Laparoscopic adjustable gastric band survival in a high-volume bariatric unit

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed.

RECENT FINDINGS

Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness.

CONCLUSION

Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.

Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding

BACKGROUND

Over recent decades, laparoscopic adjustable gastric banding (LAGB) has been among the most common bariatric surgeries. Nowadays, many patients require revision surgery due to insufficient weight loss and band-related complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most common revision surgeries for failed LAGB, but the conclusions about their efficacy and safety have been inconsistent. This meta-analysis aimed to review the clinical outcomes of SG and RYGB after failed LAGB.

METHODS

In accordance with the PRISMA guidelines, the PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for articles that had studied the efficacy and safety of SG and RYGB. The most appropriate effects model was chosen based on the heterogeneity of the articles included in this meta-analysis. Statistical analysis was conducted using Stata 14.0.

RESULTS

Of 586 articles that were retrieved, 16 articles which examined 2141 SG and 2990 RYGB patients met the inclusion criteria. The patients in RYGB groups showed increased percent excess weight loss (%EWL) at 12 and 24 months after revision surgery but no statistically significant change was found about %EWL after 3, 6, or 36 months. In addition, RYGB was associated with a higher rate of complications, interventions, and readmission in addition to being of more operative time.

CONCLUSIONS

This review suggested that RYGB was more effective at demonstrating weight loss after 12 and 24 months, but comparisons of the long-term efficacy of RYGB with that of SG remain inconclusive. In addition, RYGB was accompanied by a greater number of post-operative complications, interventions, and readmissions. Thus, surgeons should consider the overall status of the patients and their comorbidities as crucial factors when selecting a form of revision surgery. Additional high-quality randomized controlled studies are required to further compare the efficacy and safety of these treatments with longer follow-up times.

Public cost of privately inserted laparoscopic adjustable gastric bands

Background

Laparoscopic adjustable gastric banding (LAGB) remains a commonly performed procedure for morbid obesity. Concerns regarding its long‐term consequences include high rates of band removal from complications and failure to lose weight. Many private practices continue to perform LAGB but, owing to short follow‐up periods, the burden of surgical complications falls upon National Health Service (NHS) bariatric units. This study aimed to review the NHS treatment of patients for complications related to privately performed LAGB.

Methods

All surgical complications following bariatric surgery referred to the Welsh Institute of Metabolic and Obesity Surgery (WIMOS) between September 2010 and September 2014 were reviewed. Type of complication, procedures performed, and number of outpatient attendances and inpatient stays were recorded. Costs of treatment were estimated using standard tariffs.

Results

A total of 78 patients presented with complications after privately performed bariatric surgery. Sixty had undergone LAGB; the remainder had had other bariatric procedures. Median age was 45 (range 22–78) years, and 65 (83 per cent) were women. Urgent band deflation was undertaken in 53 patients. Band removal surgery was required in 32 patients; one patient needed a subtotal gastrectomy. There was a total of 123 outpatient/ward attendances and 340 days of inpatient care, including 10 days of intensive care. The estimated total cost to the NHS of managing these patients was €337 400 (€84 350 per annum).

Conclusion

The cost burden to the NHS of managing the complications of bariatric surgery performed in the private sector is considerable. Although it is imperative that such complications be managed in well equipped specialist units, private surgery providers should have better follow‐up plans and/or contractual agreements with the NHS.

Health Care Institutions Volume Is Significantly Associated with Postoperative Outcomes in Bariatric Surgery

PURPOSE

The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level.

MATERIALS AND METHODS

A cross-sectional analysis of all patients who underwent bariatric surgery procedure in France from January 2011 to December 2014 was designed. Volume-outcome relationship was analyzed using generalized estimating equations.

RESULTS

We identified 184,332 inpatient stays for bariatric surgical procedures performed in 606 hospitals. Health care institutions performing more than 200 bariatric cases per year were significantly associated with shorter average length of stay (p < 0.001) and less frequent need for intensive or critical care unit (p = 0.003) during the index stay in comparison with lower volume institutions. Reoperations rate increased from 3.1% [95% CI, 2.8-3.3] (n = 5627) at 1 month to 4.9% [4.6-5.2] at 3 months and 8.2% [7.8-8.7] at 6 months. The risk of reoperation after gastric bypass was 1.37 times less frequent in higher volume institutions (≥ 200 inpatient stays per year, p = 0.003), while it was 1.26 times more frequent after gastric banding in higher volume institutions (p = 0.057) and was unaltered regarding sleeve gastrectomy (p = 0.819).

CONCLUSION

This study showed for the first time in bariatric surgery that reoperation rate after gastric bypass or sleeve significantly increased at 3 and 6 months postoperatively. Health care institutions performing more than 200 bariatric cases per year were significantly associated with improved postoperative outcomes and less frequent need for reoperation.

Prospective, double center, 1-year results of adjustable gastric banding with MIDBAND (gastro-gastric suture vs. non-gastro-gastric suture)

Purpose

Although laparoscopic adjustable gastric banding (LAGB) is a popular bariatric procedure, few comprehensive studies have been investigated on the use of non-gastro-gastric sutures (NGGSs) for decreasing postoperative complications. This study aimed to assess and compare the safety and effectiveness of MIDBAND with or without gastro-gastric sutures (GGSs).

Methods

Between February 2013 and March 2014, 41 severely obese patients underwent primary LAGB using pars flaccid technique at double center in South Korea. Excess weight loss, operative time and postoperative complications were assessed and compared between a GGS group (group 1) and a NGGS group (group 2), and patients were followed monthly for 1 year.

Results

Mean body mass indices in groups 1 and 2 were 38.4 ± 4.7 and 38.9 ± 5.0 kg/m², respectively, and mean percentage excess weight losses (%EWLs) were 59.9% ± 28.4% and 50.9% ± 20.0%, respectively, at 6 months, and 75.8% ± 26.6% and 72.5% ± 27.5%, respectively, at 12 months, and these intergroup differences of %EWL were not significant (P = 0.256 and P = 0.704, respectively). Mean operative time (57.2 minutes) was shorter in group 2 than in group 1 (79.2 minutes) (P < 0.001). In terms of complications, pouch dilatation rates were similar in the 2 groups, and no case of gastric band erosion was encountered.

Conclusion

Operative time was shorter in the NGGS group, and pouch dilatation rates and %EWL were similar in the 2 groups. We conclude NGGS using MIDBAND is both straightforward and effective. A long-term prospective comparative study is needed to demonstrate the safety and efficacy of NGGS.

Revisional bariatric surgery after failed laparoscopic adjustable gastric banding - a single-center, long-term retrospective study

Introduction

Laparoscopic adjustable gastric banding (LAGB) used to be one of the most popular bariatric procedures.

Aim

To present our institution’s experience with LAGB, its complications, causes of failure and revisional bariatric procedures, in a long-term follow-up.

Material and methods

Records of patients who underwent pars flaccida LAGB from 2003 to 2006 were gathered. We selected data on patients with a history of additional bariatric procedures. Their initial demographic data, body mass index and causes of revision were gathered. We analyzed length of stay and early perioperative complications.

Results

60% of patients (n = 57) who underwent LAGB in our institution between 2003 and 2006 had their band removed (out of 107, 11% lost to follow-up). Median time to revisional surgery was 50 months. The main reasons for removal were: weight regain (n = 23; 40%), band slippage (n = 14; 25%), and pouch dilatation (n = 9; 16%). Thirty (53%) patients required additional bariatric surgery, 10 (33%) of which were simultaneous with band removal. The most popular procedures were: laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 15; 50%), open gastric bypass (n = 8; 27%), and laparoscopic sleeve gastrectomy (LSG) – (n = 3; 10%). Mean length of stay (LOS) was 5.4 ±2.0. One (3%) perioperative complication was reported.

Conclusions

The results show that LAGB is not an effective bariatric procedure in long-term follow-up due to the high rate of complications causing band removal and the high rate of obesity recurrence. Revisional bariatric surgery after failed LAGB may be performed in a one-stage approach with band removal.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

BACKGROUND

Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years.

PATIENTS AND METHODS

Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months.

RESULTS

The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months.

CONCLUSIONS

If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.