life obesity is associated with structural brain changes, cognitive problems and neurodegenerative diseases. Body mass can be immediately decreased by rapid weight loss via bariatric surgery (BS) and has been found to be associated with improved cognitive function. However, cognitive benefit after BS is not equally exhibited across patients and decline of cognitive function and increase in body weight are reported as well. Due to the relatively short length of follow-up and small numbers of BS recipients described in literature, it is not revealed till now how BS may impact underlying degenerative processes in cognitive decline and Alzheimer’s disease.

Objectives: We aim to determine the longitudinal effect of BS on different measures of cognition, brain function and structure investigated with neuropsychological tests and (functional) MRI parameters. Secondary, we want to determine health and inflammation status of adipose tissue, liver and gut, in relation to brain structure and function and whether BS affects gut microbiota composition and whether these changes correlate with neuropsychological measures.

Methods: 150 Dutch patients (age 35-55, men and women) will be tested at different time-points using neuropsychological tests, questionnaires, blood and feces analyses before and after RYGB and analyses on several tissues collected during the surgery in order to measure cognition, health and inflammation status overtime (Figure 1). A subgroup of 75 participants will (in addition to the other parameters) be examined using (functional) MRI scanning to indicate executive function, grey and white matter volumes and cerebral blood flow.

Conclusion: The BARICO study has the potential to be the first to demonstrate whether brain structure and function changes occur after BS and relate this to the health status of different tissues and changes in gut-microbiota. More information on the mechanisms underlying obesity and cognitive problems can lead to better health campaigns and more targeted actions against obesity. Our data might ultimately support the development of personalized treatments against obesity in combination with BS and herewith the prevention/inhibition of neurodegenerative diseases.

O-116

Obstructive sleep apnea in obese patients; postoperative outcomes of postoperative pulse oximetry without preoperative OSA screening

Sophie L. van Veldhuisen^a), Ibrahim Arslan, Ignace M.C. Janssen, Frits J. Berends, Eric J. Hazebroek, Edo O. Aarts

Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands

^a)svanveldhuisen@rijnstate.nl

Introduction: Obese surgical patients with obstructive sleep apnea (OSA) have a higher risk of peri- and postoperative desaturations and subsequent morbidity and mortality. Currently, the best perioperative management of patients without known OSA remains unclear. Although routine OSA screening of bariatric surgical patients has been advocated, sleep studies are costly and time consuming. We hypothesized that bariatric patients can be safely monitored on the surgical ward by continuous postoperative pulse oximetry without preoperative screening for OSA.

Methods: All patients who underwent bariatric surgery between November 2011 and September 2017 were included in this retrospective cohort study. Patient files were reviewed for gender, diagnosis of OSA, usage of continuous positive airway pressure (CPAP), diabetes mellitus (DM) and perioperative details. Postoperatively, continuous pulse oximetry was administered on the surgical ward. Patients with less than two saturation measurements were excluded. Postoperative desaturations of <90% and <92% were defined clinically significant and were further assessed.

Results: 5703 patients were reviewed, of which 5282 met the inclusion criteria. 4197 (79.5%) were female. 684 patients (12.9%) had a preoperative OSA diagnosis. 1326 (25.1%) patients had DM, of which 290 (22%) had both OSA and DM. A desaturation <90% occurred in 4% of patients with OSA and in 2% of patients without diagnosed OSA (p<0.005), a desaturation <92% occurred in 10% and 4% (p<0.005), respectively. Complication rates were 10% and 7% (p<0.005). No patients were admitted to the medium or intensive care unit for OSA. In the group of diagnosed OSA patients, CPAP usage showed no significant difference in desaturations or complications. Additionally, patients with DM had significantly higher rates of desaturations and complications compared to patients without DM.

Conclusions: In this cohort of >5000 bariatric patients, postoperative admission to the medium care or intensive care unit was not required in patients with or without diagnosed OSA. These findings suggest that continuous postoperative pulse oximetry without preoperative OSA screening is a safe perioperative management strategy for obese patients who undergo bariatric surgery.

O-117

Self-efficacy in weight management, patient satisfaction and lifestyle habits after standard gastric bypass

Harilaos Pappis^{1, a)}, Iraklis Perysinakis^{1, b)}, Dimitra Kotsakou^{2, c)}, Alexia Katsarou^{1, d)}

¹⁾Third Surgical Department, HYGEIA Hospital, Athens, Greece

²⁾Anaesthesia Department, HYGEIA Hospital, Athens, Greece

^a)harry.pappis@gmail.com

^b)iraklisper@gmail.com

^c)dkotsakou@gmail.com

^d)katsaroualexia@gmail.com

Aim: To evaluate self-efficacy in weight management, patient satisfaction and lifestyle habits after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods: Bariatric patients that underwent LRYGB in a single Surgical Department were included in this study. Patients were followed up for five years with interviews. During follow up patients answered questions regarding their dietary habits and eating behavior, physical activity and their general satisfaction from surgery. Self efficacy in managing weight in the long term was evaluated with a 5-point Likert scale (0: no self-confident and 5: completely confident).

Results: Between 2007 and 2012, 114 patients were recruited to undergo LRYGB. Mean age of participants was 53±4.7 years and 81% of them were postmenopausal women. Among them, 92 (80%) complied with the follow-up protocol. Preoperative BMI was 44.7± 6.7 kg/m² whereas mean BMI one and five years postoperatively was 27.3±5.2 and 28.6±6.3 kg/m² respectively. Although we managed to keep in touch with most patients, the majority of them (74%) did not follow the dietary and life style instructions. At five years postoperatively 32% of patients declared having moderately improved their dietary habits and 38% had increased their physical activity. Additionally, regarding self-efficacy, 58% of patients rated themselves to 3 (moderately confident), 19% rated themselves to 4 (very confident) and 7% rated themselves to 5. This self-rated score was positively associated with the number of follow-up visits and negatively with time after surgery. Nearly all patients (96.8%) declared that they would re-undergo surgery if time went back and 57% declared that their life changed favorably in general.

Conclusion: Patients that decide to undergo LRYGB remain satisfied with their choice. Nevertheless, they admit that they should improve their weight management skills and efficacy. Dietary and physical activity habits do not seem to change favorably as well. In order to achieve life-long weight stabilization, the importance of prospective monitoring and counseling by the bariatric team should be emphasized.

O-118

Proven post-op weight maintenance factors and behavioral follow-through using Acceptance Commitment Therapy, Motivational Enhancement Therapy and Dialectical Behavior Therapy techniques by the entire multidisciplinary team

Connie Stapleton

Psychology, Mind Body Health Services, Inc., Augusta, United States

Cstapletonphd@gmail.com

Maintaining weight loss following bariatric surgery is often difficult for patients. Much research has been devoted to those behaviors that are effective in weight maintenance.

“...successful weight maintenance is associated with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviours. Weight maintenance is further associated with an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy, assuming responsibility in life, and overall more psychological strength and stability. Factors that may pose a risk for weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems.” 1

The interdisciplinary team can help post-op patients remain engaged in following through with those behaviors. Techniques from ACT therapy, Motivational Interviewing and Dialectical Behavior Therapy can be taught to all members of the treatment team to use when interacting with patients throughout their weight loss journey.

ACT is a behavioral therapy designed to guide people to mindfully change their behaviors in the direction of their deepest desires. ACT aims to help people live in mindful, values-congruent ways. A 2012 study shows "that WLS participants in the ACT condition significantly improve on eating disordered behaviors, body dissatisfaction, quality of life and acceptance for weight-related thoughts and feelings...” 2

The goal of MET is to help lead the client to achieve the goals they have set for themselves. Its aim is to provide the client with the opportunity to develop a focus in their life, other than their focus on unhealthy behavior. “A motivation-focused maintenance program offers an alternative, effective approach to weight maintenance expanding available evidence-based interventions beyond traditional skill-based programs.” 3

Research shows that dialectical behavior therapy strengthens a person’s ability to handle distress without losing control or acting destructively.

References

• 1. Elfhag, K. and Rössner, S. (2005), Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obesity Reviews, 6: 67–85. doi:10.1111/j.1467-789X.2005.00170.x

• 2. Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Weineland, Sandra et al. Obesity Research & Clinical Practice, Volume 6, Issue 1, e21 - e30

• 3. West DS1, Gorin AA, Subak LL, Foster G, Bragg C, Hecht J, Schembri M, Wing RR. A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach. Int J Obes (Lond). 2011 Feb;35(2):259-69. doi: 10.1038/ijo.2010.138. Epub 2010 Aug 3

O-119

Nutritional status of vegetarian candidates for laparoscopic sleeve gastrectomy

Shiri Sherf-Dagan^{1, a)}, Keren Hod^{1, b)}, Assaf Buch^{2, c)}, Limor Mardy-Tilbor^{1, d)}, Ziva Regev^{3, e)}, Tair Ben-Porat^{4, f)}, Nasser Sakran^{5, 1, g)}, David Goitein^{6, 1, h)}, Asnat Raziel^{1, i)}

¹⁾Assuta Medical Center, Tel-Aviv, Israel; ²⁾Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; ³⁾Nutrition, Maccabi Healthcare Services, Tel-Aviv, Israel; ⁴⁾Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; ⁵⁾Department of Surgery A, Emek Medical Center, Afula, Israel; ⁶⁾Department of Surgery C, Sheba Medical Center, Tel Hashomer, Israel

^a)shirisherf@gmail.com

^b)kerenh@assuta.co.il

^c)buchasaf@gmail.com

^d)limorm@assuta.co.il

^e)zivaregev10@gmail.com

^f)tairbp20@gmail.com

^g)sakranas@walla.com

^h)david.goitein@sheba.health.gov.il

ⁱ⁾drraziel@zahav.net.il

Introduction: Data on vegetarianism and bariatric surgery (BS) are limited. We herein describe the nutritional status of vegetarian patients who plan to undergo laparoscopic sleeve gastrectomy (LSG).

Methods: Cross-sectional analysis of a prospectively maintained database of all primary LSG performed at a bariatric center of excellence between 2014 to 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplementation use, physical activity, smoking habits, co-morbidities and blood tests. Each vegetarian was matched to five different omnivores based on age, gender and BMI.

Results: During the study period, 1,470-patients underwent primary LSG surgery (63.7% females). Twenty one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG-candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3% vs. 47.1%;P=0.007), lower ferritin levels (54.3±50.5 vs. 96.8±121.8 ng/ml;P=0.052) and higher transferrin levels (313.9±42.7 vs. 278.4±40.4 mg/dl;P=0.009) among the vegetarian cohort. Preoperative use of vitamin B12 and iron supplementation was higher among vegetarian LSG-candidates than their omnivore counterparts (57.1% vs. 6.7%;P<0.001 and 23.8% vs. 6.7%;P=0.015, respectively).

Conclusions: Vegetarians have comparable health status and nutritional deficiencies, lower iron-stores and higher supplementation use before surgery compared to omnivore LSG-candidates.

O-120

The role of adjuvant pharmacotherapy in the management of patients with a partial response to bariatric metabolic surgery-the first Australian experience

Georgia Rigas^{1, a)}, Michael L Talbot¹⁾, Charmaine Tam²⁾

¹⁾Bariatric Metabolic Unit, St George Private Hospital Kogarah, Sydney, Australia; ²⁾School of Information Technologies, University od Sydney, Camperdown, Sydney, Australia

^a)GeorgiaR@uppergisurgery.com.au

Introduction: Bariatric /metabolic surgery induces clinically significant weight-loss in the majority of patients, but is known to be individually variable in its effectiveness. In the estimated 5-10% of patients with a sub-optimal/partial response to surgery, there are few adjuvant options other than lifestyle modification and consideration of surgical revision.

Objective: The aim of this study was to investigate the efficacy and tolerability of liraglutide as an adjunct in patients with a partial response to metabolic surgery.

Methods: We performed a retrospective audit of patients after laparoscopic sleeve gastrectomy (LSG), laparoscopic gastric bypass (GBP) or laparoscopic gastric band (LAGB) who had earlier than anticipated weight-loss plateaus and were motivated to undertake adjuvant therapy to augment weight loss. Patients commenced liraglutide (1.8- 3.0 mg /day up to 28 weeks) between May 2016 - December 2017 and were followed up after 1, 4 and 7 months of liraglutide treatment.

Results: Data was collected from n= 67 patients, 48 of which had a primary bariatric procedure (18LAGB, 26LSG, 4GBP) and were included for analysis. There were 43 females and 5 males. The median age was 40 years (range=17 to 68), median pre-op BMI was 42.3kg/m2 (31.4-63.5).

After liraglutide treatment, the median percent weight loss was -3.7% (range= -11.5 to 2.3) at 1 month (n=40), -10.2% (range= -15.1 to 0.6) at 4 months(n=16) and –13.4% (range=-32.8 to –7.2) at 7 months (n=6).

The most common reasons for discontinuing adjuvant pharmacotherapy were: cost(n=16), sufficient weight loss according to the patient (n=8) and side effects (n= 7); nausea (n=3/7) and lethargy (n=2/7).

Conclusion: In the context of limited treatment options, liraglutide can be used effectively as an adjuvant to induce further weight loss in patients who have had a partial response to bariatric surgery, and is an overall well-tolerated pharmacotherapy. Follow-up of metabolic surgery patients on liraglutide treatment is ongoing.

Acknowledgement: Drs: Talbot, Loi, Yee, Maani for providing bariatric patients for adjuvant therapy. Dr Charmaine Tam for performing data analysis

O-121

Bariatric surgery as a salvage operation in critically ill/septic superobese patients - an option ?

Kamil Yamac^a), Julian W Mall^b)

Department of General Surgery, German Competence Center For Bariatric Surgery, KRH Klinikum Region Hannover, Hannover, Germany

^a)kamyam82@gmail.com

^b)julian.mall@krh.eu

Introduction: There are approximately 150.000 sepsis cases a year in Germany. Obese patients become more septic than non-obese patients. But obese patients survive at least 1 year after sepsis more often than non-obese patients regarding to literature.

Should metabolic surgery be considered in morbidly obese septic patients, and if so, when?

Material and Methods: In our clinic we peformed 5 bariatric operations to septic super obese patients between 2014-2017. The algorithm of Klinikum Nordstadt in sepsis consist of initial sepsis therapy (volume, catecholamines, antibiotics), focus search and possibly treatment, calculated antibiotic therapy, pulmonary stabilization (tracheostomy, bronchoscopy), renal replacement therapy, cytokine filter.

Results: In 3 of 5 cases patients resolved and discharged to rehab. The other 2 patients died, one of them due to pulmonary embolism, the other after multi organ failure.

One of the finally convalescent patients was transferred to our department after being given up in our hospitals department of traumatology with an jump joint empyem in an extremely septic condition with multi organ failure after a frustran trial of 14 days treatment over there. Her BMI was 80 kg/m². Before that, she was already treated for a month in another hospital. After taking over the patient we decided to perform the salvage sleeve gastrectomy in an interdisciplinary decision and with the life partners permission of the intubated patient. The operation was without complication after changing the antibiotics and subsiding the next bacteremia. 26 days after operation the patient discharged to external rehab clinic. In the 2 months control the patient recovered with almost complete healed empyem.

Conclusion: It is a difficult decision to lead superobese patients, who are admitted to sepsis, for metabolic surgery. Interdisciplinarity is essential. Fully exploit the potential to optimize patients before surgery. The right time for operation remains unclear. Whether and how patients benefit pathophysiologically from metabolic surgery is unclear? Conclusions are always vague with individual cases and small case numbers of multimorbid obesity / intensive care patients.

References

1. Vachharajani V, Vital S, Obesity and sepsis 2006. Sept.-Oct;21(5):287-95 J Intenisve Care Med.

2. Bilski1, A.I. Mazur-Bialy1, M. Wierdak2, T. Brzozowski2, The Impact Of Physical Activity And Nutrition On Inflammatory Bowel Disease: The Potential Role Of Cross Talk Between Adipose Tissue And Skeletal Muscle

3. Pepper et al. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock:a systematic review and meta-analysis. Crit Care.2016;20:181.

4. Seymour CW; JAMA 2016;315:762.

O-122

Analgesic effect of laparoscopic-guided Transversus Abdominis Plane blockade vs Port-site infiltration as analgesic multimodal approach after Roux-en-Y gastric bypass: A prospective randomized study

Jaime Ruiz-Tovar^a), Carolina Llavero, Alejandro Garcia, Juan Gonzalez, Carlos Ferrigni, Cesar Levano, Montiel Jimenez-Fuertes, Manuel Duran, Damian Garcia-Olmo

Surgery, HOSPITAL REY JUAN CARLOS, Madrid, Spain

^a)jruiztovar@gmail.com

Introduction: Multimodal analgesia consists in the administration of diverse anaesthetic or analgesic drugs by different ways, to reduce the postoperative needs of opioids. Local anaesthetics are the most frequently used. In laparoscopic surgery, they are mostly employed for a port-site infiltration.

Transversus abdominis plane (TAP) blockade consists in the injection of local anaesthetic in the anatomical space between the internal oblique muscle and the transversus abdominis, in order to block the afferent somatic fibers, innervating the anterior abdominal wall. This blockade is usually ultrasound-guided performed. However in the obese patient, ultrasonography has a low accuracy for the guidance of the infiltration.

Patients and Methods: A prospective randomized clinical trial of patients undergoing Roux-en-Y gastric bypass was performed. Patients were randomized into 2 groups: those ones undergoing laparoscopic-guided TAP (TAP-lap) and those ones undergoing port-site infiltration (PSI). Both infiltrations were performed with 20 ml Bupivacaine 0.5%. Postoperative pain 24h after surgery, as measured by VAS, morphine needs and hospital stay were evaluated.

Results: 126 patients were included, 63 in each group. There were no significant differences in age, gender, comorbidities, baseline BMI, operation time and postoperative complications between groups. Mean postoperative pain 24h after surgery was 16,8 + 11,2mm in PSI and 10 + 8,1mm in TAP-lap(p=0,001). Morphine rescues were necessary in 12.7% in PSI and 3.2% in TAP-lap (p=0,048). Mean hospital stay was 2.3 + 1.2 days in TAP-lap and3.1 + 2.5 days in PSI (p=0,019). Hospital discharge during the first 48h after surgery was possible in 50,8% of the patients in PSI and 69.8% in TAP-lap (0,029).

Conclusion: Laparoscopic-guided TAP reduces postoperative pain, opioid needs and hospital stay, when compared with port-site infiltration with the same anaesthetic drug.

O-123

First things first: pregnancy or bariatric surgery?

Laura Heusschen¹⁾, Ignace Janssen²⁾, Merien Ashley²⁾, Edo Aarts²⁾

¹⁾Wageningen University & Research, Wageningen, Netherlands

²⁾Rijnstate Hospital, Arnhem, Netherlands

Background: Timing of pregnancy and bariatric surgery can be an important clinical challenge considering the increasing number of bariatric procedures in females of reproductive age. Though bariatric surgery decreases the risk of several obstetrical and neonatal complications in following pregnancies, it is still unclear if pregnancy during the first eighteen months after surgery is safe due to active weight loss and nutritional deficiencies.

Study design: Retrospective study including 75 pregnancies following bariatric surgery and 64 control pregnancies in obese (BMI ≥ 30 kg/m2) non-operated women. Data were extracted from medical records at the Rijnstate hospital, a large bariatric center in Arnhem, the Netherlands. Analyses were performed using multiple logistic regression models (binary data) and general linear models (continuous data), while controlling for maternal age, gravidity, parity and smoking.

Results: Women who became pregnant following bariatric surgery gained less weight (7.3 vs 12.4, (p = 0.001), had a lower risk of gestational diabetes (AOR, 0.06; 95% CI, 0.01 – 0.45) and caesarean sections (AOR, 0.30; 95% CI, 0.12 – 0.77) compared to non-operated obese women. Neonates who were born post-surgery had lower birth weight (3267 vs 3693, p < 0.001), birth length (49.9 vs 51.8, p < 0.001) and weight-for-age percentiles (46.7 vs 70.9, p < 0.001), and a lower risk of being large-for-gestational age (AOR, 0.31; 95% CI 0.13 – 0.76) compared to neonates from non-operated obese women.

The time from surgery to conception was not associated with any of the pregnancy and neonatal outcomes, except for gestational weight gain (r = 0.324, p = 0.006).

Conclusion: Practitioners should recommend a one year delay in becoming pregnant after surgery as a safe interval, and to minimize the risk of insufficient gestational weight gain or weight loss during pregnancy. Above all, special obstetric attention on fetal growth and maternal nutritional status during pregnancy should be guaranteed to women with a history of bariatric surgery.

V-001

Surgical treatment for Nesidioblastosis after Roux-en-Y gastric bypass.

Hadar Nevo^a), Nasser Sakran^b), Ron Dar^c)

Surgery A, Emek Medical Center, Afula, Israel

^a)hadaraboody@gmail.com

^b)sakrans@walla.co.il

^c)ron_dr@hotmail.com

Morbid obesity prevalence is increasing worldwide, and is associated with co-morbidities and a higher mortality rate compared to the non-obese population[i]. Roux-en-Y gastric bypass (RYGB) accounts for more than one third of metabolic operations in the world, with high and sustained excess weight loss percentages in most publications.

As data accumulated in the literature, concerns about several medical and surgical complications were raised. Among medical complications, most common complications are vitamin and nutritional deficiencies, early dumping 'syndrome', and postprandial hyperinsulinemic hypoglycemia (PHH) - Nesidioblastosis. PHH is a condition characterized by hypoglycemic symptoms occurring 1–3 hours after a meal, accompanied by low plasma glucose values, typically preceded by a high rise in both glucose and insulin concentrations[iii].

The incidence of PHH is unknown, and probably underdiagnosed as many patients are asymptomatic. Recurrent hypoglycemia is known to cause dementia, reduce quality of life, and increase all-cause mortality. Moreover, an increased rate of accidental deaths among patients who have undergone RYGB has been reported, and it is speculated that it could be the result of severe hypoglycemia[iv].

The goal for any treatment of PHH after RYGB is to moderate postprandial excursions in plasma glucose, reduce insulin secretion, and ultimately reduce hypoglycemia. Therapeutic options can be divided to medical and surgical. Medications that help control PHH are scarce, and patients are most commonly encouraged to follow dietary modifications. In cases of refractory patients, surgical treatment options include partial or total pancreatectomy, or a reversal procedure of RYGB accompanied with gastric pouch restriction[v].

A 27 year old morbid obese female underwent Roux-en-Y gastric bypass at 2013.Two years post surgery she developed severe hypoglycemic episodes which included tremor, palpitations and syncope episodes. She was diagnosed with nesidioblastosis (PHH). Despite dietary modification and medical treatment the episodes increased in severity & frequency. The surgical options discussed with the patient. A conversion of the Roux-en-Y gastric bypass to sleeve gastrectomy took place in our institution with excellent results.

References

[i] L. Sjöström. Review of the key results from the Swedish Obese Subjects (SOS) trial - A prospective controlled intervention study of bariatric surgery. J Intern Med, 273 (3) (2013), pp. 219–234

[ii] Colquitt JL1, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. bCochrane Database Syst Rev. 2014 Aug 8;(8):CD003641. doi: 10.1002/14651858. CD003641. pub4

[iii] P. Ritz, H. Hanaire. Post-bypass hypoglycaemia: a review of current findings. Diabetes Metab, 37 (4) (2011), pp. 274–281

[iv] D.A. Roth, R.C. Meade. Hyperinsulinism-hypoglycemia in the postgastrectomy patient. Diabetes, 14 (1965), pp. 526–528

[v] T. Mala. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis, 10 (6) (2014), pp. 1220–1225

V-002

Prevention of reflux-esophagitis after laparoscopic sleeve gastrectomy by creating a three-chambered gastric sleeve

Alexander Khitaryan^a), Arut Mezhunts^b), Olesya Starzhinskaya^c)

Surgical department, Rostov State Medical University, Rostov-on-Don, Russian Federation

^a)khitaryan@gmail.com

^b)arut.mezhunts@mail.ru

^c)starg@yandex.ru

Abstract: Laparoscopic sleeve gastrectomy (LSG) has become the most popular bariatric procedure in the world. It is happened because the bariatric surgery is the very effective means to sustain weight loss. However, some published follow-up studies report an increased rate of gastro-esophageal reflux disease (GERD) after a LSG. How to prevent the gastro-esophageal reflux, after LSG, is an important question at the moment.

Method: We developed and applied the new surgical technique of LSG with three-chamber gastric sleeve as a method of preventing GERD after surgery.

The surgery was performed in a standard split-leg French position using 5 laparoscopic ports. Patients were in chair- position. A special 32-French calibrating bougie with the balloon on the end was passed through the stomach before creating the three-chamber gastric sleeve. The sleeve was made with a linear laparoscopic stapler. The calibration tube is designed to form three gastric chambers of different length and volume. The most important step of this technique is the formation of a long (up to 7 cm) upper post-esophageal gastric chamber of a minimal volume (20 ml). The calibrating bougie was then pulled proximally and the distal balloon was inflated to a larger volume at each subsequent stage. Second chamber should be 10 cm long and 50 ml in the volume. The third pre-pylorus chamber was formed by a length of 5 cm and a volume of 60 ml.

Conclusion: The main mechanism of antireflux effect was possible because of the narrowness of the post-esophageal gastric chamber with its weak peristaltic activity and food evacuation due to peristaltic activity of the esophagus. This method showed a positive dynamics in our patients with GERD symptoms one year after LSG and therefore should be studied in the future.

V-003

Early Small Bowel Obstruction after Bariatric Surgery: Stratefy For Successful Laparoscopic Management

Charalampos Markakis^a), Ravi Aggarwal, Kai Tai Derek Yeung, Ahmed Ahmed

Bariatric Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom

^a)harismarkakis@hotmail.com

Aims: The purpose of this video is to present our experience with patients presenting with early bowel obstruction after bariatric surgery. We describe the patients' clinical presentation and demonstrate successful laparoscopic management.

Methods: We retrospectively searched our surgical database for all patients presenting with bowel obstruction within 30 days of discharge in the last 18 months. We reviewed the patients' notes, radiology and the video recording of the surgical procedures.

Results: 6 patients were reoperated for small bowel obstruction within 30 days of their bariatric procedure. Causes included port site hernia (2 patients), umbilical hernia (2 patients), jejunojejunostomy stricture (1 patient) and mesenteric haematoma causing small bowel kinking (1 patient).

All patients were successfully managed laparoscopically. There was no need for bowel resection. There were no postoperative complications.

Conclusion: Early small bowel obstruction after bariatric surgery is uncommon. However, when patients represent with small bowel obstruction, they need to be aggressively investigated and treated without delay. Diagnostic laparoscopy should always be the preferred approach as in most cases laparoscopic management is feasible and will result in lower morbidity.

V-004

Postoperative case: Unusual case of an upper GI bleeding years after Roux-en-Y Gastric Bypass

Maria Solovyeva^{1, a)}, Andrey Velicorechin^{2, b)}

¹⁾City Center of Bariatric and Metabolic Surgery, St. George City Hospital, Saint Petersburg, Russian Federation; ²⁾General Surgery, The Nikiforov Russian Center of Emergency and Radiation Medicine, Saint Petersburg, Russian Federation

^a)mar-sol@mail.ru

^b)velikorechin@yandex.ru

One of the possible complications after bariatric surgery is bleeding. In the majority of cases bleeding in the later stages of the postoperative period are intraluminal, with clinical manifestations of high gastrointestinal bleeding. Among all bariatric procedures, the development of this complication is more common after Roux-en-Y gastric bypass. Upper endoscopy is the diagnostic and treatment method of choice, but only bleeding in the gastric pouch or in the gastroenteroanastomosis can be stopped in this way. If localization of bleeding is in the remnant stomach or duodenum and small intestine, it is necessary to use more advanced endoscopic procedures.

Male patient, 44 years old with BMI 43 kg/m2 and comorbidities (Diabetes Mellitus type 2, decompensated in patient receiving hypoglycemic drugs), was undergone laparoscopic Roux-en-Y gastric bypass in October 2014. During the year %EWL was 81%, there was compensation of diabetes without medication (HbA1 4,9%).

In January 2016 he was hospitalized in a clinic in St. Petersburg with signs of upper gastrointestinal bleeding. He has a history of melena during the last 5 days with an episode of syncope in the hospital day. Hemoglobin was 88 g/l. Upper endoscopy and colonoscopy were performed without identification of source of bleeding. Drug therapy was conducted. A few days later the patient was transferred to our hospital with no signs of ongoing bleeding. Balloon-assisted enteroscopy was performed. Duodenal ulcer with no signs of bleeding was visualized. Endoscopic hemostasis wasn’t needed. The patient was discharged the next day. Course of anti-ulcer therapy performed.

In January 2017 the patient was admitted again to a surgical hospital with the signs of GI bleeding

Laparoscopic gastrotomy, transgastric gastroduodenoscopy (ulcer of the anterior wall of the duodenal bulb was confirmed, bleeding stopped Forrest IIc). Laparoscopic resection of the stomach and duodenal bulb.

APO revealed duodenal ulcer, stomach - hyperplasia of the underlying glands.

Uneventful recovery. The patient was discharged at 5th postoperative day.

V-005

Redo Laparoscopic Sleeve Gastrectomy. Technical Aspects to Prevent Stenosis and Late Leak Subsequent to Stomach Antrum Twisting

Georgios Ayiomamitis^a), Paraskevas Grivas^b), Athanasios Liarakos^c), Christina Kontopoulou^d), Nikolaos Paschalidis^e)

1st Surgical Department, Tzaneio General Hospital, Piraeus, Greece

^a)agiogeo@gmail.com

^b)grivas.endocrine.surgery@gmail.com

^c)ttzotzos@yahoo.com

^d)chkontopoulou@gmail.com

^e)dr.npasxalidis@gmail.com

Background: Redo bariatric procedure is the only substantial treatment for weight regain after a failed bariatric procedure.

Aim: To present a redo laparoscopic sleeve gastrectomy (LSG) after a failed laparoscopic adjustable gastric band (LAGB) and describe all the technical details to prevent stomach antrum twisting leading to stenosis and possible late leak.

Methods and Results: In redo, bariatric procedures because of the previous operations either performed open or even laparoscopic, various and multiple adhesions especially to the stomach are usually experienced. Bariatric surgeons must proceed with extensive and meticulous adhesiolysis and free-up the stomach from any attachments to the liver, posteriorly to the pancreas, mesocolon, and omentum. It is imperative for the stomach to return to the original anatomy in order to prevent tension forces due to adhesions while stapling the stomach. Stapling the antrum near the incisura twisting effects are created, while changing stapling angles. Adhesions and attachments especially of the omentum to the antrum can increase twisting forces that lead to gastric outlet stenosis or obstruction and subsequent leak.

Conclusions: Stomach twisting is quite frequent especially while stapling the stomach antrum after redo LSG. It is suggested to free-up the stomach completely from its adhesions with the surrounding viscera especially with the omentum, in order to minimize the possibility of stomach twist, stenosis, obstruction and leak.

V-006

Solution of severe reflux post LSG, post RNY: Toupet “fundoplication” with the remnant sleeve stomach (case report)

Biborka Dr. Bereczky^{1, a)}, Zaid Dr. Abdulaziz^{1, b)}, Bruno Dr. Dillemans^{2, c)}, Farah Ibrahim Bakhit Juma^{1, d)}

¹⁾Bariatric Surgery Center, General Surgery Department, Dubai Hospital, DHA, Dubai, United Arab Emirates; ²⁾Obesity Surgery Center, AZ Sint-Jan Hospital, Bruges, Belgium

^a)drbiborka.bereczky@gmail.com

^b)drzaid@emirates.net.ae

^c)bruno.dillemans@azsintjan.be

^d)farah_bakhit@hotmail.com

Background: A 31 years old female patient with not known comorbidities underwent laparoscopic sleeve gastrectomy (LSG) in 2011 (original BMI: 45.2 kg/m², 110kg) and lost her weight until 65 kg after 1 year. In 2014 laparoscopic Roux-en-Y gastric bypass (RNY) was performed due to 15kg weight regain (pre-RNY: 80kg, lowest weight post-RNY:70kg).

Material and methods: In 2017 she has presented with nausea, vomiting and severe reflux inspite receiving high dose PPI (Pantoprazole po tds). Gastroscopy showed sliding hiatus hernia and incompetent cardia, Z-line at 34cm. CT-scan has confirmed assymetric wall thickening of the herniated pouch. With upper GI series supradiaphragmatic narrowing was visualized. Her case has been discussed at BARIALINK Academy and besides Hill’s procedure, cardiopexy with ligamentum teres hepatis was suggested as alternative surgical solution.

Result: Diagnostic laparoscopy was performed where large sliding hiatus hernia was found with intrathoracally migrated gastric pouch. First cruroplasty was made. The ligamentum teres hepatis was too short to be used for cardiopexy, therefore the long remnant sleeve stomach with intact vascularization was brought from medial to lateral from behind the pouch and has been used for "fundoplication" as per Toupet (270 degree). From left lateral edge of the esophagus 4 interrupted 2/0 Ethibond stitches and from medial side 3 stitches were used to form the Toupet cuff. This proximal medial cuff was also fixed to the left crus with one suture. 36Fr orogastric tube was passing freely without resistance. The early postoperative period went without complications. 6 weeks postoperatively she was able to eat and drink, her reflux symptoms resolved completely, currently not using any PPI and returned to her everyday activity.

Conclusion: Surgical treatment of complications from revisional surgeries is a challenging task, where using non-conventional methods has place. Our unique procedure hasn’t been described before. The short-term outcome is excellent as the surgery resulted complete resolution of her symptoms. Longer follow-up and further studies needed to verify the clinical efficacy of the procedure.

References

• Hill LD, Chapman KW, Morgan EH. Objective evaluation of surgery for hiatus hernia and esophagitis J Thorac Cardiovasc Surg 1961:41:60.

• Hill LD. Intraoperative measurement of lower esophageal sphincter pressure. J Thorac Cardiovasc Surg 1978,75:378-382.

• Rossetti M, Hell K. Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia. World J Surg

• Technique of Hill's Gastropexy Combined with Sleeve Gastrectomy for Patients with Morbid Obesity and Gastroesophageal Reflux Disease or Hiatal Hernia. Sánchez-Pernaute A, Talavera P, Pérez-Aguirre E, Domínguez-Serrano I, Rubio MÁ, Torres A. Obes Surg. 2016 Apr;26(4):910-2.

• Hill procedure for recurrent GERD post-Roux-en-Y gastric bypass. Pescarus R1, Sharata AM2,3, Dunst CM2,3,1, Shlomovitz E1, Swanström LL2,3,4, Reavis KM5,6,7.Surg Endosc. 2016 May;30(5):2141-2.

• Management of Gastroesophageal Reflux Disease and Hiatal Hernia Post Sleeve Gastrectomy: Cardiopexy with Ligamentum Teres Salman Alsabah, Shehab Akrouf, Mohanad Al-Hadad, Jonathon Vaz, Surgery for Obesity and Related Diseases, Vol. 12, Issue 7, S185, Published in issue: August 2016

• Management of gastroesophageal reflux disease and hiatal hernia post–sleeve gastrectomy: cardiopexy with ligamentum teres Salman Al-Sabah, Shehab Akrouf, Mohannad Alhaddad, Jonathon D. Vaz Surgery for Obesity and Related Diseases Published online: September 1, 2017 – in press

• IFSO London 2017 Conference material

V-007

Laparoscopic repair of giant hiatus hernia and Roux en Y Gastric Bypass

Lydia Eleni Ioannidi^a), William Lynn^b), Naim Fakih^c), Marco Adamo^d), Mohamed Elkalaawy^e), Majid Hashemi^f)

Bariatric Surgery, University College London Hospital, London, United Kingdom

^a)lydiaioannidi@gmail.com

^b)william.lynn1@nhs.net

^c)n.fakih@nhs.net

^d)marco.adamo@nhs.net

^e)mohamed.elkalaawy@nhs.net

^f)majid.hashemi@nhs.net

Repair of Giant Hiatus hernia: Full hiatal dissection. Hernia fully reduced. Dissection up to mid thorax.Hiatal defect closed.

Gastric bypass: Omentum divided longitudinally. Ligament of Treitz identified. Bilio-pancreatic limb measured. Entero-entero anastomosis fashioned side by side using triple stapling technique.

Proximal small vertical 15-20 ml gastric pouch created by complete division of the medial upper part of the stomach. Gastric division commenced on the lesser curvature near the 2nd branch of the left gastric vein (divided) and taken toward the His angle. Perigastric dissection carried out on the lesser curvature in order to expose gastric serosa and to preserve ramifications of the vagal nerve. Single transverse firing followed by subsequent linear stapler firings heading to the left crus (to complete the pouch. Blue cartridges were employed. End to side anastomosis between the gastric pouch and the alimentary limb .

Anvil was loaded in the gastric pouch the remnant stomach. Gastrotomy was then closed by suture. Circular stapler inserted into the abdominal cavity through an extended port site incision in the left upper quadrant and gastro-jejunostomy performed. Air leak test negative. Mesenteric defects, at the level of the jejunojejunostomy and between the mesocolon and the mesentery of the Roux limbs (Petersen defect), closed by non-absorbable suture

V-008

Laparoscopic Conversion from Vertical Banded Gastroplasty with Hiatal Hernia Associated to Roux-en-Y Gastric Bypass

María Recarte^{1, a)}, Ramón Corripio^{1, b)}, Gregorio Vesperinas¹⁾, Joaquín Díaz²⁾

¹⁾Obesity Medical&Surgical Unit, “La Paz” University Hospital, Madrid, Spain; ²⁾General and Digestive Surgery, “La Paz” University Hospital, Madrid, Spain

^a)mariarecarterico@gmail.com

^b)rcorripio@icloud.com

Background & aims: Obesity is a significant independent risk factor for gastroesophageal reflux disease (GERD) and hiatal hernia (HH)^1,2. In appropriately selected patients, laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most durable method of weight loss and control of obesity-related comorbidities¹. Vertical banded gastroplasty (VBG) was developed in 1980 by Dr. E.E. Mason. Despite the initial success of gastric restrictive operations, many patients require revision for weight gain or anatomical/functional complications³.

Conversion from VBG to RYGBP is often considered the best option4.

Objectives: We report the case of a patient who underwent laparoscopic conversion to RYGBP after failed VBG due to weight gain and recurrent HH type III.

Material & methods: 52 years old-female with BMI of 44,7 Kg/m2 who underwent VBG and HH repair in 2000. Thirteen years later, she complained of weight gain, epigastric pain and vomiting.

Before revisional surgery, we performed a barium upper gastrointestinal study where a paraesophageal hernia was identified. The case was discussed at our multidisciplinary meeting and laparoscopic revisional surgery and concomitant HH repair were proposed.

Results: The patient underwent laparoscopic conversion from VGB to RYGB with concomitant HH repair in March 2013.

A five port technique laparoscopic approach is performed. All adhesions between the liver and the stomach were taken down and the hiatus was dissected. The HH was reduced from the thorax to the abdominal cavity, the gastric pouch was created and the crura were reapproximated anteriorly with interrupted permanent sutures. Finally, the conversion to RYGBP was completed.

The patient's postoperative course was uneventful. No leakage of contrast was observed in the upper GI contrast study.

Conclusions: Revisional bariatric surgery is technically challenging but it can be safely performed in experienced hands⁴.

HH repairs with Nissen fundoplication generally fail in patients with BMI greater than 35 Kg/m2 ^5,6 and laparoscopic RYGBP is becoming the treatment of choice for GERD and hiatal hernia in the morbidly obese population^1,6,7.

References

1- Robert B. Yates, Brant K. Oelschlager, Carlos A. Pellegrini. CHAPTER 42: Gastroesophageal Re ux Disease and Hiatal Hernia. Sabiston Textbook os Surgery. The Biological Basis of Modern Surgical Practical. Towsend, Beauchamp, Evers, Mattox. 20th Edition. Elsevier.

2- L.E. Duinhouwer et al. Treatment of giant hiatal hernia by laparoscopic Roux-en-Y gastric bypass. International Journal of Surgery Case Reports 9 (2015) 44-46.

3- Khan M, Lee F, Ackroyd R. Revision of Vertical Banded Gastroplasty Complicated by a Large Paraésophageal Hernia. OBES SURG (2010) 20:960-963.

4- Suter M, Ralea S, Millo P, Allé J.L. Laparoscopic Roux-en-Y Gastric Bypass After Failed Vertiacl Banded Gastroplasty: a Multicenter Experience with 203 Patients. OBES SURG (2012) 22: 1554-1561.

5- Vishal Kothari et al. Impact on Perioperative Outcomes of Concomitant Hiatal Hernia Repair with Laparoscopic Gastric Bypass. OBES SURG (2012) 22:1607-1610.

6- Salvador-Sanchís J.L et al. Treatment of Morbid Obesity and Hiatal Paraesophageal Hernia by Laparoscopic Roux-en-Y Gastric Bypass. OBES SURG (2010) 20:801-803.

7- Zainabadi K et al. Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients. Surg Endosc (2008) 22:2737-2740.

V-009

Laparoscopic conversion of gastric bypass into sleeve gastrectomy

Romano Schneider^a), Ralph Peterli^b)

Departement of Visceral Surgery, St. Claraspital, Basel, Switzerland

^a)romano.b.schneider@gmail.com

^b)ralph.peterli@claraspital.ch

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has the potential advantage to be reversed into normal anatomy or into sleeve gastrectomy (SG), when weight regain is to be prevented.

Methods: We present a case of a 50-year-old female patient with an initial BMI of 38.8 kg/m² with a history of LRYGB 7 years prior to the revision. The patient developed severe micronutrient deficiency with an unclear neuro-cognitive disorder in spite of consequent supplementation. After the positive effects of the re-nourishment over a temporarily placed gastrostomy tube, the indication for reversion of the LRYGB was discussed in our interdisciplinary team. To prevent secondary weight regain we decided to convert the LRYGB into a sleeve gastrectomy (SG) simultaneously.

Results: In our video recording we show the successful laparoscopic conversion of a LRYGB into a SG. For the anastomosis of the gastric pouch to the remaining stomach an end-to-end 25mm circular stapler anastomosis along the lesser curvature was applied. Subsequently, the SG was performed along a 35F bougie with a linear stapler. The staple line was secured with a running suture. Finally, the unusually short alimentary Roux limb was resected to complete the procedure. The postoperative course was uneventful.

Conclusions: Laparoscopic conversion of RYGB to a SG is feasible and can be performed safely. Nevertheless, the indication for this rare and potentially dangerous revisional bariatric procedure must be discussed in an interdisciplinary team.

Acknowledgement: The uploaded video is only a trailer of the actual video that didn't was uploaded in full lenght due to file restriction size of 30 MB.

V-010

Re-sleeve with Silastic Ring and Crurorhaphy in a Rare Case of Severe Hyperinsulimic Hypoglycemia after Sleeve Gastrectomy

Catherine Tsai^a), Jörg Zehetner^b), Rudolf Steffen^c)

Visceral Surgery, Clinic Beau Site, Bern, Switzerland

^a)catherine.tsai.md@gmail.com

^b)Joerg.Zehetner@hirslanden.ch

^c)rudolf.steffen@bluewin.ch

In contrast to Roux-en-Y gastric bypass, postprandial hyperinsulinemic hypoglycemia (phh) after sleeve gastrectomy is extremely rare. We present a salvage operation in a female patient with proven and symptomatic phh (mixed meal test followed by glucose nadir of 2.2 mmol/L 75 minutes after ingestion) in the presence of restriction loss four years after sleeve gastrectomy. She experienced daily episodes of neuroglycemic symptoms including loss of consciousness on several occasions.

The steps of the operation consisted of complete liberation of the dilated sleeve along with reduction of a hiatal hernia. To reduce leak risk the proximal portion of the sleeve was plicated, whereas the distal portion was resected. A crurorhaphy was performed to reduce the hiatal opening, and a silastic Fobi ring was placed near the sleeve entrance to avoid new dilatation in the mid- to longterm follow-up.

One year after the operation, the patient experiences only one episode of hypoglycemic symptoms per week and restriction has been restored. In a repeat mixed meal test, glucose nadir was 3.3mmol/L, no longer within the range of provoking neuroglycemic symptoms. Moreover, she has lost an additional 9 kg of total body weight (TBW).

We conclude that restoration of restriction by re-sleeve with silastic Fobi ring and crurorhaphy can be successful in treating phh after sleeve gastrectomy.

V-011

Laparoscopic Reversal of Roux-en-Y Gastric Bypass (LRYGB)

Ron Dar^a), Hadar Nevo^b), Nasser Sakran^c)

Surgery A, Emek Medical Center, Afula, Israel

^a)rondar555@gmail.com

^b)hadaraoody@gmail.com

^c)sakran_as@clalit.org.il

Introduction: With the demand for weight loss surgery increasing, surgeons are likely to encounter patients suffering from short and long term complications. Late complications of bariatric operations may vary between different operation types, and some patients develop severe complications. Stenosis of the Gastroenterostomy is a rare ad serious complication, which results in substantial morbidity. Selected patients are treated by reversal of gastric bypass to the original gastrointestinal anatomy, a complex operation that was previously thought to be non-feasible. We present a video of a patient with previous RYGB who underwent reversal operation.

Methods: A 65-year-old obese female underwent LRYGB, 3 years prior to her admission to our department. During the postoperative period, the patient suffered from postprandial vomiting, excessive weight loss and nutritional deficiencies. Upper endoscopy revealed a normal appearing esophagus, severe stenosis at the gastroenterostomy (GEA) with a marginal ulcer. After a prolonged conservative treatment had failed, the patient underwent multiple endoscopic dilatations. When diagnosed with an intractable marginal ulcer, the patient was offered to undergo an operative revision. The benefits and risks of a reversal operation were discussed with the patient who decided to proceed with a reversal.

Results: The video illustrates the operative planning and pitfalls of LRYGB reversal. The operation was conducted using a 5-port technique. After adhesiolysis the roux limb was measured (one meter), and the feasibility of reversal was assessed. The roux limb with the GEA and the bypassed stomach was resected en-block. The gastro-gastric anastomosis was fashioned using a linear stapler, and fully closed with a V-Loc™ continuous suture.

Conclusion: Laparoscopic reversal of LRYGB is technically difficult and carries greater complication rates, and as for our case report was shown to be feasible.

V-012

Failed Sleeve Gastrectomy: 3 Surgical Proposals

Maria Natoudi^{1, a)}, Eleftherios Mantonakis^{1, b)}, Gavriella-Zoi Vrakopoulou²⁾, Charidimos Theodoropoulos²⁾, Georgia Doulami²⁾, George Zografos²⁾, Emmanouil Leandros²⁾, Konstantinos Albanopoulos^{2, c)}

¹⁾2nd Department of Surgery, Henry Dunant Hospital Center, Athens, Greece

²⁾Laparoendoscopic Unit - 1st Propaedeutic Department of Surgery, “Hippocration” General Hospital – University of Athens, Athens, Greece

^a)marnatoyd@yahoo.gr

^b)lefman@gmail.com

^c)albanopoulos_kostis@yahoo.gr

Laparoscopic sleeve gastrectomy (LSG) has emerged as an increasingly popular operation for morbid obesity in the last 15 years. Its simplicity, safety and efficacy for weight loss and resolve of related comorbidities have been reported to be comparable to other bariatric operations. Despite the unquestionable advantages of sleeve gastrectomy, weight regain has been reported from 5.7% at 2 years to as high as 75.6% at 6 years. Possible mechanisms of weight regain include inadequate initial sleeve size or sleeve dilation, increased in ghrelin levels and poor dietary compliance or follow-up. We present 3 alternative surgical proposals for weight regain after sleeve gastrectomy: re-sleeve, conversion to one anastomosis gastric bypass (OAGB) and conversion to OAGB with simultaneous re-sleeve of the gastric pouch. We present video footage from these relatively complex re-interventions, in an attempt to highlight the indications, difficulties, advantages and disadvantages of each surgical approach.

References

Weight Regain Following Sleeve Gastrectomy-a Systematic Review. Lauti M. et al, Obes Surg. 2016 Jun;26(6):1326-34.

V-013

Gastric Bypass as Conversion from Abandoned Bariatric Procedures: Gastric Plication, Banding or Pacemaker, Toga or Banded Vertical Gastroplasty. A Video Remix

Cristian Boru^a), Marcello Avallone^b), Francesco De Angelis^c), Angelo Iossa^d), Gianfranco Silecchia^e)

UOC General Surgery & Bariatric Centre of Excellence-IFSO EC, University La Sapienza of Rome - Polo Pontino Polo Integrato AUSL LT-ICOT, Latina, Italy

^a)cristian.boru@yahoo.com

^b)marcello_avallone@libero.it

^c)francescodeangelis7@gmail.com

^d)angelo.iossa@gmail.com

^e)gianfranco.silecchia@gmail.com

Introduction: recently, increased numbers of revision bariatric procedures are reported worldwide, especially due to insufficient weight loss or weight regain. Some of former bariatric procedures are currently abandoned or anecdotally used due to long-term failure and increased incidence of revision surgeries needed.

Objectives: To evaluate the role of laparoscopic gastric bypass LGBP in the treatment of failure of previous, abandoned bariatric procedures.

Methods: A video remix of laparoscopic conversion from gastric banding, gastric plication, gastric pacemaker, TOGA or banded vertical gastroplasty is presented. Patients operated between 1997 and 2010 with different bariatric procedures were converted for weight regain, comorbidities recurrence, unsatisfactory results. Intraoperative difficulties, adhesiolisys, different prosthesis removal, unexpected situations are briefly presented.

Results: no conversion and no mortality were recorded. Conversion to LGBP was efficient and safe in all revision procedures, with further weight loss recorded. An important improvement of the patients’ symptoms and satisfaction was achieved 6 months postoperatively, with suspension of medical therapy, maintained one year after intervention.

Conclusions: conversion in GBP is actually the best option of treatment in case of weight regain after abandoned, former bariatric procedures.

V-014

Laproscopic Revisional MGB after open greater gastric curvature plication

Haider Alshurafa

Surgery, PSMMC, Riyadh, Saudi Arabia

haidershurafa@yahoo.com

Laparoscopic revision after open bariatric operation is a challenging operation with high demand. Here, we present the video of a patient who had open GCP before 2 years with failure to loss weight. The operation had completed as laparoscopic MGB with uneventful post operative course.

V-015

Salvation Gastric Bypass as Conversion from Failed, Open Banded Vertical Gastroplasty

Cristian Boru^a), Pietro Termine^b), Marcello Avallone^c), Gianfranco Silecchia^d)

UOC General Surgery & Bariatric Centre of Excellence-IFSO EC, University La Sapienza of Rome - Polo Pontino Polo Integrato AUSL LT-ICOT, Latina, Italy

^a)cristian.boru@yahoo.com

^b)terminepietro88@gmail.com

^c)marcello_avallone@libero.it

^d)gianfranco.silecchia@gmail.com

Introduction: Vertical-banded gastroplasty used to be one of the most performed bariatric procedures, but it fallen out of interest due to other emerging procedures and non-satisfactory long-term results. Options for revision include conversion to sleeve gastrectomy, a Roux-en-Y gastric bypass (RYGB) or VBG reversal via gastrogastrostomy. Objectives: To evaluate the role of laparoscopic RYGBP in the treatment of a previous, failed open VBG. Methods: we present the video of a laparoscopic conversion from previous open, adjustable banded vertical gastroplasty. Patient was operated in other center in 1997 at a BMI of 55.3 kg/m² and arrived a minimum of 30 kg/m². In 2017 she presented for weight regain and reflux disease (BMI 41 kg/m²), requesting further attention. Intraoperative difficulties, adhesiolisys, band removal, unexpected situations are presented. Results: Conversion to laparoscopic RYGBP was safe and efficient, with no need for open surgery conversion, and further weight loss recorded. Postoperative prolonged respiratory problems registered, successfully treated conservatively. An important improvement of the patients’ symptoms and satisfaction was achieved 6 months postoperatively, with suspension of medical therapy, at a BMI of 35 kg/m². Conclusions: Conversion of open VBG to RYGB is feasible and safe and can be performed with an acceptable complication rates, especially in experienced bariatric centers. It gives excellent weight loss results and relief of outlet obstruction.

V-016

Laparoscopic Gastric Bypass. Stapler Malfunction. How to Deal with

Harilaos Konstantinidis^a), Christos Charisis^b)

Robotic General and Oncologic Surgical Department, Interbalkan Medical Centre, Thessaloniki, Greece

^a)hakosurg@gmail.com

^b)christoscharisis1984@gmail.com

Aims: Laparoscopic Roux-en-Y gastric bypass procedure requires the performance of a gastro-enteric anastomosis between the alimentary Roux limb and the proximal gastric stump. The exposure conditions are significantly limitated by the obese patients body structure, therefore, staplers are preferably used for this anastomosis. Nevertheless, stapler malfunction is possible to occur, which will require modification of the surgical technique. Our aim is to present our experience in the management of such cases and to demonstrate our technique for the safe completion of the operation without conversion to open procedures.

Methods: We present video abstracts from a procedure of laparoscopic Roux-en-Y gastric bypass, in which the circular stapler sutured, but failed to cut efficiently the tissue. As a result, the anastomosis was impermeable, which was confirmed radiologically 12 hours after the operation. On the next day the patient was re-operated laparoscopically, with resection of the proximal stump and hand sewn purse string suture, as well as manual insertion of the orvil to the esophagus, and redo of the anastomosis.

Results: The second procedure was completed laparoscopically, with confirmed restoration of the anastomotic function and integrity. The patient had an uneventful postoperative course, with discharge on the scheduled postoperative day.

Conclusions: Stapler malfunction is a rare but very difficult situation to deal with in morbid obesity procedures and very often leads to open conversion. Nevertheless, it is possible, by experienced teams and by following proper strategies to overcome these obstacles and safely complete the treatment without sacrificing the benefits from a minimally invasive approach.

V-017

Laparoscopic Roux-en-Y gastric bypass, with long biliopancreatic limp (200cm), without division of the mesentery

Theofilos Amanatidis^a), Charalampos Lampropoulos, George Papadopoulos^b), George Skroubis^c)

Morbid Obesity Unit, Department of Surgery, University Hospital of Patras, Patras, Greece

^a)kontos_lo@hotmail.com

^b)tzi.papadopoulos@gmail.com

^c)skroubis@med.upatras.gr

Introduction: Laparoscopic Roux-en-Y gastric bypass, with long biliopancreatic limp (200cm), is a variant of the “standard” Roux-en-Y gastric bypass procedure. The increase of the length of the biliopancreatic limp, aims to more effective maintenance of weight loss, due to longer proximal jejunum that is bypassed

Purpose: The presentation of the technique, in the form of a video.

Description of procedure: After the creation of pneumoperitoneum, 5 trocars are placed. A vertical gastric pouch is created (~20 ml), with the use of endoscopic linear cutter. Measuring from the Treitz ligament, 200cm of proximal jejunum are counted. Without division of the small intestine, a side to side gastrojejunal anastomosis is created using a linear cutter. Subsequently the small intestine is divided, immediately centrally from the gastrojejunal anastomosis, without division of its mesentery. The integrity of the anastomosis is checked with an air leak test. The continuation of the gastrointestinal tract is restored, with side-to-side jejunojejunal anastomosis, at 100 cm from the gastrojejunal anastomosis with the use of linear cutter.

Discussion: Gastric bypass, with long biliopancreatic limp is a feasible and safe procedure. The elongation of biliopancreatic limp aims to better and sustainable weight loss. The avoidance of mesenteric division makes the procedure technically easier, while it also reduce potential sites of internal hernias.

V-018

Laparoscopic Roux-en-Y Gastric By-pass for Morbid Obesity. Stapler-Free (Totally Handsewn) Anastomoses. Advantages of the Technique

Georgios Ayiomamitis^a), Paraskevas Grivas^b), Stamatoula Drakopoulou^c), Nikolaos Paschalidis^d)

1st Surgical Department, Tzaneio General Hospital, Piraeus, Greece

^a)agiogeo@gmail.com

^b)grivas.endicrine.surgery@gmail.com

^c)stamatoulad@gmail.com

^d)dr.npasxalidis@gmail.com

Background: Laparoscopic Roux-en-Y Gastric By-pass (LRYGBP) for the treatment of Morbid Obesity is an established and successful technique with very good results in excessive weight loss. Though, it is a demanding procedure, being a surgical challenge for every bariatric surgeon. There are many techniques and types to perform the procedure. More than 90% of the Bariatric Surgeons are using circular or linear staplers for the construction of the gastrojejunal and jejunojejunal anastomoses.

Aim: To present our technique and describe all the important steps of totally hand-sewn LRYGBP with no use of any staplers and discuss all the advantages.

Results: Our results are similar to the stapled anastomoses. The advantages of hand-sewn technique refer to the reduction in anastomotic stenosis, and intraluminal bleeding, and reduction of the total cost of the procedure.

Conclusion: In the hands of an experienced laparoscopic surgeon, the technique of totally hand-sewn LRYGBP anastomoses is technically feasible and safe. It has a difficult learning curve which is discouraging in the beginning. Though it has advantages over the stapled techniques with much lower cost.

V-019

A video on Re-Re Do Gastric Bypass: Nutritional and technical challenges

Sachin Shenoy^a), Zaher Toumi^b), Akeil Samier^c), Andrew Mitchell^d)

General Surgery, County Durham and Darlington NHS Foundation Trust, Darlington, United Kingdom

^a)sachinshenoy@nhs.net

^b)zahertoumi1@nhs.net

^c)akeil.samier1@nhs.net

^d)amitchell12@nhs.net

Aims and objectives: To demonstrate the technical challenges in performing a re- redo gastric bypass

Learning points:

1) Addressing the nutritional requirements of patients who have undergone a bariatric procedure

2) Ideal investigations in patients who fail to progress post operatively and timing of investigations after a bariatric procedure

3) Timing of a redo operation

4) Addressing the technical difficulties in performing a redo operation

5) Importance of delineating the anatomy

V-020

Gastro-gastric herniation post gastric plication

Lydia Eleni Ioannidi^a), William Lynn^b), Naim Fakih^c), Marco Adamo^d), Majid Hashemi^e), Mohamed Elkalaawy^f)

Bariatric Surgery, University College London Hospital, LONDON, United Kingdom

^a)lydiaioannidi@gmail.com

^b)william.lynn1@nhs.net

^c)n.fakih@nhs.net

^d)marco.adamo@nhs.net

^e)majid.hashemi@nhs.net

^f)mohamed.elkalaawy@nhs.net

23 years old female, presented to our institution after a gastric placation procedure, with abdominal pain.

The CT scan clearly showed gastrogastric herniation and she was taken to theatre for a diagnostic laparoscopy.

Dissection of the gastro-gastric hernia. Dissection of omentum, adherent to the herniated fundus of the stomach

Mobilization of the fundus from spleen, closely adherent to the spleen, plain not easily identifiable, careful dissection used.

Taking down the gastric plication. Initially cephalad manner and extended towards the pylorus.

Assessing the vascularity of the herniated fundus with ICG.

Stapling of ischaemic herniated fundus.

Air leak test performed- no evidence of a leak.

The patient subsequently underwent a further postoperative contrast study which again showed no evidence of a leak and was successfully discharged five days after the operation.

V-021

Laparoscopic Sleeve Gastrectomy - How I Do It

Kamil Yamac^a), Julian W Mall^b)

Department of General Surgery, German Competence Center For Bariatric Surgery, KRH Klinikum Region Hannover, Hannover, Germany

^a)kamyam82@gmail.com

^b)julian.mall@krh.eu

This is a video of laparoscopic sleeve gastrectomy, how it is technically performed in our clinic. The video in the presentation at the congress will be in higher quality than in the submitted video in the abstract. The video has been resized and cut to fit into the max of 30mb for the abstract:

The trocars are placed as on the picture. Then the greater curvature is dissected with the ligasur clamp. The fundus is being completely prepared, presenting the His angle and the left diaphragmatic crus. The large curvature is now further prepared to the pylorus, at least 4-6 cm proximal of the pylorus. The stomach is raised, adhesions of the posterior wall of the stomach are released with the ligasur clamp and the scissors. This is one of the most important steps to avoid twisting or narrowing of the sleeve conduit. Now the 40 Charrière nasogastric tube introduced by the anesthetists is held with the clamps and thus guided in the direction of Pylorus. About 4-6 cm in front of the pylorus the formation of the sleeve begins. Formation of the sleeve in the direction of fundus with initially 2 green cartridges. Then 2 golden and blue cartridges with shorter clips are used. the proximal staple line is being buried with a continuous stratafix seam to about half of the staple line. Inspection of a staple line after the colleague of anesthesia raises blood pressure of the patient by medication to 140 mmHg syst. There are minimal bleedings, which are supplied by endoclips at the distal staple line. Remove of the gastric tube. The stomach is completely removed via the 10 trocar. Now the fascia is being close to the right 12 mm and middle 10 trocar under camera view. Under view Removal of the liver retractor and insertion of a 24ch -robinson drainage from the left 12mm trocar, which comes to rest on the left of the staple line.

V-022

Laparoscopic Intragastric Removal of Migrated Gastric Band

Konstantinos Albanopoulos^{1, a)}, Maria Natoudi²⁾, Charalampos Theodoropoulos^{1, b)}, Maria Mpousoula²⁾, Emmanouil Leandros¹⁾

¹⁾Laparoendoscopic Unit, 1st Propaedeutic Surgical Department, Hippocration General Hospital, Athens, Greece; ²⁾2nd Surgical Department, Henry Dunant Hospital Center, Athens, Greece

^a)albanopoulos_kostis@yahoo.gr

^b)chtheodoropoulos@gmail.com

Aim: To present the successful laparoscopic removal of a partially intragastrically dislocated gastric band, as an alternative to the usual endoscopic approach.

Methods: In 2006, a 19-year-old woman underwent a laparoscopic adjustable gastric band placement for weight loss (height: 1.58m, weight: 120kg, ΒΜΙ: 48.1kg/m²). In 2012 the patient had lost 45kg (ΒΜΙ: 30.0 kg/m²). However, during the following 3 years, she experienced weight regain of 20kg and in 2015 she visited her surgeon for band adjustment. In 2016 she was admitted to the ER with fever and abdominal pain. Imaging studies revealed the band having eroded and penetrating the gastric wall, as well as the presence of a perisplenic abscess. The patient was managed conservatively. In 2017, the patient underwent a laparoscopic removal of the penetrating band. The surgical approach included the placement of the trocars through the gastric wall. We present a video of the surgical technique.

Results: The patient had an uneventful postoperative course. She was placed on liquid diet the 1^st postoperative day and was discharged the 2^nd postoperative day.

Conclusions: The removal of a gastric band, which partially penetrates the stomach wall, can be performed successfully laparoscopically through a transgastric approach.

V-023

One Anastomosis Gastric Bypass (OAGB): Options Following Failure or Overtreatment

Maria Natoudi^{1, a)}, Eleftherios Mantonakis^{1, b)}, Charidimos Theodoropoulos²⁾, Gavriella-Zoi Vrakopoulou²⁾, Dimitrios Raptis²⁾, George Zografos²⁾, Emmanouil Leandros²⁾, Konstantinos Albanopoulos^{2, c)}

¹⁾2nd Department of Surgery, Henry Dunant Hospital Center, Athens, Greece; ²⁾Laparoendoscopic Unit - 1st Propaedeutic Department of Surgery, “Hippocration” General Hospital – University of Athens, Athens, Greece

^a)marnatoyd@yahoo.gr

^b)lefman@gmail.com

^c)albanopoulos_kostis@yahoo.gr

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been considered the gold-standard of bariatric operations. Laparoscopic one-anastomosis gastric bypass (LOAGB) has emerged as a simpler and faster alternative procedure, since it entails one instead of two anastomoses, with weight loss and resolve of related comorbidities comparable to LRYGB. Despite the overall favorable results, inadequate weight loss, weight regain, malabsorption and diarrhea still plague the LRYGB as well as its counterpart, the LOAGB. When conservative treatment fails, revisional surgery is proposed to these patients. These operations entail efferent limb elongation with or without gastric pouch re-sleeve, in cases of inadequate weight loss or weight regain, and efferent limb shortening, in cases of severe malabsorption, diarrhea or excessive weight loss. We present video footage from two cases, the first concerning a female patient presenting with severe diarrhea and hypoalbuminemia following LOAGB and the second of a female patient with inadequate weight loss following LOAGB. Both patients were treated mainly with interventions in the efferent limb, since this is our primary choice when the expectations following a LOAGB are not met.

V-024

Retrogastric Approach for Sleeve Gastrectomy through Three Ports

Marina Molinete^{1, 2, a)}, Ramon Vilallonga²⁾, Laura Martí³⁾, Muriel Pablo⁴⁾, Blanca De Urrutia⁵⁾, José Manuel Fort²⁾, Enric Caubet²⁾, Jose Maria Balibrea²⁾, Oscar González²⁾, Andrea Ciudin²⁾, Manuel Armengol²⁾

¹⁾Endocrine, bariatric and metabolic unit., Hospital d'Igualada, Igualada, Spain

²⁾Endocrine, bariatric and metabolic unit., Universitary Hospital Vall herbon, Barcelona, Spain, Barcelona, Spain

³⁾Endocrine, bariatric and metabolic unit., Hospital Universitario Donostia, Donostia, Spain

⁴⁾Endocrine, bariatric and metabolic unit., Hospital Arnau de Vilanova, Lleida, Spain

⁵⁾Endocrine, bariatric and metabolic unit., Hospital Álvaro Cunqueiro, Pontevedra, Spain

^a)marina_molinete03@hotmail.com

Nowadays laparoscopic sleeve gastrectomy(SG) it’s a surgical technique with increasing application in bariatric surgery. We propose, in selected cases, the details of the retrogastric approach for performing a SG.

Technique: Placed in French position, an 11mm trocar is placed for the 30ºoptic at about 11cm of the xiphoid process, 4 cm to the left side of the midline, and pneumoperitoneum is initiated. A 12mm right periumbilical port and another 12mm port in the left hypochondrium are placed for the introduction of the endostaplers.

We begin by releasing the greater curvature of the stomach, from the middle to the top. For the retrogastric approach of the fundus, a minimal opening of the greater curvature is made to access the lesser sac. The surgeon's left hand replaces the fourth standard trocar as a hepatic retractor, lifting the left lobe of the liver and the entire gastric fundus, also decreasing the risk of liver injury.

All the short vessels of the fundus are identified, in tension and exposed in vertical position, and its complete section is performed until the left pillar. A 37F tube is inserted into the pylorus. The stomach is then sectioned, respecting 2principles:

First,a stenosis of the incisura angularis should be avoided. By stapling from the left, the device will be parallel to the lesser curvature. Secondly, we must resect the entire gastric fundus, avoiding leaving a small fundus portion. The specimen is drawn through the 12mm hole.

This technique can be used in selected cases when liver can give a bad vision of the hiatus, patients with lower BMI or gynecoid distribution of fat.

Conclusion: The posterior approach of the angle of His by the retrogastric approach can improve the visualization of the dissection of the short gastric vessels and facilitates the adequate mobilization of the stomach around the left pilar, allowing the safe and efficient performance of the SG.

- The 2risk factors for leakage are stenosis in the incisura angularis and stapling near the esophagus in the angle of His.

References:

Three-port sleeve gastrectomy: complete posterior approach.

Nedelcu M, Eddbali I, Noel P.

Surg Obes Relat Dis. 2016 May;12(4):925-927. doi: 10.1016/j.soard.2015.12.033. Epub 2016 Jan 4. No abstract available.

V-025

Laparoscopic Conversion from Nissen Fundoplication to Roux-en-Y Gastric By-pass in a Morbidly Obese Patient

Ramón Corripio^{1, a)}, María Recarte^{1, b)}, Gregorio Vesperinas¹⁾, Joaquín Díaz²⁾

¹⁾Obesity Medical&Surgical Unit, “La Paz” University Hospital, Madrid, Spain; ²⁾General and Digestive Surgery, “La Paz” University Hospital, Madrid, Spain

^a)rcorripio@icloud.com

^b)mariarecarterico@gmail.com

Background & aims: In appropriately selected patients, laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most durable method of weight loss and control of obesity-related comorbidities¹. It is recommended after fundoplication if a patient is morbidly obese with gastroesophageal reflux (GERD) or if bariatric surgery is planned with a prior succesful fundoplication².

Objectives: We report the case of a patient who underwent laparoscopic conversion from Nissen fundoplication to RYGBP due to morbid obesity (OM) after a prior succesful fundoplication.

Material & methods: 50 years old-female with previous Nissen fundoplication for GERD (controlled after surgery) and open cholecystectomy who complained of OM (BMI 40 Kg/m2), arterial hypertension, obstructive sleep apnea and asthma.

The case was discussed at our multidisciplinary meeting and laparoscopic conversion to RYGBP was proposed.

Results: The patient underwent laparoscopic conversion from Nissen fundoplication to RYGBP in January 2014.

A five port technique laparoscopic approach is performed. The procedure included lysis of all adhesions between the liver and the stomach, completely takedown and resection of the wrap, and the conversion to RYGBP.

The patient's postoperative course was uneventful. No leakage of contrast was observed in the upper GI contrast study.

Conclusions: Revisional bariatric surgery is technically challenging but it can be safely performed in experienced hands.

Laparoscopic RYGBP after fundoplication in morbidly obese patients is a technically difficult but feasible option^2,3.

References:

1- Robert B. Yates, Brant K. Oelschlager, Carlos A. Pellegrini. CHAPTER 42: Gastroesophageal Re ux Disease and Hiatal Hernia. Sabiston Textbook os Surgery. The Biological Basis of Modern Surgical Practical. Towsend, Beauchamp, Evers, Mattox. 20th Edition. Elsevier.

2- Palanivelu Praveenraj et al. Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric By-pass in a Morbidly Obese Patient with Prior Nissen´s Fundoplication: A Video Report. OBES SURG (2016) 26:241

3- Kambiz Zainabadi et al. Laparoscopic Revision of Nissen Fundoplication to Roux-en-Y Gastric By-pass in morbidly obese patients. Surg Endosc (2008) 22:2737-2740.

V-026

Operation technique of laparoscopic Mini (One Anastomosis) Gastric Bypass

Karl Peter Rheinwalt^a), Martin Hemmerich^b), Andreas Plamper^c)

Bariatric, Metabolic and Plastic Surgery, St. Franziskus Hospital Cologne, Cologne, Germany

^a)karlpeter.rheinwalt@cellitinnen.de

^b)martin.hemmerich@cellitinnen.de

^c)andreas.plamper@cellitinnen.de

We present via video presention the key point steps of our technique of laparoscopic Mini (One Anastomosis) Gastric Bypass as primary operation for the treatment of morbid obesity.

V-027

Murphys law – proven by a laparoscopic bypass procedure

“Whatever can go wrong will go wrong”

A phrase, used in our everyday life, points out the possibility of accidents in the worst possible moments. But as a globally accepted law, it does not stop in front of our operation theaters and blazes its way through the doors. This law shall be underlined by using the example of a bariatric procedure.

A “normal” gastric bypass surgery, proceeded by an experienced surgeon. A stapler that cuts without clamping, an anvil, that gets stuck in the oesophagus. Everything in one surgery, everything in one video.

V-028

Laparoscopic sleeve gastrectomy: How we do it

Stylianos Kapiris, Stavros Stavropoulos^a), Evangelia Liverakou, Angeliki Kolinioti, Ioannis Alevizakis, Andreas Papatriantafylou, Mihalis Psarologos, Paraskevi Aleksakou, Panagiotis Metaksas, Theodore Mavromatis

3rd Surgical Department, Evaggelismos Hospital, Athens, Greece

^a)st.k.stavropoulos@gmail.com

Sleeve gastrectomy constitutes one widely spread and used technique in bariatric surgery. Hereby we present a video projection with the basic yet significant points during the procedure.

Patient- Method: This is a 40 year old male patient with type 2 diabetes treated with antidiabetic tablets from 5 years and BMI 48 kg / m². The patient was referred for surgical treatment of obesity after failure of every other effort for weight loss conservatively.

Surgical technique: Creation of pneumoperitoneum with Veress needle. Placement of 5 trocars. Mobilization of the gastric fundus and of the left crus of the diaphragm with removal of periphrenic fat, gastrocolic division with the use of energy source beginning 4cm medially to the pylorus towards the cardiophrenic angle, followed by further mobilization of the stomach by dividing the posterior ligaments. We then proceed to sleeve gastrectomy with linear stapler with the use of 36 Fr bougie beginning 4cm from the pylorus and ending 1 cm from the angle of His. The staple line is then reinforced with continuous suture. Placement of drains.

Results: Surgical time was 106 minutes. No major intraoperative events were encountered.

Discussion: Full stomach mobilization allows for more comfortable and safe execution of sleeve gastrectomy with adequate control during all stages of the procedure. We believe that the reinforcement of the staple line reduces the bleeding risk; and could also possibly reduce the incidence of leakage as one is yet to be documented in our series.

P-001

Lipid Variations after Bariatric Surgery in Morbidly Obese Nondiabetic Patients

Maria E Barmpari^{1, a)}, Christos Savvidis^{1, b)}, Maria Natoudi²⁾, George Zografos³⁾, Emmanouil Leandros³⁾, Konstantinos Albanopoulos^{3, c)}

¹⁾Department of Endocrinology and Metabolism, "Hippokration" General Hospital of Athens, Athens, Greece

²⁾2nd Department of Surgery, Henry Dunant Hospital Center, Athens, Greece

³⁾Laparoendoscopic Unit- 1st Propaedeutic Department of Surgery, "Hippokration" General Hospital – University of Athens, Athens, Greece

^a)barbari_maria@yahoo.com

^b)csavvidis@med.uoa.gr

^c)albanopoulos_kostis@yahoo.gr

Background: Lipoproteins such as Apolipoprotein B (ApoB), Very Low Density Lipoprotein (VLDL) and Lipoprotein(a) [LP(a)] represent more important cardiovascular risk factors to treat than Low Density Lipoprotein (LDL) because they are more atherogenic.

Objective:The aim of this prospective, clinical study was to determine the variations of lipid profile in morbidly obese nondiabetic patients, after laparoscopic sleeve gastrectomy (LSG) or laparoscopic one anastomosis gastric bypass (LOAGB).

Patients and Methods: 123 morbidly obese nondiabetic patients (68.3%women) with a body mass index (BMI) 47.61± 6.54Kg/m² were followed prior to, 1 and 6 months after LSG (66.7%) or LOAGB (33.3%). Weight loss (expressed as percent excess weight loss, EWL%), waist and hip circumference, serum Cholesterol, High Density Lipoprotein (HDL-C), LDL-C, Triglycerides, VLDL, ApolipoproteinA1 (ApoA1), ApoB, Lp(a), were analyzed.

Results: In the first month after LSG or LOAGB the mean BMI was 42.68± 6.46kg/m² (p<0.001) and 43.25± 6.79 kg/m² (p<0.001), respectively. Lipid profile of the patients performed LSG was significantly improved with a significant reduction in all serum lipid levels (p<0.001). In patients performed LSG, there was a more pronounced reduction in Lp(a) levels (p<0.05) compared to those performed LOAGB (p<0.1). After 6 months from bariatric surgery the mean BMI was 34.38± 6.43kg/m² (p<0.001) and the mean excess weight loss was 52.76± 13.81Kg. There was a significant reduction in all lipid levels, including Lp(a) (p=0.005), and VLDL, ApoB (p<0.001). Independently of the bariatric surgery performed, excess weight loss was negatively correlated with BMI, waist and hip circumference, total cholesterol, Triglicerides and VLDL serum levels. In patients performed LSG, excess weight loss was negatively correlated with BMI, waist and hip circumference,VLDL, Triglicerides and Lp(a) serum levels.

Conclusions: Weight loss after six months of bariatric surgery in morbidly obese nondiabetic patients seems to improve lipid parameters such as Lp(a), VLDL, ApoB which are difficult to be controlled even after pharmacologic interventions.

P-002

Alcohol Assumption after Laparoscopic Sleeve Gastrectomy: One Year Results

Angelo Iossa^a), Ilenia Coluzzi^b), Francesco De Angelis^c), Gianfranco Silecchia^d)

Department of medico-surgical sciences and biotechnologies, University of Rome "Sapienza", Division of General surgery and bariatric centre of excellence, Latina, Italy

^a)angelo.iossa@gmail.com

^b)ilenia.dietista@gmail.com

^c)francescodeangelis7@gmail.com

^d)gianfranco.silecchia@uniroma1.it

Introduction: Laparoscopic sleeve gastrectomy (SG) represents, at present, the most per-formed bariatric procedure worldwide with excellent long-term results on weight loss and comorbidities control. Together with hormonal modification, several changes in taste and habits occurs after the procedure including the potentially modification in alcohol consumption[1-2]. The aim of this prospective study is to determine the frequency and the amount of alcohol use before and after sleeve gastrectomy (SG) using a modified version of the Alcohol Use Disorder Identification Test (AUDIT) at 1-year follow-up and to evaluate eventual relationship between different age and sex.

Materials and methods:142 patients were prospectively enrolled and evaluated before and 1 year after the SG with a modified AUDIT (Alcohol Use Disorder Identification test) test. The exclusion criteria were: past history of alcohol abuse, presence of psychopathology or cognitive impairments, diabetes mellitus type II decompensated, or previous gastrointestinal, liver and pancreatic resective surgery. A subgroup analysis was made between male and female and between < and > 40 years old.

Results: The AUDIT median total score decreased from 2,70 (range 1-18) before surgery to 1,38 (range 1-7) 1 year after SG, indicating a marked reduction in alcohol use. The most con-sumed alcoholic drink was beer 36.6% (n=52) while after surgery the consumption of beer decreased considerably (21.1%/n=30). The frequency of alcohol use also decreased: at baseline 45% of patients consumed alcoholic drinks “from 2 to 4 times per month”, instead 26% and 39.4%, consumed alcohol “never” and “less than once a month” respectively. After surgery, nobody consumed 6 alcoholic drinks. No differences were found between the subgroups in terms of alcohol consumption and social behavior.

Conclusions: The alcohol preference is modified and decreased 1 y after SG and this could be related to the strict nutritional follow-up and to the hormonal changes. Studies with largest population and long-term follow-up are needed to confirm our data.

References:

1. Van Vuuren MAJStrodl E, White KM, Lockie PD. Taste, Enjoyment, and Desire of Flavors Change After Sleeve Gastrectomy-Short Term Results Obes. Surg. 2017

2. Coluzzi, I., Raparelli, L., Guarnacci, L., Paone, E., Del Genio, G., le Roux, C. W., et al. Food intake and changes in eating behavior after laparoscopic sleeve gastrectomy. Obes. Surg. 2016

P-003

Superiority of OAGB on glucose homeostasis

Camille Marciniak^{1, 2, a)}, Gregory Baud^{1, 2, b)}, Vincent Vangelder^{1, 2, c)}, Mehdi Daoudi^{2, d)}, Audrey Quenon^{2, e)}, Valery Gmyr^{2, f)}, Violeta Raverdi^{1, g)}, Thomas Hubert^{2, h)}, Robert Caiazzo^{1, 2, i)}, François Pattou^{1, 2, j)}

¹⁾General and Endocrine Surgery Department, Lille Univ Hospital, Lille, France; ²⁾Inserm U1190, European Genomic Institute for Diabetes, Lille Univ, Lille, France

^a)cammarciniak@gmail.com

^b)gregory.baud@chru-lille.fr

^c)vincent_vangel@yahoo.fr

^d)mehdi.daoudi@univ-lille2.fr

^e)audrey.quenon@inserm.fr

^f)vgmyr@univ-lille2.fr

^g)vraverdi@univ-lille2.fr

^h)thubert@univ-lille2.fr

ⁱ⁾robert.caiazzo@chru-lille.fr

^j)fpattou@univ-lille2.fr

Background: Obesity and type 2 diabetes are spreading worldwide. Medical treatment is insufficient to cure them. These last decades, bariatric surgery has developed beyond measure as a more potent therapy. Roux en Y Gastric Bypass (RYGB) is an old procedure and many more recent ones are now described. One Anastomosis Gastric Bypass (OAGB) is a newer and simpler technique, which seems to be more effective.

Objective: To compare RYGB and OAGB effects on glucose homeostasis and glucose absorption in a porcine model.

Methods: Adult healthy female minipigs were submitted either to RYGB surgery (n≥5), to OAGB surgery (n≥5) or to SHAM surgery (n≥5). Weight loss was monitored. Mixed-meal challenge and D-Xylose absorption test were performed 15 days after surgery. Blood glucose, D-Xylose, insulin and GLP-1 were measured for 3 hours. Blood glucose excursion (i.e. blood glucose compared to baseline), post-prandial glucose response (i.e. area under the curve of blood glucose) and glucose absorption (i.e. area under the curve of D-Xylose) were determined.

Results: Weight loss was achieved for both bypass groups compared to SHAM ten and twenty days after the surgery (p<0.001, two-way ANOVA). Blood glucose excursion was significantly lower after OAGB compared to RYGB and SHAM (p<0.05, two-way ANOVA). Post-prandial glucose response was decreased after OAGB compared to RYGB and SHAM (p<0.05 vs. RYGB, p<0.01 vs. SHAM, one-way ANOVA). Blood glucose excursion and post-prandial glucose response tended to diminish after RYGB compared to SHAM. Glucose absorption was decreased after RYGB compared to SHAM (p<0.01, one-way ANOVA) and was even more decreased after OAGB (p<0.001 vs. SHAM, p< 0.05 vs. RYGB, one-way ANOVA). Insulin secretion was increased after RYGB compared to OAGB and SHAM (p< 0.05 vs. SHAM, p<0.05 vs. OAGB, two-way ANOVA). GLP1 post-prandial secretion was higher after both RYGB and OAGB compared to SHAM (p<0.05 vs. SHAM).

Conclusion: Compared to RYGB, OAGB improves more efficiently glucose homeostasis, likely by a further reduction in glucose absorption.

P-004

Weight loss, Reduction of Comorbidities and Psychological Changes after Bariatric Surgery in Young Adults.

Mellody Cooiman^a), Edo Aarts^b), Ignace Janssen^a), Eric Hazebroek^c), Frits Berends^a)

Bariatric Surgery, Rijnstate Hospital/Vitalys Obesity Clinic, Arnhem, Netherlands

^a)mcooiman@rijnstate.nl

^b)eaarts@rijnstate.nl

^c)ehazebroek@rijnstate.nl

Introduction: Bariatric surgery is superior in the treatment of obese adults, showing durable weight loss and reduction of comorbidities. Following the IFSO criteria, patients only with an age between 18 and 65 years old are eligible. The increasing incidence of childhood obesity is requesting amplification of the current criteria. Especially when obesity during this stage of age is accompanied by related comorbidities, reduction in life expectancy, and decreased social functioning. Conservative treatments show little to no effect on weight at the long term. The positive effects of bariatric surgery in adults could therefore also be beneficial for younger obese patients. Before changing the current age criteria, it is important to determine the outcomes of bariatric surgery in our youngest patients.

Methods: In order to obtain three year follow up, all preoperative and perioperative data from patients aged 18-25 years and 35-55 years, operated between 2010 and 2014 were retrospectively collected. Follow-up data were gathered prospectively by collecting (laboratory) measurements and questionnaires.

Results: 115 young adults (mean age 22.5) were matched to 115 adult patients (mean age 42.6), matched for BMI and time of surgery. 72% of the young adults and 75% of the adults underwent a gastric bypass (GB). Three years after GB, mean %Total Body Weight Loss was 33.8 (±8.8 ) and 30 (7.7 ) ( p<0.011) respectively. Preoperatively, four patients (3.4%) in the young adult group had oral drug-dependent diabetes mellitus, with 100% remission after 1 year, compared to six (5.2%) in the adult group with 83% remission after 1 year. Quality of life(SF-36) was not significantly different between the two age groups.

Conclusion: Bariatric surgery is a safe and effective treatment of obesity in our youngest patient group.

Results are comparable to age groups in which bariatric surgery is most often performed. These data may be used in future research investigating the impact of bariatric surgery in adolescents and childhood.

P-005

Metabolic health alters the levels of TNF related apoptosis inducing ligand (TRAIL) and TNF weak inducer of apoptosis (TWEAK) in patients undergoing bariatric surgery

Ilias Doulamis^{1, a)}, Panagiotis Konstantopoulos^{1, b)}, Aspasia Tzani^{1, c)}, Asier Antoranz^{2, d)}, Angeliki Minia^{2, e)}, Afroditi Daskalopoulou^{1, f)}, Anestis Charalampopoulos^{3, g)}, Leonidas Alexopoulos^{2, 4, h)}, Despina Perrea^{1, i)}, Nicholas Katsilambros^{1, j)}, Evangelos Menenakos^{5, k)}

¹⁾Laboratory of Experimental Surgery and Surgical Research “NS Christeas”, Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece; ²⁾Protatonce, Ltd, Athens, Greece; ³⁾Third Department of General Surgery, Medical School of Athens, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; ⁴⁾Department of Mechanical Engineering, National Technical University of Athens, Athens, Greece; ⁵⁾1st Propaedeutic Surgical Department, "Hippokration" General Hospital of Athens, Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece

^a)doulamis.i@gmail.com

^b)panos2661987@gmail.com

^c)asptzani@gmail.com

^d)asier.antoranz@protatonce.com

^e)angeliki.minia@protatonce.com

^f)aphrodite.dask@gmail.com

^g)achalaral@med.uoa.gr

^h)leo@protatonce.com

ⁱ⁾dperrea@med.uoa.gr

^j)nicholaskatsilambros@gmail.com

^k)evmenenakos@hotmail.com

Aim: We sought to investigate the alterations of Tumor Necrosis Factor (TNF) related apoptosis inducing ligand (TRAIL) and TNF weak inducer of apoptosis (TWEAK) in both visceral fat and serum with respect to the metabolic health status of patients undergoing bariatric surgery.

Material and methods: 28 morbidly obese patients (15 females and 13 males) undergoing bariatric surgery were prospectively enrolled. They were divided into two groups according to their metabolic health status (existence of either hypertension, diabetes or hyperlipidemia) into metabolically unhealthy (MUO) and healthy (MHO) obese patients. Mean age was 36.7±12.6 years for MHO and 37.3±13 years for MUO while average BMI was 47.5±8.6 and 48.7±9.1 kg/m² in MHO and MUO groups, respectively. During the operation, serum samples as well as visceral adipose tissue samples (from a site near the fundus of the stomach) were collected. TWEAK and TRAIL were measured by custom dual-antibody Luminex assays.

Results: Prevalence of hypertension, diabetes and hyperlipidemia in the MUO group were 81%, 45% and 27%, respectively. Both TRAIL and TWEAK levels in adipose tissue were higher in the MUO group (p=0.037 and p=0.043, respectively). As it concerns serum, this difference was not significant in the case of TRAIL (p>0.05), while it was more prominent in the case of TWEAK (p=0.016). Linear regression analysis did not show any independent correlation between comorbidities and TRAIL, while there was an association between hypertension and hyperlipidemia and TWEAK (p=0.003 and p=0.004, respectively).

Conclusion: Our results indicate that TRAIL and TWEAK are correlated with metabolic health of obese patients suggesting a deteriorated inflammatory status in those who are unhealthy. These findings are important since, as proposed by the current guidelines, BMI is not the only indicator for eligibility for bariatric surgery, but the presence of comorbidities is also taken into consideration. Further studies are required in order to investigate the whole spectrum of underlying mechanisms involved in the comorbidities of obese patients.

References

Alfadda AA, Masood A, Al-Naami MY, Chaurand P, Benabdelkamel H. A Proteomics Based Approach Reveals Differential Regulation of Visceral Adipose Tissue Proteins between Metabolically Healthy and Unhealthy Obese Patients. Mol Cells 40: 685–695, 2017.

Harith HH, Morris MJ, Kavurma MM. On the TRAIL of obesity and diabetes. Trends Endocrinol Metab TEM 24: 578–587, 2013.

P-006

The Comparison of Jejuno-Ileal Bypass and Transit Bipartition in Patients with Type 2 Diabetes Mellitus: Preliminary Report

Halit Eren Taskin^{1, a)}, Elshad Rzayev¹⁾, Cuneyt Kirkil²⁾, Nurhan Haluk Belen²⁾, Veysel Karahan²⁾, Abdullah Kagan Zengin¹⁾, Erhan Aygen²⁾, Mustafa Taskin^{1, b)}

¹⁾General Surgery, Istanbul University Cerrahpasa Faculty of Medicine, ISTANBUL, Turkey

²⁾General Surgery, Firat University Faculty of Medicine, ELAZIG, Turkey

^a)eren_taskin@hotmail.com

^b)mtaskin@istanbul.edu.tr

Background: The jejuno-ileal bypass (JIB) and transit bipartition (TB) goals to modulate hindgut in type2 diabetes mellitus (T2DM). In this study, it was aimed to compare the results of JIB with TB in patients with insuline dependent T2DM.

Methods: The results of 30 patients who undergone JIB (group 1, n=13) or TB (group 2, n=17) in two different hospitals were retrospectively analyzed.

Results: The mean BMI of groups were 34,2±5,4 and 40,5±8,0 (p<0,05). The mean baseline fasting blood glucose (FBG) and HbA1c levels were similar (267,7±56,2 vs 277,6±80,0 and 9,6±1,8 vs 9,3±1,4 respectively, p>0,5). The mean follow—up was similar for two groups (13,0±7,4 vs 9,5±5,1 months, p>0,05). The mean excess BMI loss was also similar (125,8±92,2 vs 100,3±45,2 %, p>0,05). The mean postoperative FBG of groups were not statistically different (117,9±29,4 vs 107,2±22,6, p>0,05) but mean HbA1c levels were different (9,6±1,8 vs 9,3±1,4, p<0,05). The comparison of preoperative and postoperative levels of HbA1c reached statistically significant difference in both groups (9,6±1,8 vs 6,6±1,3 in group 1 and 9,3±1,4±5,7±0,9 in group 2, p<0,001). The number of patients who had <6,0 HbA1c level was 6 (46,1 %) in group 1 and was 11 (64,7 %) in group 2 (p>0,05). There was no patient who need to continue insuline treatment in both groups. However, two patients (15,4 %) in group 1 and 5 patients (29,4 %) in group 2 neededoral antidiabetic drugs postoperatively (p>0,05). But there was a bias because two arms were treated in two different center.

Conclusion: The results show that JIB and TB reduce effectively the FBG and HbA1c in T2DM. But, the difference between the mean BMI of groups may cause bias in comparison, so there is a need for further randomized studies to justify this fact.

P-007

Evaluation of physical activity in obese youngsters with non-alcoholic fatty liver disease

Rosa Sammarco^a), Maurizio Marra^b), Valeria Amato^c), Marianna Naccarato^d), Iolanda Cioffi^e), Franco Contaldo^f), Fabrizio Pasanisi^g)

Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy

^a)rosa.sammarco@unina.it

^b)marra@unina.it

^c)valeriamatomed@libero.it

^d)mariannanaccarato@fastwebnet.it

^e)iolanda.cioffi@unina.it

^f)contaldo@unina.it

^g)pasanisi@unina.it

Introduction: Non-alcoholic fatty liver disease (NAFLD) is probably the most common cause of liver disease in the pediatric community. It is closely associated with obesity and insulin resistance.

There are few population-based prevalence studies of pediatric NAFLD. The available data suggest a prevalence that ranges from 2.6% to 9.6% for suspected NAFLD among children and adolescences in United States and Asia. Low levels of physical activity has been associated with Non-alcoholic fatty liver disease (NAFLD) so the aim of this study is to evaluate the relationship between physical activity, anthropometry and fatty liver score in a group of young obese patients.

Methods: Anthropometry (height, weight, body mass index) and blood biochemistry were assessed in one hundred sixteen obese patients (M=43, F=73; BMI 40,7±6,44 kg/m²), age 15-25 years (mean±DS 18,6±2,82y) at the Federico II University Hospital in Naples,

Fatty liver index (FLI) was calculated according to Bedogni G et al (BMC Gastroenterol. 2006); Energy Expenditure (EE) and physical activity level, were evaluated by the validated SenseWear Armband for 48 hours consecutively.

Results: FLI≥60 was observed in 91.4% of patients (M=41, F=65). FLI was inversely correlated with mean METs (Metabolic EquivalenT) (r = -.245; p =.008) and ALT/AST ratio (r= -.491; p= .000) and steps number/day (r = -.235; p =.011).

In male patients it was inversely correlated also with active energy expenditure (r = -.522; p =.001), whereas in female only with ALT/AST ratio (r = -.443; p =.001).

Conclusions: Lower levels of physical activity were correlated with higher FLI, particularly in young male obese patients. The mechanisms underlying this relationship deserves further investigation.

References:

Bedogni G et al, BMC Gastroenterol. 2006 Nov 2;6:33

Malavolti M et al., Nutr Metab Cardiovasc. Dis. 2007 Jun;17(5):338-43

Fruin ML, Rankin JW. Med Sci Sports Exerc. 2004 Jun;36(6):1063-9.

P-008

Liver conditions in morbidly obese patients before bariatric surgery and in the long term period

Luidmila Kotelnikova^a), Ruslan Stepanov^b), Genrietta Freind^c)

Surgical, Perm State Medical University named after E.A.Vagner, Perm, Russian Federation

^a)splaksin@mail.ru

^b)rusl-stepanov@yandex.ru

^c)hirfpk159@yandex.ru

Background: The aim of this study was to estimate liver conditions before biliopancreatic diversion (BPD) and in the long term period.

Objectives: Fifty seven adolescent participants who underwent biliopancreatic diversion (BPD) between 1999 and 2008 were included in the study. Patients were 48 females and 9 males. Mean age was 43 (ranging from 18 to 63) with a mean BMI of 54 (ranging from 40 to 80).

Methods: Ultrasound examination was performed before surgery and liver biopsies – during it. Morphological examination of liver biopsies was scored according to Brunt et al., the activity of NAFLD – according to Knodell et al. The second biopsy was obtained 26-30 months after BPD in 10 cases during reoperation due to hernia. There were 10 patients with paired liver biopsies. Ultrasound liver examination was also repeated.

Results: Excess weight percent loss was 40-73% and excess BMI percent loss – 45-82%. The results depend on the basal BMI. Ultrasound liver examination before surgery showed the first stage of steatosis in 37% of patients, the second – in 38% and the third – 25%. Morbid obesity was characterized by having stestosis, fibrosis and nonalcoholic fatty liver disease (NAFLD) in all cases. Our statistical analyses revealed that before surgery the severity of steatosis and NAFLD has significant positive correlation with BMI.

After 26-30 months ultrasound liver examination showed the improvement of steatosis: 50% of patients didn’t have it and other decreased it to grade 1. In all 10 paired biopsies the degree of steatosis, lobular necrosis, ballooning degeneration significantly decreased. Mononuclear infiltrates in the portal tracts increased from 1,2± 0,6 to 2,8± 0,7. The difference was significant (p=0,01). Fibrosis has only the tendency to increase.

Conclusion: The reduction of BMI after BPD significantly improved steatosis, lobular necrosis, ballooning degeneration but mononuclear infiltrates were increased. Further investigations should be designed to confirm the influence of major weight loss on liver conditions.

P-009

Steatohepatitis in obese Slovenian morbidly obese patients: stratification of risk factors force the need for obesity surgery interventions

Tadeja Pintar^a), Gregor Kunst^b), Tanja Carli^c)

Clinical department of abdominal surgery, UMC Ljubljana, Ljubljana, Slovenia

^a)tadeja.pintar@kclj.si

^b)gregor.kunst@kclj.si

^c)tanja.carli@kclj.si

Introduction: Obesity related NAFLD represents a wide range of histologically proven liver pathologies, triggered by unclear pathognomonic mechanisms. Individual findings dictating the course of NAFLD to liver cirrhosis should be included to obesity related risk factor calculation, based on histological and humoral findings as a part of personalised patient treatment algorithms.

Methods: 37 morbidly obese patients undervent obesity surgery: SG 18 (48%), OAGBP 15 (40.54%), RYGBP 4 (10.81%); concomitant diseases: all were obese since childhood, AH (48%), OSAS (16%), DM type II (28%), smokers (32%), GERB (20%), histologically proven HP gastritis treated prior obesity surgery (74%). Average first BMI was 46.51 kg/m², average preoperative weight loss 16,8 kg. Blood tests and liver biopsy were taken on the day of surgery procedure. ERAS protocol was implemented to all cohort of operated patients. Triple BIA measurements were performed prior operation.

Results: Normal lipid and viral (HBS, anti-HCV, anti-HIV) profile (100%); basal serum insulin elevated in all patients, with average value of 28.003 mlU/L (1,12 x elevated); basal antiXa (IE/L) elevated in 92%, values after subtherapeutic preoperative dose adjustment (average 0.8 ml i.e. 80 mg) were lower and adjusted (average 1.0 ml i.e. 100 mg) in the same 92% of patients. Serum ferritin level (ng/ml) within normal range, serum ferrum levels lowered in 16%, while transferin elevated in the same 16%; AST and ALT within normal range in 98%, CRP elevated in 56% (ranged 7-56 mg/dl). Liver histology: steatohepatitis 16%, diffuse metabolic liver injury 48%, balooning degeneration 10%, grade I 75% and grade II-III 25%, lobular inflammation 91%, portal inflammation 100% (grade I 91%, grade II-II 9%). No metabolic and surgical complications were observed. Phase angle was reduced, especially among patients having grade I liver steatosis.

Conclusion: The results strongly suggest the need for preoperative patient risk factor stratification. Reliable non-invasive diagnostic tools should be developed among candidate proteins as biomarkers for diagnosis, prediction and identification of fibrosis and subsequent cirrhosis.

P-010

Diabetes 7 years after the Mini-Gastric Bypass; A Survey of 1,142 Patients

Robert Rutledge

Center for Laparoscopic Obesity Surgery, Ventura California, United States

drr@clos.net

The purpose of this study was to review the survey results for the MGB 5-10 years post MGB.

Methods: A survey of 1,141 patients were between 5 and 10 years post surgery.

Results: Mean follow up was 7.5 years. Average small bowel bypass limb length was 6 feet + 3.2 feet. 70.3% reported no diabetes and 29.7% reported that they were taking at least one Diabetic medication preoperatively.

95.3% were not diabetic and 4.7% were taking >1 diabetic medication. Comparing pre to post operative diabetic medication use (patients taking 1, 2, 3, or 4 or more diabetic medications) changed from 15% to 3.1%, 9.7% to 1.1%, 4.4% to 0.4% and 0.6% to 0.09% were respectively (P<0.01 for all).

“Non-DM” increased by 35.5%. 79.5% fewer patients reported as taking one Diabetes Medication, 88.3% fewer patients were taking two Kinds of Diabetes Medications, 90.0% fewer patients were taking three Kinds of Diabetes Medications and 85.7% fewer patients reported taking four or More Kinds of Diabetes Medications.

507 patients either reported resolution of diabetes or improvement of at least one class of the number of medications taken for diabetes.

The estimated pharmacy cost savings for these 507 patients was $10,687,500.00 in pharmacy charges alone.

Pre-operatively 11.7% of patients reported insulin use and post operatively 3.2% reported taking insulin, a decline of 73% (p<0.01). Mean preoperative HgA1c was 7.5 + 3.3 and the mean reported post operative HgA1c was 5.6 + 2.1.

Conclusions: MGB patients report decline in Diabetes and Diabetic medications at 5-10 years after MGB with estimated Pharmacy saving of more than 10 million dollars.

P-011

Surgical management of Diabetes type 2 – predictive values, type of procedure and outcome.

Ivaylo Tzvetkov^{1, a)}, Dimitar Tzankov^{2, b)}, Diana Mileva^{1, c)}

¹⁾General and Metabolic Surgery, Private Hospital Vita, Sofia, Bulgaria

²⁾General Surgery, University Hospital "Sveta Marina", Pleven, Bulgaria

^a)tzvetkov62@gmail.com

^b)dimitartzankov@abv.bg

^c)d_mileva@abv.bg

The retrospective study revealed 6 years experience with Surgical Treatment of Diabetes Type 2 in patients with BMI over 42 kg/m. Selection criteria included BMI, confirmed DT2 and DIAREM values as age, HbA1c, noninsulin drug use, Insulin use and co-morbidity as hypertension, arthritis and sleep apnoea. Two main types of surgical procedures were performed laparoscopically: gastric RNY bypass and mini-gastric bypass. Total 74 patients were operated on from 2011 till June 2016, 21 women and 53 men, aged from 21 to 62 years old. RYN gastric bypass was performed in 70 cases and mini-gastric bypass in 4 cases. 14 patients had an intra-gastric balloon placement before surgery due to BMI from 58 to 61. Follow up of the patients was from 6 months to 5 years after surgery. There was no postoperative mortality. Median postoperative stay was 4 days. Only one 50 years old patient developed stricture of gastro-jejunal anastomosis, managed endoscopically with two dilatations. Total remission of Diabetes was observed in 61 patients with DIAREM score of 1 to 4 points from 3 to 14 months after surgery. Another 9 patients with DIAREM from 4 to 7 points had significant improvement in HbA1c and used only one antiglycemic drug plus diet 1 to 2 years after surgery. The rest 3 patients, who had DIAREM score between 6 and 9 points, had improvement of blood sugar levels and HbA1c, but were still on one antiglycemic drugs without Insulin more than 3 years after surgery. The results showed greater weight loss in the patients with mini-gastric by pass, median 8 to 12 kg more than RNY bypass patients, but both procedures were safe and reliable for surgical management of Diabetes type 2.

References:

1. Bariatric Surgery - 5 years experience, pro and cons for its application,Auth: Ivaylo Tzvetkov, Jordan Birdanov, Krasimir Shiopov, National Congress of Surgery,Sofia, Ocotber 5, 2011

2. Baraitric Surgery for treatment of Type 2 Diabetes, Ivaylo Tzvetkov, Krasimir Shopov, Jordan Birdanov, BASORD Conference, Albena, Bulgaria, May 29, 2011

3. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes, Auth: Geltrude Mingrone, Simona Panunz, Andrea De Gaetano, Caterina Guidone, Francesco Rubino et al, N Engl J Med 2012; 366:1577-1585April 26, 2012

Acknowledgement: The study reveals experience with Metabolic surgery in an European Country, where there are no national Guidelines or Consensus for the problem. The issues we would like to address with the study that we need a support from IFOS and European Health Commission the Metabolic Surgery to be implemented as a part of National Health Strategy for struggle with Morbid Obesity and Diabetes Type 2 in Bulgaria.

P-012

Mobility problems and weight regain by misdiagnosed lipedemia after bariatric surgery: a case report illustrating medical and legal aspects

Hendrika Smelt¹⁾, Sjaak Pouwels^{2, a)}, Mohammed Said¹⁾, Johannes Smulders¹⁾, Maarten Hoogbergen³⁾

¹⁾Surgery, Catharina Hospital, Eindhoven, Netherlands; ²⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands; ³⁾Plastic Surgery, Catharina Hospital, Eindhoven, Netherlands

^a)sjaakpwls@gmail.com

Lipedemia is a chronic progressive disorder, characterized by abnormal distribution of subcutaneous adipose, resulting in pronounced disproportion between extremities and trunk. This disease has a negative effect on psychological and physical aspects. The presence of obesity can aggravate the clinical course of lipedema and its associated symptoms. In this case study we report on a patient with super morbid obesity who have had a Sleeve Gastrectomy with maximum of weight loss. However, a lot of abnormal distribution of excess skin on both arms and legs disturbed her physical exercise enormously. The dermatologist noted the diagnosis of lipedemia 4 years after bariatric surgery. She have had a dermolipectomy of the upper arms, but dermolipectomy of the legs was rejected by her insurance. She regained weight (30 kg) because of the physical obstruction. In this report we want to illustrating the medical and legal aspects of this case-study with lipedemia.

P-013

Lipedema in patients after bariatric surgery: report of two cases and review of literature

Sjaak Pouwels^{1, a)}, Susanne Huisman¹⁾, Hendrika Smelt²⁾, Mohammed Said²⁾, Johannes Smulders²⁾

¹⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands; ²⁾Surgery, Catharina Hospital, Eindhoven, Netherlands

^a)sjaakpwls@gmail.com

Lipedema is a disorder of adipose tissue that is characterized by abnormal subcutaneous fat deposition leading to swelling and enlargement of the lower limbs as well as the trunk. This entity is often misdiagnosed as lymphedema or obesity, and therefore may be overlooked and missed in patients scheduled for bariatric surgery. Patients with lipedema who undergo bariatric surgery may have to continue to have extensive lower extremity and trunk adiposity despite adequate weight loss. In this report we present two patients who had extensive trunk and lower extremity adiposity, one of them before bariatric surgery and the other afterwards.

P-014 Quality of life improvement following bariatric procedures

Georgia Doulami^a), Victoria Michalopoulou^b), Stamatina Triantafyllou, Maria Natoudi, Konstantinos Albanopoulos, Emmanouil Leandros, Georgios Zografos, Dimitrios Theodorou

1st Propaedeutic Surgical Department, Hippokration general Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece

^a)tzinagb@yahoo.gr

^b)victoria.michal@gmail.com

Introduction: Improvement of health-related quality of life reflected by specially designed questionnaires is a strong motivation for morbidly obese in order to undergo a bariatric procedure. Several studies have shown that weight loss is related with improvement of QOL.

Patients and methods: This was a prospective study. Morbidly obese patients who underwent bariatric procedures answered EORTC- QLQ C30 quality of life questionnaire prior and one year after the bariatric procedure.

Results: 45 patients were included in the study. Mean age was 38.57 (SE= 2.57) and mean body mass index (BMI) preoperatively was 47.41 (SE= 2.37). One year after the bariatric procedure mean BMI was 29.38 (SE= 1.51), and the mean percentage of weight reduction was 38.82% (SE= 1.99). Physical and social functioning and global health status were significantly higher one year post surgery, whereas symptoms such as fatigue and dyspnea were significantly lower one year post surgery. No difference was noted between the different bariatric procedures (sleeve gastrectomy vs one anastomosis gastric bypass).

Conclusion: Bariatric surgery and weight loss seems to improve QOL measured by EORTC-QLQ C30.

P-015 Oxidative stress in morbidly obese patients decreased after gastric bypass

Julia Peinado-Onsurbe^{1, a)}, Júlia Carmona-Maurici^{1, b)}, Eva Pardina^{2, c)}, David Ricart-Jané^{1, d)}, Albert Lecube^{3, e)}, Juan Antonio Baena-Fustegueras^{4, f)}

¹⁾Biochemistry amb Molecular Biomedicine Department, Faculty of Biology, Universitat de Barcelona, Barcelona, Spain; ²⁾Fundació Bosch i Gimpera, Universitat de Barcelona, Barcelona, Spain; ³⁾CIBER de Diabetes y Enfermedades Metabólicas Asociadas, CIBERDEM; Unitat de Recerca en Diabetes i Metabolisme, Institut de Recerca Hospital Universitari Vall d’Hebron, Barcelona; Departament d’Endocrinologia i Nutrició, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, Lleida, Spain; ⁴⁾Surgery Unit, Hospital Arnau de Vilanova, Universitat de Lleida, Lleida, Spain

^a)jpeinado@ub.edu

^b)ailujcm@gmail.com

^c)epardina@ub.edu

^d)dricart@ub.edu

^e)alecube@gmail.com

^f)jabaena@vhebron.net

Introduction: Obesity is considered an oxidative stress (OS) state, defined as the unbalance between the production of pro-oxidant substances and antioxidant defenses.

Objectives: To verify if there is OS in morbidly obese patients and evaluate changes in anti- and pro-oxidant agents after bariatric surgery.

Methods: We evaluated the amount of OS markers like oxidized LDL (ox-LDL) and malondialdehide (MDA) by ELISA and thiobarbituric acid reactive substances (TBARS) methods; the levels of antioxidant agents like superoxide dismutase 2 (SOD2) and paraoxonase 1 (PON1) by ELISA and levels of a pro-oxidant agent (nitric oxide) by Griess method in plasma from 22 morbid obese (BMI ≥ 40 kg/m²) who underwent Roux-en-Y gastric bypass, before and after a six-months follow-up period.

Results: Morbid obese had more OS in basal situation than six months after surgery: high levels of ox-LDL and MDA were found before bariatric surgery (92.2 ± 23.3 U/L ox-LDL and 3.42 ± 2.58 μM MDA). Six months after gastric bypass the amount of OS markers decreased 32.9% and 74.9%, respectively. Moreover, a positive correlation between MDA and BMI (r=0,363 p=0,008) was found. Antioxidant parameters were altered in morbid obese: SOD2 was high (60.3 ± 12.8 ng/mL), and PON1 amounts were low (122.4 ± 31.9 ng/mL). However, along the six months follow-up period the antioxidant defenses improved, SOD2 levels significantly decreased (49.9 ± 9.8 ng/mL) and PON1 amounts significantly increased (154.3 ± 29.8 ng/mL). There were negative correlation (r=0.610, p<0.0001) between PON1 and ox-LDL.

Conclusions: The high plasma ox-LDL and MDA levels observed before surgery indicates an increased OS in obese. Six months after gastric bypass, antioxidant defenses improved and OS decreased.

*Julia Peinado-Onsurbe and Juan Antonio Baena-Fustegueras share senior authorship.

Abstract topic: Oxidative stress, morbid obesity

Acknowledgement: This work was supported by the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III (ISCIII) (PI15/00190 to JP-O PI15/00332 to JAB-F) and the FEDER Funds of the EU (Fondo Europeo de Desarrollo Regional: “Una manera de hacer Europa”).

P-016 One anastomosis gastric bypass versus Roux-en-Y gastric bypass for morbid obesity: A meta-analysis

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{2, 1, b)}, Dimitris Zacharoulis^{1, 2, c)}, George Tzovaras^{1, 2, d)}

¹⁾Department of General Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)zachadim@yahoo.com

^d)geotzovaras@gmail.com

Background: We aim to review the available literature on morbidly obese patients treated with one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) in order to compare the clinical outcomes of the two methods.

Methods: A systematic literature search was performed in PubMed, Cochrane library and Scopus, in accordance with PRISMA guidelines.

Results: Eleven studies met the inclusion criteria (7,046 patients). OAGB was associated with shorter mean operative time. The length of hospital stay was comparable between the two procedures. The incidence of leaks, marginal ulcer, dumping, bowel obstruction, revisions and mortality was similar between the two approaches. The incidence of malnutrition was increased in patients treated with OAGB, while the incidence of internal hernia was greater in the RYGB group. No difference was found regarding the % excess weight loss (%EWL) at 1 year postoperatively. However, we reported increased %EWL at 2 and 5 years postoperatively for the OAGB group. The rate of comorbidities remission was also similar between OAGB and RYGB.

Conclusion: Randomized controlled studies, comparing RYGB to OAGB, are necessary to assess further their clinical outcomes.

P-017

Compareing sleeve gasterctomy results in +hpylori and -hpylori patients

Hashem Moazenzadeh

advanced laparoscopic ward, erfan hospital, tehran, Iran

dr.moazenzade@gmail.com

Background: Eradication of H pylori from stomach is a conflicting issue in bariatric surgery. Most of bariatric surgeons perform the upper GI Endoscopy for all obese patients before surgery. At now, several assessments for evaluation of presence of this organism is available such as direct biopsies or findings of evidences of microorganism like RUT. Due to high prevalence of H pylori infection in several regions of world the necessity of guidelines for eradication of this organism have important epidemiologic and cost- effective results in bariatric surgery.

Methods: Sleeve gastrectomy was performed for 284 patients by a single surgeon in two centers between 2013 and 2016. Upper GI Endoscopy was performed for all of them but preoperative biopsies was taken from several parts of stomach and RUT examination for some of them was done. Resected part of stomach was sent for tissue examinations in all patients. The early and late complication of sleeve gastrectomy, hospital stay, rehospitalization and trend of weight loss in two groups of patients was compared.

Results: According to presence of H pylori in biopsies or change in color of RUT solution, 194 patients labeled as positive H pylori patients and in 89 patients no evidences of H pylori infection was detected. Eighteen cases were excluded from positive H pylori group because of preoperative eradication of H pylori or because of treatment by PPI or antibiotics for ulcers in stomach. The rate of major complication such as bleeding, leakages and stenosis was equal in two groups. There was no any difference in hospital stay between two groups. We reported differences in presence of acid reflux, duration of PPI consumption and related rehospitalization but the differences was not statistically significant (p-value > 0.5).

Conclusion: There was not any significant difference in major complication and clinical outcome. So, there is not sufficient evidence according to present study for eradication of H pylori prior to sleeve gastrectomy.

References:

Helicobacter pylori in sleeve gastrectomies: prevalence and rate of ...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560499/

Helicobacter pylori infection in obesity and its clinical outcome after ...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921474/

Prevalence of Chronic Gastritis or Helicobacter pylori Infection in ...

http://online.liebertpub.com/doi/pdf/10.1089/sur.2014.153

Keyword: hpylori, eradication, sleeve gastrectomy

P-018

Gastric Volvulus after Laparoscopic Sleeve Gastrectomy: Presentation of a Case and its Management

Pilar Martinez, Marga Vives, Elisabeth Homs, Marta París, Èlia Bartra, Fàtima Sabench, Esther Raga, Alicia Molina, Antonio Sánchez, Daniel Del Castillo

Surgery, University Hospital of Sant Joan. Rovira i Virgili University, Reus, Spain

Objectives: In the actuality, Laparoscopic (LSG) Sleeve gastrectomy is the most bariatric surgical technique performed due to the good results obtained. Its complications are the appearance of leaks, bleeding or stenosis (0.5-5%) but also other less frequent that can lead to a bad evolution of the patient such as angulation or volvulation in its greatest degree.

Methods: We present the case of a 55-year-old male with a BMI of 37 kg/m2, 2DM, chronic liver disease and hypothyroidism. Initially proposed to perform a gastric bypass, a LSG is finally performed due to a giant hepatomegaly and its underlying liver disease. It presents a good immediate postoperative period, and is discharged without incident at 72 hours. After 3 months, he consulted for repeated postprandial vomiting; diagnosed endoscopically of substenosis, an endoscopic dilation was performed with symptomatic resolution of the symptoms. One year after the intervention he presented a similar clinic. A new endoscopy and dilatation were performed and due to the non-remission of symptom, a surgical revision was decided. During the intervention, an important adhesion syndrome was observed at the level of the body and gastric antrum with two adherent nodules of steatonecrosis that condition an axial angulation of the sleeve. Adhesiolysis and removal of the nodules was performed laparoscopically with deangulation and verification of the stapling line by intraoperative fibrogastroscopy.

Results: The patient started a progressive oral intake at 24 hours, with good tolerance, being discharged after 3 days. He follows periodic controls, being asymptomatic 5 months after the intervention.

Conclusions: The angulation/volvulation of the LSG is a rare complication but it must be taken into account in clinical cases of obstructive nature after surgery; it may involve a surgical revision or even a conversion to gastric bypass if it is not resolved. The laxity or disappearance of ligaments and the absence of omentum may leave the stomach without fixation along the entire greater curvature, which may predispose the angulation/volvulation.

References:

1: Costa MN, Capela T, Seves I, Ribeiro R, Rio-Tinto R. Endoscopic Treatment of Early Gastric Obstruction After Sleeve Gastrectomy: Report of Two Cases. GE Port J Gastroenterol. 2015 Sep 12;23(1):46-49. doi: 10.1016/j.jpge.2015.07.008. eCollection 2016 Jan-Feb. PubMed PMID: 28868430; PubMed Central PMCID: PMC5579982.

2: Subhas G, Gupta A, Sabir M, Mittal VK. Gastric remnant twist in the immediate post-operative period following laparoscopic sleeve gastrectomy. World J Gastrointest Surg. 2015 Nov 27;7(11):345-8. doi: 10.4240/wjgs.v7.i11.345. PubMed PMID: 26649158; PubMed Central PMCID: PMC4663389.

P-019

Routine drainplacement in bariatric surgery - do we really need it ?

Steffen Seyfried^{1, a)}, Christian Galata^{1, b)}, Ullrich Ronellenfitsch^{2, c)}, Georgi Vassilev^{1, d)}, Mirko Otto^{1, e)}

¹⁾Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; ²⁾Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany

^a)steffen.seyfried@umm.de

^b)christian.galata@umm.de

^c)Ulrich.ronellenfitsch@med.uni-heidelberg.de

^d)georgi.vassilev@umm.de

^e)mirko.otto@umm.de

Backround: Routine drain placement after bariatric surgery is still standard in many surgical departments. Retrospective studies¹ and a systematic review² could demonstrate, that routine drain placement has no benefit and is potentially harmful after gastric bypass. However, to indicate bleeding after gastric sleeve a drainage could be helpful.

Aim: To evaluate drainage placement in both surgical techniques we retrospectively reviewed records of all patients undergoing gastric sleeve or roux-y gastric bypass from 01/2010 to 06/2016.

Method: We could generate two groups: one with a drain placed (168) at surgery and one without (201). Demographics were statistically adjusted between the two groups. We compared surgical outcomes within 30 postoperative days (complications, hospital stay) between the two groups. A total of 367 operations (218 gastric bypass and 149 gastric sleeves) were performed during the study period.

Results: Among the non-drainage group, seven patients had complications:

1 patient had postoperative bleeding which required operation – laparoscopic clipping in the area of the stapler column

1 patient had a postoperative abscess caused by a leak which required surgery- laparoscopic drainage placement

4 patients were treated conservatively (drop of haemoglobin without circulatory effects)

1 patient died due to a stroke

In the drain group 6 complication occurred:

3 leaks which were not detected by the drainage – one required laparoscopic drainage and one could be endoscopically treated by stent placement and one needed another interventional placed drain.

1 patient required surgery because the drain dislocated and had to be removed laparoscopically

1 patient complained about abdominal pain, which stopped after drainage removal

1 patient developed a hernia in the area of the trocar position which required another operation.

The leak and reoperation rates between the groups were not statistically different. The postoperative stay was significant extended in patients with drainage. Even in multivariate analyses, drain placement is the highest risk factor for longer hospital stay.

Conclusion: Routine drains likely have no benefit after bariatric surgery and are potentially harmful. ^1,2

References:

1. Kavuturu S, Rogers AM, Haluck RS: Routine drain placement in Roux-en-Y gastric bypass: An expanded retrospective comparative study of 755 patients and review of the literature. Obes. Surg. 22: 177–181, 2012

2. Liscia G, Scaringi S, Facchiano E, Quartararo G, Lucchese M: The role of drainage after Roux-en-Y gastric bypass for morbid obesity: A systematic review. Surg. Obes. Relat. Dis. [Internet] 10: 171–176, 2014 Available from: http://dx.doi.org/10.1016/j.soard.2013.09.008

P-020

Does the size of the cartridge of linear stapled gastro-jejunostomy in gastric bypass patients influence weight loss?

Oliver Stumpf^{1, a)}, Volker Lange^{1, b)}, Anke Rosenthal^{2, b)}

¹⁾Center for Obesity and Metabolic Surgery, Vivantes Klinikum Spandau, Berlin, Germany; ²⁾Obesity Outpatient Clinic Rosenthal, Obesity Outpatient Clinic Rosenthal, Berlin, Germany

^a)oliver.stumpf@vivantes.de

^b)volker.lange@vivantes.de

Background: Size of the pouch and diameter of the gastro-jejunostomy seem to influence postoperative weight loss in gastric bypass patients. However there is no consensus which size of each component is optimal for best weight loss. We studied two different lengths of the cartridge of linear stapled gastro-jejunostomies.

Methods: In our institution gastric bypass is performed in a completely standardized fashion. Pouch volume contains around 15 ml, alimentary limb 135 cm, biliary limb 80 cm in BMI 40 – 60. Over a long time we used a 45 mm blue cartridge and a running suture to create a lateral side-to-side anastomosis to the pouch. Since 2012 we used a 30 mm instead of a 45 mm blue cartridge. Nothing else of the standard was changed.

Results: 100 consecutive patients of each group were followed over a period of 36 months ( 24 to 63 months) in regard of weight loss. The individual percentage of excess weight loss and the proportion of patients with successful weight loss ( > 50% of EWL) were more prominent in the group who received a 30 mm staple but did not reach a significant difference. In regard to therapeutic failures rates there was a significant higher rate with less than 25% EWL (p = 0.01) for the 45 mm cartridge anastomosis. Postop weight-regain exceeding the preoperative weight was only observed in the 45 mm cartridge group.

Conclusion: Linear stapled gastro-jejunostomy by 30 mm cartridge goes along with a better weight loss than using a 45 mm cartridge without reaching a significant difference. After 36 months the rate of insufficient weight loss or weight regain was significantly higher in the 45 mm cartridge group.

P-021

Comparison of operative outcome using different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass

Jessica Lange^a), Archid Rami^b), Alfred Koenigsrainer^c)

General Surgery, University Hospital, Tuebingen, Germany

^a)borboletas@gmx.de

^b)rami.archid@med.uni-tuebingen.de

^c)alfred.koenigsrainer@med.uni-tuebingen.de

Background: For morbide obese patients laparoscopic Roux-en-y-gastric bypass (LRYGB) remains the most commonly performed bariatric procedure. Nevertheless no consensus exist which method is superior for the gastrojejunostomy. We wanted to analyse our own data comparing three different ways to performe the gastrojejunostomy in the context of complications (leak and strictures) as well as operative time, hospital and icu stay and BMI 6 month postoperative.

Methods: We include retrospective data from 78 LRYGB patients operated between december 2008 and october 2015. We included operations in consecutive way. We studied operative time, length of hospital and intensive care unit stay and postoperative complications. Between 2008 and 2011 we performed circular stapling (CS), followed by linear stapling (LS) between 2011 and may 2014. Form may 2014 till now we use linear stapling and close the stapler defect with stratafix absorbable bidrectional monofilament barbed suture (LSS).

Results: Preoperatively the groups were comparable (BMI 44kg/m² for CS, 47 kg/m² for LS and 46 kg/m² for LSS with stratafix; age 49,5 years, 44,8 years, 47,3 years). Changing the operation procedure form CS and LS to LSS operative time (353 minutes, 129 minutes and 90 minutes) (Figure 1) and hospital stay reduced (from 10 days to 8 and then 5 days) as well as ICU stay (Figure 2). The rate of reoperations was 5% in CS, 10% in LS and 3% in LSS.

There were no anastomitic leakages or anastomotic stenosis in the LSS group and no mortality was observed in any group. The BMI six month postoperative showed no significant differences between the three groups.

Conclusion: Despite there is no consensus which method is better creating the gastrojejunostomy our study showed best results in postoperative complications and operative time for the linear stapled gastrojejunostomy with additional closure of the stapler defect using stratafix absorbable bidrectional monofilament barbed suture. Circular stapled gastrojejunostomy was found to be associated with longer operative time, hospital stay and postoperative complications compared to LSS.

References:

Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357 (8):741–52

Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A 2001;11(6):377–82

Olbers T, Lönroth H, Fagevik-Olsén M, Lundell L. Laparoscopic gastric bypass: development of technique, respiratory function, and long-term outcome. Obes Surg 2003;13(3):364–70

Finks JF, Carlin A, Share D, et al. Effect of surgical techniques on clinical outcomes after laparoscopic gastric bypass—results from the Michigan Bariatric Surgery Collaborative. Surg Obes Relat Dis 2011;7(3):284–9

Quereshi A, Podolsky D, Cumella L et al., Comparison of stricture rates using three different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass; Surg Endosc (2015) 29:1737-1740

P-022 Effectiveness and Safety of Sleeve Gastrectomy in Patients Older than 65 Years

Vasiliki Christogianni^a), Martin Buesing^b), Panagiotis Bemponis^c), Radostina Dukovska^d)

General and Visceral Surgery, Klinikum Vest Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

^a)bchristogianni@yahoo.com

^b)chirurgie@klinikum-vest.de

^c)bebonis@gmail.com

^d)ineto@abv.bg

Introduction: Bariatric Surgery has been proven to be the only effective long term treatment of morbid obesity. With increasing life expectancy a surgical approach of the elderly obese patients can be justified taking into consideration the low morbidity rate and the effectiveness in the treatment of obesity and its related comorbidities.

Material und Methods: The study included patients older than 65 years who underwent a surgical treatment of obesity in our clinic between the years 2009 to 2016. In all patients a laparoscopic sleeve gastrectomy was performed. Patients who underwent a revisional procedure were not included.

Results: The patients analysed were between the ages of 65 to 75 with a mean age of 68,76y. The BMI varied from 34,72 to 77,03 with an average BMI of 46,48 kg/m2. From the 42 patients 30 showed for follow up. 1 patient died direct postoperatively and in another patient a relaparoscopy due to postoperative- haemorrhage was necessary. The same patient showed a prolongated hospitalisation with a persistent septicaemia and cardiac complications. In the long term, 2 patients underwent a redo procedure due to inadequate weight loss (mini gastric bypasss) and 2 patients showed persistent dysphagia- with a need of endoscopic dilatation in one of them. One patient suffered from GERD symptoms due to a hiatal hernia and a hiatoplastic with hemifundoplication was performed. In a period of time from 1 to 3 years a mean BMI drop of 12,928 kg/m2 was observed. Most of the patients were “very satisfied” with the weight loss in the follow up.

Conclusions: The morbidity and mortality of sleeve gastrectomy in patients older than 65 years is slightly higher than younger individuals. On the other hand, the effectiveness of a bariatric procedure with satisfied weight control is well established. Taking into consideration the ageing of the population und the safety of the laparoscopic bariatric procedures, a sleeve gastrectomy in the elderly can be recommended.

P-023

Impact of Diabetes on Weight loss in Bariatric Surgery

Fàtima Sabench, Alicia Molina, Marga Vives, Marta París, Esther Raga, Elisabeth Homs, Èlia Bartra, Pilar Martínez, Carla Morales, Antonio Sánchez, Daniel Del Castillo

Surgery, University Hospital of Sant Joan. Rovira i Virgili University, Reus, Spain

Introduction: Expressing the weight loss after bariatric surgery is still a controversial issue, and can also vary depending on the surgical technique performed and the basal metabolic state of the patient. Our objective is to analyze the weight evolution of morbidly obese patients undergoing different techniques (Laparoscopic sleeve gastrectomy-LSG and Roux-en-Y Gastrojejunal Bypass-RYGBP), according to different indicators of weight loss. Also, we analyze whether the presence or absence of Diabetes Mellitus type 2 (DM2) influences on the weight loss in all of them.

Material And Methods: This is a retrospective study that selects a sample of 551 patients operated by the Bariatric Surgery team of our center since 2013. The patients are followed up for 3 years. The patients are divided into 4 groups depending on the surgical technique performed (LSG and RYGBP), and the presence or absence of type 2 DM. The anthropometric parameters are collected for the determination of the following indicators: BMI, Percentage of excess BMI lost (PEBMIL,%), Total weight loss (TWL,%), Excess weight lost (EWL,%). The different tables of corresponding percentiles are made in all groups.

Results: The main values of weight loss are shown in the attached table

Conclusions: The best results for all parameters studied are obtained in non-diabetic patients undergoing a RYGBP. Everything seems to indicate that it is related to the basal metabolic repercussion of the patient and with a lower initial BMI, which suggests a greater effectiveness.

References:

Sabench Pereferrer F, Molina López A, Vives Espelta M, Raga Carceller E, Blanco Blasco S, Buils Vilalta F, París Sans M, Piñana Campón ML, Hernández González M, Sánchez Marín A, Del Castillo Déjardin D. Weight Loss Analysis According to Different Formulas after Sleeve Gastrectomy With or Without Antral

Preservation: a Randomised Study. Obes Surg. 2017 May;27(5):1254-1260. doi: 10.1007/s11695-016-2454-z. PubMed PMID: 27995517.

P-024

Ileoileal intussusceptions on two segments of the common channel after Roux – en – Y gastric bypass

Karolin Dallago^a), Renzo Joos^b), Peter Villiger^c)

Surgery, Kantonspital Graubünden, Chur, Switzerland

^a)Karolin.dallago@ksgr.ch

^b)Renzo.Joos@ksgr.ch

^c)Peter.Villiger@ksgr.ch

Introduction: Small bowel intussusception is a rare complication after Roux-en-Y gastric bypass, of which the exact etiology remains unclear.

So far most of the reported cases are seen to be jejunojejunal, often involving the jejunojejunostomy and processing preferably retrograde into the proximal bowel.

Case report: We report a case of a 24 year old male patient presenting to our emergency department with acute abdominal pain, vomiting and diarrhea. 22 months before he had submitted laparoscopic Roux-en-Y gastric bypass because of morbid obesity and sustained over 43% excess weight loss (current BMI 23kg/m2).

Physical examination showed a tender abdomen without signs for peritonitis. On laboratory tests a mild elevated lactat level (2.3mmol/l) could be seen. Computed tomography showed typical target lesions on two distal segments of the common channel, suggestive for antegrade ileoileal intussusceptions with signs of obstruction.

We performed emergency re-laparoscopy. Preoperatively 20mg Butylscopalamin was administrated. Intraoperatively we noted active small intestine motility but no intussusceptions could be seen any more.

Postoperatively the patient suffered from persisting mild abdominal cramps, which vanished completely under antispasmodic medication (Butylscopalamin). The lactat level turned to be normal and on an ultrasound control on the 5^th day no signs of intussusception could be seen any more.

Discussion: Small bowel intussusception is a rare, but probably underreported, long-term complication after Roux-en-Y gastric bypass. In literature the incidence lies between 0.07 and 0.15%. In our case the intussusceptions occur in the common channel, which is not reported in the literature so far.

The etiology is still unclear, but different potential leading-points are discussed such as motility disorders, thinner mesentery and some more.

Although intussusception may resolve spontaneously, treatment is usually surgical. Resection of the small bowel segment is often necessary as the intussusception is most frequently seen to be recurrent. However in some cases conservative treatment with administration of spasmolytic drugs may be a first option, but continuous active clinical surveillance is crucial for not missing small bowel necrosis.

P-025

Laparoscopic Sleeve Gastrectomy in Patients Over 60: Outcomes of Mid & Long Term Follow-Up

Omer Sadeh^{1, a)}, Dvir Froylich^{1, b)}, Naama Kafri^{1, c)}, Hagar Mizrahi^{2, d)}, Nisim Geron^{2, e)}, David Hazzan^{1, f)}

¹⁾Surgery B, Carmel Medical Center, Haifa, Israel; ²⁾Surgery, The Bruch Padeh Medical Center Poriya, Poriya, Israel

^a)omersadeh@gmail.com

^b)dvirfr7@gmail.com

^c)naamka1@gmail.com

^d)Hmizrahi@poria.health.gov.il

^e)n_geron@yahoo.com

^f)hazzan2david@yahoo.com

Background: The rise in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess body weight and improvement in related co-morbidities. However, only recently surgeons began performing these operations on elderly patients on a larger scale, making data regarding middle and long term outcomes scarce. The objective of this study was to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged≥60 years.

Methods: Between 2008 and 2014, 55 patients aged 60 years or over who underwent LSG in one of 3 medical centers, and had documented surveillance for a minimum of 24 months were included in this study. Data was retrospectively collected from hospital and community electronic patient records, and from telephonic questionnaires.

Results: Mean patient age was 63.9 (range: 60-75.2) years and mean pre-operative BMI was 43±6.0 kg/m². Perioperative morbidity included 5 cases of excessive bleeding necessitating operative exploration, 2 cases of reduced hemoglobin levels treated with blood transfusion and 1 case of portal vein thrombosis managed conservatively. No mortality was reported. Mean follow-up time was 48.6 (range 25.6-94.5) months. Mean percentage of excess weight loss was 66.4±19.7, 67.5±16.4, 61.4±18.3, 66.7±25.6, 50.7±21.4 at 12, 24, 36, 37-60 and 61-96 months, respectively. Statistically significant improvement of type 2 diabetes mellitus, hypertension and dyslipidemia were observed at the latest follow-up point (p<0.01).

Conclusion: LSG offers an effective treatment of obesity and its co-morbidities in adults aged≥60, albeit higher perioperative morbidity compared to younger patients according to published literature, Efficacy is maintained for at least 4.5 years.

Keywords: Bariatric surgery; Sleeve gastrectomy, Elderly patients; Morbid obesity; Co-morbidities; Laparoscopy

P-026

Correlation of Preoperative Symptoms and Histologic Findings in Gastric Specimens Following Laparoscopic Sleeve Gastrectomy

Athanasios Pantelis^a), Ioannis-Petros Katralis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)ath.pantelis@gmail.com

^b)drpetran@yahoo.gr

^c)dimitrislapatsanis@gmail.com

Background: Increasing frequency of LSG has resulted in a large number of histologically "normal" gastric specimens. Among them, the diagnosis of gastritis is high, whereas other pathologies are also recognized.

Objective: To determine the frequency of gastritis and other significant pahtologies in the specimens of LSG in our cohort of patients.

Material & Methods: We conducted a retrospective analysis of prospectively collected data regarding 304 gastric specimens, over a seven-year period.

Results: The vast majority of gastric specimens were normal (58.2%), whereas gastritis was detected in 31% and H. pylori infection in 9.5% of them, gastric polyps in 1% and GIST in 0.3%. Notably, none of the patients reported typical (heartburn, regurgitation, dysphagia) or atypical (respiratory) symptoms of GERD and esophagitis preoperatively. Two patients in the "normal" group and 1 patient in the "positive histology" group presented with a leak, whereas no major hemorrhage events were documented in either group.

Conclusions: In our series, a relatively high incidence of inflammatory conditions was recorded in LSG specimens, in accordance with international literature. This did not correlate with the absence of pertinent symptomatology preoperatively. A low but considerable incidence of GIST was also documented, underlying the indolent nature of this entity. Specimen pathology was not correlated with postoperative complication rates, despite the fact that the population sample is rather compromised for extacting statistically significant outcomes.

References:

1) Kopach et al. Obes Surg 2017;13:463-467.

2) Safaan et al. Obes Surg 2017.

3) Miller et al. Pathology 2016;48:228-232.

4) AbdullGaffar et al. Obes Surg 2016;26:105-110.

P-027

Achalasia and Pseudoachalasia after Sleeve Gastrectomy or Gastric Bypass. A systematic review.

Gavriella Zoi Vrakopoulou^a), Maria Matiatou^b), Maria Natoudi^c), Stamatina Triantafyllou^d), Dimitrios Theodorou^e), George Zografos^f), Emmanouil Leandros^g), Konstantinos Albanopoulos^h)

1st Propaedeutic Surgical Department, Hippocratio General Hospital Medical School, National and Kapodistrian University of Athens, Athens, Greece

^a)g.z.vrakopoulou@gmail.com

^b)toxomaira@gmail.com

^c)marnatoyd@yahoo.gr

^d)t_triantafilou@yahoo.com

^e)dimitheod@netscape.net

^f)surg-clinic-uoa@hippocratio.gr

^g)leandros@hippocratio.gr

^h)Albanopoulos_kostis@yahoo.gr

Introduction: Obesity is an epidemic on the rise. Nowadays, Sleeve gastrectomy and Gastric Bypass are the most often- performed bariatric surgeries, creating a potential high-pressure zone just distal to the esophagus. Limited data exist regarding esophageal motility disorders after these procedures.

Objective: The aim of this study is to present a systematic review of the literature, in order to highlight the incidence of such a rare complication, and thus its role to differentialdiagnosis algorithm and targeted treatment.

Data Sources: A literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed in December 2017 revealed 40 articles of interest. Search terms included achalasia or pseudoachalasia after sleeve gastrectomy, or after gastric bypass.

Study Selection: We included only studies in English or German language and published material with available data in print or on the web in full text. The time of publication was not considered as a restriction for our study.

Main Outcome Measures: The articles described cases diagnosed with postoperative achalasia or pseudoachalasia after Sleeve Gastrectomy or Gastric Bypass, treated with Laparoscopic or Robotic Heller Myotomy (LHM or RHM), or Peroral Endoscopic Myotomy (POEM), and/ or Gastric Bypass revision, and/ or conversion to RYGB through laparoscopic or open procedure were evaluated.

Results: We identified 395 publications. After duplicates and irrelevant articles have been excluded, 40 publications remained for full text evaluation. Finally, 12 articles were included to this systematic review, revealing 22 cases.

Conclusions: Data on esophageal motility disorders after bariatric surgery have been limited in the literature to date. However, our results reveal an increasing tendency of case reports, related to postoperative achalasia, especially after RYGB. Moreover, our results suggest that achalasia can be effectively treated with surgical interventions. Heller Myotomy is still the procedure of choice, while POEM seems to be safe and effective, as well. Raising awareness that achalasia can occur after bariatric surgery is essential for the differentialdiagnosis and targeted treatment of these patients.

References:

• 1. Chapman R, Rotundo A, Carter N, George J, Jenkinson A, Adamo M., Laparoscopic Heller’s myotomy for achalasia after gastric bypass: A case report, Int J Surg Case Rep. 2013;4(4):396-8. doi: 10.1016/j.ijscr.2013.01.014.

• 2. Ravi K, Sweetser S, Katzka DA., Pseudoachalasia secondary to bariatric surgery, Dis Esophagus. 2016 Nov;29(8):992-995. doi: 10.1111/dote.12422.

• 3. Ran B. Luo, Domingo Montalvo, Santiago Horgan, POEM after gastric bypass: An effective solution for de novo achalasia, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.10.004

P-028

Three-Port Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Vasileios Drakopoulos^a), Athanasios Bakalis^b), Sotirios Voulgaris^c), Maria Christina Papadopoulou^d), Konstantinos Botsakis^e), Sophia Petsa-Poutouri Sophia^f), Katerina Sarafi^g), Vassilis Kalatzis^h), Vassilis Vougasⁱ⁾

1st Dep. of Surgery and Transplant Unit, Evangelismos General Hospital, Athens, Greece

^a)vasileiosdrakopoulos@gmail.com

^b)bakalisath@yahoo.gr

^c)sot.voulgaris@gmail.com

^d)mxpapadopoulou@gmail.com

^e)botsakis@hotmail.com

^f)sofiapetsapoutouri@gmail.com

^g)kathrin9@hotmail.com

^h)vas.kalatzis@gmail.com

ⁱ⁾drvougas58@yahoo.gr

Background: Sleeve gastrectomy is traditionally performed with the aid of 5 to 7 abdominal trocars. We aim to present our experience concerning laparoscopic sleeve gastrectomy for morbid obesity, with a more minimal invasive approach, using three ports- trocars.

Introduction: Laparoscopic Sleeve Gastrectomy (LSG) is traditionally performed using 5 to 7 abdominal trocars. By reducing the number of trocars, parietal trauma, pain and hernia risks can be minimized.

Objectives: We present our 3,5-year experience concerning LSG for morbid obesity using three trocars, with emphasis on a simple suture-based trocar-free liver retractor.

Methods: We retrospectively analyzed 50 patients who underwent LSG for morbid obesity, from May 2014 to December 2017. Three trocars are typically used: one 10-mm periumbilical optical trocar and two 12-mm trocars on the midclavicular lines. A suture is percutaneously inserted and fixed to the right crus of the diaphragm. Careful traction lifts the left hepatic lobe offering better surgical field and access to the gastroesophageal junction. A gauze is used to protect liver parenchyma from possible injury. Furthermore, sectioning and stapling of the stomach is performed before the gastroepiploic division, reducing the need of another left sided trocar.

Results: All the patients had an uncomplicated recovery. No liver injury or wound problem was mentioned.

Conclusions: The placement of a suture at the right crus of the diaphragm can reduce the number of trocars, leading to less postoperative pain, risk of hernia and better cosmetic outcome without compromising the safety of the operation or the rate of postoperative complications.

P-029

Bariatric surgery improves quality of life and maintains nutritional status of older obese patients

Elie CHOUILLARD^a), Antoine YOUNAN^a)

Minimally Invasive Surgery Department, Metabolic Surgery Unit, PARIS WEST MEDICAL CENTER, POISSY, France

^a)chouillard@yahoo.com

Introduction: Bariatric surgery is being safely performed in older patients. Quality of life and aggravation of sarcopenic obesity, however, have never been assessed in this subgroup of patients. This retrospective study aims to evaluate quality of life of older obese patients after surgery and to compare variations of their nutritional parameters to those of younger patients.

Methods And Procedures: 158 patients older than 60 years (Group 1) were matched 1:2 with 316 patients younger than 40 years (Group 2) for comparison of nutritional parameters. A modified Impact of Weight on Quality Of Life (IWQOL) questionnaire was filled by all included patients, at the one-year check-up.

Results: The preoperative serum albumin and prealbumin levels were comparable between the two groups. Albumin values regained preoperative levels at six months in both groups intergroup comparison showed no significant difference. The serum prealbumin levels reached back the preoperative values at 12 and 6 months in Groups 1 and 2, respectively. Values were significantly lower in Group 1 comparatively to Group 2 at three and six months (0.18 versus 0.19; p=0.04 and 0.20 versus 0.21; p=0.03, respectively) but not at one year. 139 patients (87.3%) gave a total of 3720 answers in the modified IWQOL. Among them, 362 (9.7%) and 2844 (76.5%) were in favour of mild and marked improvements, respectively.

Conclusions: Bariatric surgery improves quality of life of older obese patients with no compromise of their nutritional status. In the lack of precise recommendations, this represents a major argument that may serve to the preoperative assessment of such patients.

P-030

Fibrin glue application reduces or not leak rate after laparoscopic sleeve gastrectomy?

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Background: Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures. The most commonly feared complication is staple line dehiscence. A lot of methods have been suggested in order to reinforce the staple line, in an attempt to prevent leakage. The aim of this study is to present our experience with the use of fibrin glue as an adjunct to staple line reinforcement.

Objectives: We compare the rate of gastric leaks in LSG with and without application of fibrin glue.

Methods: All patients in our centre were operated by the same surgeon. It is standard practice in LSG to reinforce the staple line with absorbable running suture and suture the omentum over the staple line. Between September and December, 2012, in twenty-four patients that underwent LSG, fibrin glue was applied as an additional measure to staple line reinforcement following the standard placement of an absorbable running suture.

Results: Four postoperative leaks occurred after the use of fibrin glue. Two of these patients were treated conservatively, whereas the other two needed reoperation. The leak rate during the period of fibrin glue usage was statistically and clinically more significant than the general leak percentage of our centre without the use of fibrin glue (16.6% vs. 1.2%, OR 13.8, p <0.0001).Related literature is analysed and discussed.

Conclusion: The use of fibrin glue led to significantly increased morbidity in our series and was subsequently abandoned as an adjunct to staple line reinforcement in LSG.

P-031

Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Mid-term Results

Georgios Papadopoulos^a), Charalampos Lampropoulos, Theofilos Amanatidis, George Skroubis

Morbid Obesity Unit, Department of Surgery, University Hospital of Patras, Patras, Greece

^a)kreon84@gmail.com

Purpose: The laparoscopic one anastomosis/mini gastric bypass is considered a safe and effective bariatric surgical procedure. Our aim is to present our mid-term results of this bariatric intervention.

Method: From the prospective bariatric database of our unit, 250 patients who have undergone laparoscopic one anastomosis gastric bypass were studied retrospectively.

Results: Of the 250 patients, 63 were male (25%) and 187 were female (75%). The mean age was 37.3 ± 11.5 years, while the preoperative mean body mass index (BMI) was 47.4 ± 5.7 kg / m². Follow-up compliance rates were: at 1st year 80.4%, at 2nd year 89.1%, and at 3rd year 49.4%. Excess weight loss results (EWL %) were: at 1st year 78.1%, at 2nd year 81.7% and at 3rd year 75.1%. Postoperative complications were: 3 leakages from the gastric pouch (1.2%), 2 postoperative bleedings (0.8%) (conservative treatment), and 1 reflux esophagitis (0.4%) (conservative treatment). Two patients (0.8%) who experienced protein malnutrition (albumin <3g/dl), treated successfully with dietary counseling and oral protein supplements. Anemia (Hb: men <13.5g / dl, females <12.5g / dl) was presented to 30% of the patients at the 1st postoperative year, to 42% at 2nd year, and to 40% at 3rd year, whereas B₁₂ deficiency was presented to 7.7% of the cohort at the 1st postoperative year, to 13% at the 2nd year and to 12.5% at the 3rd year, successfully corrected with standard supplements.

Conclusions: The laparoscopic one anastomosis/mini gastric bypass offers excellent mid-term weight loss results, with no significant short-term and overall morbidity. The predominantly malabsorptive nature of the intervention imposes life-long clinical monitoring of the patients.

P-032

Laparoscopic Sleeve Gastrectomy for Treatment of Patients with Massive Hernias with Loss of Domain

Marina Molinete^{1, a)}, Ramon Vilallonga²⁾, Laura Martí³⁾, Pablo Muriel⁴⁾, Blanca De Urrutia⁵⁾, José Manuel Fort²⁾, Enric Caubet²⁾, Jose Maria Balibrea²⁾, Oscar González²⁾, Andrea Ciusdin²⁾, Manuel Armengol²⁾

¹⁾Endocrine, bariatric and metabolic unit., Hospital de Igualada, Igualada, Spain

²⁾Endocrine, bariatric and metabolic unit., Universitary Hospital Vall herbon, Barcelona, Spain, Barcelona, Spain

³⁾Endocrine, bariatric and metabolic unit., Hospital Universitario Donostia, Donostia, Spain

⁴⁾Endocrine, bariatric and metabolic unit., Hospital Arnau de Vilanova, Lleida, Spain

⁵⁾Endocrine, bariatric and metabolic unit., Hospital Alvaro Cunqueiro, Pontevedra, Spain

^a)marina_molinete03@hotmail.com

Repair a complex abdominal hernias have an important morbidity and mortality. We propose laparoscopic sleeve gastrectomy as first step in the management of hernias with loss of domain in morbidly obese patients.

This is a 56-year-old male patient with a history of Diabetes mellitus, HBP, with a BMI of 48 Kg/m² and with a large incisional hernia with loss of domain from a previous midline laparotomy. It was decided to undergo a vertical gastrectomy for morbid obesity prior to the repair of incisional hernia.

In this case, with patient in French position, we proceed with the placement of 5 working trocars distant from infraumbilical eventration and creation of pneumoperitoneum with Veress needle in left hypochondrium.

We release the greater curvature of the stomach, from the middle to the top with ultrasonic bipolar. A minimal opening of the greater curvature is made to in the retrogastric space. All the short vessels of the fundus are identified, in tension and exposed in vertical position, and its complete section is performed until the left pillar. A 40F tube is inserted into the pylorus and stomach was resected with linear mechanical endostapler. An extra 6^th trocar was neede to undergo the first stapling. Subsequently, we performed reinforcement of the suture with a prolene continuum with subsequent verification of the tightness of the suture with methylene blue leak test.

The postoperative course went uneventful.

Conclusion: Laparoscopic sleeve gastrectomy it’s a safety obesity procedure before major abdfominal hernia repair. It’s a minimally invasively technique with absence of anastomoses .These factors prevents less complications, without using the small bowel, and skin problems and allows resolution of obesity-associated co-morbidities. Body weight loss after surgery may be an opportunity to have sever loss of domain incisional hernia repairs.

P-033

Weight regain after laparoscopic sleeve gastrectomy

Charalampos Lampropoulos^a), Stylianos Tsochatzis^b), Dimitris Kehagias^c), Charalampos Kaplanis^d), Ioannis Kehagias^e)

Morbid Obesity Unit, Department of Surgery, University Hospital of Patras, Rio/Patras, Greece

^a)x_lamp@hotmail.com

^b)steliostsox@gmail.com

^c)dimikech@gmail.com

^d)xariskaplanis11@hotmail.gr

^e)ikehag@yahoo.gr

Background: A proportion of patients undergoing Laparoscopic Sleeve Gastrectomy (LSG) exhibit long-term weight regain after successful initial weight loss. Weight regain reduces the efficiency of LSG and is a major cause of reoperation. The aim of the present study is the assessment of long-term weight regain after LSG.

Methods: Retrospective study of 31 patients with LSG and annual follow-up up to the seventh postoperative year. The resection of the stomach began approximately 2cm proximal to the pylorus. A 32-Fr bougie was used to guide the gastric division. Relative Weight Loss (RWL) was defined as the annual percentage change in body weight [1- (Weight in n year / Weight in n-1 year)]. Weight regain was expressed as a percentage of the maximum % Excess Weight Loss (EWL) and was calculated using the relationship between % EWL in the seventh postoperative year and maximum %EWL [1 - (%EWL in the seventh postoperative time / maximum %EWL)].

Results: All patients achieved successful initial weight loss (%EWL> 50% in the first post-operative year). Τhe mean maximum %EWL was 83%. In the seventh post-operative year mean %EWL was 61%, while mean weight regain was 29% (range: 0-78%) of the maximum %EWL. 16 patients experienced low (<25% of the maximum %EWL), 11 patients experienced moderate (25-50% of the maximum %EWL), and 4 patients experienced high (> 50% of the maximum %EWL) weight regain. Patients with low and patients with moderate/high weight regain did not differ significantly in gender, age, preoperative BMI or maximum %EWL. However, patients with moderate/high weight regain exhibited statistically significantly lower RWL in the second (p = 0.006) and seventh (p = 0.001) postoperative year.

Conclusion: Despite the initial successful weight loss, about half of the patients with LSG experienced moderate or high weight regain seven years after surgery.

References:

• Lauti M, Kularatna M, Hill AG, MacCormick AD. Weight Regain Following Sleeve Gastrectomy-a Systematic Review. Obes Surg. 2016 Jun;26(6):1326-34.

• Lauti M, Lemanu D, Zeng ISL, Su'a B, Hill AG, MacCormick AD. Definition determines weight regain outcomes after sleeve gastrectomy. Surg Obes Relat Dis. 2017 Jul;13(7):1123-1129.

• Santo MA, Riccioppo D, Pajecki D, Kawamoto F, de Cleva R, Antonangelo L, Marçal L, Cecconello I. Weight Regain After Gastric Bypass: Influence of Gut Hormones. Obes Surg. 2016 May;26(5):919-25.

• Casella G, Soricelli E, Giannotti D, Collalti M, Maselli R, Genco A, Redler A, Basso N. Long-term results after laparoscopic sleeve gastrectomy in a large monocentric series. Surg Obes Relat Dis. 2016 May;12(4):757-762.

• Alvarez V, Carrasco F, Cuevas A, Valenzuela B, Muñoz G, Ghiardo D, Burr M, Lehmann Y, Leiva MJ, Berry M, Maluenda F. Mechanisms of long-term weight regain in patients undergoing sleeve gastrectomy. Nutrition. 2016 Mar;32(3):303-8.

P-034

Laparoscopic Roux-en-Y gastric bypass, with long biliopancreatic limp (200cm): Early results

Theofilos Amanatidis^a), George Papadopoulos^b), Charalampos Lampropoulos, George Skroubis^c)

Morbid Obesity Unit, Department of Surgery, University Hospital of Patras, Patras, Greece

^a)kontos_lo@hotmail.com

^b)tzi.papadopoulos@gmail.com

^c)skroubis@med.upatras.gr

Introduction: Laparoscopic Roux-en-Y gastric bypass, is one of the most frequently performed bariatric procedures. Due to weight regain, several variations in the lengths of the limps have been attempted. It seems that the length of the biliopancreatic limp determines better the weight loss and helps to maintain it

Method: The last 12 months, 9 patients with BMI 54.78±5.40 (mean±SD), underwent Roux-en-Y gastric bypass with a long biliopancreatic limp (200 cm) in our department.

Results: Mean excess weight loss (EWL%) was 35.3% at 3 months, 66.6% at 6 months and 70.9% at 12 months. No direct or delayed surgical complication and no metabolic deficiency, under standard supplements, have been observed.

Conclusion: Gastric bypass, with long biliopancreatic limp constitutes a bariatric procedure with good early results in weight loss, with no increase in direct postoperative morbidity. It seems that long-term follow-up is required to assess the maintenance of weight loss and the incidence of metabolic deficiencies.

P-035

Spontaneously Resolved Achalasia Secondary to Laparoscopic Sleeve Gastrectomy. A Case-Report.

Konstantinos Albanopoulos^a), Tania Triantafyllou^b), Dimitrios Theodorou^c), Emmanouil Leandros^d), Georgios Zografos^e)

1(st) Propaedeutic Surgical Department, Hippokration General Hospital of Athens., National and Kapodistrian University of Athens., Athens, Greece

^a)albanopoulos_kostis@yahoo.gr

^b)t_triantafilou@yahoo.com

^c)dimitheod@netscape.net

^d)leandros@hippocratio.gr

^e)surg-clinic-uoa@hippocratio.gr

Introduction: Pseudoachalasia of the esophagus is a term used to define a manometric disorder mimicking achalasia. It may be caused due to several factors, such as aneurysm, malignancies or surgical procedures [1-3]. Outflow obstruction leads to dilatation of the esophagus. Manometric findings consist of hypertensive Lower Esophageal Sphincter (LES) and failed or simultaneous contractions. Secondary achalasia may also present after bariatric surgery [4]. Treatment of pseudoachalasia should be etiologic.

Case Presentation: We present a rare case of spontaneously resolved pseudoachalasia in a 57-year-old female patient. The patient referred to our department for morbid obesity and underwent laparoscopic sleeve gastrectomy. On the second postoperative day, while starting on liquid diet, she complained of sudden onset of dysphagia. Barium swallow test was conclusive for esophageal dilatation and incomplete bolus clearance. She underwent High Resolution Manometry (HRM) that revealed achalasia with vigorous contractions [figure]. After two endoscopic dilatations, the patient continued complaining of saliva regurgitations and inability to swallow. However, while on conservative treatment with intravenous fluid for four weeks, the symptoms eliminated and the patient was discharged.

Conclusion: Bariatric surgery may result in secondary motility disorder of the esophagus. In the case of dysphagia after bariatric surgery evaluation of the clinical, manometric and radiographic findings should always be completed before deciding the optimal treatment option [5]. Conservative treatment is mandatory prior to endoscopic techniques. Whether this incidence is underestimated remains to be seen in future studies.

References:

• 1. Jia Y, McCallum RW. Pseudoachalasia: Still a Tough Clinical Challenge. Am J Case Rep. 2015 Oct 29;16:768-73.

• 2. Katzka D A, Farrugia G, Arora A S. Achalasia secondary to neoplasia: a disease with a changing differential diagnosis. Dis Esophagus 2012; 25: 331–6.

• 3. Campo SM et al. Pseudoachalasia: A peculiar case report and review of the literature. World J Gastrointest Endosc. (2013)

• 4. Ravi K, Sweetser S, Katzka DA. Pseudoachalasia secondary to bariatric surgery. Dis Esophagus. 2016 Nov;29(8):992-995. doi: 10.1111/dote.12422. Epub 2015 Sep 10.

• 5. Abubakar U, Bashir MB, Kesieme EB. Pseudoachalasia: A review. Niger J Clin Pract. 2016 May-Jun;19(3):303-7. doi: 10.4103/1119-3077.179275.

Acknowledgement: AK conceived and designed the study. TT collected patient’s data and wrote the report. TD acquired the data. LE and ZG revised the manuscript for important intellectual content.

P-036

Can septic complications after sleeve gastrectomy be predicted by simple laboratory exams?

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Introduction: The septic complications after laparoscopic sleeve gastrectomy (LSG) are major factors of the morbidity and mortality of the operation. Early detection and treatment of a staple line leak or an abdominal abscess are very important. Early biomarkers that can discern the patients at risk for a septic complication before its clinical or radiologic manifestation would be invaluable.

Objective: To elicit abnormal elevation of CRP in the early postoperative period after LSG in patients that eventually developed a septic complication.

Method: This is a cohort study. Ten patients that developed a septic complication (leak, abscess) after LSG were matched with 20 controls in terms of BMI, sex, age, comorbidities. The control group had an uneventful postoperative course. All operations were performed by the same surgeon. CRP was measured on the 2^nd postoperative day and the two groups were compared.

Results: Mean CRP in the control group was 6.8 mg/dl, while in the septic group 12.5 mg/dl. An independent t-test showed weak but evident statistically significant difference between the two groups (p=0.03).

Conclusion: The group that eventually developed a leak or an abscess had significantly higher CRP in the early postoperative period. Most importantly, the septic complication manifested itself days or weeks later. This means that an exceedingly high CRP in the early postoperative period can be a prognostic factor for septic complications.

P-037

Gastric leak after Laparoscopic Sleeve Gastrectomy

Sylvia Krivan^a), Paran Kiritharamohan^b), Egeman Tezcan^c), Douglas Whitelaw^d), Periyathambi Jambulingam^e), Vigyan Jain^f)

UGI/Bariatrics, General Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom

^a)navirk@hotmail.com

^b)paran.kiritharamohan@ldh.nhs.uk

^c)egeman.tezcan@ldh.nhs.uk

^d)douglas.whitelaw@ldh.nhs.uk

^e)periyathambi.jambulingam@ldh.nhs.uk

^f)vigyan.jain@ldh.nhs.uk

Introduction: Laparoscopic Sleeve Gastrectomy(LSG) is one of the most popular restrictive bariatric operations in surgical treatment of morbid obesity, indicated as a standalone procedure or as the first step prior to duodenal switch. The most serious complication, although infrequent(1-4.3%), remains leak from the staple line and can increase morbidity and hospital stay.

Patients and Methods: From January 2008 to January 2015, 334 patients with morbid obesity underwent LSG at our institute. Data were analyzed retrospectively and collected for all patients who presented with a gastric leak, including demographics, details of comorbidities, clinical presentation of leak (type I, type II), time of onset (early, intermediate, late), as well as investigations involved and management of each complication.

Results: From 334 patients over a period of 7years, 8patients presented with gastric leak after LSG (2.4%). 7 were female and one patient was male. Preoperative comorbidities included hypertension, type II diabetes mellitus, hypercholesterolaemia, asthma, sleep apnoea and osteoarthritis. Age ranged from 36 to 64years old and BMI from 39.7 to 79.1. Two patients developed early leak diagnosed with a computer tomography abdomen-pelvis(CT AP) with oral contrast, two intermediate leak diagnosed with barium swallow and four late leak investigated with CT, swallow or oesophago-gastro-duodenoscopy(OGD). All of them required re-operation; seven underwent wash-out, insertion of T-tube and drainage, whereas one required laparoscopy and primary repair with sutures. Prolonged hospital stay was between 2 to 15 weeks and all of them were eventually discharged symptom free. There were no conversions to Roux-n-Y gastric bypass or deaths.

Conclusion: Gastric leaks can be challenging and management is usually interventional, depending on the time of diagnosis as well as the size of the defect. A CT AP as well as barium swallow and OGD are powerful tools for diagnosis of this complication and should be considered when clinical suspicion is raised. Reoperation with laparoscopic wash out, insertion of a T-tube and drainage is still the most favorable approach.

References:

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm. Palanivelu Praveenraj, Rachel M Gomes, Saravana Kumar, Palanisamy Senthilnathan,¹ Ramakrishnan Parthasarathi,¹Subbiah Rajapandian,¹ and Chinnusamy Palanivelu¹, J Minim Access Surg. 2016 Oct-Dec; 12(4): 342–349.

Management of staple line leaks following sleeve gastrectomy. Moon RC¹, Shah N¹, Teixeira AF¹, Jawad MA². Surg Obes Relat Dis. 2015 Jan-Feb;11(1):54-9.

Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Sakran N¹, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, Matter I, Alfici R, Mahajna A, Waksman I, Shimonov M, Assalia A. Surg Endosc. 2013 Jan;27(1):240-5.

P-038

Laparoscopic Sleeve Gastrectomy after Laparoscopic Adjustable Gastric Band Removal and Laparoscopic Gastric Plication

Vasileios Drakopoulos^a), Sotirios Voulgaris^b), Maria Christina Papadopoulou^c), Konstantinos, Botsakis^d), Sophia Petsa-Poutouri^e), Vassilis Kalatzis^f), Dimitris Konstantinou^g), Athanasios Bakalis^h), Vassilis Vougasⁱ⁾

1st Dep. of Surgery and Transplant Unit, Evangelismos General Hospital, Athens, Greece

^a)vasileiosdrakopoulos@gmail.com

^b)sot.voulgaris@gmail.com

^c)mxpapadopoulou@gmail.com

^d)botsakis@hotmail.com

^e)sofiapetsapoutouri@gmail.com

^f)vas.kalatzis@gmail.com

^g)mitskonan@yahoo.com

^h)bakalisath@gmail.com

ⁱ⁾drvougas58@yahoo.gr

Background: Revision procedures after Laparoscopic Adjustable Gastric Band placement and Laparoscopic Greater Curvature Plication are often necessary in cases of inadequate weight loss or weight regain. Inflammation and foreign body reaction make the revision procedure technically demanding.

Introduction: Laparoscopic Greater Curvature Plication (LGCP) and Laparoscopic Adjustable Gastric Band (LAGB) related complications often require revision procedures with band removal and/or conversion to Laparoscopic Sleeve Gastrectomy (LSG) or Roux-en-Y Gastric By-pass (RYGB). The optimal method of revision remains controversial.

Objectives: We present our 3,5-year experience concerning Laparoscopic Adjustable Gastric Banding (LAGB) removal, Laparoscopic Greater Curvature Plication (LGCP) and laparoscopic sleeve gastrectomy (LSG).

Methods: We present the case of a 45 year old woman who underwent LSG after LAGB removal and LGCP. The patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. We emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. However, a successful LSG was achieved.

Results: No severe postoperative complications were mentioned.

Conclusion: Weight loss in the first year was 70% of the excess weight. Sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in cases of absence of gastric erosion.

P-039

Lapalaparoscopic Vertical Banded Gastroplasty–Banded Sleeve without Gastrectomy-Three Years Follow-up.

Eliezer Avinoah

Surgery A, Soroka Medical Center Faculty of Health Sciences Ben Gurion University, Beer Sheva, Israel

avinoahe@gmail.com

Introduction: Vertical banded gastorplasty (VBG) is one of the oldest gastric restrictive operations since the mid 1980s. It is still performed laparoscopically during the last years although largely replaced by adjustable banding and the sleeve gastrectomy. we reevaluate the lapaproscopic vertical banded gastroplasty describing our clinical experience in the last four years.

Patients and methods: We followed 130 patients after vertical gastroplasty. All operations performed by laparoscopic approach and followed for 24 months by their weight loss, peri operative and late complications. Their mean age was 38±12 years, original BMI 42±5 ,and 75% were females. The operation performed by creating a circular window through the gastric body which enable to divide the stomach longitudinally along 32 fr. Tube to two gastric pouches. The alimentary gastric pouch is along the lesser curve meet the other gastric pouch near the pylorus and a band situated eight cm from the gastro esophageal junction.

Results: Peri operative complications include intraperitoneal bleeding five (3.8%) patients, two patients (1.5%) had suture line leakage. Late complicatrions include three patients who had functional stricture at junction between the two gastric pouches six and nine months after surgery. Two to three years after surgery the mean BMI of the patients after (VBG)vertical banded gastroplasty reaches nadir of 25±6. There was no mortality.

Conclusions: Laparoscopic vertical banded gastroplasty is found to be safe and efficient operation. It is reversible operation as a plateform to other bypass, While results with regard to weight loss and comorbidities after gastroplasty are comparable to other bariatric surgery.

P-040

Postoperative complication of sleeve gastrectomy reguiring emergency reoperation. A rare case of peritonitis

Dimitrios Dardamanis^a), Hassan Hassan, Didier Fortunati

Department of General and Abdominal Surgery, CH Jolimont-Lobbes, site Lobbes, Lobbes, Belgium

^a)dimdardaman@gmail.com

Sleeve gastrectomy has become one the most paractised stand alone surgical operations for morbid obesity.

Long term results in weight loss and co-morbid conditions, such as diabetes, are comparable to other well established bariatric operations. Morbidity and mortality has decreased with proper training and experience.

Post-operative complications such as leaking from the staple line, abcess formation and bleeding, have been thoroughtly reported and may require complex percutaneous and endoscopic procedures or emergency re-operations.

We present the only case of acute peritionitis in the early post operative course, caused by perforated appendicitis in an adult patient. Even if appendicitis after bariatric operations is very rare, it should be in the differential diagnostic process and clinical decision making, in all patients with fever and abdominal pain, specially of the right iliac fossa.

References:

• 1. Charak G, Florin W, Zitsman J. Acute appendicitis following laparoscopic sleeve gastrectomy in an Adolescent. J Ped Surg Case Reports 2015; 3: 82-83.

• 2. Leonardi NR, Lutfi RE. Postoperative acute appendicitis after laparoscopic gastric band placement. Surg Obes Relat Dis.2012 Jul-Aug;8(4): 49-51.

• 3. Mehran A, Liberman M, Rosenthal R, et al. Ruptured appendicitis after laparoscopic Roux-en-Y gastric bypass: pitfalls in diagnosing a surgical abdomen in the morbidly obese. Obes Surg. 2003 Dec;13(6):938-40.

• 4. Albanopoulos K, Alevizos L, Natoudi M, et al. C-reactive protein, white blood cells, and neutrophils as early predictors of postoperative complications in patients undergoing laparoscopic sleeve gastrectomy. Surg Endosc. 2013 Mar;27(3):864-71.

• 5. Alvarez-Alvarez FA, Maciel-Gutierrez VM, Rocha-Muñoz AD, et al. Diagnostic value of serum fibrinogen as a predictive factor for complicated appendicitis (perforated). A cross-sectional study. Int J Surg. 2016 Jan;25:109-113.

P-041

Should Trocar-Site Be Closed Routinely After Laparoscopic Sleeve Gastrectomy; Teaching Of 10 Years’ Experience

Ali Durmus^{1, a)}, Tahir Mutlu²⁾

¹⁾General Surgeon, Nişantaşı University, İstanbul, Turkey

²⁾General Surgeon, Avrasya Hospital, istanbul, Turkey

^a)dradurmus@gmail.com

Introduction and aim: The aim of this study is searching the percentage of trocar incisional hernia after laparoscopic sleeve gastrectomy.

Material and method: Data for 1373 patients, who was performed surgery on laparoscopic sleeve gastrectomy, was collected prospectively and evaluated retrospectively between 2007 and august 2017. Average age, average hospitalization duration and BKI levels of patients, the patients that had trocar-site hernia during the controls and therefore reoperations was recorded.

Results: After evaluation of all patients, 5 patients (%0.36) was reoperation because of trocar-site hernia.

Discussion: After laparoscopic sleeve gastrectomy, in case of not to close trocar site, the development of hernia was considerable low related to incisional.

P-042 High or Low Positive End-Expiratory Pressure(PEEP), Can Post-Operative Complication Be Prevented Post General Anaesthesia In Bariatric Surgery; Early Period Result Of Prospective Clinic Study

Ali Durmus^{1, a)}, Roya Faraji Feijani^{2, b)}, oğuzhan karatepe^{3, c)}

¹⁾Nişantaşı University, general surgeon, Istanbul, Turkey; ²⁾Baypark hospital, anaesthesia, ıstanbul, Turkey; ³⁾Memorial Hospital, General Surgeon, istanbul, Turkey

^a)dradurmus@gmail.com

^b)royaanestezi@yahoo.com

^c)drkaratepe@yahoo.com

Introduction and Aim: one of the most important reasons for morbidity and mortality in obese patients is pulmonary complication after surgery. The aim of this study is searching the importance of high or low positive end-expiratory Pressure(PEEP) and recruitment manoeuvre in pulmonary complication.

Material and method: this study involves 28 patients who were diagnosed with morbid obesity (BKI 45 and up) and was performed surgery on sleeve gastrectomy and this study was performed between April 2017 and June 2017. Group 1 (n=13) and group 2 (n=15) was indicated as high PEEP (12 mm H20) and low peep (2mm H20), respectively. The postoperative pulmonary complication of patients was observed during 5 days. The result was compared statistically.

Result: The average PEEP level was 12 cm H2O (IQR 12-12) in group 1 and g 2 cm H2O (0-2) in group 2. Pulmonary complication after the surgery was indicated 4 (%30) in group 1 and 3 (%20) in group 2. Relative risk 1·01; 95% CI 0·86-1·20; (p=0·95). Also, when the intraoperative term was observed in high and low PEEP groups, low PEEP group needed more vasoactive drug.

Discussion: According to our early period result, there was statistically significant difference between preventing pulmonary complication in high PEEP and low PEEP.

P-043

Single-Stage Laparoscopic Adjustable Gastric Band Removal and Sleeve Gastrectomy

Vasileios Drakopoulos^a), Athanasios Bakalis^b), Sotirios Voulgaris^c), Konstantinos Botsakis^d), Maria Christina Papadopoulou^e), Sophia Petsa-Poutouri^f), Katerina Sarafi^g), Vassilis Kalatzis^h), George Kyriakopoulosⁱ⁾, Vougas Vassilis Vougas Vassilis^j)

1st Dep. of Surgery and Transplant Unit, Evangelismos General Hospital, Athens, Greece

^a)vasileiosdrakopoulos@gmail.com

^b)bakalisath@yahoo.gr

^c)sot.voulgaris@gmail.com

^d)botsakis@hotmail.com

^e)mxpapadopoulou@gmail.com

^f)sofiapetsapoutouri@gmail.com

^g)kathrin9@hotmail.com

^h)vas.kalatzis@gmail.com

ⁱ⁾gkyriakop@gmail.com

^j)drvougas58@yahoo.gr

Background: Revision procedures after Laparoscopic Adjustable Gastric Band placement are often necessary in cases of severe band-related complications, inadequate weight loss or weight regain. Inflammation and foreign body reaction make the procedure of band removal technically demanding.

Introduction: Laparoscopic Adjustable Gastric Band (LAGB) related complications often require revision procedures with band removal and/or conversion to Laparoscopic Sleeve Gastrectomy (LSG) or Roux-en-Y Gastric By-pass (RYGB). The optimal method of revision remains controversial. Single-stage removal and LSG or RYGB seems to be safe and efficient, while others suggest a two-stage approach.

Objectives: We present our 3,5-year experience concerning simultaneous LAGB removal and LSG.

Methods: We retrospectively analyzed 25 patients who underwent simultaneous LAGB removal and LSG, from May 2014 to December 2017. 10 men and 15 women. Average age 38 (18-49). Mean BMI before conversion was 48 and 45.5 respectively. All patients underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation, erosion or severe band slippage. We emphasize on a case of a 41-year-old male, who had undergone two operations of gastric band placement. The first band had developed slippage, while the second one infection without erosion. However, a successful single-stage definitive LAGB removal and LSG was achieved.

Results: No severe postoperative complications were mentioned, while no conversion to open surgery was required. Mean weight loss in the first year was 70% of the excess weight.

Conclusion: Simultaneous laparoscopic gastric band removal and sleeve gastrectomy for morbid obesity seems to be safe and efficient, especially in cases of absence of gastric erosion.

P-044

Nine-Year Experience with Laparoscopic Lesser Curvature Plication in a Single Institution

Athanasios Pantelis^a), Ioannis-Petros Katralis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)ath.pantelis@gmail.com

^b)katralispetros@gmail.com

^c)dimitrislapatsanis@gmail.com

Background: Laparoscopic lesser curvature plication (LGCP) represents an appealing alternative bariatric technique for patients with low obesity-range BMI, that has a theoretical advance of being leak-free as compared to laparoscopic sleeve gastrectomy (LSG). We hereby present the experience accumulated at our institution over a nine-year period.

Methods: Patient data were collected by retrospectively accessing their electronic recordings and by prospectively evaluating their progress at scheduled follow-up intervals. A standard two-row technique was implemented for plicating the greater curvature of the stomach. We studied the effect of LGCP on excess BMI loss (%EBMIL); co-morbidities (type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea; musculoskeletal pain; dyslipidemia); morbidity and mortality; and patient satisfaction.

Results: From January 2009 to December 2017, 367 patients (89.6% females, mean age 37.6 years) with mean BMI of 39.7 Kg/m² (range 35-51) were submitted to LGCP in our center. One-year mean %EBMIL was 81.6%. Overall mortality was 0%. Total complication rate was 2.2% (leaks: 1.36%; major hemorrhage: 1.1%;pulmonary embolism: 0.3%). One-year co-morbidity improvement was as follow: T2DM 91.7%; HTN 54.5%; OSA 81.5%, musculoskeletal pain 80.7%, dyslipidemia 100%.Seventy-two percent of patients reported an improved quality of life following LGCP, based on the Moorehead-Ardelt Quality of Life Questionnaire II scoring key. There were 2 conversions (1 re-plication 5 years later, 1 LSG 6 years post-index operation).

Conclusion: LGCP is a safe and efficacious restrictive bariatric procedure for obese patients with moderately elevated BMI. Weight-loss and amelioration of co-morbidities was comparable to that of laparoscopic sleeve gastrectomy (LSG), according to our series. Equally comparable was the leak rate, despite the notion that LGCP bears a substantially lower incidence of leak given that there is no cutting line. Nevertheless, in contradistinction to LSG, all cases of leak were amenable to conservative treatment. Overall, patients were satisfied with the bariatric results of the method.

P-045

10-years´ experience with sleeve gastrectomy in a mainly super-obese patient group: rather modest results

Karl Rheinwalt^{1, a)}, Marcia Viviane Rückbeil^{2, b)}, Tom Florian Ulmer^{3, c)}, Sebastian Kolec^{1, d)}, Martin Hemmerich^{1, e)}, Andreas Plamper^{1, f)}

¹⁾Bariatric, Metabolic and Plastic Surgery, St. Franziskus Hospital Cologne, Cologne, Germany

²⁾Institute for Medical Statistics, University Clinics Aachen, Aachen, Germany

³⁾General, Visceral and Transplant Surgery, University Clinics Aachen, Aachen, Germany

^a)karlpeter.rheinwalt@cellitinnen.de

^b)m.rueckbeil@ukaachen.de

^c)fulmer@ukaachen.de

^d)sebastian.kolec@cellitinnen.de

^e)martin.hemmerich@cellitinnen.de

^f)andreas.plamper@cellitinnen.de

Background / introduction: Sleeve gastrectomy has become the most popular bariatric operation worldwide although the rarely available long-term results are rather discouraging.

Objectives: Evaluation of 10 years experience with sleeve gastrectomy as a primary bariatric procedure.

Methods: Prospectively collected data were evaluated from all primary sleeve gastrectomies which had been performed from 8 / 2007 to 3 / 2017 in our center.

Results: 150 patients (93 F, 57 M) with age 43.32 years (18-64), weight 160.1kg (99.0-260.0) and BMI 54.26 kg/sqm (35.12-79.36) had an average operation time of 99.85 minutes (40-210). 30d-mortality was 0.67% (1). Major early complications occurred in 6.67% (leak rate 4.67%, postoperative hemorrhage 1.34%, mesenteric vein thrombosis 0.67%). Late postoperative complications encountered 4 stenoses, 2 gastric ulcers and first of all insufficient weight regain/insufficient weight loss (24.24%) and severe reflux symptoms (19.70%). Excess weight loss was between 57.41% (at 12 months) and 63.8% (at 60 months). Redo-procedures (gastric bypass procedures) had been performed in 31.8% (42) of 132 sleeves where the initial procedure had been performed at least 24 months before.

Conclusion: An early leak rate of 4.67% and a rather high Redo-rate of 31.8% for weight and reflux issues let our enthusiasm vapourize for sleeve gastrectomy. In our opinion this procedure should be avoided wherever better operations like gastric bypass are not contra-indicated.

P-046

Robotic versus laparoscopic sleeve gastrectomy for morbid obesity - "The debate continues": A comprehensive meta-analysis

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{1, 2, b)}, Konstantina Svokos^{3, c)}, Alexis Svokos^{4, d)}, Eleni Sioka^{1, 2, e)}, Dimitris Zacharoulis^{1, 2, f)}

¹⁾Department of Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece; ³⁾Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States; ⁴⁾Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, United States

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)konstantina.svokos@gmail.com

^d)alexis.svokos@gmail.com

^e)konstantinasioka@gmail.com

^f)zachadim@yahoo.com

Background: Laparoscopic sleeve gastrectomy (LSG) is a standalone bariatric procedure that has gained increased popularity among bariatric surgeons and morbidly obese patients. Robotic sleeve gastrectomy (RSG) has been proposed as an alternative approach to conventional LSG.

Objectives: The aim of this study is to review the available literature on obese patients treated with robotic or laparoscopic sleeve gastrectomy, in order to compare the clinical outcomes of the two approaches.

Methods: A systematic literature search was performed in PubMed, Cochrane library and EBSCO Host databases, in accordance with the PRISMA guidelines. Random or Fixed-Effects models were used appropriately. Between-study heterogeneity was assessed through Cochran Q statistic and by estimating I².

Results: Sixteen studies met the inclusion criteria (29,787 patients). RSG technique showed significantly increased mean operative time [WMD: -20.66 (-23.45, -17.88); p<0.0001] and mean hospital stay [WMD: -0.25 (-0.30, -0.20); p<0.0001]. Post-operative incidence of leakage [OR: 1.28 (CI: 0.54, 3.03); p=0.57], wound infection [4.19 (0.20, 89.46); p=0.36] and bleeding [1.76 (0.38, 8.09); p=0.47], along with weight reduction were comparable. The RSG approach was associated with increased cost.

Conclusion: RSG was associated with increased cost, operative time and hospital stay. The complications rate was similar between the two procedures. Well-designed, randomized controlled studies, comparing RSG to LSG, are necessary to assess their clinical outcomes and cost/effectiveness.

P-047

Solo Single Port Laparoscopic Resectional Roux-en Y Gastric Bypass for Morbid Obesity with Metabolic Syndrome

Sang-Hoon Ahn^a), Young-Suk Park^b), Do Joong Park^c), Hyung-Ho Kim^d)

Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

^a)viscaria@snubh.org

^b)yspark@snuhb.org

^c)djpark@snubh.org

^d)hhkim@snubh.org

With the advancement of laparoscopic devices and surgical technology, the era of minimal invasive surgery has progressed to reduced port surgery, and finally to single-incision laparoscopic surgery(SILS). Several reports show successful application of SILS to various types of bariatric surgery. Oftentimes, this requires a skilled and experienced scopist to perform the procedure. To overcome the technical difficulties of single-incision Roux-en Y gastric bypass, a manual scope holder was used instead of an assistant scopist, greatly stabilizing the field of view. This allows the surgery to be performed at any time without being influenced by the need of a highly experienced scopist. In this poster presentation, we describe in detail the world’s first solo single-incision laparoscopic resectional Roux-en Y gastric bypass.

P-048

Comparison of hand-sewn laparoscopic one anastomosis and two anastomosis band – separated gastric bypass

Oral Ospanov^a), Galymgan Eleuov^b)

Laparoscopic and Bariatric Surgery, Astana medical university, Astana, Kazakhstan

^a)bariatric.kz@gmail.com

^b)g_eleuov@mail.ru

The aim study: compare the laparoscopic one anastomosis and two anastomosis band - separated gastric bypass.

Methods: In the period from January 2015 to November 2017, 80 patients with morbid obesity were randomly divided into two groups 40 patients each. All patients underwent laparoscopic band-separated gastric bypass with the use of a hand -sewn anastomosis without using staplers. The stomach was divided into large and small parts (pouch). For stomach separation an adjustable band was used. The front wall of the stomach below the band was displaced in the upward direction through the ring band, increasing the size of the anterior portion of the stomach pouch so that a gastroenteroanastomosis could be created at this point. A jejunal loop was created about 200 cm from the ligament of Treitz and anastomosed to the gastric pouch.In the first group was performed a single gastroenteroanastomosis. In the second group two anastomoses were performed: gastroenteroanastomosis and enteroenteroanastomosis between afferent and efferent limb. Between the two anastomoses on the biliopancreatic limb, a block was created using a non-absorbable ligature.

Results: Follow up was 18 months. The duration of the procedure was significantly higher in the second group: 155.9 ± 26.0 vs 76.6 ± 9.1 minutes (P <0.001).

The complication rate was higher in the second group 8/40 versus 1/40 in first group (X2 = 4.5, P = 0.03) and was associated with problems of entero-entero-anastomosis 6/8. In one case, the first group revealed a reflux of bile into the pouch's distal area, near gastro-entero-anastomosis. In the second group was no biliary reflux (X2 = 0.000, P = 1.0).

The average percentage of weight loss was the first group of 70 ± 12.9 % vs. 67.2 ± 17.12% (P> 0.05).

Conclusion: This study demonstrated that the hand-sewn creation of entero-entero-anastomosis significantly increases the time and complexity of the operation. And the expediency of its use for the exclusion of bile reflux requires a longer follow up and a large number of observations.

P-049

Robotic Sleeve Gastrectomy Experience from 44 Cases

Pericles Chrysoheris^a), Fotios Antonakopoulos, Panagiotis Athanasopoulos, Antonia Mathioulaki, Argyrios Ioannidis, Konstantinos Konstantinidis

Department Of Minimally Invasive Surgery, Athens Medical Center, Athens, Greece

^a)chrysoheris@hotmail.com

Introduction: Sleeve Gastrectomy in one of the main procedures done to surgically treat morbid obesity. One of the most dreadful complication is a leak from the staple line. The merits of the robotic system, i.e 3D vision, fine dissection and suturing capabilities, help reduce the morbidity of the operation.

Study design: We present our experience of 44 robotic Sleeve Gastrectomies in the time period from January 2013 to June 2015. Patients underwent a totally robotic Sleeve Gastrectomy using the da Vinci Si robotic system. Some of the patients had history of upper GI Surgery like gastric band placement, previous sleeve gastrectomy, or gastric plication.

The phases of the operation were: Lysis of adhesions, entrance to the omental bursa, mobilization of the body and fundus of the stomach by dividing the short gastrics with a robotic vessel sealer. Placement of a bougie No36-38 French and start of the gastrotomy 6cm from the pylorus. We regulary use a green load staple first, followed by a gold and then blue loads for the rest of the gastrotomy.

We always reinforce the staple line by a continuous barbed suture and glue over that. A drain is placed by the staple line for 24hours.

Results: There where no conversions to open. Mean operative time was 2 hours. There was no incidence of a leak. There was one return in the OR for bleeding.

All patients managed to lose their excess body weight. In the 2 year follow-up we found 4 patients who regained 10-20% of their excess body weight.

Conclusions: Robotic Sleeve Gastrectomy is a safe and effective operation. The robotic system helps in overcoming technical limitations of laparoscopy and possibly contributes to a reduced morbidity of the operation.

P-050

Intra-gastric Botox injection, an aid for Wight reduction in obese patient in combination with diet regime

Nashwan Mahgoob

surgery, medical college, mosul, Iraq

nashwanmahgoob@yahoo.com

Back ground/aim: Obesity is a medical condition in which excess body fat has accumulated to an extent that it may have an adverse effect on health and regarded is one of the leading preventable causes of death worldwide ^-1-. Many conservative ways have been used to decrease body weight including diet regime, physical exercise, drugs and balloon insertion into the stomach apart from a more advanced ways including surgical intervention to decrease stomach size and bypassed the small bowel. This study is to evaluate the safety and possible efficacy of intra gastric Botulin toxin A (BTX-A) injection for patients with class one obesity in comparison with diet regime.

Methods: Eighty five patients with class 1 obesity (body mass index 30-35 kg/m²) after using special criteria for their selection were divided into 2 groups, the first one underwent 300 IU of BTX-A injection endoscopically into the antrum, gastric body and fundus muscle layer and informed to follow specialized diet regime for 12 months. The second group followed only the specialized diet regime. The patients were followed for 12 months and the body mass indices were recorded and compared.

Results: Satisfactory weight loss obtained in 70% and 50% of patients within six months and 12 months respectively in the first group (reduction of 5 points from the original BMI) but it was 28.5% and 20% within six months and 12 months respectively in the second group with a P value > 0.01 using the Chi-Square Calculator for 2 x 3 Contingency Table at P value of 0.5 for 6 months and 12 months. No any complication has been recorded at time of operation or later on for the first group.

Conclusion: Intra gastric injection of BTX-A for the treatment of obesity seem to reduce body weight under certain selection.

key word: Obesity. BTX-A injection. Diet regime.

References:

1-WHO. Obesity: preventing and managing the global epidemic. WHO Technical Report Series number 894. WHO, Geneva; 2000

2- Haslam DW, James WP. "Obesity". Lancet (Review). 366 (9492): 1197–209. (2005).

3-Strychar I "Diet in the management of weight loss". CMAJ. 174 (1): 56–63. PMC 1319349. PMID 16389240. doi:10.1503/cmaj.045037(January 2006). Bang CS

4- Baik GH1, Shin IS2, Kim JB1, Suk KT1, Yoon JH1, Kim YS1, Kim DJ Effect of intragastric injection of botulinum toxin A for the treatment of obesity: a meta-analysis and meta-regression. Gastrointest Endosc. 2015 May;81(5):1141-9.e1-7. doi: 10.1016/j.gie.2014.12.025. Epub 2015 Mar 9

5- Wollina U. Botulinum toxin: Non-cosmetic indications and possible mechanisms of action. Aesth Surg. 2008; 1:3

6- Jankovic J, Brin MF. Botulinum toxin: Historical perspective and potential new indications. Muscle Nerve Suppl. 1997; 6:S129–S145

7- Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl. 1997; 6:S146–S168

8- Gui D, Rossi S, Runfola M, Magalini SC. Botulinum toxin in the therapy of gastrointestinal motility disorders. Aliment Pharmacol Ther. 2003; 18:1–16

9- Naumann M, Jankovic J. Safety of botulinum toxin type A: a systematic review and meta-analysis. Curr Med Res Opin. 2004;20:981–990

10- Johannessen H, Olsen MK, et al. Preclinical trial of gastric injection of botulinum toxin type A as weight-loss-surgery. Gastroenterology 2014;146:S-1077

11- Jennifer Petrelli; Kathleen Y. Wolin. Obesity (Biographies of Disease). Westport, Conn: Greenwood. p. 11. ISBN 0-313-35275-5. (2009)

12- Peeters, T.L. Potential of ghrelin as a therapeutic approach for gastrointestinal motility disorders. Curr. Opin. Pharmacol. 2006, 6, 553–558.

13- Chang Seok Bang, Gwang HoBaik. Effect of intragastric injection of botulinum toxin A for the treatment of obesity: a meta-analysis and meta-regression. Gastrointestinal Endoscopy. Volume 81, Issue 5, May 2015, Pages 1141-1149.e7https://doi.org/10.1016/j.gie.2014.12.025.

14-Rollnik, J.D.; Meier, P.N.; Manns, M.P.; Goke, M. Antral injections of botulinum a toxin for the treatment of obesity. Ann. Intern. Med. 2003, 138, 359–360.

15- Foschi, D.; Corsi, F.; Lazzaroni, M.; Sangaletti, O.; Riva, P.; La Tartara, G.; Bevilacqua, M.; Osio, M.; Alciati, A.; Bianchi Porro, G.; et al. Treatment of morbid obesity by intraparietogastric administration of botulinum toxin: A randomized, double-blind, controlled study. Int. J. Obes. 2007, 31, 707–712.

16- Li, L.; Liu, Q.S.; Liu, W.H.; Yang, Y.S.; Yan, D.; Peng, L.H.; Li, L.Y.; Meng, J.Y.; Wang, X.D.; Ke, M. Treatment of obesity by endoscopic gastric intramural injection of botulinum toxin A: A randomized clinical trial. Hepato-Gastroenterology 2012, 59, 2003–2007.

17- Topazian, M.; Camilleri, M.; Enders, F.T.; Clain, J.E.; Gleeson, F.C.; Levy, M.J.; Rajan, E.; Nehra, V.; Dierkhising, R.A.; Collazo-Clavell, M.L.; et al. Gastric antral injections of botulinum toxin delay gastric emptying but do not reduce body weight. Clin. Gastroenterol. Hepatol. 2013, 11, 45–50.

18 Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364:2392-404.

19- Duffey KJ, Gordon-Larsen P, Steffen LM, Jacobs DR, Jr., Popkin BM. Regular consumption from fast food establishments relative to other restaurants is differentially associated with metabolic outcomes in young adults. J Nutr. 2009;139:2113-8.

20- Field AE, Willett WC, Lissner L, Colditz GA. Dietary fat and weight gain among women in the Nurses’ Health Study. Obesity (Silver Spring). 2007;15:967.

21 Ma Y, He FJ, MacGregor GA. High Salt Intake: Independent Risk Factor for Obesity? Hypertension 2015;66:00-00.

22- Ledoux TA, Hingle MD, Baranowski T. Relationship of fruit and vegetable intake with adiposity: a systematic review. Obes Rev. 2011;12:e143-50.

23 Wang L, Lee IM, Manson JE, Buring JE, Sesso HD. Alcohol consumption, weight gain, and risk of becoming overweight in middle-aged and older women. Arch Intern Med. 2010;170:453-61.

P-051

Single-Stage Laparoscopic Gastric Band Removal and Sleeve Gastrectomy

Athanasios Pantelis^{1, a)}, Ioannis-Petros Katralis^{1, b)}, Angeliki Kolinioti^{2, c)}, Vasilios Drakopoulos^{3, d)}, Stylianos Kapiris^{2, e)}, Dimitris Lapatsanis^{1, f)}

¹⁾2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece; ²⁾3rd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece; ³⁾1st Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)ath.pantelis@gmail.com

^b)katralispetros@gmail.com

^c)akolinioti@gmail.com

^d)vasileiosdrakopoulos@gmail.com

^e)stkapiris@hotmail.com

^f)dimitrislapatsanis@gmail.com

Background: A “restrictive surgery after restrictive surgery” strategy is feasible and justifies the performance of sleeve gastrectomy (LSG) following failure of adjustable gastric band (AGB). However, the bariatric surgeon is faced with two major challenges directly related to the erosive properties of the band: technical difficulties in removing the band and dissecting the stomach; and increased incidence of post-operative leaks.

Material and Methods: We retrospectively analyzed our cohort of 696 obese patients who underwent LSG.

Results: Over a 9-year period 39 patients among them (26 women) underwent simultaneous LAGB removal and LSG, with average age 38 (18-49). Mean BMI before conversion was 48Kg/m². Pre-operatively, all patients underwent endoscopy and barium swallow to rule out perforation, erosion or severe band slippage, which constitute contraindications to simultaneous AGB removal and LSG in our institution. AGB removal increased the operative time of LSG by a mean of 53 min (range 10-90 min). Two cases of post-operative leak (5.1%) were documented and treated conservatively, while no conversion to open surgery was required in any case. Mean weight loss in the first year was 83.3% of the excess weight.

Conclusion: Simultaneous laparoscopic gastric band removal and sleeve gastrectomy for morbid obesity seems to be safe and efficient in carefully selected cases. The reduction of the total number of operations by one counterbalances the prolongation in operative time. The leak rate was significantly greater than the mean leak rate of our cohort (1.2%), underlying the predisposition to leak due to AGB.

References:

1. Campanile et al. Obesity surgery 2013;23:393394

P-052

Duodenal switch after vertical gastroplasty failure: a single center experience

Gabriele Luciano Petracca^a), Vittoria Pattonieri^b), Francesco Rubichi^c), Marina Valente^d), Andrea Romboli^e), Margherita Tesan^f), Elisabetta Dall'Aglio^g), Federico Marchesi^h)

Department of Medicine and Surgery, University of Parma, Parma, Italy

^a)glpetracca@gmail.com

^b)vittoria.pattonieri@gmail.com

^c)franc.rub@hotmail.it

^d)valentemarina.bis@gmail.com

^e)andrearomboli@icloud.com

^f)margherita.tesan2@studio.unibo.it

^g)elisabetta.dallaglio@unipr.it

^h)fedemarchesi52@gmail.com

Introduction: Weight regain is one of the possible long-term complications after bariatric surgery. Many treatments have been proposed after restrictive surgery failure (in particular after vertical gastroplasty); the duodenal switch seems to be an attractive option, possibly reducing the high complication rate reported for re-restrictive procedures.

Methods: Between August 2010 and April 2015, three open duodenal switches were performed in patients previously subjected to open vertical gastroplasty. All three patients had an initial reduction in body weight after the first surgical procedure (mean 21%) but they recovered almost all the weight lost (mean 62,4%). The duodenal switch was proposed as a possible revision technique for these patients. Follow-up was performed at 6 months, 12 months, 24 months and 5 years.

Results: Preoperative mean BMI was 54,5 Kg/m2 (range 44,3-66,0). At 6 months the mean BMI was 46,4 Kg/m2 and mean weight loss 14,7%, at 12 months 43,4 Kg/m2 and 20,3%, at 24 months 42,4 Kg/m2 and 22,6% and at 5 years 38,8 Kg/m2 and 33,3%. All patients suffered from flatulence and intermittent diarrhea in the long-term. One patient developed an important incisional hernia after two years from the procedure treated with biological prosthesis.

Conclusion: Our small case series shows how duodenal switch could represent a safe and effective redo option after vertical gastroplasty failure.

P-053

Laparoscopic revisions after Open Bariatric Surgeries

Haider Alshurafa

Surgery, PSMMC, Riyadh, Saudi Arabia

haidershurafa@yahoo.com

Introduction: Laparoscopic revisional bariatric surgeries are challenging operations and specially after open previous bariatric operations. These operations need high skills and experience as well as they are increasing in number.

Aims: This study will test the safety and feasibility of laparoscopic revisional bariatric surgeries after failed open bariatric operations in high volume obesity center.

Methods and Material: This is a case series of retrospective review of medical data of the surgical team in high volume obesity center over the period from January 2003 to December 2016 in Prince Sultan Military Medical City.

Results: The total number of the patients over 14 years were 2158 of all bariatric operations. 28 patients (10.6% of LRBS, and 1.5% of all bariatric operations in this series) had laparoscopic revisional bariatric operations after failed open bariatric operations. They are 23 females and 5 male with age 23-63 years ( Mean 41.7years), BMI 27.3-73.0 Kg/m2 ( Mean 45.1). 18 patients were post open VBG, 5 patients post open RYGB, 2 post leakage after sleeve, and one post open greater gastric curvature plication. All patients had revisional bariatric operations for weight regain and/ weight loss failure except two patients treated for complications one reversal of VBG and one division of gastrocutaneous fistula after open sleeve gastrectomy. There two patients post VBG converted from laparoscopic revisional to open revisional RYGB and they were the first two cases of the all experience. There were 20 patient undergone laparoscopic revisional RYGB, 2 patients had laparoscopic revisional mini gastric bypass, 2 patients had laparoscopic revisional sleeve gastrectomy, one laparoscopic revisional biliopancreatic diversion, one laparoscopic revisional greater gastric curvature plication, one reversal of VBG, one patient had laparoscopic division of gastrocutaneous fistula after open sleeve gstrectomy. No mortality.

Conclusion: LRBS is feasible and safe after open bariatric operations. These surgeries are demanding and requiring high surgical skills. Main indication for revision is weight regain and/or failure of weight loss as it is shown in this series.

P-054

Revisional bariatric surgery – indications and post-operative outcomes

Edden Slomowitz^{1, 2, a)}, Hanoch Kashtan^{1, 2, b)}, Ilanit Mahler^{1, c)}

¹⁾Department of Surgery, Rabin Medical Center, Petach Tikva, Israel

²⁾The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

^a)edslom@gmail.com

^b)hkashtan@clalit.org.il

^c)ilansh222@yahoo.com

Introduction: The incidence of revisional procedures after bariatric surgery varies between 5% - 50% of surgeries, depending on the type of primary surgery.

Indications for revisional operations are divided into: 1) procedural complications 2) inability to obtain or sustain weight loss.

We evaluated indications and outcomes of revisional operations in a tertiary bariatric center.

Methods: A retrospective analysis of a prospective database of Rabin Medical Center Bariatric Clinic was performed. Paired t-test was performed using GraphPad software to assess changes in excess weight.

Results: Study population included 97 consecutive patients who underwent revisional bariatric surgery between 2011 and 2016.

Primary procedure was adjustable gastric banding (AGB) in 59 (60.8%), silastic ring vertical gastroplasty (SRVG) in 20 (20.6%), sleeve gastrectomy in 16 (16.5%), Roux-en-Y Gastric-Bypass (RYGB) in 1 (1%) and vertical-banded-gastroplasty (VBG) in 1 (1%) patients. The revisional procedures performed were: 60 (61.9%) RYGB 21 (21.6%) sleeve gastrectomy, 15 (15.5%) biliopancreatic-diversion with duodenal-switch (BPD+DS) and 1 (1%) AGB.

In our cohort, 10% of surgeries were performed due to uncontrollable complications while 90% failed to achieve weight loss goals. Amongst the revisional surgeries performed, 12% experienced surgical complications while 7% had complications categorized under the Clavien-Dindo classification as being ≥3. Complications occurred in 20% of SRVG revisions, 11% of AGB and 6% of sleeve gastrectomy. Amongst revisional procedures, complications occurred during 27% of BPD+DS surgeries, 11% of RYGBs and 4.5% of sleeve gastrectomies.

We found a significant reduction in excess weight of 53% 1 year following revisional surgery in those patients whose operation was due to obesity. Conversely, patients whose indication for revisional surgery was surgical complications did not achieve a significant reduction in excess weight.

Conclusion: Despite the increased technical difficulty of revisional procedures, they are necessary for treating complications and to treat the disease of obesity and its subsequent complications. Here we show that revisional surgery can be safe and effective at treating obesity even in patients who have failed previous surgeries.

P-055

Successful Laparoscopic Weight Loss Surgery-Revision in a Super-Obese Patient with Multiple Comorbidities, Adhesions and Coexisting Hernia

Stamatios Petousis^a), Konstantinos Milias, Athanasios Permekerlis, Anargyros Skalimis, Elias Sdralis

Obesity & Metabolic Disorders Surgery Department, Euromedica Kyanos Stavros, Thessaloniki, Greece

^a)petousisstamatios@gmail.com

Objective: Το present the case and procedure video of a successful laparoscopic weight loss surgery-revision in a super-obese patient with multiple comorbidities, multiple adhesions and coexisting hernia

Methods: Μedical elements and real-time video recording of laparoscopy procedure were used. Laparoscopy was performed by using Karl Storz® laparoscopy tower as well as Echelon® and Ultracision® laparoscopy tools.

Results: The video case concerns a 37-year old male patient, BMI 52 kg/m². He had undergone an open vertical banded gastroplasty in 2002, with a modification of banding (no silastic ring, but multiple absorbable sutures). He was admitted to our Unit with weight regain postoperatively along with extended incisional hernia. The patient presented multiple comorbidities, namely respiratory insufficiency, diabetes mellitus, hypertension and thyroid disorders. A new weight loss surgery - revision from an Open vertical banded gastroplasty to a Laparoscopic One-Anastomosis Gastric Bypass was decided. The surgery was performed laparoscopically after multiple adhesiolysis, resection of gastroplasty, development of a new sleeve gastric pouch with preservation of remnant stomach, using a linear cutter left and right of the gastroplasty and removing the tissue & clips. The procedure lasted 3 hours. The postoperative period was uneventful and the patient was discharged 4 days later. The 6-month follow-up of patient was characterized by satisfying weight loss, without upraise of any severe postsurgical complication.

Conclusion: Εven in patients having undergone previous open surgery, appropriate usage of laparoscopic technique may permit successful surgery-revision despite co-existing multiple adhesions.

P-056

Empowerment Patient Education and Bariatric Surgery: The ENFLOWERMENT PROJECT / A concept map for the post-operative bariatric transition

Karasavvidis Savvas

Department of Nursing Science, Uninversity of Eastern Finland, Kuopio, Finland

savvaskarasavvidis@hotmail.com

Making a concept map concerning the post-operative bariatric surgery among obese patients’ is not a very easy because of the many psychological implemented aspects (Hager 2007) such as the depression and anxiety disorders after the surgery (DeZwaan et al. 2001, Legenbauer et al. 2009, Legenbauer et al. 2011) who affects the content of the empowerment knowledge. The concept plan must be based on the content of the empowerment knowledge mentioned by Kilpi-Leino et al. (1998) and Ryhanen (2016):

• 1. Functional: mobility, performance, energetic needs, rest time, nutrition habits, hygiene and care, digestive issues, sexual life, multi activities.

• 2. Cognitive: scientific and basic elements of the obesity, the bariatric surgery, the quality of life, the general health, mental representations of the changes on the body image.

• 3. Bio-physiological: side or second effects, symptoms of the depression, BMI, complications, recovery items, anatomy and pharmacology, treatments and alternatives, skin protection.

• 4. Experiential: previous experiences by surgeries, emotions and feelings about pain, reactions, and memories from similar situations of weight loss in the past.

• 5. Ethical: human rights, specific duties, stereotypes and respects, “stigma” of the obesity, interaction and cultural approaches, religious and moral thinking issues, confidential medical information.

• 6. Social: groups of therapy, self-help groups, mental health professionals and networks, union, associations, volunteers, family issues and social interaction, health policies for the mental health disorders, support and environment items.

• 7. Financial: health assurances, costs of the surgery and hospitalisation, nutritional budget, pharmacological and medical treatments, therapies, plastic surgeries, new clothes and appearance, new costs and hobbies in the social life, sport activities.

Mapping a concept map may help to develop metacognition competencies (Virtanen 2016) of the depression and anxiety after a bariatric surgery.

References:

DeZwaan M. Enderle, J. Wagner S. MulhansB. Ditzen B. Gefeller O. Muller, A. 2011. Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. Journal of Affective Disorders, 133(1-2), 61-68.

Hager, C. 2007. Quality of life after Roux-en-Y gastric bypass surgery. AORN Journal, 85(4), 768-778.

Leino-Kilpi Helena, Luoto Eija, Katajisto Jouko. 1998. Elements of Empowerment. Journal of Neuroscience Nursing 30(2), 116-123.

Legenbauer T. DeZwaan M. Benecke A. Mühlhans B. Petrak F. & Herpertz S. 2009. Depression and anxiety: their predictive function for weight loss in obese individuals. Obesity Facts 2(4), 227–234.

Legenbauer T, DeZwaan M. Petrak F. & Herpertz S. 2011. Influence of depressive and eating disorders on short- and long-term course of weight after surgical and non-surgical weight loss treatment. Comprehensive Psychiatry, 52(3), 301–311.

Ryhanen, A. 2016. Empowerment Patient Education 2016. Module 3, Presentation 17: Written patients education material evaluation. University of Turku, Turku.

Virtanen, H. 2016. Empowerment Patient Education 2016. Module 3, Video Lecture 18: Concept Maps. University of Turku, Turku.

P-057 Inspiratory muscle strength and height as predictors for 1 year post bariatric cardiorespiratory fitness

Marcelo Cano-Cappellacci^{1, a)}, Paulina Ibacache^{2, b)}, Allan White^{3, c)}, Claudia Miranda^{4, d)}, Juan Cristian Rojas^{5, e)}

¹⁾Physical Therapy, Universidad de Chile, Santiago, Chile

²⁾Facultad de Ciencias de la Rehabilitacion, Universidad Andres Bello, Viña del Mar, Chile

³⁾Physiology and Biophysics Program, ICBM, Universidad de Chile, Santiago, Chile

⁴⁾Facultad de Ciencias de la Rehabilitacion, Universidad Andres Bello, Santiago, Chile

⁵⁾Facultad de Ciencias de la Salud, Universidad de Las Américas, Viña del Mar, Chile

^a)mcano@u.uchile.cl

^b)paulina.ibacache@unab.cl

^c)awhite@med.uchile.cl

^d)cmiranda@unab.cl

^e)jrojasm@udla.cl

Introduction: After bariatric surgery it has been published that there is a loss in cardiorespiratory fitness (CRF), associated with a loss in muscle mass. To avoid this deleterious effect, it is advisable to train the patients to improve CRF after the surgery. However, until now there is no information regarding the presurgical predictors associated with the CRF one year after sleeve gastrectomy (SG)^1-5.

Methods: Twelve female patients (38.6 ± 11.8 years old, BMI 35.3 ± 3.4 kg/m²) were evaluated about their physical fitness before and one year after SG. CRF was assessed with an incremental test in cycle-ergometer (workload increasing 15W/2min) until stopping criteria (RER>1.1, PRE>8/10) and breath by breath expired gas analysis (Cortex Metalizer3B). Inspiratory muscle strength was assessed with Powerbreath K5 (Powerbreath), and height and weight were measured with a scale (Detecto). Statistical analysis was conducted with SPSS 22.0 software, paired comparison was conducted with Wilcoxon test and for correlation Spearman’s test was applied. P value<0.05 was considered significant.

Results: The preoperatory CRF of patients was VO₂ peak of 1.82 ± 0.27 L/min. One year after the surgery VO₂ peak was 1.44 ± 0.26 L/min (p=0.002), BMI was 25.1 ± 1.5 kg/m² (p=0.002). Preoperatory assessment of height (1.59 ± 0.04 m) and inspiratory muscle strength (84.7 ± 18.1 cm H₂O) had strong predictive power over CRF one year after the surgery with Spearman Rho of 0.749 (p=0.005) and 0.725 (p=0.008) respectively.

Discussion: Even there is no doubt about the effectivity of SG upon the weight management in obese patients, there is no consensus regarding the physical training that should be the best approach for those patients. Preoperatory assessment of VO₂ peak, height and inspiratory muscle strength could be used to create a personalized training program for patients with a predicted low CRF one year after the surgery.

Conclusions: Preoperatory assessment of height and inspiratory muscle strength showed to be good predictors for CRF one year after SG.

References:

• 1. Coen, P. M. and Goodpaster, B. H. (2016), A role for exercise after bariatric surgery?. Diabetes Obes Metab, 18: 16–23.

• 2. Onofre, T., Carlos, R., Oliver, N. et al. Obes Surg (2017) 27: 2026.

• 3. Hassannejad, A., Khalaj, A., Mansournia, M.A. et al. Obes Surg (2017) 27: 2792.

• 4. Browning, M.G., Franco, R.L., Herrick, J.E. et al. Obes Surg (2017) 27: 96

• 5. Neunhaeuserer, D., Gasperetti, A., Savalla, F. et al. Obes Surg (2017) 27: 3230.

Acknowledgement: The researcher would like to thanks to our patients who made this project possible.

P-058

The patient's eating habits should be considered at the time of recommending the type of bariatric surgery to be carried out?

Ilana Nikiforova^a), Asnat Raziel^b), Royi Barnea^c), Sergio Susmallian^d)

General Surgery, Assuta Medical Center, Tel Aviv, Israel

^a)Sergio9@bezeqint.net

^b)doctor@asnatraziel.com

^c)Royib@assuta.co.il

^d)sergio9@bezeqint.net

The most common bariatric surgery carried out in our country is Laparoscopic Sleeve Gastrectomy (LSG) in 76% of the cases. The reasons for the high percentage of this type of surgery are low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption, the ability to convert to multiple other operations and offers positive metabolic changes. The objective of bariatric surgery is to reduce the intake of calories by anatomical modifications of the upper gastrointestinal tract. Eating habits must be changed after surgery to ensure the successful results of the procedure.

Our study is based on the operative results of weight reduction after 3 years of follow up according to the alimentary habits before the operation.

The study include 300 patients that underwent LSG, they were divided in four groups according with their preoperative eating habits.

The ratio of males to females was 1:2, and the average age was 41.65years old. The average baseline BMI was 42.02 kg/m2. We classified before surgery in Binge group 14%, Snack Group 50%, Sweet eaters 35.66%, volume eaters 76.66%. Patients have more than one type of eating pattern in 43%.

The mean BMI achieved after 3 years was 29.84. With no significate differences according to each eating habit at the beginning. After three years we found a significant reduction of the volume group.

What most attracts attention are the changes that patients show from one type of pathological food habit to another and not the correction of eating habits. Our results demonstrated a significant effect for gender (women lose significantly more body weight ), age (young patients lose more body weight than older patients) and physical activity (Active people lose more weight).

Our study supports the concept that eating habits do not influence the weight loss after LSG and that continuous and close multidisciplinary support is necessary and essential to prolong the success of the operation.

References:

1- Kitzinger HB, Karle B. The epidemiology of obesity. European Surgery. 2013; 2: 80-2.

2- Secord AA, Gehrig PA. Obesity: Too big a problem to ignore. Gynecol Oncol. 2012; 126(2):274-6.

3- Saikia D, Ahmed SJ, Saikia H, Sarma R. Overweight and obesity in early adolescents and its relation to dietary habit and physical activity: A study in Dibrugarh town. Clinical Epidemiology and Global Health. 2016; 4: S22-8.

4-Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: where do we go from here?. Science. 2003; 299: 853-5.

5- Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. Jama. 201; 311: 74-86.

6- Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Nanni G, Castagneto M, Bornstein S, Rubino F. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015; 386: 964-73.

7- Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, Bucher HC, Nordmann AJ. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. Bmj. 2013; 347: f5934. doi: 10.1136/bmj.f5934.

8- Kushner RF. Weight loss strategies for treatment of obesity. Progress in Cardiovascular Diseases. 2014; 56: 465-72.

9- DeMaria EJ. Bariatric surgery for morbid obesity. New England Journal of Medicine. 2007; 356(21): 2176-83.

10- Gumbs A A, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obesity Surgery; 2007, 17(7): 962-969.

11- Dimitriadis E, Daskalakis M, Kampa M, Peppe A, Papadakis J A, Melissas J. Alterations in gut hormones after laparoscopic sleeve gastrectomy: a prospective clinical and laboratory investigational study. Annals of surgery. 2013; 257(4): 647-654.

12- Pyle RL, Mitchell JE. The epidemiology of bulemia. The eating disorders: Medical and psychological bases of diagnosis and treatment. 1988: 259-66.

13- Pull CB. Binge eating disorder. Current Opinion in Psychiatry. 2004; 17(1): 43-8.

14- Robinson AH, Safer DL. Moderators of Dialectical Behavioural Therapy for Binge Eating Disorder: Results from a Randomized Controlled Trial. Int J Eat Disord. 2012;45(4):597–602.

15- Allison, D. B., & Heshka, S. Emotion and eating in obesity? A critical analysis. International Journal of Eating Disorders. 1993;13: 289–295.

16- Ruetsch O, Viala A, Bardou H, Martin P, Vacheron MN. Psychotropic drugs induced weight gain: a review of the literature concerning epidemiological data, mechanisms and management. L'Encephale. 2005; 31(4 Pt 1): 507-16.

17- Robinson E, Harris E, Thomas J, Aveyard P, Higgs S. Reducing high calorie snack food in young adults: a role for social norms and health based messages. International Journal of Behavioral Nutrition and Physical Activity. 2013; 10(1): 73-80.

18- Giesen JC, Havermans RC, Douven A, Tekelenburg M, Jansen A. Will work for snack food: the association of BMI and snack reinforcement. Obesity. 2010; 18(5): 966-70.

19- Arora S., Anubhuti. Role of neuropeptides in appetite regulation and obesity – a review. Neuropeptides. 2006; 40: 375–401.

20- Suzuki K, Simpson KA, Minnion JS, Shillito JC, Bloom SR. The role of gut hormones and the hypothalamus in appetite regulation. Endocrine Journal. 2010; 57: 359-372.

21- Cornejo MP, Hentges ST, Maliqueo M, Coirini H, Becu-Villalobos D, Elias CF. Neuroendocrine Regulation of Metabolism. J Neuroendocrinol. 2016; 7. https://doi.org/10.1111/jne.12395.

22. Monteleone P, Castaldo E, Maj M. Neuroendocrine dysregulation of food intake in eating disorders. Regulatory peptides. 2008; 149(1): 39-50.

23- Duarte-Guerra LS, Coêlho BM, Santo MA, Lotufo-Neto F, Wang YP. Morbidity persistence and comorbidity of mood, anxiety, and eating disorders among preoperative bariatric patients. Psychiatry Res. 2017; 257: 1-6.

24- Rossell J, González M, Mestres N, Pardina E, Ricart-Jané D, Peinado-Onsurbe J, Antonio Baena-Fustegueras J. Diet Change After Sleeve Gastrectomy Is More Effective for Weight Loss Than Surgery Only. Obesity Surgery. 2017; 27: 2566–2574.

25- Alvarez V, Carrasco F, Cuevas A, Valenzuela B, Muñoz G, Ghiardo D, Burr M, Lehmann Y, Leiva MJ, Berry M, Maluenda F. Mechanisms of long-term weight regain in patients undergoing sleeve gastrectomy. Nutrition. 2016; 32: 303–8.

P-059

Attitudes towards childhood bariatric surgery: a survey among Dutch General Practitioners

Yvonne Roebroek^{1, 2, a)}, Ali Talib^{1, b)}, Jean Muris^{3, 4, c)}, Francois van Dielen^{5, d)}, Nicole Bouvy^{1, 2, e)}, Ernest van Heurn^{6, 2, f)}

¹⁾Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands; ²⁾NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, Netherlands; ³⁾Department of Family Medicine, Maastricht University, Maastricht, Netherlands; ⁴⁾CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands; ⁵⁾Department of General Surgery, Máxima Medical Center, Veldhoven, Netherlands; ⁶⁾Department of Paediatric Surgery, Emma's Children's Hospital AMC/VU, Amsterdam, Netherlands

^a)y.roebroek@maastrichtuniversity.nl

^b)ali.talib@mumc.nl

^c)jean.muris@maastrichtuniversity.nl

^d)f.vandielen@mmc.nl

^e)n.bouvy@mumc.nl

^f)e.vanheurn@amc.uva.nl

Introduction: In the Netherlands, pediatric obesity is treated with combined lifestyle interventions: dietary counseling, physical therapy and behavioral therapy of the child and family. However, long-term benefits of these interventions remain small. Bariatric surgery is only allowed in research settings. Referral for surgery can only occur via pediatricians or general practitioners (GPs) after failed combined lifestyle interventions. The aim of this study was to investigate whether Dutch GPs consider bariatric surgery as possible end-stage treatment modality in morbidly obese children and adolescents.

Methods: An online survey was designed to test the attitude of GPs towards bariatric surgery in children and adolescents. Invitations for this anonymous survey were sent to the GPs enlisted in the local registries of Medical Center A and Medical Center B.

Results: Among 534 invited GPs, 184 (34.5%) completed the survey. 175 GPs estimated that combined lifestyle interventions are only effective in less than 50% of the morbidly obese children in their practice. Although 123 respondents believe bariatric surgery can be effective in morbidly obese children, only 98 would consider referring for surgery. Most mentioned reasons for a reluctant attitude towards surgery were ‘uncertainty about long-term complications’ (71.7%) and ‘uncertainty about long-term efficacy’ (64.7%).

Conclusions: Childhood bariatric surgery remains controversial among GPs. High-quality evidence on safety and efficacy of childhood bariatric surgery is needed and adequate transfer of this knowledge to GPs is mandatory.

P-060

Work resumption and changes in experienced daily life obstacles due to obesity after bariatric surgery

Marjolein Masseur-Verhagen¹⁾, Edo Aarts²⁾

¹⁾UWV, Doetinchem, Netherlands; ²⁾Rijnstate Hospital, Arnhem, Netherlands

Background: In view of the rapid growth in the number of patients with severe overweight worldwide, an increasing number of bariatric procedures are performed. Also, an increase is observed in the number of disabled with weight problems. It is important to gain more insight into the resumption of work and changes in the observed obstacles after bariatric surgery.

Methods: A cross-section study based on online questionnaires of 717 postoperative patients and 17 surgeons.

Results: The average duration until full resumption of work after a bariatric procedure is 51 days. This is 23 days longer than is to be expected based on medical recovery. Several factors influence this outcome: type of intervention, complications, co-morbid disorders, operating result and time of reporting sick. Nature of work, age and gender do not affect the duration of absence. Of the 403 patients who worked preoperatively, 369 participant resumed their work, of which 131 partially. 399 (of 403)Patients perceived obstructions due to overweight in daily life before and after the procedure. 87.7% (n = 350) of the patients noticed an improvement in their impediments after the procedure. 0.8% (n = 3) experienced a deterioration and 11.5% (n = 46) indicates that there is no difference. A large percentage shows an improvement in the preoperative impairments. And there is a significant relationship with the achieved weight loss.

Conclusion: Patients with morbid obesity undergoing bariatric surgery show a significant reduction of obstacles in daily life and work. Currently, a longer work resumption duration is found than expected, which may be reduced.

P-061

Kisspeptin and Stress Induced O.besidome

Styliani Geronikolou^{1, a)}, Konstantinos Albanopoulos^{2, b)}, Dennis Cokkinos^{1, c)}, Athanassia Pavlopoulou^{3, d)}, George Chrousos^{4, e)}

¹⁾Clinical, Translational, Experimental Surgery Dpt, Biomedical Research foundation of the Academy of Athens, Athens, Greece; ²⁾First Department of Propedeutic Surgery, Hippokrateion Hospital, University of Athens, Athens, Greece; ³⁾Izmir International Biomedicine and Genome Institute (iBG-Izmir), Dokuz Eylül University, Izmir, Turkey; ⁴⁾First Dpt Paediatrics, Aghia sophia Hospital, Athens University Medical School, Athens, Greece

^a)sgeronik@bioaacdemy.gr

^b)albanopoulos_kostis@yahoo.gr

^c)dcokkinos@bioacademy.gr

^d)athanasiapavlo@gmail.com

^e)chrousog@mail.nih.gov

Background: Kisspeptin (encoded by the KISS1 gene in humans) is proposed to be an excitatory neuromodulatory peptide in multiple homeostatic systems including anti-oxidative effect, glucose homeostasis, role in nutrition status, locomotor activity etc. Thus, as oxidative stress is the leading pathogenic mechanism of chronic-stress related obesity epidemic, kisspeptin becomes a research target of interest for the obesity-oriented scientific community.

Aim: To construct a new interactome of stress induced obesity, by virtue of advancing the insight of its pathogenesis with kisspeptin signaling.

Methods: Kisspeptin and obesity-related gene or gene products were extracted from the biomedical literature (Geronikolou 2017, Hussain 2015, Patterson and Abizaid 2013, Olaniyan 2013, Qi and Cho 2008). The interactions among them were investigated through STRING v10 (Szklarczyk et al., 2015), a database of known and predicted, physical and indirect associations among genes/proteins. In this study, a high confidence interaction score of 0.7-0.97 was used.

Results: The intermediate nodes were also predicted, showing that KISS1 and KISS1R are connected directly to ghrelin receptor (GHSR) and cholecystokinin (CCK) and indirectly, via gonadotropin releasing hormone 1 (GNRH1), to corticotropin-releasing hormone (CRH) and neuropeptide Y (NPY) of the stress-induced obesidome. The new advanced interactome involves 42 nodes of gene- gene products of known and/or predicted interactions.

Conclusions: Interactions networks may contribute to understand the kisspeptin pathway for the integral regulation of energy balance and obesity pathogenesis. Moreover, glucagon (GCG), Corticotropin-releasing hormone (CRH) and Pro-opiomelanocortin (POMC) genes are identified as major “hubs” for the stress induced (epigenetic) obesity.

All authors report no conflict of interest. The study was conducted with no financial support.

References:

S Geronikolou, A Pavlopoulou, G Chrousos, The interactome of obesity: Obesidome, Advances Medicine & Biology, 2017, doi: 10.1007/978-3-319-57379-3_21.

S Geronikolou, A Pavlopoulou, K Albanopoulos, D Cokkinos, G Chrousos, Stress induced obesidome, Eur J Pediatrics: EAP 2017 Congress and MasterCourse Abstracts Book pg 16. doi: 10.1007/s00431-017-2979-8

Olaniyan OT, Meraiyebu AB, Auta KB, Dare J.B, Anjorin YD., Shafe MO, KISSPEPTIN SYSTEM: A Multi-Homeostatic System.IOSR Journal of Pharmacy and Biological Sciences (IOSR-JPBS) e-ISSN: 2278-3008. Vol 5, Issue 4 (Mar. – Apr. 2013), 87-101.

Hussain MA, Song WJ, Wolfe A. There is kisspeptin and then, there is kisspeptin. Trends Endocrinol Metab. 2015 Oct;26(10):564-72.

Patterson ZR, Abizaid A. Stress induced obesity: lessons from rodent models of stress Front Neurosci. 2013 Jul 24;7:130.

Qi L, Cho YA. Gene-environment interaction and obesity. Nutr Rev. 2008 Dec;66(12):684-94.

Szklarczyk, D., A. Franceschini, S. Wyder, K. Forslund, D. Heller, J. Huerta-Cepas, M. Simonovic, A. Roth, A. Santos, K.P. Tsafou, M. Kuhn, P. Bork, L.J. Jensen, and C. Von Mering. 2015. String V10: Protein-Protein Interaction Networks, Integrated Over the Tree of Life. Nucleic Acids Research 43: D447–D452.

P-062

Ongoing Pursuit of Perfection; Enhanced Recovery After Bariatric Surgery (ERABS); An Overview of the Literature and the Experiences of a High Volume Bariatric Centre

Marjolijn Leeman^a), Ulas Biter^b), Jan Apers^c), Martin Dunkelgrun^d)

Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands

^a)m.leeman@franciscus.nl

^b)u.biter@franciscus.nl

^c)j.apers@franciscus.nl

^d)m.dunkelgrun@franciscus.nl

Obesity has become pandemic and the obesity-related comorbidities, mortality and costs have an increasing impact on society. The only long-term effective treatment for morbid obesity is surgery. To optimize perioperative management in bariatric surgery, the Enhanced Recovery After Bariatric Surgery pathway (ERABS) has been developed, which starts at the first visit to the outpatient clinic and continues until full recovery after surgery. ERABS can be enhanced by optimization of the preoperative and postoperative phase, which is called the Fast Track protocol and aims to create a care path that is as safe, efficient and patient-friendly as possible. Continuous evaluation and optimization of ERABS and the Fast Track Protocol is important and can result in more procedures per day and better outcomes. Over the years we have made several alterations to our hospital’s protocol, including, amongst other things, an extra dietary educational session before discharge and ambulation under the guidance of a physical therapist. Here, we present the impact of these alterations, placed in the context of current literature. Data was prospectively collected from patients undergoing bariatric surgery between January 2016 and September 2017 under the newest ERABS protocol. Patients were compared to matched (age, BMI, medical history, procedure) controls who underwent bariatric surgery between January 2014 and December 2015 under the earlier protocol, for rates of complications, revisits to the emergency ward or outpatient clinic, and readmissions within 30 days postoperatively. Our results show that these additional steps made to optimize the fast track protocol, result in improved perioperative patient experience and fewer unplanned hospital visits.

P-063

The predictive value of pre-existing psychological and social-environmental factors for weight regain after bariatric surgery

Danielle Bonouvrie^{1, a)}, Martine Uittenbogaart^{1, b)}, Arijan Luijten^{1, c)}, Francois Van Dielen^{1, d)}, Wouter Leclercq^{1, e)}, Charlotte Lieverse^{2, f)}, Noor Schuilwerve^{2, g)}

¹⁾Bariatric Surgery, Maxima Medical Center, Veldhoven, Netherlands

²⁾Psychological, Maxima Medical Center, Veldhoven, Netherlands

^a)danielle.bonouvrie@mmc.nl

^b)m.uittenbogaart@mmc.nl

^c)a.luijten@mmc.nl

^d)F.vandielen@mmc.nl

^e)w.leclercq@mmc.nl

^f)charlotte.lieverse@mmc.nl

^g)noor.schuilwerve@mmc.nl

Introduction: One major concern of bariatric surgery is weight regain, which is observed in up to 50% of the patients. Causes mentioned are surgical related and non-surgical related (including psychological, socio-environmental and biological). Psychological disorders, of which somatization is the most common, are observed in about 50% of the patients. Understanding the association between pre-existing non-surgical factors and weight regain is important to enable better patient selection. Aim of this study was to determine whether non-surgical factors, especially somatization, are associated with subsequent weight regain.

Methods: 111 patients were retrospectively included in this study. Data were obtained from medical health records and the electronic patient register of patients referred for bariatric surgery between January 2012 and October 2013. Psychological factors were assessed using the SCL-90 as part of pre-surgical screening.

Results: At two years follow-up, 13.5% of the patients showed weight regain with a mean regain of 8%. Higher levels of somatization were independently predictive of less weight regain. There was no statistically significant association between weight regain and other non-surgical factors.

Conclusion: Successful maintenance of weight loss following bariatric surgery appears to occur more often in patients who rapport more somatic complaints at baseline. There was no other significant association between non-surgical factors and weight regain. These findings suggest that focusing on physical symptoms does not contribute to patient selection to ensure better outcome. Prospective large studies are needed to confirm this finding and evaluate intervention that target somatic symptom perception following bariatric surgery.

P-064

Long term results after standard gastric bypass regarding nutritional status

Harilaos Pappis^{1, a)}, Iraklis Perysinakis^{1, b)}, Dimitra Kotsakou^{2, c)}, Alexia Katsarou^{1, d)}

¹⁾Third Surgical Department, HYGEIA Hospital, Athens, Greece; ²⁾Anaesthesia Department, HYGEIA Hospital, Athens, Greece

^a)harry.pappis@gmail.com

^b)iraklisper@gmail.com

^c)dkotsakou@gmail.com

^d)katsaroualexia@gmail.com

Aim: To evaluate the prevalence of nutritional deficiencies and diabetes mellitus (DM) after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods: Bariatric patients that underwent LRYGB in a single Surgical Department were included in this study. Pre-existing nutritional deficiencies were corrected preoperatively. Postoperative nutritional supplementation and dietary support were recommended to all participants for at least two years according to published guidelines. Patients were followed-up for five years with phone interviews and biochemical nutritional screening. The impact of surgery on DM was also recorded.

Results: Between 2007 and 2012, 114 patients were recruited to undergo LRYGB. Mean age of participants was 53 years and 81% of them were postmenopausal women. Among them, 92 (80%) complied with the follow-up protocol. Preoperative BMI was 44.7± 6.7 kg/m² whereas mean BMI one and five years postoperatively was 27.3±5.2 and 28.6±6.3 kg/m² respectively. The majority of patients (65 out of 92) complied with nutritional supplementation. Most patients (74%) did not undertake the appropriate visits to the dietitian, whereas only 32% of patients declared having moderately improved their dietary habits. Regarding nutritional deficiencies, 32% of patients developed asymptomatic anemia, 16% developed Vitamin D deficiency and 9% presented elevated PTH levels, irrespectively of nutritional supplementation compliance. Protein levels remained normal in all patients. Decrease in B12 and folic acid levels developed in 33% of patients not taking nutritional supplementation (9 out of 27). Preoperatively 37 patients had diabetes mellitus and were under medication. Euglycemic response was observed in the majority of diabetic patients. Interestingly, DM resolved in 21 out of 37 patients.

Conclusion: LRYGB may cause mild anemia and calcium dyshomeostasis (to a lesser extent) in Greek postmenopausal women but not protein deficiency. Preserving B12 and folic acid levels appears to depend on nutritional supplementation compliance. DM resolves in most patients. Although these deficiencies are easily corrected, preventive nutritional supplementation postoperatively must be emphasized. Furthermore, compliance with dietary advice and follow-up visits may improve the outcome.

P-065

Using mHealth for weight loss: A systematic review of evidence

Katerina Dounavi^{1, a)}, Olga Tsoumani^{2, b)}

¹⁾School of Social Sciences, Education and Social Work, Queen's University Belfast, Belfast, United Kingdom; ²⁾Department of Marketing & Organization Studies/Behavioural Engineering Group, KU Leuven, Leuven, Belgium

^a)k.dounavi@qub.ac.uk

^b)olga.tsoumani@kuleuven.be

Weight management, encompassing both weight loss and the long-term maintenance of weight-loss changes, requires the modification of dietary and physical activity habits. The present paper reviews the latest research on the efficacy of mobile health (mHealth) technology as a facilitator of behavioural changes (i.e. eating and physical activity behaviour changes) required for successful weight management. A systematic search was conducted in Ovid MEDLINE and Ovid PsychInfo databases, aiming to identify studies published in peer-reviewed journals since 2012. Results are presented in terms of participant characteristics, mobile health components, additional treatments, dependent variables, and treatment efficacy. Indicators of study quality and social validity are also presented. Recommendations are issued about future developments in the use of mHealth for weight management interventions, supported by a behaviour-analytic approach.

Keywords: systematic review, weight management, mobile health, behaviour change

Funding disclosure: This study was funded by MyHabeats.

P-066

Sexual Dysfunction Is Common in the Obese Female and Improves after Bariatric Surgery

Dita Pichlerova

Obesitology, OB clinic Prague, Prague, Czech Republic

dita.pichlerova@seznam.cz

60 obese women (mean initial BMI of 43.7 ± 5.99 kg/m²; mean age of 41.7 ± 10.8 years) completed the questionnaire on sexual function (FSFI) before a bariatric procedure (laparoscopic adjustable gastric banding, 22 women; gastric plication, 33 women; and biliopancreatic diversion, 5 women), 6 months and 12 months after the procedure, i.e. after substantial weight loss (final mean BMI of 35.5 ± 5.5 kg/m²). The control group consisted of 60 non-obese women (mean BMI of 22.2 ± 1.9kg/m²; mean age of 36.4 ± 10.7 years). The FSFI assesses sexual function across 6 domains: sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction and sexual pain; higher scores indicating better sexual function. The FSFI total score (range 2-36) of ≤ 26.55 is indicating FSD.

Baseline sexual function in the preoperative obese female was significantly lower than in the control group of non-obese women (p < 0.01) in each domain. Average postoperative FSFI scores increased from preoperative levels in all domains, but significant improvement occurred only in the domain for desire (p < 0.01). The results at 6 and 12 months after surgery did not show significant differences from each other. Before surgery, 31 obese women (51.6%) had scores indicative of FSD, while by 6 months postoperatively it was only 17 women (39.5%), and by 12 months postoperatively, 18 women (41.9%), had scores indicative of FSD. In the control group of non-obese women, only 9 women (15%) had scores indicative of FSD. The FSFI total scores improved 12 months after surgery from 20.1 ± 11.7 to 23.7 ± 11.5, but the FSFI total score in the control group of non-obese women was 30.3 ± 3.5 (p < 0.01).

P-067

Initial results in morbidly obese patients to evaluate and increase the reliability of Epworth sleepiness scale in predicting obstructive sleep apnea.

Vitish Singla^a), Sandeep Aggarwal, Gattu Tharun, Samagra Agarwal^b)

Department of Surgery, All India Institute Of Medical Sciences, New Delhi, India

^a)vitishaiims@gmail.com

^b)samagra.agarwal@gmail.com

Introduction: Some studies have shown that Epworth sleeping scale (ESS) is not a good tool to predict OSA, however data regarding accuracy of ESS in morbidly obese patients is lacking.

Methods: 232 patients underwent polysomnography and also undertook the ESS questionnaire preoperatively. An ESS score > 10 was taken as indicator of presence of excessive daytime reference sleepiness and OSA. The dataset was divided randomly into derivation and validation subgroups in an approximately 2:1 ratio. A new score was derived using age, sex, BMI, ESS as the variables to predict OSA in the derivation cohort and tested in the validation cohort.

Results: The mean age was 40.5 ± 11.8 years, the mean weight was 123.2 ± 23.8 kg and mean body mass index (BMI) was 47.6 ± 7.3 kg/m². 70 patients (30.1 %) had symptoms of excessive daytime sleepiness (ESS score > 10). On polysomnography, 199 (85.7) patients had OSA and 152 patients (65.6 %) had moderate or severe OSA. Among the 162 patients who had an ESS less than 10, a significant majority (93 patients, 57.4 %) also had moderate to severe OSA (AHI > 15). The sensitivity of ESS to predict moderate to severe OSA was found to be 38.8% and positive predictive value was 84.2% (Positive likelihood ratio 2.82, 95% CI: 1.57-5.06). A predictive score was identified as 0.031Age (years) + 0.039BMI (kg/m²) + 0.038ESS + Sex (1 for male, 0 for female). The score had a sensitivity of 80 % and a specificity of 62.3% at a cut off of 3.3 in the derivation cohort. The predictive score performed similarly in the validation cohort as well.

Conclusion: The utility of ESS in predicting OSA is limited and requires development of better scores, especially in morbidly obese patients.

P-068

Quality of Life exist after Bariatric Surgery: Does Honeymoon exist?

Brigitte Obermayer

Surgery, Göttlicher Heiland Krankenhaus, Vienna, Austria

obermayers@gmx.at

We can state that medical conditions and BMI can be improved after Bariatric Surgery, but does quality of life increase after Bariatric Surgery?

Since 1998, when Oria and Moorehead developed the BAROS Score to measure not only the medical but also the psychological outcome of Bariatric Surgery, a great number of instruments was developed to measure the quality of life after Bariatric Surgery, for example Bariatric Quality of Life Index (BQL), Obesity Realted Problem Scale(OP), Bariatric and Obesity Specific Survey, Obesity Related Well Being 97 (ORWELL 97), and Impact of Weight on Quality of Life.

We compared several instruments focusing on the four dimensions of Health Related Quality of Life and developed a new instrument combining the measurement of all four dimensions.

From November 2016 to March 2017 we examinated 108 postoperative patients of a single Austrian Center of Bariatric Surgery and tested for different outcomes regarding gender, preoperative BMI and length of postoperative phase. We documented an overall gain in quality of life after surgery in all dimensions of health related quality of life.

Comparing one patient group whose operation was less than a year ago, to a group of patients whose operation was more than a year ago showed us a significant difference in quality of life, in favour of the early postoperative group.

Therefore we could measure signs of a "honeymoon phase" shortly after Bariatric Surgery.

References:

1: Sjöström L., Lindroos A., Peltronen M., Bouchard C., Carlsson B., Dahlgren S., Larsson B., Narbro K., Sjöström C., Sullivan M., Wedel H. ( 2004) Lifestyle, Diabetes, and Cardiovascular Risk Faktors 10 Years after Bariatric Surgery. New England Journal of Medicine 2004, 351, 2683-2693

2: Oria, H. E., Moorehead M. K. (1998) Bariatric analysis and reporting outcome system (BAROS ). Obesity Surgery, 1998, 5, 487-499

3: Weiner, S., Sauerland, S.,Fein M., Blanco R., Pomhoff I., Weiner, R. (2005) The Bariatric Quality of Life (BQL) Index: A Measure of Well-being in Obesity Surgery Patients. Obesity Surgery, 15, 2005, 538-545

4: Karlsson J., Sjöström L., Torgerson J.S., Sullivan M. (2003) Psychosocial Functioning in the Obese Before and After Weight Reduction: Construct Validity and Responsiveness of the Obesity-related Problem Scale. International Journal of Obesity 2006, 27, 617-630

5: Tayyem R. M., Atkinson J.M., Martin C.R. (2014) Development and validation of a new Bariatric specific health related quality of life instrument „ bariatric and obesity-specific survey (BOSS). Journal of Postgraduate Medicine, 2014, vol.60, issue 4, 357-361

6: Camolas J., Ferreira A., Manucci E., Mascarenhas M., Carvalho M., Moreira P., do Carmo I., Santos O. (2016) Assessing Quality of Life in Severe Obesity: Development and Psychometric Properties oft he ORWELL-R. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, Volume 21, Issue 2, 277-288

7: Kolotkin R. L., Crosby R. D., Koloski K. D., Williams G. R. (2001) Development of a Brief Measure to Assess Quality of Life in Obesity. Obesity 2001, Volume 9, Issue 2, 102-111

P-069

Connection between obesity and leptin expression and serum level with breast cancer

Ivan Koprivčić^{1, a)}, Radivoje Radić^{2, b)}, Robert Selthofer^{3, c)}

¹⁾Surgery, University Hospital Osijek, Osijek, Croatia; ²⁾Anatomy, Faculty of Dental Medicine and Health, University in Osijek, Osijek, Croatia; ³⁾Anatomy, Faculty of Medicine, University in Osijek, Osijek, Croatia

^a)ivankoprivcic@yahoo.com

^b)rradic@mefos.hr

^c)rselthofer@gmail.com

Study analyse connetcion between serum leptin level, leptin exprerssion in breast cancer tissue at gene and protein level with early cancer detection and survival prognosis. Further aim was to determine if leptin serum concentration increaces the chance of specific type of cancer or cancer as general homogenous group. 98 patients were included in the study. 75 of them were were patients with malignant tumors and 23 were control group (benign toumors). Results demonstrate higher serum leptin levels in group with malignant tumors. There was no significant difference in leptin gene expression, but the group that showed highest serum leptin levels showed lowest receptor expression.

References:

1. Snoussi K, Strosberg AD, Bouaouina N, Ben Ahmed S, Helal AN and Chouchane L: Leptin and leptin receptor polymorphisms are associated with increased risk and poor prognosis of breastcarcinoma. BMC Cancer 6: 38, 2006.

2. Jeong YJ, Bong JG, Park SH, Choi JH and Oh HK: Expression of leptin, leptin receptor, adiponectin, and adiponectin receptor in ductal carcinoma in situ and invasive breast cancer. J Breast Cancer 14: 96‐103, 2011.

3. Rene Gonzalez R, Watters A, Xu Y, Singh UP, Mann DR, Rueda BR and Penichet ML: Leptin‐signaling inhibition results in efficient anti‐tumor activity in estrogen receptor positive or negative breast cancer. Breast Cancer Res 11: R36, 2009.

P-070

Is there a need for one-month medical follow-up after laparoscopic sleeve gastrectomy?

Lidia Iuliana Arhire^a), Sergiu Serghei Padureanu^b), Andreea Gherasim^c), Otilia Nita^d), Andrei Catalin Oprescu^e), Radu Sebastian Gavril^f), Laura Mihalache^g)

Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

^a)lidia.graur@umfiasi.ro

^b)sergiu.padureanu@umfiasi.ro

^c)andreea.gherasim@umfiasi.ro

^d)otilia.nita@umfiasi.ro

^e)andreicatalinoprescu@yahoo.com

^f)rgavril87@yahoo.com

^g)laura.mihalache@umfiasi.ro

The long-term success of metabolic surgery lies with a careful multidisciplinary follow-up. This approach can prevent nutritional deficiencies and other medical complications that could occur due to an altered digestive system and can also minimize weight regain. Currently, there are no strict guidelines as to the frequency or content of medical follow-ups after laparoscopic sleeve gastrectomy (LSG).

In our bariatric surgery center we have been performing medical follow-ups at one, three, six and 12 months after LSG, and yearly afterwards. These visits include a comprehensive discussion about symptoms, a complete clinical examination, blood tests and other measurements (Figure 1 describes this protocol). We provide nutritional counselling at each of these visits, tailored by the test results. Whereas the 3, 6, and 12 month after surgery visits are recommended by most guidelines, we also included the one-month after surgery visit to detect and correct promptly any nutritional problems, mainly related to dehydration or improper protein intake. As the number of patients followed in our center increases and resources are limited, we debated whether there is a need for a complete check-up one month after LSG.

We investigated 120 patients (38 men) that have been folllowed in the previous year in our center. Their average age was 42.2+/-11 years and average body mass index prior to surgery was 45.8+/-7.4 kg/m2. At one month after surgery we did not encounter renal or hepatic ambormalities. There was a significant decrease in hemoglobin and total protein level, but not in albumin level, and these differences were consistent with those found at 3, 6, 12 months after surgery. Only uric acid level had a significant increase at one month, which was then reversed. These data are presented in Figure 2.

One month after LSG performing biological tests could be redundant, but the nutritional councelling is certainly useful and we will need further research to see whether this visit could be omitted without decreasing efficiency of treatment.

P-071

Role of the gastric balloon for the treatment of morbid obesity

Mohammad Alkilani^a), Giuseppe Musolino, Cecille Lenard

Surgery, S. Camillo, Messina, Italy

^a)alkilani@alkilani.it

The use of the gastric balloon is useful in two categories of patients: to obtain a decrease in body weight and surgery risk in selected patients; this group also includes patients who require other surgery; the second category to obtain a weight reduction in a borderline patient and therefore not candidates for bariatric surgery; for this category of patients it is possible to use more balloons sequentially to reach target.

Method: The gastric balloon, either liquid filled (normal saline) or gas, is inserted into the gastric cavity under endoscopic control in order to be certain of the positioning of the balloon in the gastric cavity, the standard filling volume is 500 ml with the addition of 10 ml of methylene blue. Treatment includes a 48-hour fast and an anti-emetic therapy for 48 hours. The balloon can remain in place for a period of 4 months but it is possible to extend the period to 6 months. In exceptional cases, we removed the balloon after the end fourth month. Extraction of balloon takes place in endoscopy by emptying the balloon and extraction with dedicated instruments. Patients were prescribed a liquid diet within 48 hours prior to extraction.

Discussion: We treated 150 patients of which 100 females and 50 males, average BMI 40. 70 patients were treated propaedeutically to other bariatric surgery, 15 for the reduction of operative risk in patients candidates for other surgery and 65 patients as alternative treatment of a major bariatric surgery for a starting BMI below 40.

Results: Patients who followed assigned diet had positive result where the group absent on followup and not comply diet did not achieve expected risults; Weight loss varies according to patient's initial weight, average was 20 kg and closely linked to patient compliance with assigned diet, 1200 calories day. 2 patients balloon was extracted after 36 hours for psychological intolerance. 1 patient underwent hypercapnic coma after 72 hours with balloon removal.

P-072

Multidisciplinary approach in bariatric surgery: initial experience for the Bulgarian Public Health System

Konstantin Grozdev^{1, a)}, Teodora Handjieva-Darlenska²⁾, Zdravko Kamenov³⁾, Elena Ivanova⁴⁾, Ognian Georgiev⁵⁾, Nabil Khayat¹⁾, Georgi Todorov¹⁾, Kostadin Angelov¹⁾

¹⁾Department of Surgery, Alexandrovska University Hospital, Sofia, Bulgaria

²⁾Department of Pharmacology and Toxicology, Medical Univesity, Sofia, Bulgaria

³⁾Department of Internal Diseases, Alexandrovska Univesity Hospital, Sofia, Bulgaria

⁴⁾Department of Psychiatry, Alexandrovska Univesity Hospital, Sofia, Bulgaria

⁵⁾Department of Propaedeutic Medicine, Alexandrovska Univesity Hospital, Sofia, Bulgaria

^a)k.grozdev@yahoo.com

Introduction: Obesity is one of the greatest public health problems in many developed countries. It is associated with adverse effects on almost all the organ systems and can dramatically decrease the life expectancy and the quality of life. Bariatric surgery is currently the gold standard treatment for severe and morbid obesity allowing improvement of type 2 diabetes and metabolic syndrome. In Bulgaria this treatment method is just making its first steps. Our team was the first in the country to develop and apply a multidisciplinary program for bariatric surgery for the Bulgarian Public Health System (BPHS).

Patients and methods: Between September 2016 and November 2017 fifty patients were included in our multidisciplinary program for bariatric surgery. After weekly consultations and proper preoperative examinations carried out respectively by surgeons, dietitians, psychiatrists, endocrinologists, cardiologists and pulmonologist the patients were selected for surgery. Ten patients (six females and four males) underwent laparoscopic bariatric procedure. Seven Roux-en-Y gastric bypass, two sleeve gastrectomies and one mini (omega) gastric bypass were performed. The mean age was of 44,3 +/- 12,2 and the mean preoperative BMI was of 48,8 +/- 6,4 kg/m². The studied variables included hospital stay, intraoperative complications, early and late postoperative complications, mortality. Percentage of excess weight loss (%EWL) and metabolic marker data were abstracted at 3 and 6 months postoperatively.

Results: The mean hospital stay was 4,1 +/- 0,8 days. No intraoperative and early postoperative complications were registered. Perioperative and postoperative mortality was 0. One year after the operation the first patient develop an internal hernia treated uneventfully. The %EWL at 3 and 6 months was 40,5% and 53,9%. All metabolic markers showed improvement.

Conclusion: Bariatric surgery allows substantial short-term reduction in weight and amelioration in metabolic markers. The adoption of a comprehensive multidisciplinary approach led to proper patient selection and to significant improvements in the complications rate and in the postoperative outcomes. It is reproducible and potentially beneficial within the context of the BPHS.

P-073

Effect on vitamin B12 on neuropathy in pernicious anemia treated with folic acid supplementation: a case report

Hendrika Smelt¹⁾, Sjaak Pouwels²⁾, Mohammed Said¹⁾, Johannes Smulders¹⁾

¹⁾Surgery, Catharina Hospital, Eindhoven, Netherlands

²⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands

The rising rates of bariatric surgery (BS) are accompanied by neurologic complications related to nutrient deficiencies. One of the risk factors for neurologic complications in BS patients is less vitamin and mineral supplementation. Prevention, diagnosis, and treatment of these disorders are necessary parts of lifelong care after BS. Particularly important for optimal functioning of the nervous system are thiamine, pyridoxine, niacin, cobalamin, vitamin E, copper, and possibly folic acid (1). In this case report we report on a patient with anemia and a lot of deficiencies in blood results after BS who developed psychiatric-neurological symptoms due to folic acid supplementation in an untreated cobalamin deficiency. Secondly we tried to elucidate the vitamin physiology to understand specific mechanisms after BS.

P-074

Strict attendance of an obesity medical clinic is associated with improved weight outcomes; the presence of diabetes is a negative prognostic factor

Theodora Kolokytha, Elpida Athanasopoulou, Stavros Liatis, Dimitrios Eliopoulos, Konstantinos Tzirogiannis, Melina Karaolia, Nicholas Tentolouris, Alexander Kokkinos^a)

First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece

^a)rjd@otenet.gr

Introduction

Frequent follow up has been associated with increased weight loss in obese patients, while diabetes seems to impede weight loss efforts. The present study assessed whether frequency of obesity clinic attendance affects weight loss, and whether diabetes interferes with outcomes.

Methods: Data retrospectively collected for 150 obese patients completing 1 year of lifestyle modification (hypocaloric diet and physical activity counseling) in a medical obesity clinic. Anthropometrics (weight, height, BMI), number of visits, and diabetic status were recorded. Subjects were divided by the median number of visits (7.0) into a frequent (FA) and infrequent attendance (IFA) group, and their respective weight loss at 1, 3, 6, and 12 months was expressed as ΔBMI%. The percentage of patients achieving the clinically relevant weight loss goals of 5% and 10% was assessed.

Results: Initial BMI was higher in the FA group (40.0±8.1 vs 37.3±7.8 kg/m², mean±SD, p=0.04). ΔBMI% was higher in the former group at 6 and 12 months (6months: 10.3±5.9% vs 8.3±4.9%, p=0.03, and 12months: 12.3±7.0% vs 8.3±6.7%, mean±SD, p<0.001, respectively). Differences remained significant after adjustment for initial BMI. The 5% weight loss goal was achieved by a higher percentage of FA patients (89.3% vs 63.6%, p<0.001), as was the 10% goal (57.1% vs 33.3%, p=0.004).

In multivariable linear regression analysis, FA status was associated with a higher ΔBMI% at 12 months (standardized β-coefficient: 0.252, p=0.002), whilst diabetes was a negative predictor of ΔΒΜΙ% (standardized β-coefficient: -0.156, p=0.05), independently of baseline BMI and other possible confounders. In multivariable binary regression analysis, frequent attendance was associated with higher probability of 10% weight loss (OR: 2.61 [1.30-5.22], p=0.007), and diabetes with a lower one (OR: 0.29 [0.10-0.89], p=0.03).

Conclusion: An increased frequency of clinic attendance is associated with better outcomes in obese patients following a lifestyle weight loss intervention. Diabetes seems to be detrimental to the achievement of weight loss goals.

P-075

Long-Term Evaluation of Biliary Reflux After One-Anastomosis Gastric Bypass

Alexander Khitaryan^a), Arut Mezhunts^b), Kamil Veliev^c), Olesya Starzhinskaya^d)

Surgical department, Rostov State Medical University, Rostov-on-Don, Russian Federation

^a)khitaryan@gmail.com

^b)arut.mezhunts@mail.ru

^c)koma.81@yandex.ru

^d)starg@yandex.ru

Keywords: Morbid obesity. Mini-gastric bypass. One-anastomosis gastric bypass. Biliary reflux

Introduction: One-anastomosis gastric bypass is one of the most popular bariatric procedure in the world. Nevertheless, there is сontroversy remains regarding biliary reflux after mini-gastric bypass/one-anastomosis gastric bypass (MGB/OAGB). The aim of this study was to analyze biliary reflux and its potential long-term consequences on esofagogastric mucosae in OAGB operated patients.

Methods: Immediate and long-term outcomes (up to 30 months, mean 12 month) in a cohort of 70 patients undergoing surgery between 2014 and 2017 were analyzed. Patients were divided into two clinical groups, depending on the technique of gastroenteroanastomosis. A standard five-port laparoscopic technique was used. The first group included 32 patients who underwent MGB in a modified way in our clinic with the making of hand-sewn gastroenteroanastomosis. 38 patients were used the traditional technique with the making of anastomosis with using a linear stapler with a 45 mm blue cartridge. Then, mean 12 months after MGB, all patients was filled out a reflux symptom questionnaire (GerdQ). A gastroscopy with biopsies was done for all patients with a bile-reflux positive symptoms.

Results: The number of patients who underwent surgery were 70 (mean body mass index 46 kg/m2). Mean percent excess weight loss (%EWL) at 12 months was 74.3%. Comorbidity resolution, determined by medication use, showed a reduction in diabetes (71.8% to 15.6%), hypertension (37.2% to 21.4%) and hypercholesterolaemia (40.4% to 13.4%). The absence of enterogastric biliary reflux was observed in 81.2% of patients in the study group, the absence of an ulcer of the gastroenteroanastomosis was observed in 97% of the study group, respectively. There was one death unrelated to surgery.

Conclusions: Modified MGBP appears to be a safe and effective operation for the morbidly obese. It is durable, with good weight loss at up to 12 months post-surgery. The proposed technique for the formation of hand-sewn gastroenteroanastomosis allows decreasing the postoperative bile reflux up to 8,8%.

P-076

Mid- and long-term changes in frequency intake of foods in patients undergoing a sleeve gastrectomy

Jaime Ruiz-Tovar^a), Carolina Llavero, Lorea Zubiaga, Jose Luis Munoz

Surgery, Centro de excelencia para el estudio y tratamiento de la obesidad, Valladolid, Spain

^a)jruiztovar@gmail.com

Purpose: Dietary intake and food preferences change after bariatric surgery, secondary to gastrointestinal symptoms and dietitian counseling. The aim of this study was to evaluate the changes in the frequency intake of different foods in patients undergoing a sleeve gastrectomy and following a strict dietary control.

Patients and methods:A prospective observational study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between 2007-2012, was performed. Dietary assessment was performed using the Alimentary Frequency Questionnaire 1991-2002, developed and validated by the Department of Epidemiology of Miguel Hernandez University (Elche, Alicante Spain).

Results: 93 patients were included for analysis, 73 females and 20 males, with a mean preoperative BMI of 46.4+7.9 kg/m². One year after surgery, excess weight loss was 81.1±8.3% and 5 years after surgery 79.9±6.4%.Total weight loss at 1 year 38.8+5.3% and at 5 years 35.4+4.9%. Postoperatively, a reduction in the intake of dairy products, red meat, deli meat products, shellfish, fried potatoes, sweets, rice, pasta, beer and processed foods was observed. Vegetables, fruits and legumes intake increased after surgery. In the first postoperative year there was a slight intolerance to red meat, fruits, vegetables and legumes, dairy products, pasta and rice, that mostly disappeared 5 years after surgery.

Conclusion: One year after SG, calibrated with a 50Fr bougie, there are not important problems in the intake of foods a priori difficult to digest. These problems mostly disappeared 5 years after surgery. The decrease intake of other unhealthy foods is mostly based on the dietary counseling.

P-077

Unpredictable evolution of a 20-years history of a bariatric patient. Case report of a migrated gastric band after redo gastric bypass.

Cristian Eugeniu Boru^{1, a)}, Tommaso Manzia^{2, b)}, Angelo Iossa^{1, c)}, Gianfranco Silecchia^{1, d)}

¹⁾UOC General Surgery & Bariatric Centre of Excellence-IFSO EC, University La Sapienza of Rome - Polo Pontino Polo Integrato AUSL LT-ICOT, Latina, Italy

²⁾Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy

^a)cristian.boru@yahoo.com

^b)tomanzia@libero.it

^c)angelo.iossa@gmail.com

^d)gianfranco.silecchia@gmail.com

Introduction: Morbid obesity is a chronic disease, with resistance to multiple therapies. Bariatric surgery is the most efficient nowadays treatment, but with a certain price when we speak of surgeon’s efforts, patient’s compliance and tolerance, available technology and long term evolution.

Materials: We present the case of 20 years evolution of a female obese patient, with multiple, sequential bariatric minimally-invasive interventions: intragastric balloon, gastric banding, gastric bypass (GBP), banding positioning on GBP, all complicated. Last attempt to treat weight regain was laparoscopic positioning of an adjustable banding over a failed gastric bypass in 2015, complicated 12 months after by acute intestinal occlusion due to band migration, leading to open emergency band removal, wound dehiscence and finally incisional hernia.

Results: After multiple interventions, the patient has a BMI of 38 kg/m², large incisional hernia, depression, over a non-satisfactory gastric bypass.

Conclusion: Bariatric surgery has some limitations in case of patient’s non-compliance and bad-luck, even with persistent, experienced tailored bariatric treatment. Non-responsive obese patients should be considered as possible subcategory of long-term outcomes.

P-078

Long-term evolution of nutritional deficiencies after Roux-en-Y gastric bypass and biliopancreatic diversion with Roux-en-Y gastric bypass

Charalampos Lampropoulos^a), Theofilos Amanatidis^b), George Papadopoulos^c), George Skroubis^d)

Morbid Obesity Unit, Department of Surgery, University Hospital of Patras, Rio/Patras, Greece

^a)x_lamp@hotmail.com

^b)kontos_lo@yahoo.gr

^c)kreon84@gmail.com

^d)skroubis@med.upatras.gr

Background: Patients undergoing bariatric surgery are at an increased risk of developing nutritional deficiencies. We have studied retrospectively, nutritional deficiencies after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) with Roux-en-Y gastric bypass, up to 15 years postoperatively.

Methods: Between 1994 and 2001, 78 obese patients with body mass index (BMI) from 37.6 to 62.9 kg/m² underwent RYGB (gastric pouch: 15 ± 5 ml, biliopancreatic limb: 60-80 cm, alimentary limb: 80-100 cm, common limb: the remainder of the small intestine), while 94 super obese patients (BMI ≥ 50 kg/m²) underwent a modification of BPD (gastric pouch: 15 ± 5 ml, biliopancreatic limb: 150-200 cm, common limb: 100 cm, alimentary limb: the remainder of the small intestine). Patients were examined before and 1, 5, 10 and 15 years after surgery for nutritional deficiencies. Parameters studied were hemoglobin, albumin, iron, ferritin, folate and vitamin B12.

Results: The follow-up rate at 1, 5, 10 and 15 years after surgery was 95%, 79%, 42% and 20%, respectively. Percent excess weight loss in the 15th postoperative year was 52.9 ± 20.6% for patients with RYGB, and 54.7 ± 23.4% for patients with BPD. The most common preoperative nutritional deficiencies were anemia (19.8%) and iron deficiency (31.4%). For both patient groups, the incidence of anemia up to 10 years postoperatively was higher when compared to preoperative (p ≤ 0.035), combined with higher incidence of low ferritin levels at 5 and 10 years after surgery (p ≤ 0.033). Patients with BPD experienced a higher incidence of vitamin B12 deficiency, throughout the follow-up period, compared to preoperative values (p ≤ 0.046). 84% of patients received some kind of nutrient supplementation in the last year of follow-up.

Conclusion: RYGB and BPD were associated with an increase in the incidence of anemia during the first 10 postoperative years. BPD was also associated with a consistent increase in the incidence of vitamin B12 deficiency.

References:

• Weng TC, Chang CH, Dong YH, Chang YC, Chuang LM. Anaemia and related nutrient deficiencies after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis. BMJ Open. 2015 Jul 16;5(7):e006964.

• Kwon Y, Kim HJ, Lo Menzo E, Park S, Szomstein S, Rosenthal RJ. Anemia, iron and vitamin B12 deficiencies after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a meta-analysis. Surg Obes Relat Dis. 2014 Jul-Aug;10(4):589-97.

• Homan J, Betzel B, Aarts EO, Dogan K, van Laarhoven KJ, Janssen IM, Berends FJ. Vitamin and Mineral Deficiencies After Biliopancreatic Diversion and Biliopancreatic Diversion with Duodenal Switch--the Rule Rather than the Exception. Obes Surg. 2015 Sep;25(9):1626-32.

• Currò G, Centorrino T, Cogliandolo A, Dattola A, Pagano G, Barbera A, Navarra G. A clinical and nutritional comparison of biliopancreatic diversion performed with different common and alimentary channel lengths. Obes Surg. 2015 Jan;25(1):45-9.

P-079 Weight loss after primary omega gastric bypass compared with converted Omega gastric bypass after gastric band

Sami Salem Ahmad^a), Suhaib Ahmad^b)

Obesity and gastrointestinal surgery, Istishari Hospital/Amman, Amman, Jordan

^a)info@drsami-clinic.com

^b)suhaibsami94@gmail.com

Background: Laparoscopic omega gastric bypass is increasing world in the last years. We see more cases in the last years who need conversions from gastric band to other bariatric procedures. Common reasons are dissatisfaction of the patients or complications. We observed the weight loss in both groups for two years.

Methods: between 2012-2014. we have converted 52 patients with gastric band to omega gastric bypass (group A). At the same period we have performed 133 primary omega bypass operations (group B) We collected our data prospectively. Recorded data preoperatively included age, sex, comorbidity, body mass index (BMI), Postoperatively recorded data included, intra and post operative morbidity and mortality, percentage of excess weight loss (%EWL).

Results: Available for follow up were 48(92%) patients in group A and 122 (91%) patients in group B.

Mean BMI was 39 in Gr A and 41 in B preoperatively and has decreased to 30 and 29 respectively.

Incidence of heart burn and reflux symptoms were higher in the converted group 12.5% and 6.5% respectively. Diabetes and hyperlipidaemia and arterial hypertension incidence was lower preoperatively in GR. A and got similar in both groups after 2 years.

Conclusions: Omega gastric bypass after gastric banding seems to be effective with significant weight loss however less than the primary omega gastric bypass. There was no difference on the effect on comorbidities.

P-080

Prediction of diabetes remission 2 and 5 years after RYGB, Sleeve gastrectomy and adjustable gastric banding using DiaRem and Advanced-DiaRem scores

Rachel Golan^{1, a)}, Dror Dicker²⁾, Judith Aron-Wisnewsky³⁾, Jean-Daniel Zucker⁴⁾, Natalyia Sokolowska³⁾, Doron S Comaneshter⁵⁾, Rina Yahalom⁵⁾, Shlomo Vinker⁵⁾, Karine Clément³⁾, Assaf Rudich⁶⁾

¹⁾Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel

²⁾Internal Medicine, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Israel

³⁾INSERM, UMR S U1166, Nutriomics Team, Paris, France and Sorbonne Universités, UPMC University, Institute of Cardiometabolism and Nutrition, ICAN, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière hospital, Paris, France

⁴⁾Sorbonne Universités, UPMC Univ Paris06, IHU ICAN, IRD, unité de modélisation mathématique et informatique des systèmes complexes (UMMISCO), F-93143, Institute of Cardiometabolism and Nutrition, ICAN, Integromics team, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière hospital, Paris, France

⁵⁾Central Headquarters, Clalit Health Services, Tel Aviv, Israel

⁶⁾Clinical Biochemistry and Pharmacology and the National Institute of Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer Sheva, Israel

^a)golanra@bgu.ac.il

Objective: To explore the value of DiaRem and an advanced-DiaRem score (Ad-DiaRem) as predictive tools for long-term diabetes remission (DR) following Roux-en-Y Gastric Bypass (RYGB), sleeve gastrectomy (SG) or gastric banding (GB).

Research Design and Methods: We used a large HMO dataset of persons with type-2-diabetes undergoing any of the above procedures, who had pre- and postoperative data enabling calculation of the two scores and assessing DR 2 and 5y postoperatively (n=1502 and 1459, respectively).

Results: Two/Five year DR was achieved in 62.4%/53.7%, 61.8%/53.5%, 56.4%/53.8% of patients after RYGB, SG and GB, respectively. DiaRem’s predictability of long-term-DR was moderate-high for RYGB and SG (AUROC: 0.81/0.78; 0.85/0.82 at 2/5y, respectively), and lower for GB (AUROC: 0.78/0.73). The lowest score range that includes at least 80% of persons exhibiting DR (sensitivity>0.8) exhibited positive predictive values (PPV) of 81.3%/73.2%; SG: 82.1%/71.0% GB: 70.4%/64.3% at 2/5y, respectively. Yet, persons who did not achieve DR were distributed bi-modally across the score range. Ad-DiaRem trended to improve the predictive capacity, exhibiting non-significant increased AUROC only for RYGB (0.85/0.85), but improved PPV for the three procedures RYGB: 86.4%/78.2%; SG: 85.1%/76.2% GB: 72.2%/66.3% at 2t/5y postoperatively, respectively. This likely partially reflected improved score distribution among the non-DR participants.

Conclusions: DiaRem, originally designed to predict DR 1y post-RYGB, exhibits moderate predictability of DR also 2 and 5y postoperatively, for both RYGB and SG, with lower performance for GB. Ad-DiaRem possibly provides mild improvement in predicting DR 2,5y post-RYGB or SG. Procedure-type and follow-up length–specific scores are warranted.

References

Dicker D, Yahalom R, Comaneshter DS, Vinker S. Long-Term Outcomes of Three Types of Bariatric Surgery on Obesity and Type 2 Diabetes Control and Remission. Obes Surg 2016; 26(8): 1814-20.

Vest AR, Heneghan HM, Agarwal S, Schauer PR, Young JB. Bariatric surgery and cardiovascular outcomes: a systematic review. Heart 2012; 98(24): 1763-77.

Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN et al. Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017; 377(12): 1143-1155.

Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric Surgery Worldwide 2013. Obes Surg 2015; 25(10): 1822-32.

Aminian A, Brethauer SA, Andalib A, Nowacki AS, Jimenez A, Corcelles R et al. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Ann Surg 2017; 266(4): 650-657.

Lee WJ, Hur KY, Lakadawala M, Kasama K, Wong SK, Chen SC et al. Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score. Surg Obes Relat Dis 2013; 9(3): 379-84.

Still CD, Wood GC, Benotti P, Petrick AT, Gabrielsen J, Strodel WE et al. Preoperative prediction of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a retrospective cohort study. Lancet Diabetes Endocrinol 2014; 2(1): 38-45.

Aron-Wisnewsky J, Sokolovska N, Liu Y, Comaneshter DS, Vinker S, Pecht T et al. The advanced-DiaRem score improves prediction of diabetes remission 1 year post-Roux-en-Y gastric bypass. Diabetologia 2017; 60(10): 1892-1902.

Cotillard A, Poitou C, Duchateau-Nguyen G, Aron-Wisnewsky J, Bouillot JL, Schindler T et al. Type 2 Diabetes Remission After Gastric Bypass: What Is the Best Prediction Tool for Clinicians? Obes Surg 2015; 25(7): 1128-32.

Aminian A, Brethauer SA, Andalib A, Nowacki AS, Jimenez A, Corcelles R et al. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Ann Surg 2017.

Lee MH, Lee WJ, Chong K, Chen JC, Ser KH, Lee YC et al. Predictors of long-term diabetes remission after metabolic surgery. J Gastrointest Surg 2015; 19(6): 1015-21.

Wood GC, Mirshahi T, Still CD, Hirsch AG. Association of DiaRem Score With Cure of Type 2 Diabetes Following Bariatric Surgery. JAMA Surg 2016; 151(8): 779-81.

Lee WJ, Chong K, Chen SC, Zachariah J, Ser KH, Lee YC et al. Preoperative Prediction of Type 2 Diabetes Remission After Gastric Bypass Surgery: a Comparison of DiaRem Scores and ABCD Scores. Obes Surg 2016; 26(10): 2418-24.

Craig Wood G, Horwitz D, Still CD, Mirshahi T, Benotti P, Parikh M et al. Performance of the DiaRem Score for Predicting Diabetes Remission in Two Health Systems Following Bariatric Surgery Procedures in Hispanic and non-Hispanic White Patients. Obes Surg 2017.

Aminian A, Brethauer SA, Kashyap SR, Kirwan JP, Schauer PR. DiaRem score: external validation. Lancet Diabetes Endocrinol 2014; 2(1): 12-3.

Mehaffey JH, Mullen MG, Mehaffey RL, Turrentine FE, Malin SK, Kirby JL et al. Type 2 diabetes remission following gastric bypass: does diarem stand the test of time? Surg Endosc 2017; 31(2): 538-542.

Tharakan G, Scott R, Szepietowski O, Miras AD, Blakemore AI, Purkayastha S et al. Limitations of the DiaRem Score in Predicting Remission of Diabetes Following Roux-En-Y Gastric Bypass (RYGB) in an ethnically Diverse Population from a Single Institution in the UK. Obes Surg 2017; 27(3): 782-786.

Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres AJ, Weiner R et al. Interdisciplinary European Guidelines on metabolic and bariatric surgery. Obes Facts 2013; 6(5): 449-68.

Buse JB, Caprio S, Cefalu WT, Ceriello A, Del Prato S, Inzucchi SE et al. How do we define cure of diabetes? Diabetes Care 2009; 32(11): 2133-5.

Liu Y, Aron-Wisnewsky J, Marcelin G, Genser L, Le Naour G, Torcivia A et al. Accumulation and Changes in Composition of Collagens in Subcutaneous Adipose Tissue After Bariatric Surgery. J Clin Endocrinol Metab 2016; 101(1): 293-304.

Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 2008; 299(3): 316-23.

Acknowledgement: This study was supported in part by grants from the Ministry of Science, Technology & Space, Israel (Israeli-French collaboration), and by The Ministe're de L'Education National, de l’Enseignement Sup'erieur et de la Recherche, France (Maimonide ‘Franco-Israeli project’). We thank Ms. Tal Pecht, Dr. Ilana Harman-Boehm and Dr. Ilya Polischuck for their support and excellent discussions that contributed to this work. Dr. Dror Dicker is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

P-081

Portomesenteric vein thrombosis after sleeve gastrectomy- early diagnosis and treatment important for prevention of major complications

Vasiliki Christogianni^a), Radostina Dukovska^b), Martin Buesing^c), Panagiotis Bemponis^d)

General and Visceral Surgery, Klinikum Vest- Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

^a)bchristogianni@yahoo.com

^b)ineto@abv.bg

^c)chirurgie@klinikum-vest.de

^d)bebonis@gmail.com

Introduction: The portomesenteric vein thrombosis is a rare, though life threatening complication in bariatric surgery. Risk factors are considered to be diabetes mellitus, BMI > 40kg/m2, thombophilia, deep vein thrombosis, smoking and oral contraceptives. The optimal duration of prophylactic low molecular weight heparin is not yet established.

Material and methods: The study group included patients undergoing a sleeve gastrectomy from 2013 to 2016 in which a PMVT was verified with a ct scan. All patients received a low molecular weight heparin prophylaxis. The time of occurring of symptoms, the clinical status, the need of a re-operation, the site of the thrombosis and the risk factors were analysed.

Results: A PMVT was diagnosed in 7 patients (3 female, 4 male). Directly after the operation no complications were observed and all patients were mobile. Unspecified abdominal pain was the main symptom which lead to a re-hospitalisation, 3-6 weeks later to a sleeve operation. In 4 patients the PMVT was localised in the portal vein, 2 patients showed an isolated thrombosis of the superior mesenteric vein and in one patient a combination of splenic and superior mesenteric vein thrombosis was observed. All patients were treated with i.v. heparin under ptt-monitoring. In 2 patients a diagnostic laparoscopy was performed with no signs of hemorrhagic infraction of the intestinal wall. The majority of patients showed an improvement in clinical status after 2-3 days. One patient died as a result of PMVT. Possible risk factors (contraceptives, coagulopathy, or prior thrombosis) could not be recognised.

Conclusion: PMVT is a rare complication after sleeve gastrectomy. Usually the thrombosis is incomplete and can be treated with i.v. heparin. In case of persistent abdominal pain a diagnostic laparoscopy should be performed. In our group the symptoms occurred after a period of 3 weeks as the LMH prophylaxis was completed, which lead to an actual extension of the LMH treatment to 4 weeks.

Acknowledgement:

M. Büsing, P. Bemponis, A. Knapp, R. Riege

Klinikum Vest- Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

P-082

Surgical management of gastroesopgageal reflux after sleeve gastrectomy- our experience after 3000 operations

Vasiliki Christogianni^a), Martin Buesing^b), Panagiotis Bemponis^c), Radostina Dukovska^d)

General and Visceral Surgery, Klinikum Vest Knappschaft Hospital Recklinghausen, Recklinghausen, Germany

^a)bchristogianni@yahoo.com

^b)chirurgie@klinikum-vest.de

^c)bebonis@gmail.com

^d)ineto@abv.bg

Introduction: The gastroesophageal reflux in patients undergoing a sleeve gastrectomy, frequently resistant to PPI medication, is a long term complication and the treatment of which can be a great challenge. We present a one to two step surgical approach for the treatment of GERD after a sleeve gastrectomy.

Materials and Methods: The data was collected from our data base of more than 3000 sleeve operations. The initial operation consisted of a repair of the hiatal hernia with a modified gastroplication/ anterior hemifundoplication (117 Patients). In 4 patients with a hiatal hernia grater than 6 cm we used a mesh augmentation. 4 Patients underwent direct a roux y bypass operation. In one case, in which an extreme dilatation of the sleeve was observed, a re-sleeve was performed.

Results: The average time of the antireflux operation after the sleeve gastrectomy was 35 months. The mean initial BMI was 48,9 and at the time of the second operation 34,1kg/m2, the average age 40,7y. In 93% of the patients the reflux could be verified before the second operation with endoscopy or radiology. During the operation we could identified a HH in all patients. Major complications were not observed although in one patient due to adhesions an open RNY Bypass was performed. After an average hospital stay of 2,5 days all patients were released. The symptoms of GERD were effectively treated in 75% of the patients with reducing or ending the need of PPI medication. 24 Patients with excessive GERD underwent a Bypass operation after 1 Year ( Roux- Y oder SADI- S). In all patients moderate weight loss was observed ( BMI drop 1,6 to 2,5 kg/m2 after 6 to12 months).

Conclusion: The laparoscopic hiatoplasty with a modified gastroplication is an effective and safe alternative procedure to the RNY Bypass for the treatment of GERD after sleeve gastrectomy. Furthermore there is always the option of bypass operation in case of persistent GERD Symptoms.

Acknowledgement:

C.J. Halter, A. Knapp, R. Riege

Klinikum Vest- Knappschaft Krankenhaus Recklinghausen, Recklinghausen, Germany

P-083

Assessment of ursodeoxycholic acid as a preventive agent for postoperative gallstone formation.

Dimitrios Magouliotis^{1, 2, a)}, Vasiliki Tasiopoulou^{1, 2, b)}, Christina Chatedaki^{3, 2, c)}, Eleni Sioka^{1, 2, d)}, Dimitris Zacharoulis^{1, 2, e)}

¹⁾Department of General Surgery, University Hospital of Larissa, Larissa, Greece; ²⁾Faculty of Medicine, University of Thessaly, Larissa, Greece; ³⁾Department of Microbiology, University Hospital of Larissa, Larissa, Greece

^a)dmagouliotis@gmail.com

^b)vasilikitasiopoulou@gmail.com

^c)chatechristina@yahoo.gr

^d)konstantinasioka@gmail.com

^e)zachadim@yahoo.com

Background: Bariatric surgery is associated with rapid weight loss and consequent increased risk for gallstone formation. Historically, some studies have reported early evidence regarding the administration of ursodeoxycholic acid after bariatric surgery in order to reduce the risk of gallstone disease.

Objectives: The purpose of this study is to review the available literature on obese patients treated with ursodeoxycholic acid (UDCA) in order to prevent gallstone formation after bariatric surgery.

Methods: A systematic literature search was performed in PubMed, Cochrane library and Scopus databases, in accordance with the PRISMA guidelines. Random-effects statistical model was used. Between studies heterogeneity was tested by calculating Cochrane Q and statistic I².

Results: Eight studies met the inclusion criteria (1,355 patients). Our meta-analysis showed a significantly lower incidence of gallstone formation in patients taking UDCA. Subgroup analysis reported fewer cases of gallstone disease in the UDCA group in relation to different bariatric procedures, doses of administered UDCA and time from bariatric surgery. Adverse events were similar in both groups. Fewer patients required cholecystectomy in UDCA group. No deaths were reported. Time-points

Conclusion: The administration of UDCA after bariatric surgery seems to prevent gallstone formation.

P-084

The influence of Helicobacter pylori infection on gastro-intestinal symptoms and complications in bariatric surgery patients: a systematic review and meta-analysis

HJM Smelt^{1, a)}, JF Smulders^{1, b)}, LP Gilissen^{2, c)}, M. Said^{1, d)}, S Pouwels^{3, e)}, S Ugale^{4, e)}

¹⁾Bariatric Surgery, Catharina Hospital, eindhoven, Netherlands; ²⁾Department of Gastroenterology and Hepatology, Catharina Hospital, eindhoven, Netherlands; ³⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/schiedam, Netherlands; ⁴⁾Bariatric & Metabolic Surgery Clinic, Kirloskar Hospital, Hyderabad, India

^a)marieke.smelt@catharinaziekenhuis.nl

^b)frans.smulders@catharinaziekenhuis.nl

^c)lennar.gilissen@catharinaziekenhuis.nl

^d)mohammed.said@catharinaziekenhuis.nl

^e)sjaakpwls@gmail.com

Introduction: Numerous amount of papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in bariatric patients. This systematic review specifically focuses on the influence of HP infection on clinical symptoms, complications and abnormal endoscopic findings in post-bariatric patients.

Materials and methods: A systematic search on the influence of HP infection on postoperative complications in bariatric surgery was conducted. The methodological quality of the included studies was rated using the Newcastle Ottawa Rating scale. The agreement between the reviewers was assessed with Cohen’s kappa.

Results: Twenty-one studies were included with a methodological quality ranging from poor to good. The agreement between the reviewers, assessed with the Cohen’s kappa, was 0.69. Overall tendency in the included studies was that HP infection was associated with an increased risk for developing marginal ulcers and postoperative complications. A meta-analysis on the incidence of marginal ulcers and overall postoperative complications was conducted and showed respectively an Odds Ratio (OR) of 0.508 [0.031-8.346] and 2.863 [0.262–31.268]. Due to significant heterogeneity, sensitivity analyses were performed.

Limitations: A few limitations need to be discussed. Among the included studies there is lack of adequate methodology and statistical analysis that impairs the possibility of good comparison. Also, the combination of different HP testing methods and/or the lack of confirmation test after eradication therapy in many studies is a limitation.

Conclusion: HP infection is frequently seen entity in patients prior to and after bariatric and metabolic surgery. We assessed whether according to current literature there is an increased risk for developing postoperative complications after surgery in case of HP presence. Our meta-analysis showed significant heterogeneity among the included studies, but an increased risk for developing postoperative complications in patients with a HP infection. After sensitivity analysis a decreased risk was found. This meta-analysis shows that a methodologically good study should be performed to clarify the role of HP in bariatric patients and the question whether HP should be eradicated preoperatively

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• 37. Schulman AR, Abougergi MS, Thompson CC. H. Pylori as a predictor of marginal ulceration: A nationwide analysis. Obesity (Silver Spring, Md). 2017;25(3):522-6.

• 38. Wolter S, Dupree A, Miro J, Schroeder C, Jansen MI, Schulze-Zur-Wiesch C, et al. Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases. Obesity surgery. 2017;27(8):1938-43.

• 39. Atkinson NS, Braden B. Helicobacter Pylori Infection: Diagnostic Strategies in Primary Diagnosis and After Therapy. Digestive diseases and sciences. 2016;61(1):19-24.

Contributions:

Initial idea and design of the study: HS, JS, LG, MS, SU, SP

Drafting and finalising manuscript: HS, JS, LG, MS, SU, SP

Final approval: HS, JS, LG, MS, SU, SP

P-085

Late Leak after Laparoscopic Sleeve Gastrectomy: an Extremely Infrequent Condition Presented in Four Patients.

Tania Triantafyllou^{1, a)}, Victoria Michalopoulou^{1, b)}, Evangelos Menenakos^{1, c)}, Konstantinos Albanopoulos^{1, d)}, Georgios Zografos^{1, e)}, Dimitrios Theodorou^{2, f)}

¹⁾1(st) Propaedeutic Surgical Department, Hippokration General Hospital of Athens., National and Kapodistrian University of Athens., Athens, Greece; ²⁾Foregut Surgical Department of Surgery, Hippocration General Hospital of Athens, Athens, Greece

^a)t_triantafilou@yahoo.com

^b)victoria.michal@gmail.com

^c)evmenenakos@hotmail.com

^d)albanopoulos_kostis@yahoo.gr

^e)surg-clinic-uoa@hippocratio.gr

^f)dimitheod@netscape.net

Introduction: Morbid obesity is becoming a common disease in Western countries. Laparoscopic sleeve gastrectomy (LSG) is widely performed in obese individuals. Although it is considered to be a simple technique, 0.7-5.3% is the rate reported for gastric leak [1]. Staple-line gastric leak is the most severe complication of the procedure and is common mainly in the upper portion of the gastric remnant. Leak is most frequently an early complication after surgery and is classified according to Csendes et al system based on the time of presentation after surgery [2]. On the other hand, late leak is infrequently reported [3-4].

Case Series Presentation: We present four rare cases of gastric leak 6, 14, 16 and 19 months after LSG in four obese patients who referred to our hospital. Although, all patients were treated and discharged uneventfully, they presented with abdominal pain and/or fever during their long-term follow-up period. Ultrasound of the abdomen, barium swallow studies, computed tomography and upper gastrointestinal tract endoscopies were obtained for each patient. Two of the patients underwent endoscopic treatment. Eventually, all of them had to undergo surgery due to deterioration of clinical condition. The patients have been discharged and are being followed-up in an outpatient basis.

Conclusion: While LSG is gaining popularity due to the increasing rates of obesity worldwide, its technical considerations and possible complications are becoming more clearly understood. Among all possible complications, late leak from the staple-line of the stomach is an extremely rare condition. Current literature lacks an official consensus on treatment of leak post LSG [5]. The presentation of this case-series aims to outline the mandatory role of the physician during the follow-up period of patients surgically treated for obesity as such complications may prove to be underestimated if not life-threatening.

References:

• 1. Organisation for Economic and Cooperation Development. Obesity 2014:1-8. Available at: http://www.oecd.org/els/healthsystems/Obesity-Update-2014.pdf. Accessed August 25, 2015.

• 2. Csendes,I.Braghetto,P.Le´on,andA.M.Burgos,“Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity,” Journal of Gastrointestinal Surgery, vol. 14, no. 9, pp.1343–1348,2010.

• 3. Osland E, Yunus RM, Khan S, Memon B, Memon MA. Late Postoperative Complications in Laparoscopic Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-y Gastric Bypass (LRYGB): Meta-analysis and Systematic Review. Surg Laparosc Endosc Percutan Tech.2016 Jun;26(3):193-201.

• 4. Dakwar A, Assalia A, Khamaysi I, Kluger Y, Mahajna A. Late complication of laparoscopic sleeve gastrectomy. Case Rep Gastrointest Med.2013;2013:136153. doi: 10.1155/2013/136153. Epub 2013 Apr 11.

• 5. Deitel,R.D.Crosby,andM.Gagner,“Thefirstinternational consensussummitforsleevegastrectomy(SG),NewYorkCity, October25–27,2007,”ObesitySurgery,vol.18,no.5,pp.487–496, 2008.

Acknowledgement: TT wrote the report and VM collected patients’ data. ME and AK contributed in providing detailed history of the patients. ZG revised the manuscript. TD conceived and designed the study and revised the manuscript for important intellectual content.

P-086

Anterior Cutaneous Nerve Entrapment Syndrome: a common cause of abdominal pain after Bariatric Surgery

Chekame Nizak^a), Guy Vijgen^b), Ralph Gadiot^c), Martin Dunkelgrun^d), Ulas Biter^e), Jan Apers^f)

Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands

^a)c.nizak2@Franciscus.nl

^b)g.vijgen@Franciscus.nl

^c)r.gadiot@Franciscus.nl

^d)m.dunkelgrun@Franciscus.nl

^e)u.biter@Franciscus.nl

^f)j.apers@Franciscus.nl

Background: Unexplained abdominal pain is a common complication after bariatric surgery leading to extra emergency and outpatient clinic visits. In these patients, anterior cutaneous nerve entrapment syndrome (ACNES) can be a possible cause of the abdominal pain. ACNES is caused by the entrapment of the intercostal nerves between the aponeurosis and the rectus abdominis muscle and causes neuropathic abdominal wall pain.

Objective: The aim of this study was to describe the patient characteristics, diagnostics and incidence of ACNES in patients with a gastric bypass or sleeve gastrectomy in their medical history. We also aimed to present the results of the several therapeutic options.

Methods: A retrospective observational cohort study was performed on patients with the diagnosis ACNES and a medical history of gastric bypass or sleeve gastrectomy, who were treated between 2015 and 2017 in our clinic.

Results: A total of 34 patients were evaluated (94% women, mean age 45 years). 22 out of 34 (65%) patients had a medical history of a gastric bypass and 12 out of 34 (35%) a sleeve gastrectomy. The incidence of this diagnosis after bariatric surgery is estimated around 2-5%. In the majority of cases the pain was located in the left upper abdominal wall. The mean interval between the bariatric surgery and treatment for ACNES was 30 months. The mean maximum weight loss in these patients was 43 Kg. Lidocaine injection as treatment was possible in 32% of the patients and 68% underwent a surgical local neurectomy. The success rate of the surgical neurectomy in this group was 92%.

Conclusion: ACNES is a common late complication after bariatric surgery and could be a cause of unexplained abdominal pain. Local neurectomy is an effective treatment for this diagnosis.

References:

• 1. JB Carnett. The Treatment of Intercostal Neuralgia of the Abdominal Wall. Annals of Surgery 1933 Nov

• 2. Boelens et al. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. British Journal of Surgery 2012

• 3. Boelens et al. A Double-Blind, Randomized, Controlled Trial on Surgery for Chronic Abdominal Pain Due to Anterior Cutaneous Nerve Entrapment Syndrome. Annals of Surgery 2013

• 4. Pierik AS, Coblijn UK, de Raaff CAL, van Veen RN, van Tets WF, van Wagensveld BA. Unexplained abdominal pain in morbidly obese patients after bariatric surgery. Surg Obes Relat Dis. 2017

P-087

Late Leak Following Laparoscopic Sleeve Gastrectomy – Myth or Reality? – Report of Two Cases

Ioannis-Petros Katralis^a), Athanasios Pantelis^b), Dimitris Lapatsanis^c)

2nd Department of General Surgery, Evaggelismos General Hospital of Athens, Athens, Greece

^a)katralispetros@gmail.com

^b)ath.pantelis@gmail.com

^c)dimitrislapatsanis@gmail.com

Background: Leak is the most common and feared complication of laparoscopic sleeve gastrectomy (LSG). Post-LSG leaks are usually evident in the short-term postoperative period, presenting either as fever or as elevated drain amylase. According to Csendes, late leaks are defined as those presenting >10 days post-operatively. Very late leaks (presenting >1 month postoperatively) are rare, and the pertinent literature is scarce, to the point that the existence of this entity is doubted by many authors.

Material and Method: We present two cases of late leak following LSG. The first was a 35-year-old male who presented five months postoperatively, complaining of excruciating abdominal pain after binge eating, followed by low grade fever. The diagnosis was made by means of CT scanning and confirmed by upper GI series. The second was a 45-year-old male who had been operated elsewhere 9 years ago and had vague symptoms beginning almost immediately postoperatively, complaining of recent deterioration of abdominal pain before presenting to our department. Serial CT scans were non-conclusive, and diagnosis was eventually made by use of dynamic Sonovue^® and upper GI series.

Results: Percutaneous drainage and one month of conservative treatment in the first patient was successful in controlling the symptoms, without healing of the fistula. Endoscopic treatment was tried in both patients, but failed due to the size of the leak. Laparoscopic internal drainage of the leak was initially attempted without success and conversion to total gastrectomy ensued. The second patient was initially treated with laparoscopic dissection and primary closure of the leak. Postoperative upper GI series showed recurrence of the leak, consequently total gastrectomy was also performed. Further postoperative course was uneventful for both and the bariatric effect was maintained.

Conclusions: Late leaks are sporadic events post-LSG, but bear tremendous sequelae on pathophysiology and gastric anatomy. A high index of suspicion must be attained in any patient who has undergone bariatric operation, regardless of the time elapsed since the index operation.

References:

1. Csendes et al. J Gastrointest Surg 2010;14:1343-1348

P-088

Case Series: Portomesenteric Venous Thrombosis Complicating Laparoscopic Bariatric Procedures

Marwan Bucheeri^a), Abdulmenem Abualsel^b)

General Surgery, King Hamad University Hospital, Busaiteen, Bahrain

^a)marwan.bucheerei@gmail.com

^b)abualsel@hotmail.com

Introduction: Portomesenteric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide.

Methods: A retrospective analysis was performed on all bariatric procedures performed in our center between July 2012 & September 2017 to identify cases complicated by portomesenteric venous thrombosis. The cases were compared in terms of operative details, patient presentation, diagnosis, patient risk factors for developing thrombosis, demographics and thrombophilia analysis & subsequent treatment and prognosis.

Results: A total of 957 bariatric procedures were performed between July 2012 & September 2017. Portomesenteric venous thrombosis complicated 3 of these cases (0.31%). Two of these cases had underwent a laparoscopic sleeve gastrectomy while the third had underwent a gastric band removal and a conversion to a single anastomosis gastric bypass. Amongst these patients, 2 were female while 1 was male with an average BMI 38.9 kg/m2. Only one of these patients was a smoker while none of them tested positive for thrombophilias. The diagnosis of portomesenteric venous thrombosis was confirmed with a contrast CT of the abdomen as all patients were re-admitted between 4-20 days post operatively after being discharged on postoperative day 2. All three cases were managed with systemic anticoagulants and none underwent invasive procedures or were re-explored surgically. All were subsequently discharged in good condition.

Conclusion: Portomesenteric venous thrombosis is an uncommon yet potentially fatal complication of bariatric surgery. A high index of suspicion, early diagnosis and subsequent adequate management is required. Based on this case series and the potential risk of portomesenteric venous thrombosis, we altered our clinical practice to include a 1 week course of low molecular weight heparin to be administered to all patients after discharge.

References:

• Angrisani L, Santonicola A, Iovino P et al. Bariatric Surgery Worldwide 2013. Obes Surg. 2015 Oct;25(10):1822-32.

• Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg. 2009 Dec;19(12):1605-11.

• Chang S, Stoll C, Song J et al. The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2003-2012. JAMA Surg. 2014;149(3):275-87.

• James AW, Rabl C, Westphalen AC et al. Portomesenteric Venous Thrombosis After Laparoscopic Surgery: A Systematic Literature Review. Arch Surg. 2009;144(6):520-526.

• Belnap L, Rodgers GM, Cottam D, Zaveri H, Drury C, Surve A. Portal vein thrombosis after laparoscopic sleeve gastrectomy: presentation and management. Surg Obes Relat Dis. 2016 Dec;12(10):1787-94.

• Salinas J, Barros D, Salgado N, Viscido G, Funke R, Pérez G, Pimentel F, Boza C. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy. Surg Endosc. 2014 Apr;28(4):1083-9.

• Villagrán, R., Smith, G., Rodriguez, W. et al. Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: Incidence, Analysis and Follow-Up in 1236 Consecutive Cases. Obes Surg (2016) 26: 2555.

• Swartz DE, Felix EL. Acute mesenteric venous thrombosis following laparoscopic Roux-en-Y gastric bypass. JSLS. 2004 Apr-Jun;8(2):165-9.

• Ögren M, Bergqvist D, Björck M, et al. Portal vein thrombosis: prevalence, patient characteristics and lifetime risk: a population study based on 23,796 consecutive autopsies. World J Gastroenterol. 2006;12(13):2115–9.

• Hansson PO, Eriksson H, Welin L, Svärdsudd K, Wilhelmsen L. Smoking and abdominal obesity: risk factors for venous thromboembolism among middle-aged men: "the study of men born in 1913". Arch Intern Med. 1999 Sep 13;159(16):1886-90.

• Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet. 1999 Apr 3;353(9159):1167-73.

• Denninger MH, Chaït Y, Casadevall N, Hillaire S, Guillin MC, Bezeaud A et al. Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors. Hepatology. 2000 Mar;31(3):587-91.​

• Rocha AT, de Vasconcellos AG, da Luz Neto ER, Araújo DM, Alves ES, Lopes AA. Risk of venous thromboembolism and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery. Obes Surg. 2006 Dec;16(12):1645-55.

• Herron DM. C-reactive protein and adiposity: obesity as a systemic inflammatory state. Surg Obes Relat Dis. 2005 May-Jun;1(3):385-6.

• Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism: A meta-analysis. Circulation. 2008;117:93–102.

• Steffen LM, Cushman M, Peacock JM, Heckbert SR, Jacobs DR, Jr, Rosamond WD, et al. Metabolic syndrome and risk of venous thromboembolism: Longitudinal investigation of thromboembolism etiology. Journal of Thrombosis and Haemostasis. 2009;7:746–751.

• Borch KH, Braekkan SK, Mathiesen EB, Njolstad I, Wilsgaard T, Stormer J, et al. Abdominal obesity is essential for the risk of venous thromboembolism in the metabolic syndrome: The Tromso study. Journal of Thrombosis and Haemostasis. 2009;7:739–745.

• Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O, et al. Overweight, obesity, and the risk of recurrent venous thromboembolism. Archives of Internal Medicine. 2008;168:1678–1683.

• Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005 Feb;241(2):219-26.

• Ishizaki Y, Bandai Y, Shimomura K, Abe H, Ohtomo Y, Idezuki Y. Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide. Surg Endosc. 1993 Sep-Oct;7(5):420-3.

• Odeberg S, Ljungqvist O, Sollevi A. Pneumoperitoneum for laparoscopic cholecystectomy is not associated with compromised splanchnic circulation. Eur J Surg. 1998 Nov;164(11):843-8.

• Rosenberg JM, Tedesco M, Yao DC, Eisenberg D. Portal Vein Thrombosis Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity. JSLS. 2012 Oct-Dec; 16(4): 639–643.

• van’t Riet M, Burger JW, van Muiswinkel JM, et al. Diagnosis and treatment of portal vein thrombosis following splenectomy. Br J Surg. 2000;87(9):1229–33.

• Goitein D, Matter I, Raziel A, et al. Portomesenteric thrombosis following laparoscopic bariatric surgery: incidence, patterns of clinical presentation, and etiology in a bariatric patient population. JAMA Surg. 2013;148(4):340–6.

• Rottenstreich A, Khalaileh A, Elazary R. Sleeve gastrectomy and mesenteric venous thrombosis: report of 3 patients and review of the literature. Surg Obes Relat Dis. 2014;10(6):e57–61.

• Darcy DG, Charafeddine AH, Choi J, et al. Portomesenteric vein thrombosis, bowel gangrene, and bilateral pulmonary artery embolism two weeks after laparoscopic sleeve gastrectomy. Case Rep Surg. 2015;2015:705610.

• Denne JL, Kowalski C. Portal vein thrombosis after laparoscopic gastric bypass. Obes Surg. 2005;15(6):886–9.

• Johnson CM, de la Torre RA, Scott JS, et al. Mesenteric venous thrombosis after laparoscopic roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005;1(6):580–2. Discussion:582–3.

• Bellanger DE, Hargroder AG, Greenway FL. Mesenteric venous thrombosis after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2010;6(1):109–11.

• Singh P, Sharma M, Gandhi K, et al. Acute mesenteric vein thrombosis after laparoscopic gastric sleeve surgery for morbid obesity. Surg Obes Relat Dis. 2010;6(1):107–8.

• Sonpal IM, Patterson L, Schreiber H, et al. Mesenteric venous thrombosis after gastric bypass. Obes Surg. 2004;14(3):419–21.

• Carlin A, Finks J, Birkmeyer N, et al. An unintended consequence of sleeve gastrectomy: portomesenteric venous thrombosis. Surg Obes Relat Dis. 2015;11(6):S31.

• Keung CH, Gander JW, Zitsman JL. Mesenteric venous thrombosis following vertical sleeve gastrectomy in an adolescent. Surg Obes Relat Dis. 2015;11(2):e23–6.

• Roy P, De A. Liver and bowel infarction secondary to portomesenteric vein thrombosis following laparoscopic sleeve gastrectomy. Saudi J Obes. 2015;3:29–31.

• Cesaretti M, Elghadban H, Scopinaro N, et al. Portomesenteric venous thrombosis: an early postoperative complication after laparoscopic biliopancreatic diversion. World J Gastroenterol. 2015;21(8):2546–9.

• Berthet B, Bollon E, Valero R, et al. Portal vein thrombosis due to factor 2 Leiden in the post-operative course of a laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg. 2009;19(10):1464–7.

• Anewenah LS, Asif M, Francesco R, Ramachandra P. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy for morbid obesity. BMJ Case Rep. 2017 Jan 9; 2017.

P-089

Fistulojejunostomy as a Treatment for Unusual Complication after LRYGB

Pavel Shmulevsky

General Surgery A, Meir Medical Center, Kfar Sava, Israel

pshmulevsky@yahoo.com

Laparoscopic Roux-en-Y gastric bypass remains a gold standard bariatric procedure in many countries. Excellent long term results both in weight control and treatment of co-morbidities and low rate of complications are proven by large amount of publications. One of major complications of LRYGB is leakage from gastro-jejunostomy or gastric pouch with incidence between 0.1% and 8.3% in reported series. Most patients are treated conservatively with good results. Chronic fistulae rarely observed after LRYGB. Fistolojejunostomy described as possible treatment after sleeve gastrectomy but at the best of our knowledge not as a treatment of chronic fistula after gastric bypass.

We present a case of 59 year old male patient with morbid obesity ( BMI of 42.3) and severe metabolic syndrome. 40 years ago the patient had a laparotomy due to perforated duodenal ulcer. After comprehensive preoperative evaluation he was scheduled for LRYGB. On laparoscopy multiple adhesiones were found. After release of adhesions gastric pouch was created and gastrojejunostomy was done by linear stapler with negative leak test. On third postoperative day large amount of saliva- like fluid has been drained and a leak was diagnosed. On CT scan retrogastric collection was found and a pig-tail catheter was inserted. Large amount of discharge has been observed during next month. On upper GI series small leakage of contrast media was revealed with normal gastrojejunal anastomosis and without distal obstruction. An attempt to close a fistula by injection of bioglue failed –pigtail drain located in gastric pouch has been detected on gastroscopy without visible anastomosis between gastric pouch and jejunum. The patient was operated by open approach, pgtail drain was removed and after re-shaping of a pouch a new gastrojejunostomy by circular stapler was created. Post-operative course was uneventful and the patien continues his follow-up in bariatric clinic.

References:

1. Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015 Jul-Aug;11(4):739-48.

2. Lind R, Teixeira AF, Jawad MA. Management of a persistent staple line leakage with Roux-en-Y fistulojejunostomy following sleeve gastrectomy. Surg Obes Relat Dis. 2017 Mar;13(3):e16-e18.

3. Hernández J, Boza C. Novel treatments for complications after bariatric surgery. Ann Surg Innov Res. 2016 Mar 15;10:3

4. Thomopoulos T, Thoma M, Navez B. Roux-En-Y Fistulojejunostomy: a New Therapeutic Option for Complicated Post-Sleeve Gastric Fistulas, Video-Report. Obes Surg. 2017 Jun;27(6):1638-1639

P-090

Remnant Diseases in patients with obesity after Roux-en-Y gastric bypass

Maria Solovyeva^a), Eva Spichakhova^b), Valery Strizheletsky^a)

City Center of Bariatric and Metabolic Surgery, St. George City Hospital, Saint Petersburg, Russian Federation

^a)mar-sol@mail.ru

^b)spichakova.eva@yandex.ru

Gastric bypass has become increasingly popular worldwide. Gastric remnant creates difficulties for diagnostics in post-surgical period, considered as potentially dangerous area. 21 cases of malignant neoplasms after bariatric procedures have been officially registered since 1991. 12 cases were observed after Gastric bypass. Predictors of malignant neoplasms: polyps, GIST, H.pylori, ulcers, metaplasia, ectopic pancreas, gastric vascular ectasia, Menetrier’s disease. In case of detection of these changes, another type of procedures should be chosen or regular planned follow-up of gastric remnant has to be carried out. Ulcer disease in gastric remnant is quite rare complication. Out of 3,000 post-surgical patients, who underwent Roux-en-Y gastric bypass 8 (0.3%) was diagnosed with bleedings from the ulcers of gastric remnant and duodenum. Endoscopic diagnostics is significantly impaired. Double-balloon enteroscopy was described in 2001. Successful visualization is possible in 85%. However, this method cannot be used in case of prolonged bleeding. Diagnostic laparoscopy or laparotomy with intraoperative endoscopy through gastrotomy remains the most reliable method in case of prolonged bleeding. The surgical tactic depends on specific clinical case and remains at the discretion of surgeon. Dilation of gastric remnant is very rare complication after bypass surgeries and usually is a result of biliopancreatic loop obstruction. Incidence rate of this complication is 0.3%-0.6%. In this case, it is possible to detect enlarged remnant in X-ray and CT. Laparotomy or laparoscopy must be carried out immediately for decompression and elimination of possible causes of dilation. In 1999 gastro-gastric fistula was described in 49% of patients due to formation of so called stapled septum, without stomach dissection. Even with current approaches and technologies, rate of this complication is 3-6%. The treatment is only surgical, but endoscopic closure of fistulae could be achieved. The frequency of occurrence of choledocholithiasis after Roux-en-Y Gastric bypass is 0.4%. Methods of treatment are open or laparoscopic transgastric endoscopic retrograde cholangiopancreatography or open revision of common bile duct, endoscopic papillosphincterotomy and lithoextraction is also possible.

P-091

Validation of the Nexfin® non-invasive continuous blood pressure monitoring validated against Riva-Rocci/Korotkoff in a bariatric patient population

Sjaak Pouwels^{1, a)}, Bianca Lascaris²⁾, Simon Nienhuijs³⁾, Arthur Bouwman²⁾, Marc Buise²⁾

¹⁾Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, Netherlands; ²⁾Anesthesiology, Catharina Hospital, Eindhoven, Netherlands; ³⁾Surgery, Catharina Hospital, Eindhoven, Netherlands

^a)sjaakpwls@gmail.com

Background The present study aimed to validate the Nexfin^® monitor