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

High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid obesity

OBJECTIVE

To report the results from one of the eight original U.S. centers performing laparoscopic adjustable silicone gastric banding (LASGB), a new minimally invasive surgical technique for treatment of morbid obesity.

SUMMARY BACKGROUND DATA

Laparoscopic adjustable silicone gastric banding is under evaluation by the Food & Drug Administration in the United States in an initial cohort of 300 patients.

METHODS

Of 37 patients undergoing laparoscopic placement of the LASGB device, successful placement occurred in 36 from March 1996 to May 1998. Patients have been followed up for up to 4 years.

RESULTS

Five patients (14%) have been lost to follow-up for more than 2 years but at last available follow-up (3-18 months after surgery) had achieved only 18% (range 5-38%) excess weight loss. African American patients had poor weight loss after LASGB compared with whites. The LASGB devices were removed in 15 (41%) patients 10 days to 42 months after surgery. Four patients underwent simple removal; 11 were converted to gastric bypass. The most common reason for removal was inadequate weight loss in the presence of a functioning band. The primary reasons for removal in others were infection, leakage from the inflatable silicone ring causing inadequate weight loss, or band slippage. The patients with band slippage had concomitant poor weight loss. Bands were removed in two others as a result of symptoms related to esophageal dilatation. In 18 of 25 patients (71%) who underwent preoperative and long-term postoperative contrast evaluation, a significantly increased esophageal diameter developed; of these, 13 (72%) had prominent dysphagia, vomiting, or reflux symptoms. Of the remaining 21 patients with bands, 8 currently desire removal and conversion to gastric bypass for inadequate weight loss. Six of the remaining patients have persistent morbid obesity at least 2 years after surgery but refuse to undergo further surgery or claim to be satisfied with the results. Overall, only four patients achieved a body-mass index of less than 35 and/or at least a 50% reduction in excess weight. Thus, the overall need for band removal and conversion to GBP in this series will ultimately exceed 50%.

CONCLUSIONS

The authors did not find LASGB to be an effective procedure for the surgical treatment of morbid obesity. Complications after LASGB include esophageal dilatation, band leakage, infection, erosion, and slippage. Inadequate weight loss is common, particularly in African American patients. More study is required to determine the long-term efficacy of the LASGB

Surgery for obesity

As were most types of gastrointestinal surgery, antiobesity surgery was dominated by the development of laparoscopic techniques during the last decade. The feasibility of performing any primary antiobesity operation safely laparoscopically was convincingly demonstrated during the last 2 years. This represents a significant continued improvement in the perioperative safety of "bariatric" surgery. However, antiobesity surgery entails very much more than technique. Unfortunately, little progress has been made in optimizing patient selection, improving follow-up, and devising strategies for reoperative antiobesity surgery. The latest publications in the field are mainly confirmatory, demonstrating durable medically significant weight loss resulting in comorbidity reduction with increased life expectancy. The most interesting contribution of this surgery is provision of "experimental models" using gastrointestinal physiology to study the pathophysiology of obesity and undernutrition by guaranteeing substantial weight loss maintained long-term. It is unfortunate that surgery for obesity is seriously underutilized.

Surgical aspects and future developments of laparoscopy

Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.

Elevated homocysteine levels with weight loss after Lap-Band surgery: higher folate and vitamin B12 levels required to maintain homocysteine level

OBJECTIVE

To investigate homocysteine levels and their relationship with serum folate and vitamin B12 concentrations with weight loss after the Lap-Band form of gastric restrictive surgery, with the view to minimizing risk.

METHODS

We measured levels of fasting plasma homocysteine (tHcy), folate (serum and RBC) and vitamin B12 in two groups. The study group was 293 consecutive patients at 12 (n=192) or 24 (n=101) months review after surgery. The controls were 244 consecutive patients presenting for this surgery.

RESULTS

The group losing weight had higher geometric mean tHcy levels: 10.4 (95% CI, 9.8-10.8) micromol/l compared with 9.2 (95% CI, 8.9-9.7) in controls (P<0.001). This occurred with higher folate levels and unchanged vitamin B12 levels. Levels of folate and B12 together explained 35% (r (2)) of the homocysteine variance in the weight loss group compared with only 9% (r (2)) in controls (P<0.001). Those taking regular multivitamin supplements had lower tHcy levels: 9.6 (9.1-10.0) micromol/l vs 12.3 (11.4-13.3) in those not taking supplements (P<0.001). A low normal plateau of tHcy levels occurred at levels of folate >15 ng/l and B12)600 ng/ml. A curvilinear relationship exists between these cofactors and tHcy levels, with the dose-response relationship shifted to the right in the weight loss group.

CONCLUSION

This study shows elevated tHcy levels with weight loss, without lower serum folate or vitamin B(12) levels. There is an altered dose-response relationship with higher serum B(12) and folate levels required to maintain recommended tHcy levels. Patients losing weight have significant health benefits; however, they may be at greater risk of vascular events or fetal abnormality in association with raised tHcy levels. Multivitamin supplementation is effective in lowering tHcy levels.

Current status of medical and surgical therapy for obesity

The incidence of obesity (especially childhood obesity) and its associated health-related problems have reached epidemic proportions in the United States. Recent investigations suggest that the causes of obesity involve a complex interplay of genetic, environmental, psychobehavioral, endocrine, metabolic, cultural, and socioeconomic factors. Several genes and their protein products, such as leptin, may be particularly important in appetite and metabolic control, although the genetics of human obesity appear to involve multiple genes and metabolic pathways that require further elucidation. Severe obesity is frequently associated with significant comorbid medical conditions, including coronary artery disease, hypertension, type II diabetes mellitus, gallstones, nonalcoholic steatohepatitis, pulmonary hypertension, and sleep apnea. Long-term reduction of significant excess weight in these patients may improve or resolve many of these obesity-related health problems, although convincing evidence of long-term benefit is lacking. Available treatments of obesity range from diet, exercise, behavioral modification, and pharmacotherapy to surgery, with varying risks and efficacy. Nonsurgical modalities, although less invasive, achieve only relatively short-term and limited weight loss in most patients. Currently, surgical therapy is the most effective modality in terms of extent and duration of weight reduction in selected patients with acceptable operative risks. The most widely performed surgical procedure, Roux-en-Y gastric bypass, achieves permanent (followed up for more than 14 years) and significant weight loss (more than 50% of excess body weight) in more than 90% of patients.

[Laparoscopic gastroplasty for morbid obesity: prospective study of 300 cases]

STUDY AIM

Laparoscopic gastric banding for morbid obesity is noninvasive and reversible. The aim of this prospective study was to report the preliminary results of this procedure in the first 300 patients.

PATIENTS AND METHODS

From April 1997 to January 2000, 300 patients were laparoscopically operated for severe obesity: 266 women, 34 men, with a mean age of 40.1 years (range: 16-66). The mean preoperative weight was 118 kg (range: 85-195) and the mean body mass index (BMI) was 43.6 kg/m2 (range: 35.1-65.8). This is a recent and complete series with a mean follow-up of 10 months (range: 3-31). The primary endpoint was excessive weight loss (EWL) and the secondary endpoints were tolerance and morbidity.

RESULTS

There were no postoperative deaths. The mean operating time was 129 minutes (range: 50-380). A conversion to laparotomy was necessary in 11 patients. The mean hospital stay was 4.76 days (range: 3-42). There were 29 complications (9.6%), 16 among the first 50 procedures: 14 patients underwent an abdominal reoperation (2 perforations, 3 early slippages, 7 late slippages, 2 incisional hernias); 6 had respiratory complications with 2 ARDS and 9 developed a complication related to the port. At one year, BMI decreased from 43.6 to 33.7 kg/m2 and EWL reached 44.2%; 80% of the patients lost 60% of their excess weight.

CONCLUSION

Our experience is encouraging with an acceptable complication rate (5%) after 50 procedures. Slippage remains the main reason for close surveillance. Half of the excess weight can be comfortably lost in one year when the whole medical and surgical staff provide close support for each patient.

Results and complications after adjustable gastric banding in a series of 250 patients

BACKGROUND

Morbid obesity contributes to many health risks including physical, emotional, and social problems. The increasing prevalence of obesity is a major public health concern since obesity is associated with several chronic diseases. Morbid obesity is the biggest independent risk factor for early mortality. Various options for the surgical treatment of morbid obesity have been developed with varying results.

METHODS

Between January 1996 and December 1999, we operated on a series of 250 patients (200 women and 50 men) at the General Surgical Department of the University Hospital in Innsbruck. The parameters that were evaluated included age, preoperative and postoperative body mass index (BMI), type of surgery, and intraoperative and postoperative complications.

RESULTS

The mean follow-up period was 12 months (range 3 to 18). The average preoperative weight was 135.5 kg (BMI 46.69 kg/m(2)). The average total weight-loss was 5.5 kg per month, reaching an average total of 35 kg after one year. The excess weight loss (EWL) after 12 months was 72%. Complications requiring reoperation occurred in 8.8%.

CONCLUSIONS

In the first year after laparoscopic adjustable gastric banding, weight reduction of the study population was excellent. Additionally, the complication rate was reasonable with no mortalities.

A simple technique for laparoscopic vertical banded gastroplasty--the JOVO procedure

A simple technique for laparoscopic vertical banded gastroplasty is described. With the surgeon to the patient's left, four trochars are placed as cephalad as possible. Short gastric vessels are divided and the posterior wall of the stomach mobilized. The ETS-Flex with Articulating Head (Ethicon Endosurgery Inc.) is used to divide the stomach close to a 42-french bougie against the lesser curvature. An additional stapler bite abuts directly against a 28-french bougie to obtain correct stoma size. A ribbon of Prolene mesh is pulled through a tunnel behind the stomach at the apex of the divided gastroplasty and sutured around the distal end of the gastroplasty. To date we have used this method successfully in 5 patients with 1-11 months of follow-up. Although we lack a sufficient number of patients or follow-up for definitive conclusions, we believe this technique will produce good results, as it reproduces exactly that used successfully in open surgery and our early results parallel those following open surgery.

A prospective randomized trial of different laparoscopic gastric banding techniques for morbid obesity

BACKGROUND

Slippage of the stomach is the most common postoperative complication after laparoscopic adjustable silicone gastric banding (LASGB) for morbid obesity. Retrogastric placement (RGP) of the band through the lesser sac can cause posterior slippage Incomplete suturing often is responsible for anterior slippage. A randomized prospective study was constructed to determine whether laparoscopic esophagogastric placement (EGP) is associated with a lower incidence of postoperative slippage and pouch dilation than RGP.

METHODS

Morbid obese patients presenting for LASGB were randomized to undergo either an EGP (n = 50) or an RGP (n = 51). Patients were blinded to which procedure they underwent, and follow-up date were obtained by a blinded independent investigator. Standardized clinical and radiologic controls were used to assess pouch enlargement and slippage.

RESULTS

Operating time was similar for the two procedures (54.5 min for EGP vs 58 min for RGP). There was no significant difference in postoperative weight loss (34 kg after EGP vs 37 kg after RGP within 12 months), esophagus dilation, or postoperative quality of life. There were two postoperative slippages and one pouch dilation in the RGP group and no postoperative complication in the EGP group.

CONCLUSIONS

The placement of a LAP-BAND adjustable gastric banding system by the EGP technique is safe and results in a lower frequency of postoperative complications than its placement by the RGP technique. Clear anatomic landmarks are a benefit to education and to the learning curve for LASGB.

Socioeconomic issues affecting the treatment of obesity in the new millennium

The prevalence of obesity among the populations of most developed countries has increased to such an extent that the healthcare and social security/disability system will accumulate direct and indirect costs related to obesity that will be more substantial than those for any other primary disease within this generation. For the past decade, the Healthcare Financing Agency, which oversees the Medicare and Medicaid programmes, has required all physicians and healthcare agencies serving beneficiaries of these programmes to include diagnoses using codes established by the ninth revision of the World Health Organization's International Classification of Diseases. This coding system actually distorts data collection and undermines appropriate medical insurance reimbursement for the treatment of obesity. Societal prejudices, inability of governmental agencies to address future concerns and the business community's attempts to control healthcare costs without addressing the underlying issues contributing to these costs have led to confusion on how to confront this emerging epidemic. How will we develop the scientific knowledge and the political willpower to confront this epidemic? First, we need more accurate methods for classifying obesity and for measuring the cost of treatment. We can then determine if it is more cost effective to prevent or treat obesity early in its evolution or pay for its consequences in the form of treatment costs associated with its multiple comorbid diseases, such as hypertension, other cardiovascular disorders, diabetes mellitus, osteoarthritis and cancers, plus the lost productivity from absenteeism, premature retirement and death.

Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity

OBJECTIVE

To determine prospectively the results of Roux-en-Y gastric bypass (RYGB) used as the primary weight-reducing operation in patients with medically complicated ("morbid") obesity. The RYGB procedure combines the advantages of a restrictive physiology (pouch of 10 mL) and a "dumping physiology" for high-energy liquids without requiring an externally reinforced (banded) stoma.

PATIENTS AND METHODS

Between April 1987 and December 1998, a total of 191 consecutive patients with morbid obesity (median weight, 138 kg [range, 91-240 kg]; median body mass index, 49 kg/m2 [range, 36-74 kg/m2]), all of whom had directly weight-related morbidity, underwent RYGB and prospective follow-up.

RESULTS

Hospital mortality was 0.5% (1/191), and hospital morbidity occurred in 10.5% (20/191). Good long-term weight loss was achieved, and patients adapted well to the required new eating habits. The mean +/- SD weight loss at 1 year after operation (113 patients) was 52 +/- 1 kg or 68% +/- 2% of initial excess body weight. By 3 years postoperatively (74 patients), weight loss was still 66% +/- 2% of excess body weight. Overall, 53 (72%) of 74 patients had achieved and maintained a weight loss of 50% or more of their preoperative excess body weight 3 years after the operation. In addition, only 1 (1%) of 98 patients had persistent postoperative vomiting 1 or more times per week.

CONCLUSION

We believe that RYGB is a safe, effective procedure for most patients with morbid obesity and thus may be the current procedure of choice in patients requiring bariatrics++ surgery for morbid obesity.

Bariatric surgery. Surgery for weight control in patients with morbid obesity

Morbid obesity has become a health crisis in the United States. Medical programs developed at nonoperative attempts to lose (and maintain) an adequate weight loss are largely unsuccessful. Bariatric surgery has been proven to be effective at inducing and maintaining a satisfactory weight loss to decrease weight-related comorbidity. Bariatric operations include procedures that decrease mechanically the volume capacitance of the proximal stomach (vertical banded gastroplasty, laparoscopic gastric banding) or decrease the proximal gastric capacitance and establish a partial selective malabsorption (gastric bypass and its modifications, partial biliopancreatic bypass, and duodenal switch with partial biliopancreatic bypass). These operations should induce a loss of at least 50% (or more) of excess body weight. Not all patients are candidates for these procedures, and the best results are obtained by a multidisciplinary team (including nutritionist, physician, dietitian, psychologist or psychiatrist interested in eating disorders, and surgeon).

Open versus laparoscopic adjustable silicone gastric banding: a prospective randomized trial for treatment of morbid obesity

OBJECTIVE

To perform the first prospective trial of laparoscopic versus open adjustable silicone gastric banding (ASGB) in patients with morbid obesity.

SUMMARY BACKGROUND DATA

Vertical banded gastroplasty has been used for many years to treat morbid obesity, but the size of the stoma has remained a source of failure after the procedure. ASGB has the advantages of maintaining gastric integrity and the potential for readjustment of the band, if needed. It has been suggested that laparoscopic ASGB, recently introduced to reduce postoperative complications and hospital stay, has a negative impact on outcome.

METHODS

Fifty patients with morbid obesity of >5 years' duration and a body-mass index (BMI) > 40 kg/m2 were randomized to undergo laparoscopic or open ASGB. The difficulty of the procedure, surgical time, postoperative complications, and hospital stay were assessed. Stoma adjustments, long-term complications, readmissions, weight loss, and BMI were determined.

RESULTS

All procedures were successfully carried out. Of 25 patients assigned to laparoscopic ASGB, 2 were converted to an open procedure. Surgical time was significantly longer for laparoscopic ASGB (150 minutes vs. 76 minutes for open ASGB). There was no difference in complications. Mean hospital stay was 5.9 days for the laparoscopic procedure versus 7.2 days for open ASGB (p < 0.05). The total number of readmissions (6 vs. 15) and overall hospital stay in the first year (7.8 vs. 11.8 days) were lower after laparoscopic ASGB (p < 0.05). Weight and BMI were reduced significantly in both groups, but there was no difference between the groups.

CONCLUSION

Laparoscopic and open ASGB were equally effective in terms of early (first-year) weight loss, reduction of BMI, and postoperative complications. The laparoscopic procedure was associated with a shorter initial hospital stay and fewer readmissions during follow-up and is therefore the preferred treatment in morbidly obese patients undergoing ASGB.