Analysis of poor outcomes after laparoscopic adjustable gastric banding. Surg Endosc. 2011;25:41-47. [PMID: 20589514 DOI: 10.1007/s00464-010-1126-7]

Preoperative Localization in Colonic Surgery (PLoCoS Study): a multicentric experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization.

Racial disparities in bariatric surgery postoperative weight loss and patient satisfaction

BACKGROUND

A growing body of evidence has demonstrated racial disparities in bariatric surgery (BS) outcomes. We aimed to investigate the impact of race on postoperative percent excess weight loss (%EWL) and patient satisfaction.

METHODS

Single center retrospective study of patients who underwent BS January 2012 to November 2017. Statistical analysis utilized Chi-squared, ANOVA and multivariable regression.

RESULTS

A total of 378 patients were included. African American patients lost significantly less weight compared to Caucasian and Hispanic patients (39.0 %EWL, 53.4 %EWL and 52.3 %EWL, respectively). A significant difference remained after adjustment for possible confounders. No difference in postoperative satisfaction was found.

CONCLUSIONS

Our study adds to the existing literature demonstrating racial disparities in BS postoperative EWL, despite adjusting for possible confounders, while contributing to the limited literature examining Hispanic patients. Furthermore, we examined an understudied outcome in postoperative patient satisfaction and found no racial disparity despite disparity in EWL.

Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review

While bariatric surgery is an accepted treatment for morbid obesity, the impact of race on surgical outcomes remains unclear. This systematic review aims to compare differences in weight loss and co-morbidity outcomes among various races after bariatric surgery. PubMed, Medline, and SCOPUS databases were queried to identify publications that included more than 1 racial group and reported weight loss outcomes after bariatric surgery. A total of 52 studies were included. Non-Hispanic black (NHB) patients comprised between 5.5% and 69.7% and Hispanic patients comprised between 4.7% and 65.3% of the studies' populations. Definitions of weight loss success differed widely across studies, with percent excess weight loss being the most commonly reported outcome, followed by percent total weight loss and change in body mass index (BMI). Statistical analyses also varied, with most studies adjusting for age, sex, preoperative weight, or BMI. Some studies also adjusted for preoperative co-morbidities, including diabetes mellitus, hypertension, and hyperlipidemia, or socioeconomic status, including income, education, and neighborhood poverty. The majority of studies found less favorable weight loss in NHB compared to Hispanic and non-Hispanic white (NHW), patients while generally no difference was found between Hispanic and NHW patients. The trend also indicates no association between race and resolution of obesity-related co-morbidities. Racial minorities lose less weight than NHW patients after bariatric surgery, although the factors associated with this discrepancy are unclear. The heterogeneity in reporting weight loss success and statistical analyses amongst the literature makes an estimation of effect size difficult. Generally, racial disparity was not seen when examining co-morbidity resolution after surgery. More prospective, robust, long-term studies are needed to understand the impacts of race on bariatric surgery outcomes and ensure successful outcomes for all patients, regardless of race.

Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery

Importance

Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known.

Objective

To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort.

Design, Settings, and Participants

This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed.

Main Outcomes and Measures

Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations.

Results

Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device.

Conclusions and Relevance

Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.

A multidisciplinary approach to laparoscopic sleeve gastrectomy among multiethnic adolescents in the United States

BACKGROUND

Childhood obesity has become a serious public health problem in our country with a prevalence that is disproportionately higher among minority groups. Laparoscopic sleeve gastrectomy (LSG) is gaining attention as a safe bariatric alternative for severely obese adolescents.

STUDY DESIGN

A retrospective study on morbidly obese adolescents that underwent LSG at our institution from 2009 to 2017. Primary outcomes were weight loss as measured by change in BMI and percent excess weight loss (%EWL) at 1 year after surgery, resolution of comorbidities and occurrence of complications.

RESULTS

Thirty-eight patients, of whom 71% were female and 74% were ethnic minorities, underwent LSG between 2009 and 2016. Mean age was 16.8years, mean weight was 132.0kg and mean BMI was 46.7. There were no surgical complications. Mean %EWL was 19.4%, 27.9%, 37.4%, 44.9%, and 47.7% at 1.5, 3, 6, 9, and 12month follow up visits, respectively. Comorbidity resolution rates were 100% for hypertension and nonalcoholic fatty liver disease, 91% for diabetes, 44% for prediabetes, 82% for dyslipidemia and 89% for OSA.

CONCLUSIONS

LSG is an effective and safe method of treatment of morbid obesity in adolescents as it can significantly decrease excess body weight and resolve comorbid conditions. Further studies are needed to investigate the long-term effects of LSG in adolescents.

CLINICAL RESEARCH STUDY

Descriptive case series with prospective database.

LEVEL OF EVIDENCE

IV.

Closed-loop gastric electrical stimulation versus laparoscopic adjustable gastric band for the treatment of obesity: a randomized 12-month multicenter study

OBJECTIVE

To compare the weight loss, change in quality of life (QOL) and safety of closed-loop gastric electrical stimulation (CLGES) versus adjustable gastric band (LAGB) in the treatment of obesity.

METHODS

This multicenter, randomized, non-inferiority trial randomly assigned the patients in a 2:1 ratio to laparoscopic CLGES versus LAGB and followed them for 1 year. We enrolled 210 patients, of whom 50 were withdrawn preoperatively. Among 160 remaining patients (mean age=39±11 years; 75% women; mean body mass index=43±6 kg m^-2) 106 received CLGES and 54 received LAGB. The first primary end point was non-inferiority of CLGES versus LAGB, ascertained by the proportion of patients who, at 1 year, fulfilled: (a) a ⩾20% excess weight loss (EWL); (b) no major device- or procedure-related adverse event (AE); and (c) no major, adverse change in QOL. Furthermore, ⩾50% of patients had to reach ⩾25% EWL. The incidence and seriousness of all AE were analyzed and compared using Mann-Whitney's U-test.

RESULTS

At 1 year, the proportions of patients who reached all components of the primary study end point were 66.7 and 73.0% for the LAGB and CLGES group, respectively, with a difference of -6.3% and an upper 95% CI of 7.2%, less than the predetermined 10% margin for confirming the non-inferiority of CLGES. The second primary end point was also met, as 61.3% of patients in the CLGES group reached ⩾25% EWL (lower 95% CI=52.0%; P<0.01). QOL improved significantly and similarly in both groups. AE were significantly fewer and less severe in the CLGES than in the LAGB group (P<0.001).

CONCLUSIONS AND RELEVANCE

This randomized study confirmed the non-inferiority of CLGES compared with LAGB based on the predetermined composite end point. CLGES was associated with significantly fewer major AE.

Under and over 50: exploring long-term weight-loss outcomes following laparoscopic adjustable gastric band by age and body mass index group

BACKGROUND

Laparoscopic adjustable gastric band (LAGB) surgery is used to enable individuals to lose weight. However, the long-term weight loss outcomes for individuals with a body mass index (BMI)≥50 kg/m² and/or age≥50 years at time of banding remains debated. To date, data reported is largely from populations outside the United Kingdom.

OBJECTIVES

To explore long-term weight loss outcomes based on individuals' pre-LAGB age and BMI.

SETTING

Data were collected from individuals in the United Kingdom attending a national health service weight loss surgery service.

METHOD

Data pertaining to weight were collected in a prospective 5-year study in the United Kingdom. Individuals were grouped according to preoperative age and BMI before analysis.

RESULTS

Data from 53 individuals were analyzed. Individuals age≤49 years weighed 142.7±17.4 kg preoperatively, whereas individuals age≥50 years weighed 137.6±19.4 kg. Over the 5 years post-LAGB, significant weight loss was achieved by the whole sample. Additionally, there was an interaction between weight loss and age/BMI group. The sample had a significant percent total weight loss and percent excess weight loss between 6 months and 5 years post-LAGB. However, only individuals age≥50 years with a BMI≥50 kg/m² preoperatively had continual weight loss over the 5 years.

CONCLUSION

Individuals lost weight following LAGB; however, only individuals with a BMI≥50 kg/m² and age≥50 years before banding appeared to continue to lose weight as time since banding increased, compared with the other groups.

Bariatric surgery outcomes in ethnic minorities

BACKGROUND

The primary aim of this study was to examine percent excess weight loss (%EWL) across and between racial groups at 6, 12, 24, and 36 months follow-up in patients who received sleeve gastrectomy (SG) or a Roux-en-Y gastric bypass (RYGB) operation. We hypothesized that ethnic minorities (blacks and Hispanics) would have a lower %EWL than whites at 6, 12, 24, and 36 months for both SG and RYGB operations. The secondary aim was to examine %EWL within racial groups at 6, 12, 24, and 36 months as a function of the type of bariatric operation. We hypothesized that whites, blacks, and Hispanics would have a greater %EWL with RYGB than with SG.

METHODS

A total of 749 patients who underwent an SG or an RYGB operation from January 2008 to June 2014 were included. Data were collected from patients' electronic medical records. Self-reported data on race/ethnicity were also obtained from the electronic medical record and were classified into the following categories: white, Hispanic/Latino, African American or black, or other.

RESULTS

Results revealed overall differences in %EWL between blacks and whites (P < .05) and no overall differences in %EWL between Hispanics and whites (P = .697). Follow-up analyses revealed that Hispanics differed from blacks in %EWL at 6, 12, 24, and 36 months (all P < .01) and that whites differed from blacks at 6 months (P < .05). There were no significant differences between whites and Hispanics during any follow-up period. Overall, the %EWL differed by operation type (P < .01), with RYGB associated with greater %EWL than SG. When stratified by race, the only difference was found in blacks, who had a greater %EWL after RYGB compared with SG (P < .01).

CONCLUSION

Our primary hypothesis was partially supported, as blacks but not Hispanics had a lower %EWL compared to whites at 6 months. An interesting finding is that blacks had a lower %EWL than Hispanics at every time point. Moreover, our secondary hypothesis was partially supported. Results revealed that overall RYGB was related to greater %EWL compared with SG, and within racial groups, among blacks only, RYGB was associated with a greater %EWL compared with SG.

Analysis of reoperations after laparoscopic adjustable gastric banding

BACKGROUND AND OBJECTIVES

Laparoscopic adjustable gastric banding is considered the least invasive surgical option for the treatment of morbid obesity. Its initial popularity has been marred by recent long-term studies showing high complication rates. We sought to examine our experience with gastric banding and factors leading to reoperation.

METHODS

We reviewed retrospective data of 305 patients who underwent laparoscopic adjustable gastric banding between 2004 and 2011 at a single institution, 42 patients of whom required a reoperation, constituting 13.8%. Patients undergoing elective reoperations for port protrusion from weight loss as a purely cosmetic issue were excluded (n = 10). Patients' demographic data, weight loss, time to reoperation, and complications were analyzed.

RESULTS

Of 305 patients, 42 (13.8%) required reoperations: 26 underwent band removal (8.5%) and 16 underwent port revision (5.2%). The mean weight and body mass index for all patients who underwent reoperations were 122.6 kg and 45.0 kg/m(2), respectively. The most common complication leading to band removal was gastric prolapse (n = 14, 4.6%). The most common indication for port revision was a nonfunctioning port (n = 10, 3.3%).

CONCLUSION

Laparoscopic adjustable gastric banding was initially popularized as a minimally invasive gastric-restrictive procedure with low morbidity. Our study showed a 13.8% reoperation rate at 3 years' follow-up. Most early reoperations (<2 years) were performed for port revision, whereas later reoperations (>2 years) were likely to be performed for band removal. Laparoscopic adjustable gastric banding is associated with high reoperation rates; therefore bariatric surgeons should carefully consider other surgical weight-loss options tailored to the needs of the individual patient that may have lower complication and reoperation rates.

From bariatric to metabolic surgery: Looking for a “disease modifier” surgery for type 2 diabetes

In this review the recent evolution of the comprehension of clinical and metabolic consequences of bariatric surgery is depicted. At the beginning bariatric surgery aim was a significant and durable weight loss. Later on, it became evident that bariatric surgery was associated with metabolic changes, activated by unknown pathways, partially or totally independent of weight loss. Paradigm of this “metabolic” surgery is its effects on type 2 diabetes mellitus (T2DM). In morbid obese subjects it was observed a dramatic metabolic response leading to decrease blood glucose, till diabetes remission, before the achievement of clinically significant weight loss, opening the avenue to search for putative anti-diabetic “intestinal” factors. Both proximal duodenal (still unknown) and distal (GLP1) signals have been suggested as hormonal effectors of surgery on blood glucose decrease. Despite these findings T2DM remission was never considered a primary indication for bariatric surgery but only a secondary one. Recently T2DM remission in obese subjects with body mass index (BMI) greater than 35 has become a primary aim for surgery. This change supports the idea that “metabolic surgery” definition could more appropriate than bariatric, allowing to explore the possibility that metabolic surgery could represent a “disease modifier” for T2DM. Therefore, several patients have undergone surgery with a primary aim of a definitive cure of T2DM and today this surgery can be proposed as an alternative therapy. How much surgery can be considered truly metabolic is still unknown. To be truly “metabolic” it should be demonstrated that surgery could cause T2DM remission not only in subjects with BMI > 35 but also with BMI < 35 or even < 30. Available evidence on this topic is discussed in this mini-review.

Evaluation of pre- and postoperative physical activity participation in laparoscopic gastric banding patients

BACKGROUND

Weight loss outcomes following laparoscopic adjustable gastric banding (LAGB) are widely variable, and physical activity (PA) participation improves these results. The purpose of this study was to retrospectively describe PA behaviors before and after LAGB and to evaluate the impact of PA on weight loss outcomes.

METHODS

Participants were 172 individuals (145 females, mean age 43.3 ± 12.0 years, mean body mass index [BMI] 43.8 ± 5.1 kg/m(2)) who underwent LAGB at a university medical center. Height, weight, presence of comorbidities, and PA participation were assessed prior to and 3, 6, and 12 months after surgery. Those who reported engaging in ≥ 150 min of weekly moderate-to-vigorous PA (MVPA) were considered active.

RESULTS

Less than 40 % of participants were active prior to surgery, while 31 % of those who were inactive before surgery became active at 6 months of follow-up. Unlike previous reports on gastric bypass patients, there was no statistically significant (p > 0.05) relationship between postoperative PA status and weight loss outcomes at 3, 6, or 12 months in LAGB patients. Interestingly, participants who reported ≥ 150 min of MVPA prior to surgery achieved approximately 10 % greater excess weight loss (p < 0.05) and a 2.4-kg/m(2) greater decrease in BMI (p < 0.05) at 1 year post-LAGB compared to those who were inactive preoperatively.

CONCLUSIONS

In our sample, higher levels of preoperative PA participation were associated with improved weight loss outcomes following LAGB. We posit that higher preoperative volumes are indicative of habitual exercise and that those who report being active prior to surgery are likely to maintain these behaviors throughout follow-up.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

Analysis of reoperations after laparoscopic adjustable gastric banding

Background and Objectives:

Laparoscopic adjustable gastric banding is considered the least invasive surgical option for the treatment of morbid obesity. Its initial popularity has been marred by recent long-term studies showing high complication rates. We sought to examine our experience with gastric banding and factors leading to reoperation.

Methods:

We reviewed retrospective data of 305 patients who underwent laparoscopic adjustable gastric banding between 2004 and 2011 at a single institution, 42 patients of whom required a reoperation, constituting 13.8%. Patients undergoing elective reoperations for port protrusion from weight loss as a purely cosmetic issue were excluded (n = 10). Patients' demographic data, weight loss, time to reoperation, and complications were analyzed.

Results:

Of 305 patients, 42 (13.8%) required reoperations: 26 underwent band removal (8.5%) and 16 underwent port revision (5.2%). The mean weight and body mass index for all patients who underwent reoperations were 122.6 kg and 45.0 kg/m², respectively. The most common complication leading to band removal was gastric prolapse (n = 14, 4.6%). The most common indication for port revision was a nonfunctioning port (n = 10, 3.3%).

Conclusion:

Laparoscopic adjustable gastric banding was initially popularized as a minimally invasive gastric-restrictive procedure with low morbidity. Our study showed a 13.8% reoperation rate at 3 years' follow-up. Most early reoperations (<2 years) were performed for port revision, whereas later reoperations (>2 years) were likely to be performed for band removal. Laparoscopic adjustable gastric banding is associated with high reoperation rates; therefore bariatric surgeons should carefully consider other surgical weight-loss options tailored to the needs of the individual patient that may have lower complication and reoperation rates.

Ethnic variation in weight loss, but not co-morbidity remission, after laparoscopic gastric banding and Roux-en-Y gastric bypass

BACKGROUND

Demographic factors such as ethnicity may affect bariatric surgery outcomes. We examined weight loss and co-morbidities outcomes in African American, Caucasian, and Hispanic patients who underwent laparoscopic gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). The primary aim was to investigate demographic differences in weight loss and co-morbidities outcomes.

METHODS

We retrospectively examined weight change and co-morbidities outcomes in our prospective database. A total of 1,903 patients underwent LAGB or RYGB between January 1, 2005 and March 31, 2012. Of those, 1828 completed their 1-year follow-up visit (9-15 mo) and had complete data. We excluded patients who were missing ethnicity information, resulting in a final cohort of 1,684 patients. Multivariate analyses and χ2 tests were used to examine demographic variables in body mass index (BMI) change, percent excess weight loss (%EWL), and remission of co-morbidities. We also examined weight loss outcomes at 2- and 3-year follow-up.

RESULTS

Overall, those who underwent RYGB had a lower BMI and greater %EWL at 1, 2, and 3 years compared to those who had undergone LAGB. Overall, African American patients had a higher postoperative BMI than either Caucasian or Hispanic patients. African American patients also showed less %EWL than Caucasian and Hispanic patients. When we examined within surgery type, ethnic differences between African American and Caucasian patients were present across all 3 years in RYGB, but there were no ethnic differences by year 3 in LAGB. Additionally, African American and Hispanic patients no longer differed by year 3 in RYGB and by year 2 in LAGB. There were no significant ethnic differences in remission of diabetes, hyperlipidemia, hypertension, and sleep apnea at 1 year.

CONCLUSION

Our study found significant ethnic differences in the postoperative BMI and %EWL, which were more pronounced in patients undergoing RYGB than LAGB at the 3-year time point. These weight loss differences did not translate to a lower rate of co-morbidities remission.

Gender influence on long-term weight loss after three bariatric procedures: gastric banding is less effective in males in a retrospective analysis

BACKGROUND

Identifying factors that influence weight loss after bariatric surgery is one way to predict a successful surgical outcome. Knowledge of the effect of gender on weight loss after bariatric surgery has not been well demonstrated in the literature despite being noted in every day practice. The aim of this study was to find the influence of gender on long-term weight loss after bariatric surgery.

METHODS

A retrospective analysis of data retrieved from a prospectively maintained bariatric database was conducted.

RESULTS

The study included 640 consecutive patients. Their mean age was 38 ± 10 years, mean preoperative body mass index was 44.9 ± 8.4 kg/m2, and mean preoperative excess weight (EW %) was 108.3 ± 38.4%. The mean of the average excess weight loss (EWL %) was 43.3 ± 42.4%. Three procedures were utilized: Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty (VBG), and gastric banding (GB). Both VBG and RYGB induced significantly more EWL % than GB (d = 22.1%, p < 0.001 and d = 16, p = 0.02, respectively). In patients who underwent VBG and GB, males had significantly lower preoperative EW % (Student t = -4.86, p < 0.001, and Student t = 4.69, p < 0.001, respectively), and postoperative mean of the average EWL % (Student t = -2.43, p = 0.016, and Student t = -3.33, p = 0.002, respectively) than females. In patients who underwent RYGB, there were no differences in the preoperative EW % (t = -1.03, p = 0.309) or the mean of the average EWL % (t = 0.406, p = 0.688). The simple linear regression model used to explain the variability in EWL %, accounted for by the variability in the preoperative EW %, was significant (F = 180, p < 0.001). Analysis of the residual errors in predicting the EWL % revealed no significant difference between males and females after VBG and after RYGB (t = 0.117, p = 0.907 and t = 1.052, p = 0.3, respectively), while it was significant after GB (t = -2.999, p = 0.003).

CONCLUSION

From our experience, we suggest that GB not to be offered as a first choice for obese male patients.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysis

Bariatric surgery is now widely accepted for treatment of morbid obesity. This study compared the effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) on excess weight loss (EWL) and type 2 diabetes mellitus (T2DM). PubMed and Embase were searched for publications concerning LAGB and LSG from 2000 to 2012, with the last search on August 17, 2012. EWL and T2DM improvement over 6 and 12 months were pooled and compared by meta-analysis. Odds ratios (ORs) and mean differences were calculated with 95 % confidence intervals (CIs). Eleven studies involving 1,004 patients met the inclusion criteria. Compared with LAGB, LSG achieved greater EWL. The mean percentage EWL for LAGB was 33.9 % after 6 months in six studies and 37.8 % after 12 months in four studies; for LSG, EWL was 50.6 % after 6 months and 51.8 % after 12 months in the same studies. LSG was also superior to LAGB in treating T2DM. In five studies, T2DM was improved in 42 of 68 (61.8 %) patients after LAGB and 66 of 80 (82.5 %) after LSG, representing a pooled OR of 0.34 (95 % CI 0.16–0.73) and pooled mean differences of −12.55 (95 % CI −15.66 to −9.43) and −4.97 (95 % CI −7.58 to −8.36), respectively. LSG is more effective than LAGB in morbid obesity, with higher percentage EWL and greater improvement in T2DM.

Long follow-up of patients with gastric band

BACKGROUND

The adjustable gastric band laparoscopic technique is safe, reversible and potentially effective alternative to gastric bypass Y-deRoux. However, it has a high rate of reoperation and unsatisfactory weight loss.

OBJECTIVE

To present a cases series with the use of gastric banding in long term follow-up analyzing the withdrawal rate, its causes and the surgical conversions performed

METHODS

Retrospective study based on the analysis of 19 patients who underwent the procedure between November 1999 and November 2002, and reviewed with clinical follow-up until late February 2011. The patients were analyzed in the following aspects: gender, age, preoperative weight, preoperative BMI, duration of follow-up, reasons for removal of the gastric band, need for conversion to another type of surgery and failure rate of surgical method.

RESULTS

Nineteen patients underwent the procedure, four women and 15 men. The mean preoperative BMI was 41.95 kg/m² (36-54). The band was withdrawn in 13 patients (68.42%), including seven by erosion, four for unsatisfactory weight loss and two for gastroesophageal reflux. The gastric bypass was conducted in ten patients and Scopinaro operation in one. Two patients had not been reoperated till nowadays and four were lost in late follow-up.

CONCLUSION

The gastric band is technically unsatisfactory in long-term evaluation, have high withdrawal rate due to migration or unsatisfactory weight loss.

What happens after gastric band removal without additional bariatric surgery?

BACKGROUND

The laparoscopic adjustable gastric band (LAGB) is widely used for the treatment of morbid obesity. Many patients benefit from this procedure initially, but experience complications after a few years. The treatment for many complications is revisional bariatric surgery. A number of patients, however, request only band removal without secondary bariatric surgery. The aim of this study was to assess the perioperative and medium term outcomes of patients who had their LAGB removed without secondary bariatric surgery.

METHODS

Patients were retrospectively selected using a prospectively collected database. The LAGB had to be in situ for at least 1 year, and minimum postoperative follow-up had to be 12 months.

RESULTS

Thirty-eight patients who had their LAGB laparoscopically removed between 2000 and 2010 were included. Median follow-up after LAGB removal was 3.0 (1.4 to 8.9) years. Only 2 complications (5%) and no mortality occurred perioperatively. In the 21 patients who did not undergo additional bariatric surgery, the median excess weight loss (EWL) decreased from 41% (-12% to -100%) at band removal to 9% (-10% to 90%), 0% (-20% to 78%), and -11% (-12% to 56%) after 1, 2, and 5 years, respectively. Percentage weight loss (%WL) was 17% (-54% to -5%), 4% (-47% to -9%), 0% (-41% to 11%), and -5% (-29% to 9%) after these same time intervals, respectively. After a median 2.1 (.5 to 9.9) years, 17 patients underwent either a Roux-en-Y gastric bypass (14 patients) or a Scopinaro (3 patients) all because of weight regain. The current EWL and %WL in these patients is 67% (24% to 113%) and 30% (12% to 53%), respectively compared with -11% (-33% to 57%) and -4% (-14% to 34%) in patients without a secondary bariatric procedure (P< .001).

CONCLUSION

Patients who have their LAGB removed are guaranteed to suffer from weight regain. It is inadvisable to only remove the LAGB without performing an additional bariatric procedure when deemed technically feasible and safe. In this study, no patient was able to maintain the weight loss achieved with the LAGB after its removal.

The impact of bariatric surgery on obstructive sleep apnea: a systematic review

There is a strong relationship between obesity and the development of obstructive sleep apnea (OSA). Respectively, bariatric surgery is often touted as the most effective option for treating obesity and its comorbidities, including OSA. Nevertheless, there remains paucity of data in the literature of the comparison of all the specific types of bariatric surgery themselves. In an effort to answer this question, a systematic review was performed, to determine, of the available bariatric procedures [Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, or biliopancreatic diversion (BPD)], which procedures were the most efficacious in the treatment of OSA. A total of 69 studies with 13,900 patients were included. All the procedures achieved profound effects on OSA, as over 75 % of patients saw at least an improvement in their sleep apnea. BPD was the most successful procedure in improving or resolving OSA, with laparoscopic adjustable gastric banding being the least. In conclusion, bariatric surgery is a definitive treatment for obstructive sleep apnea, regardless of the specific type.

Laparoscopic repair of hiatal hernias: new classification supported by long-term results

BACKGROUND

Mesh repair may decrease the recurrence rate but bears risk of esophageal complications. This study aimed to analyze the long-term results of laparoscopic hiatal repair depending on hiatal surface area (HSA).

METHODS

The results from 658 procedures were analyzed. Group 1 had 343 patients with HSA smaller than 10 cm(2) (small hernias), for whom primary crural repair was performed. Group 2 had 261 patients with HSA size 10-20 cm(2) (large hernias), for whom primary crural repair (subgroup A) or mesh repair (subgroup B) was performed. Group 3 had 54 patients with HSA larger than 20 cm(2) (giant hernias), for whom only mesh repair was performed.

RESULTS

The mean follow-up period was 28.6 months (range, 10-48 months). Primary repair results in a higher recurrence rate for large hernias (11.9 %) than for small hernias (3.5 %) (p = 0.0016). For large hernias, the original method of sub-lay lightweight partially absorbable mesh repair provides a lower recurrence rate than primary repair (4.9 % vs 11.9 %; p = 0.0488) and a comparable dysphagia rate (2.1 % vs 2.2 %; p = 0.6533). For giant hernias, mesh repair results in a higher recurrence rate than for large hernias (20 % vs 4.9 %; p = 0.0028). The analysis of variance (ANOVA) HSA recurrence ratio confirmed the correctness of the chosen threshold levels (10 and 20 cm(2)) for subdividing hernias into three classes according to the new classification.

CONCLUSIONS

The authors advise routine measurement of HSA and use of relative classification, primary suturing as the optimal repair for small hernias, the original technique of sub-lay lightweight partially absorbable mesh repair as the apparent best treatment for large hernias, and the original technique for giant hernias, which provides results corresponding to those reported in the literature, although these results require improvement.

Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is one of the commonest bariatric procedures in the UK. This study reports our experience with this procedure over the last 10 years.

METHODS

A prospectively maintained database of all the patients undergoing LAGB at our centre between March 2000 and August 2010 was analysed.

RESULTS

Five hundred seventy-five patients underwent LAGB at our centre. There was no mortality in this series. Early (30-day) morbidity rate was 2.2 %. Late complications (20 %) comprised: 78 repositioning of the inflation port in 65 patients, repositioning of band in 24 patients (4 %), removal of band in 20 patients (3.4 %), conversion to bypass in 41 patients (7 %), diagnostic laparoscopy in 1 patient and subtotal gastrectomy in 1 patient. Median follow-up was 29 months. The median of percentage of weight loss (%WL) and excess body weight loss (EBWL) was 18.3 and 40 %, respectively, at ≥ 5 years post-LAGB. Patients with body mass index (BMI) over 50 kg/m(2) were compared to those with BMI ≤ 50 kg/m(2). No significant difference was noted in the weight loss between both of these groups. No significant difference was noted with regards to weight loss between patients <60 and >60 years of age.

CONCLUSIONS

In this cohort of patients, %WL and EBWL were 18.3 and 40 % ≥ 5 years after LAGB, respectively, and early and late complication rates were 2.2 and 20 %, respectively. Majority of late complications were in the first 100 patients. Multifactorial causes included the surgical learning curve and patient selection process.

Metabolic changes one year after laparoscopic adjustable gastric banding operation in morbidly obese subjects

Introduction

Laparoscopic adjustable gastric banding (LAGB) is effective for weight reduction in severely obese patients. However, the data about its effect on metabolic syndrome (MS) are limited.

Aim

To assess weight loss and changes of metabolic parameters 1 year after LAGB in a prospective, nonrandomized single center cohort study in morbidly obese subjects.

Material and methods

Physical examination, body weight (BW) parameters and metabolic profile were assessed at baseline and 1 year after LAGB in morbidly obese subjects. The incidence of MS was evaluated according to National Cholesterol Education Program Adult Treatment Panel III criteria.

Results

One year after the operation data from 90 patients out of 103 were available. Mean excess weight (EW) loss of 33.1% was associated with a significant improvement in all metabolic parameters: decrease of hypertension by 15.8%, hypertriglyceridemia by 42.6%, and hyperglycemia by 46.3%; and increase in high density lipoprotein cholesterol by 48.3%. This resulted in the resolution of MS in 44.2% of subjects. The significant change in the distribution of MS components was observed with the highest frequency of 4 components before and 2 components after surgery. Patients with MS at baseline lost 29.9% of EW compared to 44.3% in those without MS (p = 0.009).

Conclusions

The LAGB resulted in effective reduction of BW parameters in morbidly obese subjects 1 year after the operation. Along with the weight loss, resolution of MS and a significant shift towards decrease in the number of MS components was observed. Patients with MS were more resistant to the weight loss.

Ethnic differences in weight loss and diabetes remission after bariatric surgery: a meta-analysis

OBJECTIVE

It has been postulated that the effectiveness of bariatric surgery varies between ethnic groups. However, data regarding this topic are inconclusive, as most studies included few patients from minority groups. We conducted a meta-analysis to determine the difference in percentage of excess weight loss (%EWL) 1-2 years after bariatric surgery in people of African and Caucasian descent. We also studied differences in diabetes mellitus (DM) remission.

RESEARCH DESIGN AND METHODS

We performed a MEDLINE and EMBASE search for studies reporting %EWL and/or DM remission after bariatric surgery and including both African Americans and Caucasians. The 613 publications obtained were reviewed. We included 14 studies (1,087 African Americans and 2,714 Caucasians); all provided data on %EWL and 3 on DM remission. We extracted surgery type, %EWL, and DM remission 1-2 years after surgery. After analyzing %EWL for any surgery type, we performed subanalyses for malabsorptive and restrictive surgery.

RESULTS

The overall absolute mean %EWL difference between African Americans and Caucasians was -8.36% (95% CI -10.79 to -5.93) significantly in favor of Caucasians. Results were similar for malabsorptive (-8.39% [-11.38 to -5.40]) and restrictive (-8.46% [-12.95 to -3.97]) surgery. The remission of DM was somewhat more frequent in African American patients than in Caucasian patients (1.41 [0.56-3.52]). However, this was not statistically significant.

CONCLUSIONS

In %EWL terms, bariatric surgery is more effective in Caucasians than in African Americans, regardless of procedure type. Further studies are needed to investigate the exact mechanisms behind these disparities and to determine whether ethnic differences exist in the remission of comorbidities after bariatric surgery.

Complications and outcome after laparoscopic bariatric surgery: LAGB versus LRYGB

BACKGROUND AND AIMS

Unsatisfactory patient compliance and unfavorable results of weight loss let centers prefer the Roux-en-Y gastric bypass (RYGB) as a combined restrictive and malabsorptive procedure. The aim of this study was to evaluate results of laparoscopic adjustable gastric banding (LAGB) versus laparoscopic RYGB.

SETTING

The study was conducted at Centre Hospitalier Emil Mayrisch Clinic for specialized care (n = 618 beds) in Luxembourg (South).

MATERIALS AND METHODS

Of 620 procedures, 204 patients had LAGB and 416 LRYGB. Short-term (t(1), 6 months to 2 years), middle-term (t(2), 2 to 5 years), and long-term follow-up (t(3), >5 years) were performed, including weight loss evolution, Bariatric Analysis, and Reporting Outcome System (BAROS).

RESULTS

Percent EBWL mean values for LAGB vs. LRYGB were at t(1) 64.3 vs. 79.5, p = 0.01; at t(2) 49.4 vs. 91, p < 0.0001; and at t(3) 52.6 vs. 79.9, p < 0.0001. The BAROS mean values were at t(1) 3.81 vs. 4.00, p = 0.183; at t(2) 3.57 vs. 4.12, p < 0.001; and at t(3) 3.71 vs. 4.04, p = 0.02. Major complication rate (<30 days) was similar (p = 0.601). Long-term (>30 days) complications were more common after LAGB (14.3 versus 3.6%, p < 0.001). Fifty patients (25%) required a second and 36 patients (18%) a third operation (LRYGB).

CONCLUSION

The significant difference in %EBWL and BAROS and late adverse events with high re-operation rates in LAGB made the LRYGB more attractive.

Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures; a systematic review of the randomised controlled trials

BACKGROUND

Bariatric surgery can provide efficient weight loss and improvement in obesity-related co-morbidities in adults. Laparoscopic adjustable gastric banding (LAGB) comprised 30.3% of all bariatric procedures between 2009 and 2010 in the UK. This review evaluates the level 1 evidence for change in co-morbidities, quality of life (QoL) and weight provided by LAGB compared with other bariatric procedures.

METHOD

Systematic literature search of MEDLINE, EMBASE and CENTRAL (1988 to May 2011) was performed. Only randomised controlled trials (RCTs) were included. Studies with non-surgical comparators, open gastric banding procedures or adolescent participants were excluded. Primary outcome was change in co-morbidities. Secondary outcomes included QoL, weight loss, complications, operation time and length of stay.

RESULTS

Five RCTs met the inclusion criteria. Vertical banded gastroplasty, sleeve gastrectomy and gastric bypass were compared to LAGB. Co-morbidities were reported in two studies and QoL in one. LAGB was comparable to other procedures for both of these outcomes. All five trials showed LABG to be effective in weight loss, however all comparative procedures resulted in greater weight loss. Operative time and length of hospital stay were significantly shorter with LAGB. Short-term complications were found to be consistently lower in the LAGB group. Evidence was divided with respect to long-term complications.

CONCLUSION

Co-morbidities and QoL are poorly reported and showed no difference between LAGB and other bariatric procedures. Evidence suggests that LAGB is not the most effective surgical procedure to reduce weight. LAGB is associated with lower early complications and shorter operative time and length of stay, and therefore may be preferable to patients.

Impact of laparoscopic adjustable gastric banding on type 2 diabetes

Bariatric surgery is becoming an accepted option for obese people with type 2 diabetes. Our aim was to assess the impact of laparoscopic adjustable gastric banding (LAGB) through a systematic review of the literature. Data was sourced from Scopus, MEDLINE and EMBASE published from 2000 through May 2011, and five unpublished studies that were performed by industry for regulatory approval were also included. Studies were selected on the basis that they provide some detail of diabetes status before and after LAGB. There were 35 studies meeting the inclusion criteria. There was considerable heterogeneity in study design, sample size, length of follow-up, attrition rates and classification of diabetes status. Weight loss was progressive over the first 2 years with a weighted average of 47% excess weight loss at 2 years. Remission or improvement in diabetes varied from 53% to 70% over different time periods. Results were broadly consistent, demonstrating clinically relevant improvements in diabetes outcomes with sustained weight loss in obese people with type 2 diabetes following LAGB surgery. However, there were significant shortcomings in the reviewed literature with few high-quality studies, inconsistent reporting of diabetes outcomes and high attrition rates. Long-term studies that address these limitations are needed.