Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity

Comparison of those who succeed in losing significant excessive weight after bariatric surgery and those who fail

BACKGROUND

Gastric bypass and adjustable gastric banding currently are the most commonly performed weight loss surgeries. The results are encouraging for most patients, but some patients have a better experience than others. This report aims to define differences between those who succeeded and those that failed to lose significant excessive weight after bariatric surgery.

METHODS

The authors retrospectively reviewed their database over the past 4 years. They studied 484 bariatric patients who had 1 year of follow-up evaluation. Success was defined as more than 50% excess weight loss (EWL) and failure as less than 30% EWL. Student's t-tests were performed between the groups of bypass patients, band patients, men, women, whites, and minorities.

RESULTS

An overall success rate of 58% and a failure rate of 15% were observed. The successful group was significantly younger. The starting body mass index (BMI) was significantly lower for the successful band patients. The starting excess weight was significantly less in both the successful band and bypass groups, as was the starting weight. The successful whites were significantly younger, and the starting BMI was significantly lower in the successful minority group. The unsuccessful bypass patients and whites were significantly taller than the successful group. Gender was not a significant variable in success or failure regardless of procedure.

CONCLUSION

Without consideration for the procedure performed, the patients who successfully lost weight were younger. The unsuccessful band patients had a higher starting BMI, whereas the successful band and bypass patients had lower average starting and excess weights. The successful bypass patients were significantly shorter. Among whites, the successful patients were significantly younger and shorter. The successful minorities had a lower starting BMI. These variables give further insight into the complexity of successful excess weight loss.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Predictability of outcome in laparoscopic gastric banding

BACKGROUND

The success rate of laparoscopic adjustable gastric banding (LAGB) in the treatment of morbid obesity is very variable.A reasonable preoperative selection of eligible patients seems to be important for a successful outcome of LAGB. In the present study, criteria were investigated to predict the outcome of LAGB.

METHODS

85 morbidly obese patients were operated with LAGB between 1999 and 2005. 71 of these patients were analysed according to several possible predictive parameters of success or failure of LAGB. Success was defined as excess body weight loss(EBWL) > 50% without band removal, failure was defined as EBWL < 20% and/or band removal. Median follow-up was 27 months (range 8-90 months).

RESULTS

After LAGB a median EBWL of 43% (-41 to 171.5%) was observed in all patients with a decrease in BMI of 8.0 kg/m2 (-9 to 35 kg/m2). The success rate after LAGB was 37%, the failure rate 19.7%. Female sex(p = 0.023), baseline weight (p = 0.024), and eating behaviour after LAGB (p = 0.008) were significant predictors of success following LAGB, whereas complications such as port dislocation and reoperation after LAGB did not have a significant impact on a successful course following LAGB. Significant predictors of failure were male sex (p = 0.038) and missing physical activity after LAGB (p = 0.045), whereas the eating behaviour did not have a significant effect concerning failure following LAGB. Baseline excess body weight (EBW) was identified as an independent predictor of failure in a multivariate analysis.

CONCLUSION

According to the results of this study, female patients with a lower EBW who improve their postoperative eating behaviour have the best chance of success following LAGB.

Stoma obstruction after laparoscopic adjustable gastric banding for morbid obesity: report of two cases and treatment options

Laparoscopic adjustable gastric band is one of the surgical options available for morbid obesity in the current century. Its popularity is gained by its proven efficacy with a reported low incidence of the intraoperative as well as the postoperative complications. Stomal obstruction post-laparoscopic adjustable gastric band (LAGB) has been under reported in the English literature. We report this complication in two patients and discuss two different simple modalities of treatment. Post-LAGB complications are numerous, dealing with their complications have a steeping curve. Educating the patients postoperatively in regard to food ingestion manner is a must and should prevent such complication.

Failure of adjustable gastric banding: starting BMI of 46 kg/m2 is a fulcrum of success and failure

BACKGROUND

To determine the body mass index (BMI) located at the fulcrum of success and failure in a prospective study conducted at the University of Texas Health Science Center at Houston. On average, our patients whose percentage of excess weight loss (%EWL) was >50% at 1 year had a significantly lower BMI than those with <30% EWL.

METHODS

We prospectively collected the weight loss data for 430 patients who had had an adjustable gastric band placed. We stratified the %EWL within 1 year for patients with a BMI of 30-59 kg/m2. A line was generated for the %EWL over time for BMI groups of 30-39, 40-49, and 50-59 kg/m(2) and compared with the average %EWL over time. The y-intercepts of the resulting four lines were graphed against the average BMI for each group.

RESULTS

The generated y-intercept line had an R2 of .9237. Using the equation of this line and the known y-intercept for the average, we solved for x, resulting in a BMI of 46 kg/m2. Patients with a BMI <46 kg/m2 had a 50% EWL at 1 year, and those with a BMI >46 kg/m2 had only a 33% EWL at 1 year. The %EWL between the groups was significantly different at all measured intervals (P <.0001).

CONCLUSION

A BMI of 46 kg/m2 identifies those at high risk of failure to lose a significant percentage of excess weight after adjustable gastric banding and who require closer follow-up. Furthermore, patients who have a BMI >46 kg/m2 should be advised that their weight loss might be suboptimal at 1 year.

Crural repair permits morbidly obese patients with not large hiatal hernia to choose laparoscopic adjustable banding as a bariatric surgical treatment

BACKGROUND

Hiatal hernia, present radiologically in about 50% of patients desiring bariatric surgery, has been thought a contraindication to laparoscopic adjustable gastric banding (LAGB). Posited was the notion that adding crural repair to LAGB would enable this procedure to be offered to patients desiring bariatric surgery who had hiatal hernias.

METHODS

After obtaining IRB approval, charts of all patients who underwent simultaneous crural repair and LAGB from June 2003 to January 2006 were reviewed. All patients were evaluated with the DeMeester score and the GERD-HQRL score pre- and postoperatively. Statistical analyses included the Mann-Whitney U test and the Chi-squared test.

RESULTS

Twenty-one patients underwent laparoscopic procedure with crural repair; none required conversion to an open procedure. There were no mortalities. Two complications, a wound infection at the level of the port, and a case postoperative dysphagia resolved with therapy. Eighty-six percent of the patients ceased regular intake of heartburn medicines, P<.01. Median percent excess weight loss was 45% at 1 year and 55% at 2 years. The modified DeMeester score fell to 0-2 postoperatively (P<.01). Two years after the procedure, symptoms were less, as assessed by GERD-HQRL scores (P<.01).

CONCLUSION

Crural repair permits LAGB to be safely and effectively performed in patients with hiatal hernia.

Preliminary results of the laparoscopic adjustable gastric banding procedure by a new generation of silicone band: MIDBAND

BACKGROUND

The surgical treatment of morbid obesity by laparoscopic adjustable gastric banding has become a "gold standard" in Europe. Currently, five types of silicone bands are used in the majority of countries performing bariatric surgery.

METHODS

The MIDBAND was introduced to the European market in 2000. It is placed around the stomach using the Pars Flaccida technique described by Forsell. A prospective multicentric study on 113 cases was carried out to evaluate technical feasibility, complications, and the midterm weight loss outcomes (2 years).

RESULTS

The percentage of excess body weight loss was 52.58% at 2 years. Perioperative mortality was nil and the complication rate was low (slippage <2%).

CONCLUSION

These encouraging results require longer-term studies to validate this procedure.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.

METHODS

We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.

RESULTS

For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.

CONCLUSION

The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Who benefits from gastric banding?

BACKGROUND

In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB).

MATERIALS AND METHODS

85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) >50% and no band removal. Median follow-up was 27 months (range 8-90 months).

RESULTS

In total, median EBWL was 43% (-41 to 171.5%) with a decrease in BMI of 8.0 kg/m(2) (-9 to 35 kg/m(2)). Success rate was 37% (n = 26). These patients were compared to all other patients (n = 45). Significant success predictors were baseline absolute BW, EBW, BMI (p < 0.01), BMI with a threshold value of 50 kg/m(2) (p = 0.02), and female sex (p = 0.02) as well as postoperative vomiting (p = 0.02), eating behavior and physical activity after LAGB (p < 0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis.

CONCLUSION

Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB.

Treating morbid obesity with laparoscopic adjustable gastric banding

BACKGROUND

Morbid obesity results in multiple comorbidities and an increased mortality rate. The National Institutes of Health has stated that surgery is the most effective long-term therapy; therefore, we evaluated a laparoscopically implantable adjustable gastric band.

METHODS

We reviewed 2 multicenter prospective, open-label, single-arm surgical trials--trial A (3 years) and trial B (1 year)--with ongoing safety follow-up. These trials were conducted in United States community and university hospitals (trial A = 8 sites and trial B = 12 sites). Trial A comprised 292 subjects (mean +/- SD preoperative weight: 133 kg +/- 24.4), and trial B comprised 193 subjects (129 kg +/- 20.8). Intervention included placement of a constrictive, adjustable band around the upper stomach to limit food intake and induce weight loss. Main outcome measures were the primary efficacy end point of weight loss. Secondary end-points were change in quality-of-life, safety parameters, and complications, including band slippage, reoperation, and device explantation.

RESULTS

In the 2 trials, 485 devices were implanted (92% laparoscopically), and no deaths occurred. Of the patients in trial A, 206 (70.5%) completed the 3-year follow-up, and 142 (73.6%) of patients in trial B completed the 1-year follow-up. Weight-loss results, using the last value carried forward, for all 292 patients in trial A and all 193 patients in trial B demonstrated a change in mean body mass index (kg/m2) +/- SD from 47.4 +/- 7.0 to 39.0 +/- 7.3 in trial A and from 46.7 +/- 7.8 to 38.4 +/- 7.6 in trial B subjects at 1 year (P < .001 for both trials A and B), with minimal further change at 3 years (39.0 +/- 8.5) in trial A subjects. The percentage of initial body weight lost at 1 year was 17.7% +/- 9.4% for trial A subjects and 18.2% +/- 8.9% for trial B subjects, whereas the 3-year total for trial A subjects was 18.3% +/- 13.1%. At 1 year, 76% of patients in trial A and 66% of patients in trial B had complications, mostly related to upper gastrointestinal symptoms. By 9 years after surgery, 33% (96 of 292) of trial A subjects had their devices explanted because of complications or inadequate weight loss.

CONCLUSIONS

These first-generation implantable adjustable gastric band results suggest that this is a viable bariatric surgery therapeutic option for the treatment of obesity.

Ala55Val Polymorphism on UCP2 Gene Predicts Greater Weight Loss in Morbidly Obese Patients Undergoing Gastric Banding

BACKGROUND

Variability in weight loss has been observed from morbidly obese patients receiving bariatric operations. Genetic effects may play a crucial role in this variability.

METHODS

304 morbidly obese patients (BMI > or =39) were recruited, 77 receiving laparoscopic adjustable gastric banding (LAGB) and 227 laparoscopic mini-gastric bypass (LMGB), and 304 matched non-obese controls (BMI < or =24). Initially, all subjects were genotyped for 4 SNPs (single nucleotide polymorphisms) on UCP2 gene in a case-control study. The SNPs significantly associated with morbid obesity (P < 0.05) were considered as candidate markers affecting weight change. Subsequently, effects on predicting weight loss of those candidate markers were explored in LAGB and LMGB, respectively. The peri-operative parameters were also compared between LAGB and LMGB.

RESULTS

The rs660339 (Ala55Val), on exon 4, was associated with morbid obesity (P = 0.049). Morbidly obese patients with either TT or CT genotypes on rs660339 experienced greater weight loss compared to patients with CC after LAGB at 12 months (BMI loss 12.2 units vs 8.1 units) and 24 months (BMI loss 13.1 units vs 9.3 units). However, this phenomenon was not observed in patients after LMGB. Although greater weight loss was observed in patients receiving LMGB, this procedure had a higher operative complication rate than LAGB (7.5% vs. 2.8%; P < 0.05).

CONCLUSION

Ala55Val may play a crucial role in obesity development and weight loss after LAGB. It may be considered as clinicians incorporate genetic susceptibility testing into weight loss prediction prior to bariatric operations.

Palatal Ulcers due to Vomiting after Gastric Band Tightening

Adjustable gastric banding is a widely used modality in some countries for the treatment of morbid obesity, and several complications have been reported. We report the unusual case of a patient who developed bilateral ulcers of the palate after intense vomiting caused by tightening of her gastric band.

Benchmarking hospital outcomes for laparoscopic adjustable gastric banding

BACKGROUND

Since the Food and Drug Administration (FDA) approval of laparoscopic adjustable gastric bands (LAGB) in June 2001, the number LAGB procedures performed in the United States has increased exponentially. This study aimed to benchmark the authors' initial hospital experience to FDA research trials and evidence-based literature.

METHODS

Over a 2-year period, 87 consecutive patients with a mean age of 43 years (range, 21-64 years) and a body mass index of 45.6 kg/m2 (range, 35-69 kg/m2) underwent an LAGB procedure at the authors' institution. The authors conducted a retrospective review of the outcomes including conversion, reoperation, mortality, perforation, erosion, prolapse, port dysfunction, excess weight loss, and changes in comorbidities, then compared the data with published benchmarks.

RESULTS

Gender, age, and body mass index were comparable with those of other series. Perioperative adverse events included acute stoma obstruction (n = 1) and respiratory complications (n = 2). Delayed complications included gastric prolapse (n = 4) and port reservoir malposition (n = 4). Five bands were explanted. The mean follow-up period was 14 months (n = 79). The mean percentage of excess weight loss was 30% (range, 4.7-69%) at 6 months, 41% (range, 9.6-82%) at 12 months, and 47% (range, 14-92%) at 24 months. Comorbidities resolved included diabetes (74%), hypertension (57%), gastroesophageal reflux disease (55%) and dyslipidemia (38%).

CONCLUSIONS

The short-term outcomes for LAGB were comparable with published benchmarks. With adequate weight loss, most patients achieve significant improvement in obesity-related illnesses. With new bariatric accreditation standards and mandates required for financial reimbursement, hospitals will need to demonstrate that their clinical outcomes are consistent with best practices. The authors' early experience shows that LAGB achieves significant weight loss with low mortality and morbidity rates. Despite a more gradual weight loss, most patients achieve excellent weight loss with corresponding improvement of comorbidities within the first 2 years postoperatively.

Bariatric surgery: a review of procedures and outcomes

The prevalence of obesity has increased in recent decades, and obesity is now one of the leading public health concerns on a worldwide scale. There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgery procedures performed has risen dramatically in recent years. This review will summarize historic and contemporary bariatric surgical techniques, including gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion (with or without duodenal switch). Data are presented on bariatric surgery outcomes, focusing on weight loss and obesity-related comorbidities. We also review possible complications from surgery. Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive presurgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. In addition, comprehensive presurgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Further research focused on presurgical variables that predict outcome-especially the longer term outcome-of bariatric surgery is needed. At present, approximately 1% of eligible individuals with morbid obesity receive bariatric surgery. In addition, there appears to be inequity in access to weight loss surgery. Given the accumulating evidence that bariatric surgery is efficacious in producing significant and durable weight loss, improving obesity-related comorbidities, and extending survival, the U.S. healthcare system should examine ways to improve access to this treatment for obesity.

Short- and long-term results of laparoscopic gastric banding for morbid obesity

BACKGROUND

Today, gastric banding has become a common bariatric procedure. Weight loss can be excellent, but is not sufficient in a significant proportion of patients. Few long-term studies have been published. We present our results after up to 9 years of follow-up.

MATERIALS AND METHODS

One hundred twenty-seven patients (1997-2004) were analyzed retrospectively after laparoscopic gastric banding (perigastric technique: n = 60; pars flaccida technique: n = 67) in terms of preoperative characteristics, weight loss, comorbidities, short- and long-term complications, and quality of life.

RESULTS

Median follow-up was 63 months (range 2-104). Incidence of postoperative complications were: gastric perforation in 3.1%, band erosion in 3.1%, band or port leak in 2.3%, port infection in 5.3%, port dislocation in 6.9%, and pouch dilatation in 16.9%. Total number of patients requiring reoperation was 34 (26.7%) [perigastric technique n = 23 (38.8%) versus pars flaccida technique n = 11 (16%), p = 0.039]. Mean excess body weight loss (%) was 50.6%. Most patients reported an increase in quality of life after surgery.

CONCLUSIONS

Gastric banding is effective for achieving weight loss and improving comorbidity in obese patients. Obviously, gastric banding can be performed more safely with the pars flaccida technique, although the complication rate remains relatively high. Nevertheless, based on adequate patient selection, gastric banding should still be considered a valuable therapeutic option in bariatric surgery.

Laparoscopic Adjustable Gastric Banding Surgery for Morbid Obesity: Imaging of Normal Anatomic Features and Postoperative Gastrointestinal Complications

OBJECTIVE

The purpose of this essay is to describe the normal anatomic findings after laparoscopic adjustable gastric banding surgery and the imaging findings of postoperative gastrointestinal complications.

CONCLUSION

With the increasing prevalence of morbid obesity, laparoscopic adjustable gastric banding surgery has evolved to be a leading surgical technique. Radiologists need to be familiar with the normal anatomic findings after laparoscopic adjustable gastric banding surgery and with the imaging findings of postoperative complications.

Weight loss and improvement of obesity-related illness following laparoscopic adjustable gastric banding procedure for morbidly obese patients in Taiwan

BACKGROUND/PURPOSE

Laparoscopic adjustable gastric banding (LAGB) is a newly developed minimally invasive surgical procedure for the treatment of morbid obesity. This study was conducted to evaluate body weight loss, surgical complications, and comorbidities after LAGB surgery.

METHODS

Ninety-one morbidly obese patients (mean age, 31.2 years; mean preoperative weight, 120.8 kg) underwent LAGB in a private Taiwan hospital setting within a comprehensive multidisciplinary bariatric program. Patients were followed up to 36 months. Comorbidities were assessed in 55 patients who completed more than 12 months of follow-up by comparing each comorbid condition before surgery and during follow-up.

RESULTS

All procedures were performed laparoscopically with no conversion. Mean operation time was 88.7 +/- 32.9 minutes. There were no intraoperative or major postoperative complications. Minor complication of stoma stenos is occurred in three (3.3%) patients. At 36 months after surgery, mean body mass index had decreased from 42.7 to 33.9 kg/m2, and mean percentage of excess weight loss was 44.8%. Late complications were as follows: intractable vomiting requiring band removal in one (1.1%) patient, tubing problems requiring revision surgery in four (4.3%), and stoma obstruction in two (2.1%). There was no mortality. Resolution or improvement of comorbidities was significant for hyperglycemia and diabetes-related index, dyslipidemia, abnormal liver function, hyperuricemia, sleep apnea, and arthralgia, but not for hypertension.

CONCLUSION

LAGB provides good weight loss and significant reduction in comorbidities with few minor complications.

New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery

Endoluminal and transgastric procedures are evolving concepts that combine the skills and techniques of flexible endoscopy with minimally invasive surgery. Precisely how this technology and skill set will be applied in the field of general surgery is not yet known, but the treatment of obesity with an endoluminal or transgastric procedure holds great promise. As the demand for bariatric surgery increases, efforts will be directed toward developing less morbid and less costly treatment options that can provide substantial weight loss and resolution of comorbid conditions. Natural orifice bariatric procedures may include short-term weight loss in preparation for a definitive laparoscopic procedure, revisional procedures to reduce stoma or pouch size or repair fistulas, or primary therapy that provides durable weight loss. The latter application will undoubtedly appeal to patients and referring physicians if it can be performed as an outpatient procedure with significantly less morbidity than a laparoscopic procedure. Early preclinical and clinical work has been published in this area, but many technical obstacles must be overcome before a primary endoluminal or transgastric bariatric procedure can be offered. This article reviews the endoluminal and transgastric technology currently available, the endoluminal procedures currently performed, and the future of these technologies with respect to bariatric surgery.

Conservative management of esophageal perforation following obesity surgery

CONTEXT

Laparoscopic adjustable silicone gastric banding (LASGB) is one of the several surgical techniques for treating patients with morbid obesity. Erosion and perforation in the gastric chamber caused by LASGB are rare complications that have already been described. There have not yet been any reports of perforation of the middle esophagus during this procedure.

CASE REPORT

The authors describe the case of a patient who presented the complication of very extensive perforation of the middle third of the esophagus following LASGB. This was successfully managed using conservative treatment.

Pouch enlargement and band slippage: two different entities

BACKGROUND

Pouch enlargement and band slippage are the most common late complications of laparoscopic adjustable gastric banding (LAGB). Often, confusion exists among surgeons regarding the denomination or even the treatment of these two different entities. This study aimed to establish the differences in clinical presentation, radiologic features, and management between pouch enlargement and band slippage. The authors hypothesized that pouch enlargement can be managed nonoperatively (via band deflation), that band slippage is an acute complication requiring surgical treatment, and that tailored adjustment allows earlier diagnosis of pouch enlargement in asymptomatic patients.

METHODS

From March 2001 to December 2004, 516 patients underwent LAGB placement. Barium swallow was performed preoperatively, postoperatively, and during band adjustments ("tailored adjustment"). Pouch enlargement was defined as dilation of the pouch, and band slippage was considered when band and stomach were prolapsed. Four radiologic types of pouch enlargement were considered: band 45 degrees, band 45 degrees with covering of the band, band 0 degrees, and band smaller than 0 degrees.

RESULTS

A total of 1,600 barium swallows were performed with 516 patients. As a result, pouch enlargement was diagnosed for 61 patients (12%) and band slippage for 12 patients (2%).

CONCLUSION

In this study, pouch enlargement was found to be a chronic complication that can be managed conservatively with a 77% success rate. Tailored adjustment allows early diagnosis of pouch enlargement, thus preventing adjustments in patients with undiagnosed pouch enlargement. Surgical treatment should be considered when medical treatment fails. By comparison, band slippage is an acute complication that requires surgical treatment in every case (100%).

Obesity in the United States: is there a quick fix? Pros and cons of bariatric surgery from the pediatric perspective

Bariatric surgery has become a standard of care for the treatment of severely obese adults who meet National Institutes of Health criteria. Unfortunately, there is a need for weight loss surgery in adolescents. Criteria developed for adolescents are generally more restrictive than those for adults due to concerns about the ability of children to consent for life-altering surgery and the lack of long-term results. Several preliminary series have reported adolescent bariatric procedures with promising results. The two primary bariatric procedures performed on adolescents are Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). Each procedure has its advantages and disadvantages. RYGB has the longest follow-up results and is considered the "gold standard." AGB has promising results, is reversible, and can be performed with less morbidity and mortality.

Resting energy expenditure and fuel metabolism following laparoscopic adjustable gastric banding in severely obese women: relationships with excess weight lost

BACKGROUND

Although adjustable gastric banding is increasingly proposed for massively obese patients, little is known about the modifications of resting metabolic rate and substrate oxidation or about metabolic determinants of weight loss following this type of bariatric surgery.

OBJECTIVES

To evaluate the relationships between excess weight loss, resting metabolic rate (RMR) and substrate oxidation, and to identify metabolic predictive factors of weight loss after adjustable gastric banding.

SUBJECTS

Seventy-three obese nondiabetic women aged 39.1+/-10.4 years (18.4-64.8).

DESIGN

Resting metabolic rate and substrate oxidation (indirect calorimetry), body composition (bio-impedance), lipid profile and insulin sensitivity indexes were assessed before and after (13.3+/-6.0 months, range 6.0-31.1) adjustable gastric banding. Patients were classified according to postsurgery time: group A (6-12 months, n=39); group B (12-18 months, n=21); group C (>18 months, n=13). Metabolic parameters associated with the percentage of excess weight lost (EWL) 1 year after surgery were analyzed in univariate and multivariate regressions.

RESULTS

Mean weight loss was 26.2+/-11.4 kg. Mean fat mass loss was 17.3+/-8.1 kg. All biological parameters associated with excess weight improved after surgery. Excess weight lost at 1 year was 45.9+/-17.1% in group A, 47.4+/-17.1% in group B and 51.4+/-18.5% in group C (P=NS). Resting metabolic rate/fat-free mass (FFM) slightly decreased (28.9+/-3.26 vs 30.3+/-2.8, P<0.00001) and RMR/body weight slightly increased (18.5+/-2.8 vs 17.3+/-1.9, P<0.00001) after surgery. Respiratory quotient (0.81+/-0.06 vs 0.82+/-0.05) and FFM-adjusted lipid oxidation (1.10+/-0.41 vs 1.05+/-0.33 mg/min/kg FFM) were not significantly modified after surgery. In multiple linear regression analysis, difference in RMR/body weight, difference in energy sparing, baseline BMI and postsurgery time, were significantly and independently correlated with EWL (total R2=72.5%).

CONCLUSIONS

Adjustable gastric banding promotes gradual but sustained weight loss and is associated with long-term conservation of lipid oxidation and energy expenditure. The individual variability in energy sparing mechanisms predicts weight loss during the first year after surgery.

Implantable gastric stimulation to achieve weight loss in patients with a low body mass index

This report describes the authors' early outcomes with implantable gastric stimulation (IGS) used to achieve weight loss in patients with a low body mass index (BMI). After prescreening of potential candidates with a selection algorithm, 24 patients (21 women and 3 men) with a low BMI (30-34.9) underwent IGS implantation at two centers. The patients had a mean age of 43 years (range, 32-60 years), a mean BMI of 33 (range, 30-36), and a mean weight of 92 kg (range, 80-117 kg). At this writing, 6 months postoperatively, there have been no serious adverse events related to the device. The mean percentage of excess weight loss (EWL) was 5.9%, with three patients explanted because of noncompliance. The mean waist circumference decreased 5.8%, which was significant (p = 0.009). A subset of nine patients (37.5%) had an EWL exceeding 10% (mean, 20.1%). A subset of low BMI patients lost a clinically significant amount of weight with IGS within 6 months. Further study is required for better identification of potential candidates for this novel approach.

Early U.S. outcomes of laparoscopic gastric bypass versus laparoscopic adjustable silicone gastric banding for morbid obesity

Laparoscopic gastric bypass (LGBP) is the gold standard operation for long-term weight control in the United States. Laparoscopic adjustable silicone gastric banding (LASGB) is the preferred operative method for morbid obesity worldwide. Limited data are available comparing the two procedure in the United States. This study compares weight loss, complications, and early outcome of comorbidity resolution in patients who underwent LGBP versus LASGB. A review of prospectively collected data was performed on 392 patients undergoing primary LGBP (n = 232) and LASGB (n = 160) procedures between February 2001 and July 2004. Differences in percentage excess weight lost (%EWL) at 3, 6, 12, 18, and 24 months postop, improvement or resolution of comorbidities, and complications across procedure types were evaluated. Mean initial body mass index between groups was not significantly different (LGBP 47.2 vs LASGB 47.1, p < 0.53). There were significant differences in age, gender, and self-reported sweet-eating behavior between operative groups. There was a significantly greater %EWL in patients who underwent LGBP compared to patients of the LASGB groups 3, 6, 12, and 18 months after surgery. There were no significant differences in resolution or improvement of comorbidities between the groups. Although LGBP patients experienced more complications compared to LASGB patients (5.6 vs 4.3%, respectively; p < 0.56), this did not reach statistical significance. Early after surgery, LGBP patients lose more weight than LASGB patients but have similar improvements in comorbidities. Further follow-up is needed to determine the relative long-term efficacy of these procedures.

Laparoscopic adjustable gastric banding: 1,014 consecutive cases

BACKGROUND

The purpose of this study was to examine 1,014 consecutive laparoscopic adjustable gastric banding (LAGB) procedures with up to 48 months of followup, including evolution and changes in surgical technique, learning curve issues, weight loss outcomes, and complications.

STUDY DESIGN

Between October 2000 and December 2004, 1,014 consecutive patients (81.8% women, mean age 42.3 years, mean body mass index 47.7 +/- 8.6 kg/m(2)) underwent LAGB operation at our center. Perigastric dissection was used in the first 44 patients; pars flaccida technique was used for the latter 970 patients. Fluoroscopy-guided adjustments were performed and patients received intensive followup.

RESULTS

Excess weight loss at 12, 24, 36, and 48 months was 40.5 +/- 17%, 52.9 +/- 19.5%, 62 +/- 20.9%, and 64.3 +/- 19%, respectively, with data available in > 85% of patients who had reached each of the time intervals. Patients with lower preoperative body mass index had higher excess weight loss initially, but this difference was not apparent at 3 and 4 years' followup. At 36 and 48 months, respectively, 73.5% and 75% of patients had > 50% excess weight loss. Perigastric dissection led to 9 of 44 (20.5%) slippages, compared with 14 of 970 (1.4%) with pars flaccida technique. Other complications included 2 erosions (0.2%), 5 tubing breaks (0.5%), 7 access port problems (0.7%), and 14 acute stoma obstructions (1.4%). Eight (0.8%) bands were explanted. No deaths occurred.

CONCLUSIONS

LAGB can achieve effective and safe weight loss. Change from perigastric to pars flaccida technique reduced slippage rate. Preoperative body mass index alone was not found to be a predictor of effective weight loss in the longterm.

Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome

OBJECTIVE

To evaluate the effects of surgical weight loss on fatty liver disease in severely obese patients.

SUMMARY BACKGROUND DATA

Nonalcoholic fatty liver disease (NAFLD), a spectrum that extends to liver fibrosis and cirrhosis, is rising at an alarming rate. This increase is occurring in conjunction with the rise of severe obesity and is probably mediated in part by metabolic syndrome (MS). Surgical weight loss operations, probably by reversing MS, have been shown to result in improvement in liver histology.

METHODS

Patients who underwent laparoscopic surgical weight loss operations from March 1999 through August 2004, and who agreed to have an intraoperative liver biopsy followed by at least one postoperative liver biopsy, were included.

RESULTS

There were 70 patients who were eligible. All patients underwent laparoscopic operations, the majority being laparoscopic Roux-en-Y gastric bypass. The mean excess body weight loss at time of second biopsy was 59% +/- 22% and the time interval between biopsies was 15 +/- 9 months. There was a reduction in prevalence of metabolic syndrome, from 70% to 14% (P < 0.001), and a marked improvement in liver steatosis (from 88% to 8%), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%; all P < 0.001). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to improvement of 82% (P < 0.001) in grade and 39% (P < 0.001) in stage of liver disease.

CONCLUSION

Surgical weight loss results in significant improvement of liver morphology in severely obese patients. These beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.

Nonsurgical and surgical treatment of obesity

An increasing number of morbidly obese patients are presenting for surgery, with the potential for increased perioperative morbidity and mortality. This article reviews surgical and nonsurgical options in the management of morbidly obese patients. Overweight and obese individuals should be treated with diet, exercise, and behavioral therapy. The failure of this approach is an indication for pharmacologic therapy. Bariatric surgery reduces obesity-related complications and reduces long-term morbidity, mortality, and health care resources use.

Gastric Banding: chirurgisch-technische Aspekte

Morbid obesity (body mass index >40 kg/m(2)) is a risk factor for cardiovascular, pulmonary, metabolic, neoplastic, and psychologic sequelae. Laparoscopic adjustable gastric banding (LAGB) has been established for more than 10 years as a good, safe therapy for morbid obesity if strict operational indications are observed and there is multidisciplinary, long-term follow-up. The technical aspects of LAGB are important for its long-term success. The pars flaccida technique is standard and leads to fewer complications. The bands should be placed above the bursa omentalis. Different types of bands are available. Band fixation by suturing with nonabsorbable stitches prevents slippage. The port system also must be fixated by nonabsorbable sutures.

[Evidential basis in bariatric surgery]

Bariatric surgery is currently considered the best treatment option for morbid obesity. With the rapid development of laparoscopic techniques, a significant increase in the number bariatric procedures in recent years can be observed. Various surgical techniques to treat morbid obesity have been described, but only few prospective studies compare the different procedures, leading to a lack of evidence for their use. However, from the available literature some general recommendations can be given: (a) preoperative workup in an interdisciplinary team is mandatory, (b) primary bariatric procedures should be performed laparoscopically, and (c) the combination of restrictive and malabsorptive techniques is more efficient than a purely restrictive method, which is also true for the treatment of comorbid diabetes and arterial hypertension. In this paper, we present recent developments in bariatric surgery, with special emphasis on the available evidence for the best treatment of morbidly obese patients.

Laparoscopic revisional bariatric surgery: myths and facts

BACKGROUND

Bariatric surgery is growing worldwide. An increasing number of patients will require revisional procedures because of inadequate weight control, complications, or loss of quality of life.

METHODS

From August 1999 to September 2003, 62 patients were submitted to laparoscopic revisional surgery.

RESULTS

The primary operations consisted of laparoscopic adjustable gastric banding in 39 cases, banded and nonbanded Roux-en-Y gastric bypass (RYGB) in 17 cases, vertical banded gastroplasty in 4 cases, and biliopancreatic diversion in 2 cases. Although technically demanding, laparoscopic conversion to RYGB was possible in all cases. Mean operative time was 100 min. Mean hospital stay was 77 h. There were no intraoperative or postoperative complications. A good body mass index reduction after the revisional procedure was observed with a 24 month follow-up period.

CONCLUSIONS

Laparoscopic revisional bariatric surgery is safe and effective. However, it should be performed only by experienced bariatric and laparoscopic surgeons.

Metabolic risk factors in formerly obese women--effects of a pronounced weight loss by gastric band operation compared with weight loss by diet alone

AIM

The aim of the present study was to evaluate differences in the metabolic risk profile in formerly obese women, in whom a significant weight loss was obtained by Swedish adjustable gastric band (SAGB) operation or by diet alone.

METHODS

A total of 40 patients (24 after SAGB and 16 after diet) participated in the study. Clinical data, including body mass index (BMI), waist-to-hip ratio, body fat content and blood pressure values, as well as laboratory results [fasting glucose, insulin, homeostasis model assessment (HOMA) index, leptin, lipid values and markers of subclinical inflammation] were evaluated before a planned abdominoplastic operation.

RESULTS

Patients in the SABG group had lost a significantly greater amount of weight (52.7 +/- 10.0 kg) compared with the diet group (20.0 +/- 11.5 kg; p < 0.001), and the percent excess weight loss was 69.1 +/- 11.4 in the SAGB group and 54.5 +/- 17.7 (p < 0.040) in the diet group. Before the abdominoplastic operation neither the mean BMI nor the percentage of fat mass revealed a significant difference between the groups. Fasting insulin (6.1 +/- 3.0 microU/ml) and the HOMA index (1.4 +/- 0.7) as a measure of insulin resistance were significantly lower in the SAGB than in the diet group (fasting insulin: 8.2 +/- 3.8 microU/ml; p < 0.048; HOMA index: 2.0 +/- 1.0; p < 0.031). Swedish adjustable gastric band patients showed significantly lower plasma leptin levels (9.4 +/- 10.8 ng/ml) than the dietary-treated patients (13.9 +/- 9.6 ng/ml; p < 0.014), while tumour necrosis factor-alpha serum levels were increased in the SAGB group (17.6 +/- 7.3 pg/ml) compared with the diet group (11.9 +/- 0.49 pg/l; p < 0.048).

CONCLUSIONS

The extensive weight loss in formerly obese women after SAGB operation was paralleled by a favourable metabolic profile indicating a higher degree of insulin sensitivity than in women after a successful, but less pronounced weight loss by diet alone.

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.

Risk factors for the intermediate outcome of morbid obesity after laparoscopically placed adjustable gastric banding

BACKGROUND

The overall long-term results of medical treatment for morbid obesity are poor. Surgery is the only treatment option to obtain long-term weight reduction. Analysis of risk factors for treatment success of laparoscopically placed gastric banding (LGB) has not been available until now.

METHODS

Prospective study with 99 patients with LGB between January 1997 and July 2003. The parameters assessed as risk factors included onset of obesity, feeling of postprandial satiety, and initial body mass index (BMI).

RESULTS

Median follow-up was 36 months (3 to 72). Independent prognostic factors of excess body weight reduction (>25%) were for the first postoperative year: onset of obesity as an adolescent (relative risk [RR] 0.21), an initial BMI <45 kg/m(2) (RR 4.76), and a BMI between 45.1 and 50 kg/m(2) (RR 3.23). After the second year, independent prognostic factors were as follows: feeling of postprandial satiety (RR 5.26) and an initial BMI <45 kg/m(2) (RR 3.03).

CONCLUSION

LGB is suitable to achieve intermediate weight reduction in patients with morbid obesity. To obtain the best results, patients should be treated before they achieve a BMI >45 kg/m(2). Additionally a postprandial feeling of satiety after LGB is mandatory for good long-term results.

Laparoscopic gastric banding: a prospective, randomized study comparing the Lapband and the SAGB: early results

OBJECTIVE

The objective of this study was to evaluate the results of laparoscopic gastric banding using 2 different bands (the Lapband [Bioenterics, Carpinteria, CA] and the SAGB [Swedish Adjustable Gastric Band; Obtech Medical, 6310 Zug, Switzerland]) in terms of weight loss and correction of comorbidities, short-and long-term complications, and improvement of quality of life in morbidly obese patients

SUMMARY BACKGROUND DATA

During the past 10 years, gastric banding has become 1 of the most common bariatric procedures, at least in Europe and Australia. Weight loss can be excellent, but it is not sufficient in a significant proportion of patients, and a number of long-term complications can develop. We hypothesized that the type of band could be of importance in the outcome.

METHODS

One hundred eighty morbidly obese patients were randomly assigned to receive the Lapband or the SAGB. All the procedures were performed by the same surgeon. The primary end point was weight loss, and secondary end points were correction of comorbidities, early- and long-term complications, importance of food restriction, and improvement of quality of life.

RESULTS

Initial weight loss was faster in the Lapband group, but weight loss was eventually identical in the 2 groups. There was a trend toward more early band-related complications and more band infections with the SAGB, but the study had limited power in that respect. Correction of comorbidities, food restriction, long-term complications, and improvement of quality of life were identical. Only 55% to 60% of the patients achieved an excess weight loss of at least 50% in both groups. There was no difference in the incidence of long-term complications.

CONCLUSIONS

Gastric banding can be performed safely with the Lapband or the SAGB with similar short- and midterm results with respect to weight loss and morbidity. Only 50% to 60% of the patients will achieve sufficient weight loss, and close to 10% at least will develop severe long-term complications.