Manish S. Parikh, M.D.

Does a preoperative medically supervised weight loss program improve bariatric surgery outcomes: A pilot randomized study
Dasari M.; Ayo D.; McMacken M.; Ogedegbe O.; Parikh M.
2011 ;25:S255-S255, Surgical endoscopy
Introduction: Participation in a medically-supervised weight management (MSWM) program before bariatric surgery is mandated by several insurance payers. However, this requirement is not evidencebased and serves as a barrier to medically necessary treatment. We conducted a pilot randomized trial funded by SAGES to determine the effect of an insurance-mandated MSWM prior to surgery. Our hypotheses are: (1) There is no difference in BMI between patients who have participated in a medically-supervised weight management program and those who don't. (2) MSWM does not change self-reported adherence, physical activity, eating behavior, and health beliefs. Methods & Procedures: 55 patients were scheduled for laparoscopic adjustable gastric banding (LAGB) and consented to enroll in an ongoing prospective pilot study in a large public hospital. of these, 12 patients cancelled surgery and 10 patients have been enrolled for less than 6 months. Thus, 33 patients were included in the analysis, with 17 randomized to MSWM (defined as monthly visits over 6 months directed by a physician or nutritionist) and 16 randomized to usual care. Measures of weight, height, adherence, activity level, health beliefs, and eating behavior were obtained at enrollment (ie, baseline) and 6 months after enrollment (ie, MSWM program completion and 2 weeks prior to surgery). For categorical and continuous data, Fisher's Exact Test and t-test were used to compare groups at the 2 time points before surgery. Results: Mean age was 45.5 (SD = 12.5) years. Majority were female (97%) and non-Caucasian (85%) with an income of less than $20,000 (64%). No significant differences were found between MSWM and usual care for age, gender, ethnicity, education, and income, indicating that the 2 groups were evenly matched for demographic variables. Mean BMI for the MSWM group was 46.3 kg/m2 at baseline and 46.0 kg/m2 at 6 months. Mean BMI for usual care was 44.7 kg/m2 and 44.6 kg/m2 (see Table 1). After 6 months of eitherMSWMor wait and at pre-surgery, no significant differences in BMIor patient behaviors were found between the 2 groups. Preliminary analysis of available 3-month post-operative data (n = 13) showed similar mean BMI when comparing MSWM (41.3 kg/m2) and usual care (41.2 kg/m 2). Conclusion: Our preliminary results indicate that MSWM does not affect BMI changes or patient behaviors prior to or after LAGB surgery
— id: 135628, year: 2011, vol: 25, page: S255, stat: Journal Article,

Does gastric emptying after laparoscopic sleeve gastrectomy or calculated sleeve Volume correlate with weight loss?
Eisner J.A.; Hindman N.; Emil B.; Parikh M.
2011 ;21(8):1006-1006, Obesity surgery
Introduction: The purpose of this study is to correlate gastric emptying after laparoscopic sleeve gastrectomy (LSG) and calculated sleeve size (based on radiographic characteristics and pathologic resection) with post-op weight loss. Methods: Data was collected from an IRB-approved electronic registry, including patient demographics, weight, and body mass index (BMI). All sleeves were done with 40Fr Bougie, starting 5-7 cm proximal to pylorus. Post-op esophagrams were evaluated by 2 attending radiologists who specialized in body-imaging for 1) post-op radiographic sleeve diameter near top of sleeve, mid-sleeve and in antrum and 2) antrum-to-duodenum transit time. Sleeve volume was calculated utilizing the formula for cylinder volume r2h, where r=radius of mid-sleeve and h=height of the sleeve from gastroesophageal junction to distal antrum. Resected gastric volume was calculated utilizing radius and length of resected specimen (based on path report.) Excess weight loss (%EWL) was calculated based on ideal body weight. Pearson's correlation coefficient was used to evaluate the association between: transit time and weight loss, sleeve volume and weight loss, and transit time and sleeve diameter. Results: 62 patients underwent LSG (21% concurrent hiatal hernia repair) between Jan 2009 and Jan 2011 at an urban safety-net hospital. The population was 84% female, average pre-op age and BMI was 42 years and 47.0 kg/m², respectively. The transit time (available in 60 patients) ranged from 0-88 seconds (mean=21.3, SD= 19.8). 99% of the patients demonstrated gastric emptying under 60 seconds. Mean radiographic diameter of mid-sleeve was 4.0 cm and mean radiographic height was 26.4 cm. Based on these dimensions, mean calculated sleeve volume (based on cylindrical volume) was 115 cm3 (+/-81.0). Mean resected gastric volume (based on pathology specimen) was 658 cm3 (+/-945). Mean %EWL at 3, 6, and 12 months was 23.8% (+/-9.8), 37.9% (+/-11.8) and 52.2% (+/-10.8). There was no correlation found between transit time and %EWL at 3, 6 or 12 months. When dichotomizing the data between those with transit time <30 seconds vs. >30 seconds, there was still no significant correlation. There was also no correlation found between calculated sleeve volume or resected gastric volume and %EWL at 3, 6 or 12 months. However, shorter transit times were correlated with smaller mid-sleeve diameter (r=0.295, p-value=0.022) and smaller antrum diameter (r=0.255, p-value=0.049) but were not significantly correlated with upper sleeve diameter (r=0.120, p-value=0.360). Conclusion: We found no correlation between transit time after sleeve gastrectomy and weight loss, between sleeve volume and weight loss, and between resected gastric volume and weight loss. However, shorter transit time was correlated with smaller mid-sleeve and antrum diameter; the clinical significance of this remains to be determined
— id: 137858, year: 2011, vol: 21, page: 1006, stat: Journal Article,

Objective assessment of obesity-related comorbidity resolution following bariatric surgery
Liu J.X.; Saunders J.K.; Parikh M.
2011 ;21(8):1027-1028, Obesity surgery
Background: The purpose of this study was to objectively assess the resolution of obesity-related comorbidities (ORC) after bariatric surgery and to compare the status and resolution of comorbidities following laparoscopic adjustable gastric banding (LAGB), roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (LSG). Methods: Data was collected from an IRB-approved electronic registry, including patient demographics, weight, BMI, and ORC status. Using the registry, ten ORCs were scored, pre-op and post-op, from 0-5 according to severity using the Assessment of Obesity-Related Comorbidities (AORC) Scale, the basis for the Bariatric Outcomes Longitudinal Database. The ten ORCs were: osteoarthritis (OA), diabetes, hypertension (HTN), obstructive sleep apnea, hyperlipidemia (HLD), gastroesophageal reflux disease, depression, urinary stress incontinence, hernia, and lower extremity edema (LEE). Resolution of disease was defined as having AORC>0 pre-surgery and AORC=0 post-surgery. Change in ORC status was calculated with the following equation: (pre-op AORC score) - (post-op AORC score). Paired t-tests were utilized to determine whether comorbidity change was significant following bariatric surgery. Fisher's exact tests were used to determine if there was a significant difference in ORC resolution between procedures. Results: 264 patients with ORC underwent bariatric surgery between January 2008 and March 2010 at an urban safety-net hospital. Average pre-op age was 42.5, and average pre-op BMI was 44.2. At mean patient follow-up of 17.2 months, the %EWL of RYGB, LSG and LAGB was 43.6%, 37.4% EWL, and 23.3% EWL, respectively (p < .0001). Resolution of 4 comorbidities (OA, HTN, HLD, and LEE) was found to be significantly different between surgery types (p<0.05): The percentage of patients with OA resolution was 71% for RYGB, 63% for LSG, and 51% for LAGB. HTN resolution was 57% for RYGB, 23% for LAGB, and 29% for LSG. HLD resolution was 71% for LSG, 67% for RYGB, and 34% for LAGB. LEE resolution was 100% for LSG (n=6), 94% for RYGB, and 68% for LAGB. RYGB produced an overall mean ORC resolution of 66%, vs 60% and 44% produced by LSG and LAGB, respectively. All bariatric surgery procedures had statistically significant AORC score change for all 10 documented comorbidities (p < .0001). The overall mean change in AORC score for all comorbidities, from pre-op to post-op, was 1.7 for RYGB patients, 1.4 for LSG patients, and 1.2 for LAGB patients. There was no significant association between initial BMI and change in AORC score. The pre-op AORC scores were not significantly different between surgery types. Conclusions: RYGB had the greatest ORC resolution for patients with OA and HTN, as well as the greatest mean ORC status improvement overall. LSG produced the greatest significant ORC resolution for patients with HLD and LEE. RYGB, LSG, and LAGB had statistically significant ORC status improvement for all 10 documented comorbidities
— id: 137857, year: 2011, vol: 21, page: 1027, stat: Journal Article,

LSG bougie size should be larger (40Fr or more)
Parikh M.
2011 ;21(8):958-958, Obesity surgery
Laparoscopic sleeve gastrectomy (LSG) techniques vary significantly, including bougie size (32-60Fr), distance from pylorus (2-8 cm), antral preservation, proximity to GE junction, staple height/oversewing, and concurrent hiatal hernia repair. The literature is controversial regarding bougie size and weight loss after LSG, however there is certainly a trend towards the use of more narrow bougies (32Fr) with increasing surgeon experience. We have previously published a study comparing weight loss after LSG between 40Fr and 60Fr bougie and seeing no significant weight loss difference at 1 year; however the 60Fr bougie group was mainly firststage duodenal switch patients who were primarily superobese (mean BMI 63.1 at baseline). If one calculates the volume of the sleeve using the formula for cylinder (r2h) where h=25 cm (length of sleeve), the calculated volume for 32Fr bougie is 20cc, for 40Fr bougie is 32cc and 60Fr bougie is 71cc. At our institution, we have found no correlation between calculated sleeve volume (radiographically) and weight loss up to 1 year postoperatively. We did find a correlation between smaller diameter at midsleeve and more rapid emptying of liquid contrast postoperatively, however the accelerated emptying did not correlate with improved weight loss. What is the downside of using a more narrow bougie? There is conflicting literature regarding the complication rates and bougie size for LSG. There is concern that the tighter the sleeve, the higher the risk of a leak, especially near the GE junction. There are also reports of higher reflux rates with tighter bougies. Other large studies (e.g. Spanish Registry Data) have found no correlation between bougie size and complication rate. It is difficult to compare outcomes based on bougie size due to the variability of other intraoperative factors, including how closely the stapler is applied along the bougie, the amount of posterior fundus mobilized, the distance from the pylorus where the LSG begins, the amount of stretch applied laterally on the fundus, the presence of gastritis that affects thickness and distensibility of the stomach, and the use of buttressing material. These factors combined with the accelerated gastric emptying seen after LSG (suggesting that LSG may not be solely a restrictive procedure) make evidence-based comparisons difficult to perform. Larger studies with standardized techniques are needed to determine optimal bougie size
— id: 137859, year: 2011, vol: 21, page: 958, stat: Journal Article,

Comparison of diagnostic accuracy of upright Vs. recumbent esophagram in predicting hiatal hernia
Parikh M.; Heacock L.; Hindman N.; Jain R.; Balthazar E.
2011 ;21(8):1070-1070, Obesity surgery
Background: Hiatal hernia repair at the time of bariatric surgery improves patient outcome, decreases GERD symptoms and reduces the need for reoperation. The aim of this report is twofold: first, to compare the sensitivity of esophagram with surgical findings at the time of bariatric surgery, and second, to compare the sensitivities of upright versus right anterior oblique (RAO) recumbent esophagram in predicting the presence of hiatal hernia intraoperatively. Methods: Between 2008 and 2010, 389 patients undergoing bariatric surgery were prospectively evaluated for hiatal hernia by barium esophagram. 70 (18%) were performed only in the upright position and 319 (82%) only in the RAO recumbent position. Esophagram technique was changed from upright to recumbent because we hypothesized that we would be able to better detect hiatal hernia utilizing RAO recumbent technique. Hiatal hernia was assessed intraoperatively by laxity/dimpling of the phrenoesophageal ligament and, when present, was repaired posteriorly with permanent sutures. Results: Compared with the surgical findings, the sensitivity and specificity for upright esophagram was 50% and 97%, respectively. For recumbent esophagram, sensitivity was 70% and specificity was 77%. Recumbent esophagram had a lower percentage of false negatives than upright esophagram (11% vs. 21%). Conclusions: Use of a recumbent technique for preoperative esophagram has a higher sensitivity for diagnosis of hiatal hernia than upright esophagram. Routine use of recumbent esophagram results in increased preoperative detection of hiatal hernia and facilitates planning of crural closure
— id: 137856, year: 2011, vol: 21, page: 1070, stat: Journal Article,

Five-year outcomes of patients with type 2 diabetes who underwent laparoscopic adjustable gastric banding
Sultan, Samuel; Gupta, Deepali; Parikh, Manish; Youn, Heekoung; Kurian, Marina; Fielding, George; Ren-Fielding, Christine
2010 Jul-Aug;6(4):373-376, Surgery for Obesity & Related Diseases
BACKGROUND: Evidence of the positive effects of gastric banding on patients with diabetes has continued to increase. The long-term follow-up of such patients, however, has been limited. The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric banding at our institution. METHODS: From January 2002 through June 2004, 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric banding. The study parameters included preoperative age, gender, race, body mass index, duration of diabetes before surgery, fasting glucose level, hemoglobin A1c (HbA1c), and medications used. Preoperative data from all patients were collected prospectively and entered into an institutional review board-approved database. Beginning in 2008, efforts were made to collect the 5-year follow-up data. RESULTS: Of the 102 patients, 7 were excluded because they had not reached the 5-year follow-up point (2 patients had had the band removed early and 5 patients had died; 2 of cancer and 3 of unknown causes), leaving 95 patients for the present study. The mean preoperative age was 49.3 years (range 21.3-68.4). The mean preoperative body mass index was 46.3 kg/m(2) (range 35.1-71.9) and had decreased to 35.0 kg/m(2) (range 21.1-53.7) by 5 years of follow-up, yielding a mean percentage of excess weight loss of 48.3%. The mean duration of the diabetes diagnosis before surgery was 6.5 years. Of 94 patients, 83 (88.3%) were taking medications preoperatively, with 14.9% overall taking insulin. At 5 years postoperatively, 33 (46.5%) of 71 patients were taking medications, with 8.5% taking insulin. The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively (P = .004). The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients (P <.001). Overall, diabetes had resolved (no medication requirement, with HbA1c <6 and/or glucose <100 mg/dL) in 23 (39.7%) of 58 patients and had improved (use of fewer medications and/or fasting glucose levels of 100-125 mg/dL) in 41 (71.9%) of 57 patients. The combined improvement/remission rate was 80% (64 of 80 patients). CONCLUSION: Our data have demonstrated that laparoscopic adjustable gastric banding results in a substantial sustained positive effect on diabetes in morbidly obese patients, with a significant reduction in HbA1c and an 80% overall rate of improvement/remission
— id: 111359, year: 2010, vol: 6, page: 373, stat: Journal Article,

Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2
Sultan, Samuel; Parikh, Manish; Youn, Heekoung; Kurian, Marina; Fielding, George; Ren, Christine
2009 Jul;23(7):1569-1573, Surgical endoscopy
BACKGROUND: Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m(2) have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m(2) underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board-approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities. RESULTS: The mean preoperative age of the patients was 46.9 years (range, 16-68 years), and the mean preoperative BMI was 33.1 kg/m(2) (range, 28.2-35.0 kg/m(2)). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 +/- 2.4 kg/m(2), 25.8 +/- 2.9 kg/m(2), and 25.8 +/- 3.1 kg/m(2) and mean %EWL was 48.3 +/- 17.6, 69.9 +/- 28.0, and 69.7 +/- 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality. CONCLUSION: The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m(2)
— id: 100185, year: 2009, vol: 23, page: 1569, stat: Journal Article,

Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass
Gobble, Ryan M; Parikh, Manish S; Greives, Matthew R; Ren, Christine J; Fielding, George A
2008 Apr;22(4):1019-1022, Surgical endoscopy
BACKGROUND: This study reviews outcomes after laparoscopic adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGBP). METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-operative age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percentage excess weight loss (EWL), and postoperative complications. RESULTS: 11 patients (seven females, four males) were referred to our program for weight loss failure after RYGBP (six open, five laparoscopic). Mean age and BMI pre-RYGBP were 39.5 years (24-58 years) and 53.2 kg/m(2) (41.2-71 kg/m(2)), respectively. Mean EWL after RYGBP was 38% (19-49%). All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain. The average time between RYGBP and LAGB was 5.5 years (1.8-20 years). Mean age and BMI pre-LAGB were 46.1 years (29-61 years) and 43.4 kg/m(2) (36-57 kg/m(2)), respectively. Vanguard (VG) bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 76 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosions; however, one patient required reoperation for a flipped port. The average follow-up after LAGB was 13 months (2-32 months) with a mean BMI of 37.1 kg/m(2 )(22.7-54.5 kg/m(2)) and an overall mean EWL of 59% (7-96%). Patients undergoing LAGB after failed RYGBP lost an additional 20.8% EWL (6-58%). CONCLUSION: Our experience shows that LAGB is a safe and effective solution to failed RYGBP
— id: 79291, year: 2008, vol: 22, page: 1019, stat: Journal Article,

Laparoscopic sleeve gastrectomy for morbid obesity
Moy, Jason; Pomp, Alfons; Dakin, Gregory; Parikh, Manish; Gagner, Michel
2008 Nov;196(5):e56-e59, American journal of surgery
The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index > or = 30 kg/m(2)). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG
— id: 90958, year: 2008, vol: 196, page: e56, stat: Journal Article,

Comparison of rates of resolution of diabetes mellitus after gastric banding, gastric bypass, and biliopancreatic diversion
Parikh, Manish; Ayoung-Chee, Patricia; Romanos, Eleny; Lewis, Nichole; Pachter, H Leon; Fielding, George; Ren, Christine
2007 Nov;205(5):631-635, Journal of the American College of Surgeons
BACKGROUND: Bariatric operation is the most effective treatment for diabetes mellitus in the morbidly obese. The purpose of this study is to compare the rate of resolution of diabetes mellitus after three common laparoscopic bariatric procedures: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD/DS). STUDY DESIGN: All data were prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included preoperative age, body mass index, duration of diabetes, race, gender, operative time, length of stay, percent excess weight loss, oral hypoglycemic requirements, and insulin requirements. RESULTS: A total of 282 bariatric patients with diabetes mellitus were analyzed (218 LAGB, 53 RYGB, and 11 BPD/DS). Preoperative age (46 to 50 years), body mass index (46 to 50; calculated as kg/m(2)), race and gender breakdown, and baseline oral hypoglycemic (82% to 87%) and insulin requirements (18% to 28%) were comparable among the three groups (p = NS). Percent excess weight loss at 1, 2, and 3 years was: 43%, 50%, and 45% for LAGB; 66%, 68%, and 66% for RYGB; and 68%, 77%, and 82% for BPD/DS (p < 0.01 LAGB versus RYGB and LAGB versus BPD/DS at all time intervals). At 1 and 2 years, the proportion of patients requiring oral hypoglycemics postoperatively was 39% and 34% for LAGB; 22% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). At 1 and 2 years, the proportion of patients requiring insulin postoperatively was 14% and 18% for LAGB; 7% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). CONCLUSIONS: Despite the disparity in percent excess weight loss between LAGB, RYGB, and BPD/DS, the rate of resolution of diabetes mellitus is equivalent
— id: 75399, year: 2007, vol: 205, page: 631, stat: Journal Article,

Four-year review of trends in nutritional deficiencies and clinical sequelae after biliopancreatic diversion with duodenal switch (BPD/DS)
Harris, M; Ren, C; Fielding, G; Kumar, P; Parikh, M
2006 AUG ;16(8):990-990, Obesity surgery
— id: 69036, year: 2006, vol: 16, page: 990, stat: Journal Article,

Laparoscopic adjustable gastric banding for patients with body mass index of <or=35 kg/m2
Parikh, M; Duncombe, J; Fielding, G A
2006 Sep-Oct;2(5):518-522, Surgery for Obesity & Related Diseases
BACKGROUND: Many mild-to-moderately obese individuals (body mass index [BMI] 30-35 kg/m(2)) have serious diseases related to their obesity. Nonoperative therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 1996 and 2004, 93 patients with a BMI of 30-35 kg/m(2) underwent laparoscopic adjustable gastric banding with the LAP-BAND. All patients were referred by their primary physician, entered into a comprehensive bariatric surgery program at one Australian center, and operated on by one surgeon. Data on all patients were collected prospectively and entered into an electronic registry. The study parameters included preoperative age, gender, BMI, presence of co-morbidities, percentage of excess weight loss, and resolution of co-morbidities. RESULTS: The mean age was 44.6 years (range 16-76), mean weight was 98 kg, and the mean BMI was 32.7 kg/m(2) (range 30-34). Of the 93 patients, 42 (45%) had co-morbidities, including asthma, diabetes, hypertension, and sleep apnea. The proportion of patients in follow-up was 79%, 85%, and 89% at 1, 2, and 3 years, respectively. The mean weight was reduced to 71 kg at 1 year, 72 kg at 2 years, and 72 kg at 3 years. The mean BMI was reduced to 27.2 +/- 2.2, 27.3 +/- 3.1, and 27.6 +/- 3.7 kg/m(2), respectively, and the mean percentage of excess weight loss was 57.9% +/- 24.5%, 57.6 +/- 29.3%, and 53.8% +/- 32.8% at 1, 2, and 3 years, respectively. At 3 years, the BMI was 18-24 kg/m(2) in 34%, 25-29 kg/m(2) in 51%, and 30-35 kg/m(2) in 10%. At 3 years, the percentage of excess weight loss was <25% in 10%, 25-50% in 24%, 50-75% in 51%, and >75% in 10%. The co-morbidities improved or completely resolved in most patients. No mortality occurred. CONCLUSION: We are very encouraged by this series of low BMI patients treated with the LAP-BAND. Their weight loss has been good, the complications have been minimal, and the co-morbidities have partially or wholly resolved. With additional study, it is reasonable to expect the weight guidelines for bariatric surgery to be altered to include patients with a BMI of 30-35 kg/m(2)
— id: 69692, year: 2006, vol: 2, page: 518, stat: Journal Article,

Objective comparison of complications resulting from laparoscopic bariatric procedures
Parikh, Manish S; Laker, Scott; Weiner, Matt; Hajiseyedjavadi, Omid; Ren, Christine J
2006 Feb;202(2):252-261, Journal of the American College of Surgeons
BACKGROUND: Several surgical treatment options for morbid obesity exist. Currently, there are no studies that objectively compare complication rates after laparoscopic bariatric operations performed at a single institution. We objectively classify and compare complications resulting from laparoscopic adjustable gastric banding (LABG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD) with duodenal switch (DS). STUDY DESIGN: A retrospective review of a prospective database of all patients undergoing laparoscopic bariatric operation was performed. Complications were categorized according to severity score using a well-described classification system and compared between procedures. RESULTS: From September 2000 to July 2003, 780 laparoscopic bariatric operations were performed: 480 LAGB, 235 RYGB, and 65 BPD+/-DS. There was one late death. Total complication rates were: 9% for LAGB, 23% for RYGB, and 25% for BPD+/-DS. Complications resulting in organ resection, irreversible deficits, and death (grades III and IV) occurred at rates of 0.2% for LAGB, 2% for RYGB, and 5% for BPD+/-DS. LAGB group had a statistically significant lower overall complication rate, both by incidence and severity, as compared with other groups (p < 0.001). After controlling for differences of admission body mass index, gender, and race, the LAGB group had an almost three and a half times lower likelihood of a complication compared with the RYGB group (odds ratio, 3.4; 95% CI, 2.2-5.3, p < 0.001) and had an over three and a half times lower likelihood of a complication compared with the BPD with DS group (odds ratio, 3.6; 95% CI, 1.8-7.1, p < 0.001). There was no statistically significant difference between complication rates of RYGB and BPD+/-DS. CONCLUSIONS: Bariatric operation complication rates range from 9% to 25%; very few complications are serious. Laparoscopic adjustable gastric banding is the safest operation in terms of complication rate and severity when compared with laparoscopic Roux-en-Y gastric bypass or laparoscopic malabsorptive operations
— id: 62815, year: 2006, vol: 202, page: 252, stat: Journal Article,

Comparison of outcomes after laparoscopic adjustable gastric banding in African-Americans and whites
Parikh, Manish; Lo, Helen; Chang, Christopher; Collings, Dinee; Fielding, George; Ren, Christine
2006 Nov-Dec;2(6):607-610, Surgery for Obesity & Related Diseases
BACKGROUND: Race may affect outcomes after bariatric surgery. This study compares outcomes in terms of weight loss and comorbidity resolution between African-Americans and whites after laparoscopic adjustable gastric banding (LAGB). METHODS: Data from 959 patients undergoing LAGB between July 2001 and July 2004 were prospectively collected and entered into an electronic registry. Propensity score matching analysis was used to match whites to African-Americans on the basis of age, gender, and preoperative body mass index (BMI). Preoperative comorbidities (diabetes, hypertension, obstructive sleep apnea, hypercholesterolemia, and hypertriglyceridemia) were also compared. Operative time (OR), length of stay (LOS), comorbidity resolution, and percent excess weight loss (%EWL) at 1, 2, and 3 years were analyzed. All data were updated through May 2006. RESULTS: A total of 65 white LAGB patients were matched to 58 African-American LAGB patients on the basis of age, gender, and preoperative BMI. The preoperative mean age and BMI were 37 +/- 19 years and 47 +/- 7 kg/m2, respectively. A total of 55% of the white group and 64% of the African-American group had one or more comorbidities (P = NS). Median OR time and LOS were similar in both groups: 50 minutes and 23 hours, respectively. The majority of patients in both groups had major improvement or resolution of one or more comorbidities (61% whites vs 77% African-Americans, P = NS). There was, however, a significant difference in %EWL between whites and African-Americans at each time interval (49% vs 39% at 1 year; 55% vs 44% at 2 years; 52% vs 41% at 3 years; P < .05 for all values.). CONCLUSION: Despite the disparity in weight loss with the LAGB in African-Americans and whites, both patient populations experienced a similar improvement/resolution of obesity-related comorbidities
— id: 71142, year: 2006, vol: 2, page: 607, stat: Journal Article,

A comparison of the rate of resolution of diabetes mellitus after laparoscopic adjustable-gastric banding, gastric bypass and biliopancreatic diversion with duodenal switch
Parikh, MS; Ayoung-Chee, P; Romanos, E; Lewis, N; Ren, C
2006 SEP ;203(3):S12-S12, Journal of the American College of Surgeons
— id: 69818, year: 2006, vol: 203, page: S12, stat: Journal Article,

U.S. experience with 749 laparoscopic adjustable gastric bands: intermediate outcomes
Parikh, M S; Fielding, G A; Ren, C J
2005 Dec;19(12):1631-1635, Surgical endoscopy
BACKGROUND: Laparoscopic adjustable gastric band (LAGB) has consistently been shown to be a safe and effective treatment for morbid obesity, especially in Europe and Australia. Data from the U.S. regarding the LAGB has been insufficient. This study reveals our experience with 749 primary LAGB over a 3-year period in a U.S. university teaching hospital. METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study include preoperative age, BMI, gender, race, conversion rate, operative time, hospital stay, percent excess weight loss (%EWL) and postoperative complications. Annual esophagrams were performed RESULTS: From July 2001 through September 2004, 749 patients (531 females, 218 males) underwent LAGB for the treatment of morbid obesity. There were 630 Caucasians, 61 African-Americans, and 49 Latin Americans, with a mean age of 42.3 (range 18, 72 years) and mean BMI of 46.0 +/- 7.0 (range 35, 91.5 kg/m(2)). There was one conversion to open (0.1%). Median operative time and hospital stay were 60 minutes and 23 hours, respectively. The mean %EWL at 1 year, 2 years, and 3 years was 44.4 (+/-17.8), 51.8 (+/-20.9), and 52.0 (+/-19.6), respectively. There were no mortalities. Postoperative complications occurred in 12.8% of patients: 1.5% acute postoperative band obstruction, 0.9% wound infection, 2.9% gastric prolapse ('slip'), 2.0% concentric pouch dilatation (without slip), 0.8% aspiration pneumonia, 2.4% port/tubing problems, 0.3% severe esophageal dilatation/dysmotility (reversible), and 1.5% overall band removal. CONCLUSION: These American results substantiate the data from abroad that LAGB is a safe and effective treatment for morbid obesity
— id: 66995, year: 2005, vol: 19, page: 1631, stat: Journal Article,

Laparoscopic adjustable gastric banding for patients with a Body Mass Index < 35 kg/m(2)
Parikh, M; Duncombe, J; Fielding, G
2005 AUG ;15(7):983-983, Obesity surgery
— id: 57879, year: 2005, vol: 15, page: 983, stat: Journal Article,

Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of 332 patients
Parikh, Manish S; Shen, Roy; Weiner, Matt; Siegel, Niccole; Ren, Christine J
2005 Jun-Jul;15(6):858-863, Obesity surgery
BACKGROUND: Bariatric surgery in super-obese patients (BMI >50 kg/m(2)) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities. METHODS: A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30 day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations. RESULTS: From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m(2). Patients were aged 42 years (13-72), and 75% were female. When categorized by operation (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3+/-12.6, 45.8+/-19.4, and 49.5+/-18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7+/-15.4, 54.7+/-21.2, and 56.8+/-21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6+/-15.9, 69.4+/-13.0 and 77.4+/-11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths. CONCLUSION: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant
— id: 58063, year: 2005, vol: 15, page: 858, stat: Journal Article,

Erratum: Interval gangrene complicating superficial femoral artery stent placement (Journal of Vascular Surgery (2005) 42 (564-566))
Pua BB; Muhs BE; Parikh MS; Cayne N; Lamparello PJ
2005 ;42(6):1285-1285, Journal of vascular surgery
— id: 61430, year: 2005, vol: 42, page: 1285, stat: Journal Article,

Interval gangrene complicating superficial femoral artery stent placement
Pua, Bradley B; Muhs, Bart E; Parikh, Manish S; Cayne, Neal; Lamparello, Patrick J
2005 Sep;42(3):564-566, Journal of vascular surgery
Interval gangrene-necrosis of tissue proximal to a successful distal revascularization procedure-is an exceeding rare complication. To date, only nine cases have been reported in the literature, and all were secondary to traditional open bypass procedures. We report the first case, to our knowledge, of interval gangrene after endovascular stent placement in the superficial femoral artery. We believe that with the increasing utilization of endovascular techniques to treat limb ischemia, the serious complication of interval gangrene must be revisited. Assessment of collateral circulation, precise stent placement, and the appropriate choice of stents and stent grafts will become increasing important as more and more of these lesions are treated with endovascular techniques
— id: 58712, year: 2005, vol: 42, page: 564, stat: Journal Article,

Laparoscopic bariatric surgery in superobese patients (BMI > 50) is safe: A review of 213 patients
Parikh, M; Shen, R; Weiner, M; Siegel, N; Ren, CJ
2004 AUG ;14(7):915-915, Obesity surgery
— id: 48736, year: 2004, vol: 14, page: 915, stat: Journal Article,

Effect of hemorrhage on medial collateral ligament healing in a mouse model
Wright, Rick W; Parikh, Manish; Allen, Tracy; Brodt, Michael D; Silva, Matthew J; Botney, Mitchell D
2003 Sep-Oct;31(5):660-666, American journal of sports medicine
BACKGROUND: Medial collateral ligament injuries heal by a scar response. HYPOTHESIS: Increased hemorrhage at the site of medial collateral ligament injury improves healing. STUDY DESIGN: Controlled laboratory study. METHODS: Ninety-six mice were divided into two groups. Group 1 mice underwent knee medial collateral ligament transection with the opposite knee as a sham-operated control and group 2 animals additionally had 0.25 ml of tail cut blood pipetted to the medial collateral ligament transection site and sham-operated opposite knee. Ligament specimens were harvested at 3, 7, 21, and 28 days. RESULTS: Immunohistochemical analysis demonstrated peak macrophage counts at day 7 in all transected specimens. Macrophage counts were higher in group 2 than in group 1 at all time points, with a statistically significant increase of macrophages noted at day 7. In situ hybridization demonstrated increased collagen gene expression, with peaks at 7 and 28 days after transection. Group 2 animals showed increased gene expression at all time points as compared with group 1, with a statistically significant increase noted at 7 and 28 days. Biomechanical testing demonstrated progressive healing at each time point. At 28 days, the load to failure was 67% that of the sham-operated knee. CONCLUSIONS: This study suggests there is an increased healing response with bleeding at the ligament injury site. Clinical Relevance: Identification of the factors involved with increased healing may allow manipulation of the healing response in the clinical setting
— id: 73184, year: 2003, vol: 31, page: 660, stat: Journal Article,