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

Multimodality imaging of adult gastric emergencies: A pictorial review

Acute gastric emergencies require urgent surgical or nonsurgical intervention because they are associated with high morbidity and mortality. Imaging plays an important role in diagnosis since the clinical symptoms are often nonspecific and radiologist may be the first one to suggest a diagnosis as the imaging findings are often characteristic. The purpose of this article is to provide a comprehensive review of multimodality imaging (plain radiograph, fluoroscopy, and computed tomography) of various life threatening gastric emergencies.

Value of contrast-enhanced multidetector computed tomography in imaging of symptomatic patients after laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy

Background

To assess the role of contrast-enhanced multidetector computed tomography (MDCT) in the assessment of symptomatic patients following laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Results

We reviewed the studies of 129 cases and found complications in 113 patients: 55 early complications and 48 late complications. All of these complications were diagnosed with intravenous contrast-enhanced MDCT. Statistically significant difference was found between UGIS and MDCT in the diagnosis of many cases.

Conclusion

The rate of complications in bariatric surgery is high and the associated mortality is not negligible. The interpreting radiologists should know the normal postoperative findings and be aware of possible complications.

Gastric bands: what the general radiologist should know

Obesity in the UK is increasing, it is estimated that in England 24% of men and 25% of women are obese.(1,2) In recent years bariatric surgery has become increasingly common and is effective in producing long-term weight loss.(4,5) The most popular form of bariatric surgery in Europe is laparoscopic adjustable gastric banding (LAGB).(6) Radiologists play a key role assessing the normal function of bands, adjusting their filling under fluoroscopic guidance, and in recognizing and managing complications. This review will describe the general principles of LAGB; how they are assessed, how to recognize the most common complications, an overview of the appearances of the bands used in the UK, and novel developments in their use and design.

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.

Long-term results of adjustable gastric banding in a cohort of 186 super-obese patients with a BMI≥ 50 kg/m2

BACKGROUND

There are conflicting results concerning the bariatric effectiveness of adjustable gastric banding in super-obese patients with a Body Mass Index (BMI) more or equal to 50 kg/m(2).

METHOD

A cohort of 186 patients with a BMI greater or equal to 50 kg/m(2) who underwent adjustable gastric banding (AGB) at the Bichat-Claude-Bernard University Hospital (Paris, France) were prospectively entered into a database. The following data were recorded: BMI, percentage of BMI loss, percentage of excess weight lost (%EWL), complications, and surgical re-interventions. Loss of greater than 50% of excess weight was considered a success (primary endpoint). A %EWL of less than 25% after one year, or the removal of the gastric band was considered a failure.

RESULTS

Thirty-five men (18.8%) and 151 women (81.2%), with a mean age of 38.9 years (range: 16-65) underwent AGB between September 1995 and December 2007. The mean BMI was 55.06 kg/m(2) (range: 50-74.4). Mean follow-up was 112.5 months with a minimum of 28 months and a maximum of 172 months. The follow-up rate was maintained at 89% at ten years. The technique of AGB was by "peri-gastric dissection" in the first 115 patients (61.82%) and by "pars flaccida dissection" in 71 patients (38.17%). The gastric band was removed in 87 of 186 patients (46.8%); band ablation was due to a complication of the gastric band in 62 of these cases (33.3%), to failure of weight loss in 23 cases (12.4%), and to patient request in two cases (1%). The major complications requiring re-operation were: chronic dilatation of the proximal gastric pouch (27 patients - 14.5%), acute dilatation (21 patients - 11.3%), intragastric migration of the prosthesis (six patients - 3.2%), reflux esophagitis (six patients - 3.2%), infection of the gastric band (one patient - 0.5%), and Barrett's esophagus (one patient - 0.5%). No statistically significant difference was found between the two operative techniques with regard to the possibility of preserving the gastric band for ten years. For patients who underwent band removal, no further follow-up analysis of patient data after band ablation was performed. The results were best at two years after AGB with a median BMI of 42.72 kg/m(2), a band removal rate of 8.6% (16 of 186 patients), and a failure rate of 16.4% (28 of 170 patients) of those patients who still had their band in place. However, at 10 years, the picture was completely reversed with a band removal rate of 52.2% (47 of 90 patients), a failure rate of 22% (seven of 33 patients) of those who still had their band in place, and a median BMI of 43.43 kg/m(2).

CONCLUSION

Laparoscopic gastroplasty using the adjustable gastric band appeared to be a promising intervention for super-obese patients when the results at two years were analyzed - fairly simple to perform, with perioperative morbidity and mortality near zero. However, these results do not persist in the long-term for super-obese patients. At ten years, only 11% of patients (nine of 80) have successful bariatric results (%EWL>50%) and we were forced to remove the gastric band in 52.2% of patients (47 of 90) because of complications, regardless of the initial operative technique used. Given these results, AGB gastroplasty is not a recommended method for super-obese patients and we believe that a BMI greater or equal to 50 kg/m(2) is a contra-indication for this procedure.

Long-term results of bariatric restrictive procedures: a prospective study

Laparoscopic adjustable gastric banding (LAGB) and vertical-banded gastroplasty (VBG) are surgical treatment modalities for morbid obesity. This prospective study describes the long-term results of LAGB and VBG. One hundred patients were included in the study. Fifty patients underwent LAGB and 50 patients, open VBG. Study parameters were weight loss, changes in obesity-related comorbidities, long-term complications, re-operations including conversions to other bariatric procedures and laboratory parameters including vitamin status. From 91 patients (91%), data were obtained with a mean follow-up duration of 84 months (7 years). Weight loss [percent excess weight loss (EWL)] was significantly more after VBG compared with LAGB, 66% versus 54%, respectively. All comorbidities significantly decreased in both groups. Long-term complications after VBG were mainly staple line disruption (54%) and incisional hernia (27%). After LAGB, the most frequent complications were pouch dilatation (21%) and anterior slippage (17%). Major re-operations after VBG were performed in 60% of patients. All re-operations following were conversions to Roux-en-Y gastric bypass (RYGB). In the LAGB group, 33% of patients had a refixation or replacement of the band, and 11% underwent conversion to another bariatric procedure. There were no significant differences in weight loss between patients with or without re-interventions. No vitamin deficiencies were present after 7 years, although supplement usage was inconsistent. This long-term follow-up study confirms the high occurrence of late complications after restrictive bariatric surgery. The failure rate of 65% after VBG is too high, and this procedure is not performed anymore in our institution. The re-operation rate after LAGB is decreasing as a result of new techniques and materials. Results of the re-operations are good with sustained weight loss and reduction in comorbidities. However, in order to achieve these results, a durable and complete follow-up after restrictive procedures is imperative.

The surgical management of obesity with emphasis on the role of post operative imaging

The role of surgery in the morbidly obese is becoming more prominent. There are a variety of surgical approaches which can be used and radiology plays a crucial role in post operative follow up, particularly in the management of complications. Many general radiologists remain unfamiliar with both the normal and abnormal appearances after bariatric surgery and this pictorial review aims to bridge this gap.

Reducing band slippage in laparoscopic adjustable gastric banding: the mesh plication pars flaccida technique

BACKGROUND

Band slippage is a significant complication of laparoscopic adjustable gastric band (LAGB) surgery for the treatment of morbid obesity. This involves prolapse of part of the stomach, with varying degrees of gastric obstruction. The original perigastric technique (PGT) was associated with slippage rates of up to 25%. The pars flaccida technique (PFT) is the more commonly used technique today, reducing slippage rates to as low as 1.4%. We report a technique not previously described, the modified PFT with the use of mesh, and compare slippage rates between these three techniques for band placement.

METHODS

A prospectively entered, retrospective review of 1,446 consecutive patients undergoing LAGB by a single surgeon was undertaken. Patients were divided into five consecutive groups: PGT learning curve (PGTLC) (n = 68), PGT (n = 19), mesh PFT (MPFT) (n = 415), mesh plication PFT (MPPFT) (n = 131), and MPPFT with inadequate follow-up (n = 813). Patient characteristics, band slippage, and other complication rates were compared between groups.

RESULTS

The slippage rates for each group were: PGTLC (10%), PGT (5%), MPFT (0.8%), and MPPFT (0%). This demonstrated a statistically significant difference between the slippage rates for each group (p < 0.001). Combining the MPFT and MPPFT groups, there was a statistically significant difference in band slippage compared to the PGT group (p < 0.001).

CONCLUSION

While the MPFT is associated with low band slippage rates, the MPPFT results in further reductions in band slippage. The routine use of this modification to the MPFT is safe and may reduce operative morbidity. A randomized comparison of these techniques is warranted.

Surgery for obesity

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and previously updated in 2005.

OBJECTIVES

To assess the effects of bariatric surgery for obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with searches of reference lists and consultation with experts in obesity research.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different surgical procedures, and RCTs, controlled clinical trials and prospective cohort studies comparing surgery with non-surgical management for obesity.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality.

MAIN RESULTS

Twenty six studies were included. Three RCTs and three prospective cohort studies compared surgery with non-surgical management, and 20 RCTs compared different bariatric procedures. The risk of bias of many trials was uncertain; just five had adequate allocation concealment. A meta-analysis was not appropriate.Surgery results in greater weight loss than conventional treatment in moderate (body mass index greater than 30) as well as severe obesity. Reductions in comorbidities, such as diabetes and hypertension, also occur. Improvements in health-related quality of life occurred after two years, but effects at ten years are less clear.Surgery is associated with complications, such as pulmonary embolism, and some postoperative deaths occurred.Five different bariatric procedures were assessed, but some comparisons were assessed by just one trial. The limited evidence suggests that weight loss following gastric bypass is greater than vertical banded gastroplasty or adjustable gastric banding, but similar to isolated sleeve gastrectomy and banded gastric bypass. Isolated sleeve gastrectomy appears to result in greater weight loss than adjustable gastric banding. Evidence comparing vertical banded gastroplasty with adjustable gastric banding is inconclusive. Data on the comparative safety of the bariatric procedures was limited.Weight loss and quality of life were similar between open and laparoscopic surgery. Conversion from laparoscopic to open surgery may occur.

AUTHORS' CONCLUSIONS

Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

The association between gastroesophageal reflux disease and obesity

Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). Changes in gastroesophageal anatomy and physiology caused by obesity may explain the association. These include an increased prevalence of esophageal motor disorders, diminished lower esophageal sphincter (LES) pressure, the development of a hiatal hernia, and increased intragastric pressure. Central adiposity may be the most important risk for the development of reflux and related complications such as Barrett's esophagus and esophageal adenocarcinoma. Weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD. The mechanism of action through which this surgery is successful at improving GERD may be independent of weight loss and needs further examination. Current evidence suggests that laparoscopic adjusted gastric banding should be avoided in these patients as the impact on gastroesophageal reflux disease appears unfavorable.

Radiographical imaging of the normal anatomy and complications after gastric banding

Laparoscopic adjustable gastric banding is a surgical procedure that is increasingly being performed for the treatment of morbid obesity. As with any intervention, gastric banding is not free from complications. Complications after gastric banding can be divided into early and late complications. Early complications include band malposition and perforation of the stomach. Late complications comprise pouch dilatation, intraluminal band penetration and oesophageal dilatation. Understanding the principles of the intervention is essential for both the interpretation of the resulting radiographical findings and the diagnosis of potential complications. We report on the normal anatomy and the most frequent complications seen after gastric banding.

Preventing Obesity in America: Is It Achievable?

The prevalence of obesity has increased significantly in the past 40 years. Although difficult to treat, physicians must continue contributing to the solution by not only advocating for dietary interventions and increased exercise but also should target at-risk populations and promote more prevention strategies for combating obesity. Given the close association with the comorbidities of diabetes and hypertension, obesity is closely linked with the number one killer of all Americans: heart disease. This alone makes obesity an enormous public health threat. General, broad public health strategies for supporting weight loss are also discussed.

Adjustable laparoscopic gastric banding for morbid obesity: imaging assessment and complications

Laparoscopic adjustable gastric banding (LAGB) is a safe and effective means of weight loss for patients who have morbid obesity. LAGB currently is the least invasive surgical treatment for morbid obesity. Radiologists must be aware of the expected postoperative imaging findings, the optimal technique for radiologic assessment, and the postoperative complications that may occur. In addition, because band-adjustment procedures often are performed fluoroscopically, the radiologist may play a direct role in the management of weight loss in patients following LAGB.

Complications of antiobesity surgery

Bariatric surgery is an effective long-term treatment for patients who suffer from morbid obesity, the incidence of which is increasing in North America. Laparoscopic gastric bypass and laparoscopic adjustable gastric band placement are the two commonly performed bariatric procedures. This article discusses the indications for bariatric surgery and the early and late complications associated with these two procedures. Laparoscopic biliopancreatic diversion and laparoscopic sleeve gastrectomy are also briefly discussed.

Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years

To evaluate influence of laparoscopic gastric banding (LGB) on quality of life (QOL) in patients with morbid obesity. Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. The objectives of surgical therapy in patients with morbid obesity are reduction of body weight, and a positive influence on the obesity-related comorbidity as well the concomitant psychologic and social restrictions of these patients. In a prospective clinical trial, development of the individual patient QOL was analyzed, after LGB in patients with morbid obesity. From October 1999 to January 2001, 152 patients [119 women, 33 men, mean age 38.4 y (range 24 to 62), mean body mass index 44.3 (range 38 to 63)] underwent evaluation for LGB according the following protocol: history of obesity; concise counseling of patients and relative on nonsurgical treatment alternatives, risk of surgery, psychologic testing, questionnaire for eating habits, necessity of lifestyle change after surgery; medical evaluation including endocrinologic and nutritionist work-up, upper GI endoscopy, evaluation of QOL using the Gastro Intestinal Quality of Life Index (GIQLI). Decision for surgery was a multidisciplinary consensus. This group was follow-up at least 2 years, focusing on weight loss and QOL. Mean operative time was 82 minutes; mean hospital stay was 2.3 days and the mean follow-up period was 34 months. The BMI dropped from 44.3 to 29.6 kg/m and all comorbid conditions improved markedly: diabetes melitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 90%. However, 26 patients (17%) had late complications requiring reoperation. Preoperative global GIQLI score was 95 (range 56 to 140), significant different of the healthy volunteers score (120) (70 to 140) P < 0.001. Correlated with weight loss (percentage loss of overweight and BMI), the global score of the group increased to 100 at 3 months, 104 at 6, 111 at 1 year to reach 119 at 2 years which is no significant different of healthy patients. Analyzing the subscale, physical condition, emotional status, and social integration increased significantly (P < 0.001) from preoperative to end of follow-up. Digestive symptoms were not modified. In case of failure of the procedure (10.5%) global Giqli score is not modified. Patients who have required successful revisional surgery for late complications (6.5%) have an excellent QOL outcome that are not different from the whole group. Together with a satisfactory reduction of the excess overweight, laparoscopic gastric banding may lead in a carefully selected population of patients with morbid obesity to a significant improvement of patient QOL, in at least 2 years follow-up.

Surgery for morbid obesity

BACKGROUND

Obesity is associated with increased morbidity and mortality. Surgery for morbid obesity is considered when other treatments have failed. A number of procedures are available, but the effects of these surgical procedures compared with medical management and with each other are uncertain.

OBJECTIVES

To assess the effects of surgery for morbid obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with hand searches of selected journals and consultation with experts in obesity research. Date of the most recent searches: December 2004.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical procedures, and randomised controlled trials and prospective cohort studies comparing surgery with non-surgical management for morbid obesity.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality.

MAIN RESULTS

Twenty-six trials were included. Two randomised controlled trials and three prospective cohort studies compared surgery with non-surgical management, and 21 randomised controlled trials compared different surgical procedures. The quality of most of the trials was poor; just three trials had adequate allocation concealment. A meta-analysis was not possible due to differences in the surgical procedures performed, measures of weight change and length of follow-up. Compared with conventional management, surgery resulted in greater weight loss (21 kg weight loss at eight years versus weight gain), with improvements in quality of life and comorbidities. Some complications of surgery occurred, such as wound infection. Gastric bypass was associated with greater weight loss, better quality of life and fewer revisions, reoperations and/or conversions than gastroplasty, but had more side-effects. Greater weight loss and fewer side-effects and reoperations occurred with adjustable gastric banding than vertical banded gastroplasty, but laparoscopic vertical banded gastroplasty produced more patients with an excellent or good result and fewer late complications than laparoscopic adjustable silicone gastric banding. Vertical banded gastroplasty was associated with greater weight loss but more vomiting than horizontal gastroplasty. Some postoperative deaths occurred in the studies. Weight loss was similar between open and laparoscopic procedures. Fewer serious complications occurred with laparoscopic surgery, although conversion to open surgery was sometimes required. Most studies found that laparoscopic surgery had a longer operative time. But, it resulted in reduced blood loss and quicker recovery.

AUTHORS' CONCLUSIONS

The limited evidence suggests that surgery is more effective than conventional management for weight loss in morbid obesity. The comparative safety and effectiveness of different surgical procedures is unclear.

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.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Prevention of catheter disconnection after laparoscopic adjustable gastric banding

In a consecutive series of 138 laparoscopic adjustable gastric bandings (LAGB) we observed disconnection of the gastric band catheter at the site of the port connector in 17 patients. During operative revision we established a new port position with a minimal distance of 10 cm between the connector and the entrance of the catheter to the abdominal cavity. Using this technique no complications and no catheter disruptions occurred during a median followup period of 25 months.

Retrospective study of laparascopic adjustable silicone gastric banding for the treatment of morbid obesity: results and complications in 127 patients

OBJECTIVES

Laparoscopic gastric banding is currently the most popular surgical technique for morbId obesity. This wIdespread use of surgery has been evaluated by a number of clinical studies, particularly on weight change.

METHODS

In a retrospective study of 127 obese patients operated between 1996 and 2000, data were collected for weight change, medical and surgical complications.

RESULTS

Of 127 patients, failures of gastric banding were noted during 2 surgical operations. The average follow-up period was 33 +/- 20 Months. Average weight loss in all patients was 19.9 +/- 5.3 kg (15.3 +/- 4.2%). No difference in weight loss was observed between diabetic and non-diabetic patients. During the follow-up, data were collected on 53 complications (42.4% of all gastric banding operations). 3 main types of complication were found: access port related complications (22.6% of the total), band slippage (20.7% of the total) and tubing related complications (16.9% of the total). No prognostic factor for these complications could be Identified from multivariate analysis.

CONCLUSIONS

Our results are very similar to those of other weight evolution studies. We found that there was a significant incIdence of surgical and medical complications during the follow-up because of the meticulous way all complications were recorded, even the most insignificant. This morbIdity must be borne in mind before surgery is performed.

Laparoscopic adjustable silicone gastric banding versus vertical banded gastroplasty in morbidly obese patients: a prospective randomized controlled clinical trial

OBJECTIVE

To compare, in a prospective, randomized, single-institution trial laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbidly obese patients.

SUMMARY BACKGROUND DATA

LASGB is a simple and safe procedure, but some reports have suggested disappointing long-term results. Despite the recent widespread use of LASGB, there are no prospective nor randomized trials comparing LASGB with other laparoscopic procedures.

METHODS

A total of 100 morbidly obese patients, with body mass index (BMI) 40 to 50 kg/m2, without compulsive eating, were randomized to either LASGB (n = 49) or LVBG (n = 51). Minimum follow-up was 2 years (mean 33.1 months).

RESULTS

There were no deaths or conversions in either group. Mean operative time was 94.2 minutes in LVBGs and 65.4 in LASGBs (P < 0.05). Early morbidity rate was lower in LASGBs (6.1%) versus LVBGs (9.8%) (P = 0.754). Mean hospital stay was shorter in LASGBs versus LVBGs: 3.7 days versus 6.6 (P < 0.05). Late complications rate in LVBGs was 14% (7 of 50) and in LASGBs 32.7% (16 of 49) (P < 0.05). The most frequent complication was the slippage of the band (18%). Late reoperations rate in LVBGs was 0% (0 of 50) versus 24.5% (12 of 49) in LASGBs (P < 0.001). Excess weight loss in LVBGs was, at 2 years, 63.5% and, at 3 years, 58.9%; in LASGBs, excess weight loss, respectively, was 41.4% and 39%. BMI in LVBGs was, at 2 years, 29.7 kg/m2 and, at 3 years, 30.7 kg/m2; in LASGBs, BMI was 34.8 kg/m2 at 2 years and 35.7 kg/m2 at 3 years. According to Reinhold's classification, a residual excess weight <50% was achieved, at 2 years, in 74% of LVBG and 35% of LASGB (P < 0.001).

CONCLUSIONS

This study demonstrates that, in patients with BMI 40 to 50 kg/m2, LASGB requires shorter operative time and hospital stay but LVBG is more effective in terms of late complications, reoperations, and weight loss.

Port function after laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited.

METHODS

In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years.

RESULTS

Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).

CONCLUSION

The high number of complications suggests that the port is the Achilles' heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

Evolution of a paradigm for laparoscopic adjustable gastric banding

The first human laparoscopic adjustable gastric banding procedure, using the LAP-BAND device (INAMED Health, Santa Barbara, CA), was performed on September 1, 1993. Because of its minimal invasiveness, reversibility, and adjustability, it is considered a breakthrough in bariatric surgery. Placement of the LAP-BAND is the least invasive operative procedure that can be offered to patients with morbid obesity. The technique has evolved since it was first performed on humans. This evolution mainly concerns the band's position in relation to the gastric wall, which necessitated modifying the posterior dissection for band passage and placement. These technical changes have been aimed at reducing morbidity, especially the major complication, prolapse/slippage or pouch dilatation above the band. Based on personal experience and a review of the literature, the authors describe how the surgical technique has developed since the introduction of the LAP-BAND. The advantages of the LAP-BAND have contributed to its increasing use throughout the world. The authors believe that the approach represents a paradigm shift in bariatric surgery.

Avoiding postoperative complications with the LAP-BAND system

The most frequently occurring complications associated with the LAP-BAND (INAMED Health, Santa Barbara, CA) include gastric prolapse, stoma obstruction, esophageal and gastric pouch dilatation, erosion, and access port problems. This article describes the causes of these complications and details some points for their prevention and treatment. As techniques for placement of the LAP-BAND have evolved, complication rates have declined. For example, occurrence of gastric prolapse was reduced from the initially reported rates of 22% to less than 5%. The emergence of many problems, such as gastric pouch dilatation or prolapse, can be minimized with proper operative technique and close postoperative management and follow-up. As with other major surgical procedures, particularly those performed in the bariatric population, complications associated with the LAP-BAND system are unavoidable but are rarely life-threatening if managed appropriately. Surgeons and patients should adopt strategies that will help avoid complications and be sensitive to any indication of their emergence.

[Video-laparoscopic placement of adjustable gastric banding (lap-band) in the treatment of morbid obesity. Preliminary results after 407 interventions]

INTRODUCTION

Morbid obesity is the most frequent nutritional disorder in developed countries. Bariatric surgery is one option for the definitive treatment of this disorder. We present 407 patients who underwent implantation of adjustable silicone gastric banding. Ninety-four percent of the patients were satisfied with the procedure and its results.

MATERIAL AND METHOD

We performed a retrospective study in the Surgery Department of the Nordwestkrankenhaus teaching hospital of the University of Frankfurt. From April 1996 to January 2000 we performed laparoscopic placement of adjustable silicone gastric banding in 407 patients, using Kuzmak's technique. Mean body mass index was 49.1 and mean weight was 139.2 kg. We describe the patient selection method and provide a detailed description of the technique and its possible problems.

RESULTS

There was no operative or postoperative mortality. None of the patients required conventional surgery. Mean operating time was 62 minutes (including operating times during the learning period). Mean hospital stay was 5 days. We performed 24 (5,89%) reinterventions: 11 for displacement, 2 for erosion, 4 for infection of the reservoir, 2 due to review of the reservoir to prevent penetration and 4 due to dilatations of the pouch (changing the banding from a retrogastric to a retroesophageal position); one patient requested removal of the banding. Follow-up was performed at months 1, 6, 9 and 12. Mean weight loss was 28 kg at 6 months and 54 kg at 1 year. Mean weight loss in patients followed-up for 2 years was 58 kg. A total of 94.9% of the patients were satisfied with the procedure.

CONCLUSIONS

Laparoscopic implantation of adjustable gastric banding (Lap-Band) combines the aims of conventional gastroplasty with the advantages of laparoscopic surgery in terms of postoperative morbidity and minimal invasiveness.