Minimally Invasive Surgical Treatment of Morbid Obesity in Patients ...

Minimal invasive surgery for morbid obesity
Minimally Invasive Surgical Treatment of Morbid Obesity
in Patients with Specific Comorbidities. A Case Report
Nicolae Constantea 1 , Dan Axente 1 , Dan Miclaus 1 , Vlad Dudric 1 , Florin Jianu 1 , Constantin Bodolea 2
1) 5 th Surgical Clinic. 2) Department of Intensive Care, Municipal University Hospital, Cluj-Napoca
Abstract
The mortality of patients with morbid obesity is 2 to 12
times higher according to age, comorbidities and the degree
of obesity. Surgical treatment has proved to be the only
type of treatment that has led to favorable long-term results.
We present the therapeutic strategy used in a 39 year old
obese patient with BMI=39.8 kg/m 2 , type 2 diabetes mellitus,
arterial hypertension, severe hypercholesterolemia,
nonalcoholic steatohepatitis and metabolic syndrome. The
patient underwent laparoscopic gastric banding with
adjustable silicon band.
Key words
Morbid obesity - diabetes mellitus type 2 – laparoscopy
- gastric banding
Introduction
Obesity represents a major health issue that has reached
epidemic proportions globally. Currently it accounts for 2-
7.8% of total health care costs in developed countries.
Morbid obesity is characterized by a body mass index
(BMI) of 40kg/m 2 or higher. The following contribute to the
severity of this disease: the growing number of patients
with morbid obesity, the occurrence of this pathology at
increasingly younger ages and especially the severity of
specific comorbidities which severely influence the life
expectancy of patients.
Diet, physical exercise or medical therapy has not proved
to be efficient in treating morbid obesity in the long term.
Therefore, once laparoscopic surgical procedures were
introduced, the number of patients with morbid obesity who
received surgical treatment increased exponentially. The
Roux -en-Y gastric bypass (RYGB) and gastric banding (GB)
J Gastrointestin Liver Dis
December 2007 Vol.16 No 4, 449-451
Address for correspondence: Dr.Nicolae Constantea MD
5 th Surgical Clinic
Tabacarilor Str., no.11
Cluj-Napoca, Romania
with adjustable silicon band are currently the most
frequently used techniques (1).
Recent metaanalyses on bariatric surgery outcomes
revealed that in the long term, patients who underwent RYGB
or GB lost 61.6% and 47.5%, respectively of excess body
weight, while the complete resolution or improvement of
comorbidities were registered in most patients with type 2
diabetes mellitus, hyperlipemia, hypertension, nonalcoholic
steatohepatitis (NASH) and sleep apnea (1,2).
Case report
A 39 year-old female patient was admitted to our clinic
on the 25 th of June 2007. She had already been registered at
the Clinical Center for Diabetes, Nutrition and Metabolic
Diseases, where she had been last admitted in March 2006
and diagnosed with: insulin-dependent type 2 diabetes
mellitus, arterial hypertension, severe hypercholesterolemia,
NASH, metabolic syndrome and class II obesity.
The patient had had several hospital admissions to the
3 rd Medical Clinic Cluj, where she was first diagnosed in
February 2004 with NASH based on laboratory, imaging
and histopathologic investigations after liver biopsy.
She had had a history of insulin-dependent type 2
diabetes mellitus for 15 years. The patient received insulin,
hypotensive medication, silymarin and a hypocaloric diet.
Her evolution was unfavorable, she gained weight, the
insulin doses had to be increased, glycemia was difficult to
control, she had elevated blood pressure, altered hepatic
function and the metabolic syndrome became more severe.
The investigations carried out at that time revealed poor
glycemic balance (HbA1c 10.2%).
Given this evolution, the patient was referred to the 5 th
Surgical Clinic for laparoscopic surgical treatment of obesity.
On admission the patient had good general condition
and BMI 39.8 kg/m 2 . She was being treated with Novorapid
30 u and Lantus 70 u, plus hypotensive agents.
The physical examination indicated lower body obesity
with predominantly abdominal obesity, blood pressure 150/
100 mmHg. Laboratory investigations: hyperglycemia 289
mg/dl, hepatocytolysis AST 133 UI/l, ALT 69 UI/l, GGT 103

450
UI/l, hypercholesterolemia 345 mg/dl, hypertriglyceridemia
190 mg/dl, ESR 42 mm at 1 hour, hs–CRP 3.6 mg/dl. The
other laboratory investigations, including thyroid hormones
FT4 and TSH, were within normal limits.
The respiratory functional tests and the examination of
the cardiac function indicated normal values. The chest Xray
revealed bilateral hilar interstitial lung design. The patient
had been smoking 10-15 cigarettes a day for the last 10
years.
The abdominal ultrasonography indicated hepatomegaly
(right lobe diameter 23 cm), hyperechogenic echostructure
with posterior attenuation.
Surgery was performed after brief preoperative
preparations. Laparoscopic GB with adjustable silicon band,
drainage under the left diaphragm and under the left liver
lobe were carried out (Fig.1).
The postoperative evolution was favorable, intestinal
transit was restored, the drains were removed, per oral
feeding was initiated and insulin therapy was re-instituted.
The postoperative x-ray of the esophagus, stomach and
duodenum with Gastrografin identified a correctly positioned
band, proper evacuation through the band, reduced
gastric peristalsis and normal transit in the duodenum.
The patient was discharged on the 4th postoperative
day. Adequate diet was prescribed at the Center for Diabetes,
Nutrition and Metabolic Diseases.
The surgical control performed 2 months postoperatively
revealed a 7 kg weight loss, BMI of 37.3 kg/m 2 , decreased
cholesterolemia (208 mg/dl) and triglyceridemia (160 mg/dl),
lower transaminase levels (AST 90 UI/l, ALT 59 UI/l, GGT 80
UI/l), normal ESR values, hs–CRP 2.1 mg/dl. The insulin
dose was also decreased from 30u of Novorapid to 10u,
Lantus from 70 to 50u. Normal blood pressure values were
registered under the initial treatment.
The gastric band was filled with 3 ml saline solution and
the passage with contrast material was checked under
radioscopic control.
The surgical control at 4 months revealed a total body
weight loss of 11 kg, BMI of 35.9 kg/m 2 , normal serum lipid
levels, lower aminotransferase and GGT levels, hs–CRP 0.3
mg/dl, continuous decrease of insulin doses (Novorapid 5-
10u, Lantus 30-35u) and normal blood pressure values under
treatment.
Fig.1 Position of gastric band during surgery.
Fig.2 Radiological control with contrast material of
band position and gastric passage.
The filling of the gastric band under radioscopic control
required an extra 3 ml saline solution; the passage was
verified with contrast (Fig.2).
The patient reported feelings of satiety after quantitatively
reduced meals.
Discussion
Constantea et al
Previously published studies have demonstrated the
reduced efficiency of conservative treatment in the long
term with only 5% of patients having a normal weight, 5
years after treatment initiation. Surgical treatment has proved
to be the only type of treatment that led to long-term
favorable results. The laparoscopic approach and the
assimilation of traditional techniques in laparoscopic surgery
has strongly advocated the surgical treatment of morbid
obesity, due to the obvious advantages of this surgical
technique: postoperative comfort, lack of parietal
complications, early intestinal transit, reduced dosis of
postoperative pain-relieving medication, rapid social and
professional reinsertion. These are crucial advantages
especially for patients with associated comorbidities and
increased anesthetic or surgical risk.
Laparoscopic adjustable gastric banding (LAGB) is
currently the most frequently used procedure. This technique
has proved to be safe. The available data indicate a
perioperative mortality of 0.05% and a complication rate of
2.6%, which is 10 fold lower than that registered in malabsorptive
surgery (RYGB) (3).
The long-term favorable evolution of patients who have
underwent GB is also related to the possibility of adjusting
the gastric passage through the band by filling it with saline

Minimal invasive surgery for morbid obesity 451
solution or voiding it. The reversibility of the surgical
intervention is another advantage since the band can also
be removed laparoscopically.
The long-term efficiency is reduced when compared with
malabsorptive techniques, especially in cases of extreme
obesity (BMI > 50 kg / m 2 ). Brown et al demonstrated an
85% body weight loss, two years after LAGB in patients
with BMI between 30 and 40 kg/m 2 (4). Postoperative
nutritional deficiencies are less frequent in patients who
undergo LAGB if a balanced diet is followed. The long-term
disadvantages of this technique include the need for careful
monitoring of patient evolution, band adjustment, possible
complications, band slippage, gastric wall erosion with
intraluminal migration, complications related to implanting
and securing the injection port. However, such situations
rarely occur when an adequate surgical technique is
employed (5).
Morbid obesity is associated with several specific
comorbidities such as type 2 diabetes mellitus and insulin
resistance, coronary heart disease, arterial hypertension,
NASH, osteoarthritis, respiratory dysfunctions, etc. Morbid
obesity significantly decreases the life expectancy of young
patients.
Constant weight loss favors the remission of diabetes
mellitus in two thirds of diabetic morbidly obese patients.
This therapeutic effect is obvious especially if surgery is
performed 1-2 years after diabetes is diagnosed (3).
In our patient, the favorable evolution was proven by
the halving of the insulin dose required and stable glycemia
levels, 4 months postoperatively.
Nonalcoholic steatohepatitis in morbidly obese patients
is signaled by increased transaminase and gamma-glutamyltransferase
levels, insulin resistance, hepatomegaly, hepatic
steatosis as revealed by ultrasound examination in patients
who were not given hepatotoxic drugs or alcohol and had
negative viral and autoimmune markers (6). It frequently
occurs in combination with metabolic syndrome
components. Most studies indicate that simple steatosis
does not usually turn into NASH or cirrhosis. On the other
hand, 30-40% of NASH cases turn into fibrosis over a 4year
period. The risk factors for such an evolution include
obesity, type 2 diabetes mellitus, increased tranaminase
levels (AST/ALT >1) and age over 45 years (6,7).
The therapy of NASH is usually targeted at the
associated disorders: obesity, diabetes, dyslipidemia. A slow
reduction in body weight (1.5 kg/week) proved efficient in
both reducing transaminase levels, and improving histological
liver changes (7). The liver ultrasonography carried
out 2 and 4 months postoperatively did not detect changes
as compared with the preoperative investigation.
The metabolic syndrome is frequently associated with
chronic inflammatory syndrome and coronary heart disease,
demonstrated by the inflammatory biomarkers hs–CRP, IL-
6 (8) and the assessment of the cardiac function (9,10). Body
weight loss and the implicit decrease in insulin resistance
led to a significant reduction of the inflammatory bio-markers,
in our patient. Regarding cardiac func-tion, this patient had
not ECG or echocardiographic signs of coronary heart
disease prior to the surgical intervention.
Conclusions
Surgery is currently the most efficient method of treating
morbid obesity. It provides the best results as far as body
weight loss and long-term evolution of specific comorbidities
are concerned. The surgical laparoscopic techniques for
morbid obesity have numerous advantages over traditional
surgery. Gastric banding is a restrictive procedure used in
laparoscopic surgery. The presence of comorbidities and
their favorable evolution, accompanied by an increased life
expectancy after surgery represent additional arguments for
choosing surgical therapy.
References
1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a
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surgery on body weight, comorbidities, and nutritional status. J
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3. Brown W, Dixon JB, Brien PO. Management of obesity—the
role of surgery. Aust Fam Physician 2006; 35: 584-586.
4. Bowne WB, Julliard K, Castro AE, Shah P, Morgenthal CB,
Ferzli GS. Laparoscopic gastric bypass is superior to adjustable
gastric band in super morbidly obese patients. A prospective,
comparative analysis. Arch Surg 2006 ; 141: 683-689.
5. Mehanna MJ, Birjawi G, Moukaddam HA, Khoury G, Hussein
M, Al-Kutoubi A. Complications of adjustable gastric banding,
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6. Olteanu D, Olariu C. Diagnosticul creºterii cronice a
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Tarcoveanu et al

Titlu scurt
QUIZ HQ 41
Is any intrahepatic mass a tumor?
A 56-year-old normoponderal woman with a crural hernia
surgically cured 3 years before, was admitted in our unit for
complete evaluation of an intrahepatic mass diagnosed at a
routine ultrasound (US) performed in another unit and
considered a neoplastic lesion. Medical history did not reveal
chronic drug consumption or alcohol abuse. At admission,
the patient was asymptomatic, with no complaints except
moderate asthenia (no abdominal pain, weight loss, or fever).
Physical examination was normal, without hepatomegaly or
spleen enlargement. Routine laboratory parameters did not
show any pathological findings; serological screening for
hepatic viruses B and C was negative; plasma cholesterol
and triglycerides were in normal range and tumoral markers
(alpha-foetoprotein, carcinoembrionic antigen, CA 19-9, CA
125, CA 15-3) were within normal limits as well. US revealed
a normal liver size with a hyperechoic, inhomogeneous mass,
with irregular margins, involving more than one half of the
right hepatic lobe; Doppler examination has shown a normal
vascular pattern inside the hiperechoic mass (Figs. 1,2). The
sonoelastographic examination showed a low-medium
stiffness of the hyperechoic mass (Fig.3).
An extensive examination comprising upper and lower
gastrointestinal endoscopy, X-Ray chest examination and
gynaecological exam was performed. The MRI confirmed
the presence of a large intrahepatic mass located in the right
hepatic lobe showing hypocaptation of hepatocellular
specific contrast agent and a huge amount of intracellular
fat accumulation; no vascular abnormalities were detected
(Figs. 4,5). Finally, an US-guided liver biopsy into the
suspected area was performed. The histological aspect of
the liver mass is depicted in Figs. 6-8.
Question
Fig.1Ultrasound examination showing a hyperecogenic
inhomogeneous area in the right hepatic lobe.
What is the focal abnormality of the liver ?
J Gastrointestin Liver Dis
December 2007 Vol.16 No 4, 453-454
Fig.2 Doppler examination: normal vascular pattern
and no mass effect.
Fig.3 Elastogram: low-medium stiffness of the liver
mass.
Fig.4 Native MRI: the liver mass showing hyposignal
in T1.
Fig.5 MRI washout phase: evidence of fat accumulation
(“steatosis in geographic map”).

454
Fig.6 Liver biopsy specimen: micro- and macrovezicular
steatosis; a net demarcation between the fat
area and the normal adjacent hepatic parenchyma (HE
x40).
References
Iulia Simionov1 , Liana Gheorghe1 ,
Gheorghe Becheanu1 , Ioana Lupescu2 1Center of Gastroenterology
and Hepatology
2Radiology Department
Fundeni Clinical Institute
Bucharest, Romania
1. Brawer MK, Austin GE, Lewin KJ. Focal fatty change of the
liver, a poorly recognized entity. Gastroenterology 1980; 78:
247-250
Education in gastroenterology
Fig.7 Liver biopsy specimen: grade 3 steatosis in the
focal area (HE 400x).
2. Mathiesen UL, Fransen LE, Aselius H et al. Increased liver
echogenicity at ultrasound examination reflects degree of
steatosis but not of fibrosis in asymptomatic patients with
mild/moderate abnormalities of liver transaminases. Dig Liver
Dis 2002; 34: 516-522
3. M. Lupsor, R. Badea. Imaging diagnosis and quantification of
hepatic steatosis: is it an accepted alternative to needle biopsy.
Rom J Gastroenterol 2005; 14: 419-425
4. Siegelman ES, Rosen MA. Imaging of hepatic steatosis. Semin
Liver Dis 2001; 21:71-80.
5. Fishbein M, Castro F, Sailaja C, et al. Hepatic MRI for fat
quantitation: its relationship to fat morphology, diagnosis and
ultrasound. J Clin Gastroenterol 2005; 39: 619-625