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George A Fielding

Publications and source records attributed to George A Fielding.

17 recordsLinked to original sources
PubMed2007

Short-term results in 53 US obese pediatric patients treated with laparoscopic adjustable gastric banding.

BACKGROUND: Obesity in the adolescent population has reached epidemic proportions. Although diet and behavior modification can help a minority of teenagers, most of these patients go on to become obese adults. Recently, surgical intervention for morbid obesity has gained increasing support. To date, this has only included gastric bypass procedures. However, this procedure carries at least a 1% mortality rate even in the hands of the most experienced surgeons. Therefore, our center has been using laparoscopic adjustable gastric banding (LAGB) to treat adolescents with morbid obesity. This analysis is a report of our short-term results in our first 53 patients. METHODS: All adolescents aged 13 to 17 years who had undergone LAGB at our institution and had been entered into our prospectively collected database since 2001 were reviewed. Data collected preoperatively included age, sex, race, and body mass index (BMI). Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, as well as percentage of excess weight loss (%EWL) and BMI at 3-month intervals. RESULTS: Fifty-three teenagers aged 13 to 17 years (mean, 15.9 years) underwent LAGB at our institution since September 2001. Of these, 41 were female and 12 were male. The mean preoperative weight was 297 +/- 53 lb and the mean initial BMI was 47.6 +/- 6.7 kg/m2. The %EWL was 37.5 +/- 17.0 at 6 months, 62.7 +/- 27.6 at 1 year, and 48.5 +/- 15.6 at 18 months of follow-up. There were no intraoperative complications. Two patients had band slips that required laparoscopic repositioning, and 2 patients developed a symptomatic hiatal hernia that required laparoscopic repair. All of these procedures were performed as outpatient procedures. A fifth patient developed a wound infection requiring incision and drainage. Other complications included mild hair loss in 5 patients, iron deficiency in 4 patients, nephrolithiasis and cholelithiasis in 1 patient, and gastroesophageal reflux in 1 patient. CONCLUSIONS: Laparoscopic adjustable gastric banding is not only a safe operation for morbidly obese pediatric patients, but also represents an effective treatment strategy with a %EWL of approximately 50% at both 1 year and 18 months of follow-up. Because of the minimal morbidity and complete absence of mortality of the LAGB, it is the optimal surgical option for pediatric patients with morbid obesity.

Adolescent↗
PubMed2005

Poor weight loss despite biliopancreatic diversion and subsequent revision to a 30-cm common channel after initial laparoscopic adjustable gastric banding: an analysis of 8 cases.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) fails in 5% of patients due to band-related complications or patient intolerance. A subset of patients subsequently managed with biliopancreatic diversion (BPD) have failed to achieve a percentage of excess weight loss (%EWL) > 50% or a body mass index (BMI) < 35 kg/m(2) even after a further procedure shortening the common channel to 30 cm. METHOD: A computerized obesity database was used to identify the study group and collect preoperative and outcome data. Patient outcomes were analyzed in 2 groups: LAGB removed either because of a failure to lose weight (FTLW) or because of a band-related complication (eg, recurrent gastric prolapse, gastric erosion, intractable dysphagia). RESULTS: A total of 2300 patients underwent LAGB between 1996 and 2003. LAGB failed in 95 (4%) of these patients, 79 of whom had subsequent BPD. Of these 79 patients, 8 (10%) failed to lose further weight and had their common channel shortened to 30 cm. Six patients were identified who, despite this revision surgery, still had a BMI > 35 kg/m(2) or %EWL < 50 and are considered failures. Two further patients failed to lose any weight after revision for what they saw as an unsatisfactory outcome. There was minimal evidence of malabsorption in these 8 patients, and 4 had slow intestinal transit down the alimentary limb of the BPD. CONCLUSION: The reasons for the failure of malabsorption and restrictive surgery in these patients appear to be physiological, not psychological. Uncontrolled hunger, particularly in the patients with FTLW, and an abnormally slow metabolism are likely to be important.

Adult↗
PubMed2005

Laparoscopic adjustable gastric band.

Only a fraction of morbidly obese patients have come forward for bariatric surgery. This article confirms that the laparoscopic adjustable gastric band (LAGB) is a safe, effective, primary weight-loss operation for morbidly obese patients. The LAGB offers a simple, genuinely minimally invasive approach, with the potential to be attractive to many more patients. The key questions are whether it is effective in the longterm and whether it is safe. The midterm data confirm that, so far, LAGB is living up to its early promise as an effective tool. LAGB surgery is safe, and the change to the pars-flaccida approach will lead to even higher patient satisfaction and lower incidence of band removal.

Gastroplasty↗
PubMed2005

Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial.

OBJECTIVE: Prospectively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct (BD) stones they should have laparoscopic choledochotomy or postoperative endoscopic retrograde cholangiography (ERCP). SUMMARY BACKGROUND DATA: Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones. This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients and rare unpredictably severe ERCP morbidity can result in this group. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients' BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33% requiring choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations, for patients failing laparoscopic trans-cystic clearance, of laparoscopic choledochotomy or postoperative ERCP. METHODS: Across 7 metropolitan hospitals after failed trans-cystic duct clearance, patients were intraoperatively randomized to have either laparoscopic choledochotomy or postoperative ERCP. Exclusion criteria were: ERCP prior to referral for cholecystectomy, severe cholangitis or pancreatitis requiring immediate ERCP drainage, common BD diameter of less than 7 mm diameter, or if bilio-enteric drainage was required in addition to stone clearance. Drain decompression of the cleared BD was used in the presence of cholangitis, an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis. The ERCP occurred prior to discharge from hospital. Mechanical and extracorporeal shockwave lithotripsy was available. Sphincter balloon dilation as an alternative to sphincterotomy to allow stone extraction was not used. Major endpoints for the trial were operative time, morbidity, retained stone rate, reoperation rate, and hospital stay. RESULTS: From June 1998 to February 2003, 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286, leaving 86 patients randomized into the trial. Total operative time was 10.9 minutes longer in the choledochotomy group (158.8 minutes), with slightly shorter hospital stay 6.4 days versus 7.7 days. Bile leak occurred in 14.6% of those having choledochotomy with similar rates of pancreatitis (7.3% versus 8.8%), retained stones (2.4% versus 4.4%), reoperation (7.3% versus 6.6%), and overall morbidity (17% versus 13%). CONCLUSIONS: These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically, with those failing having either choledochotomy or postoperative ERCP. However, because of the small trial size, a significant chance exists that small differences in outcome may exist. We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection. We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy, failed ERCP access, or where long delays would occur for patient transfer to other locations for the ERCP.

Adolescent↗
PubMed2005

Factors influencing patient choice for bariatric operation.

BACKGROUND: No study has surveyed the factors that influence morbidly obese patients' preference for a particular bariatric operation. METHOD: 469 consecutive patients in 2 major bariatric surgery centers in the United States (US, 124) and Australia (AU, 345) were prospectively studied to determine referral pattern and reason for their choice of operation. RESULTS: The predominant operation was laparoscopic adjustable gastric banding (LAGB) in both US (75%) and AU (83%) centers. Gender (70% female), BMI (45 kg/m2) and age (42.5 years) were similar in both cohorts. In Australia, 53% had referral initiated by primary doctors and 25% by another patient, while in the US, 43% by another patient and 27% by the Internet. Safety of the operation (43%) was the highest-rated factor in choosing LAGB. LAGB being "least invasive" was most significant in the US (46%), and "surgical safety" in Australia (45%). In the US, Rouxen-Y gastric bypass was preferred due to "lack of a foreign body" (31%) and "inability to cheat" (28%), while in Australia, "dumping" was the most significant reason (50%). Duodenal switch (BPD/DS) was selected in 11% of patients, primarily because of "durability of the weight loss" (51%). Surprisingly, only 1 patient in the US group selected BPD/DS because the pylorus remains intact. CONCLUSION: Safety and invasiveness had the greatest impact on patient choice for bariatric operation in two different countries. This information may help clinicians better understand their patients' concerns, and their treatment choices.

Adolescent↗
PubMed2005

Laparoscopic adjustable gastric banding prior to renal transplantation.

End-stage renal failure is most commonly caused by the obesity-related diseases, diabetes mellitus and essential hypertension, and is best treated with renal transplantation. Obesity may contribute to poor patient and graft survival, and is an exclusion criterion in some renal transplant programs. Diet and exercise programs have not proven to be effective for weight loss before transplantation, and bariatric surgery in any form has not been used in this setting before. We report three morbidly obese patients who underwent laparoscopic adjustable gastric banding to meet the criteria for renal transplantation and subsequently were successfully transplanted.

Adult↗
PubMed2005

Clinical and radiological follow-up of laparoscopic adjustable gastric bands, 1998 and 2000: a comparison of two techniques.

BACKGROUND: Concerns still exist about the long-term effectiveness and rate of retention of the laparoscopic adjustable gastric band (LAGB). Furthermore, esophageal dilatation has been suggested as a long-term complication for LAGB. We therefore sought to objectively analyze our follow-up results in patients with LAGB performed in 1998 by perigastric technique and 2000 by pars flaccida technique. We also offered patients for 1998 a barium esophagram to assess dilatation. METHODS: Data on all 2,300 LAGBs performed since 1996 have been prospectively collected in LapBase. This data was accessed for 1998 and 2000, for follow-up complication, band removal, weight loss and comorbidity reduction. Patients were offered barium esophagrams. RESULTS: 123 patients (mean weight 127 kg, mean BMI 44.5 kg/m2) had LAGB in 1998, and 162 patients (mean weight 123 kg, mean BMI 44) had LAGB in 2000. Follow-up was a mean 67 months in 88% for 1998 and 94% at 34 months for 2000. Mean %EWL for 1998 was 51.2% with mean BMI 31.9. Slippage occurred in 9.5% in 1998 compared to 4.3% in 2000 (P<0.01). 20 of 23 diabetics are off all treatment. 1 of 34 patients had esophageal dilatation on barium esophagram, which resolved on band deflation. CONCLUSION: LAGB is a safe and effective at midterm follow-up. Less slippage occurred after the pars flaccida technique. No evidence of permanent esophageal dilatation was found on barium studies.

Adolescent↗
PubMed2004

Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery.

Weight loss after biliopancreatic diversion or duodenal switch is due to decreased calorie absorption secondary to fat malabsorption. Fat malabsorption may also cause essential fat-soluble vitamin deficiencies, which may have severe clinical consequences and alter calcium metabolism. Serum vitamins A, D, E, and K, zinc, parathyroid hormone, corrected calcium, and alkaline phosphatase levels were measured in a cohort of patients who had previously undergone biliopancreatic diversion. Two bariatric surgery units were involved in the study: New York University School of Medicine (New York, NY), and the Wesley Medical Center (Brisbane, Australia). A total of 170 patients completed the study. The incidence of vitamin A deficiency was 69%, vitamin K deficiency 68%, and vitamin D deficiency 63% by the fourth year after surgery. The incidence of vitamin E and zinc deficiency did not increase with time after surgery. The incidence of hypocalcemia increased from 15% to 48% over the study period with a corresponding increase in serum parathyroid hormone values in 69% of patients in the fourth postoperative year. There is a progressive increase in the incidence and severity of hypovitaminemia A, D, and K with time after biliopancreatic diversion and duodenal switch. Calcium metabolism is affected with an increasing incidence of secondary hyperparathyrodisim and evidence of increased bone resorption in 3% of patients. Long-term nutritional monitoring is necessary after malabsorptive operations for morbid obesity.

Adolescent↗
PubMed2004

Combining laparoscopic adjustable gastric banding and biliopancreatic diversion after failed bariatric surgery.

BACKGROUND: A percentage of all types of bariatric surgery will fail. Our experience with failed biliopancreatic diversion (BPD) as a primary operation or revision operation for failed laparoscopic adjustable gastric banding (LAGB) convinced us that uncontrolled hunger is often the underlying cause. To control hunger after failed bariatric surgery,a novel approach combining LAGB with BPD-duodenal switch (DS) has been tried. METHODS: Patients who had failed to lose weight after BPD or LAGB were considered in 2 groups. Group 1: patients who had failed LAGB underwent laparoscopic BPD-DS without sleeve gastrectomy, with the LAGB left in-situ. Group 2: patients who had failed primary (subgroup 2a) or revision (subgroup 2b) BPD had a LAGB placed with no other revision of their surgery. RESULTS: 11 patients have undergone this form of revision surgery with little morbidity. Mean age at the original operation was 45 years, mean (range) BMI was 45.3 (38-62) kg/m(2). After the reoperation, at 3 months (9 patients) mean BMI was 30 kg/m(2) and at 6 months (4 patients) mean BMI was 27 kg/m(2). CONCLUSION: In this small study, combination surgery was safe and effective for failed BPD or LAGB. LAGB failure may be best managed with DS malabsorption without gastric resection.

Adult↗
PubMed2004

Bowel-associated dermatosis-arthritis syndrome after biliopancreatic diversion.

The bowel-associated dermatosis-arthritis syndrome (BADAS), originally called the bowel bypass syndrome, and described after jejuno-ileal bypass, has subsequently been reported in association with inflammatory bowel disease and after gastric resection. BADAS has not been reported after biliopancreatic diversion (BPD). This case report describes a 47-year-old female who presented with recurrent skin rashes and arthralgia after a BPD, consistent with a clinical diagnosis of BADAS which was confirmed by skin biopsy. To date, she has been managed with cyclical courses of antibiotics without reversal of her surgery. This syndrome may be under-diagnosed and is a condition with which bariatric surgeons should be familiar.

Arthritis↗
PubMed2003

Laparoscopic adjustable gastric banding: surgical technique.

Laparoscopic adjustable gastric banding is an effective and safe surgical treatment for morbid obesity. Initial experience with the Lap-Band system (Inamed Health, Santa Barbara, California) in the United States and Australia has demonstrated that surgical technique can affect outcomes in terms of weight loss, quality of life, and complication rates. Placement of the gastric band by means of the perigastric technique is associated with high rates of gastric prolapse, food intolerance, and weight loss failure that frequently lead to band explantation. In the pars flaccida technique, band placement higher on the stomach results in the formation of a smaller pouch and lower rates of gastric prolapse, which may contribute to greater weight loss and improved quality of life. This article describes the technical aspects of the pars flaccida approach in the laparoscopic placement of adjustable gastric bands.

Adult↗
PubMed2002

The case for laparoscopic common bile duct exploration.

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.

Cholangiography↗
PubMed2002

A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system.

The early promise of laparoscopic adjustable gastric banding was tempered by reports of high rates of gastric herniation or prolapse. These complications are a function of the operative technique used early on. At the time, in the early 1990s, the LAP-BAND device (INAMED Health, Santa Barbara, CA) was placed lower on the stomach, near the first short gastric vessel. The required perigastric dissection was difficult and variable in its extent, depending on the width of the stomach and where the surgeon began the dissection. To combat these problems, a new surgical method for placement of the band has evolved. Called the pars flaccida technique, it emphasizes minimal dissection and placement of the LAP-BAND out of the lesser sac. This leads to a higher position of the band, away from the body of the stomach. The technique serves to make band placement simple, safe, reproducible, and easily teachable, as well as to decrease the rate of gastric herniation or prolapse. Keeping the band out of the lesser sac, away from the peristalsing stomach, minimizing dissection of the attachments to the stomach, paying strict attention to gastric-to-gastric suturing, and leaving all fluid out of the band until at least 6 weeks after surgery appear to be the most important factors in reducing the incidence of this complication.

Gastroplasty↗
PubMedDate not supplied

Laparoscopic adjustable gastric banding in severely obese adolescents.

BACKGROUND: Severely obese adolescents are suffering all the consequences well known in adults. A decision was made to offer laparoscopic adjustable gastric band surgery to severely obese adolescents. METHODS: This retrospective study reviewed the outcomes of 41 adolescents aged 12-19 years (mean 15.6 years) who underwent laparoscopic adjustable gastric band surgery. At surgery, their mean weight was 125 +/- 9 kg (range 83-220), and the mean body mass index was 42.4 +/- 8.2 kg/m(2) (range 31-71). The comorbidities included 2 patients with diabetes, 1 with sleep apnea requiring continuous positive airway pressure, 2 with hypertension, and 1 with Perthe's disease of the hip. RESULTS: No operative or 60-day morbidity or mortality occurred. One patient was lost to follow-up, but returned at 3 years. The mean follow-up was 33.8 +/- 19 months (range 1-70). Eighteen patients have had a Lap-Band for at least 3 years. Compliance was excellent, with 12.2 visits per child (range 7-22) at 2 years. At 3 years, the mean body mass index had decreased to 29 +/- 6 kg/m(2) (range 23-47), which was maintained at 5 years. Of the 41 adolescents, 83% were no longer obese, with a BMI <30 kg/m(2). The estimated weight loss was 70% +/- 21% (range 37-101%) and was maintained at 5 years. CONCLUSION: Laparoscopic adjustable gastric band surgery is a valid option for the care of severely obese adolescents.

Adolescent↗