Changes in satiety, supra- and infraband transit, and gastric emptying following laparoscopic adjustable gastric banding: a prospective follow-up study

Recent advances in bariatric surgery: a narrative review of weight loss procedures

Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity.

Roles of Gastric Emptying and Gastrointestinal Transit Following Ileal Interposition in Alleviating Diabetes in Goto-Kakizaki Rats

OBJECTIVE

This study aimed to determine the change of gastrointestinal (GI) emptying time after ileal interposition (IT) and elucidate the role of altered GI peristalsis in diabetic control.

MATERIALS AND METHODS

Twelve male Goto-Kakizaki rats were randomly divided into IT and sham groups. Body weight and food intake were recorded. Oral glucose tolerance test (OGTT), insulin tolerance test (ITT), plasma glucagon-like peptide-1 (GLP-1), and gastric emptying were measured at baseline and 4 and 8 weeks after operation. At 9 weeks postoperatively, the rats in the IT group were given atropine which can suppress the emptying of stomach and upper intestine, while sham rats were given metoclopramide (to expedite gastric emptying) for 1 week. At week 10 postoperatively, OGTT and GLP-1 were detected. The intestinal transit was tested at postoperative 12 weeks.

RESULTS

No differences were found between groups at baseline. After operation, the IT rats had lower body weight than sham rats. At 4 and 8 weeks postoperatively, the IT group showed better OGTT and ITT, with significantly elevated GLP-1 relative to sham. After administration of the GI motility drugs, however, the effect of diabetic control for the two groups became similar. The GI transit after IT was significantly slower than sham at all tested time points.

CONCLUSIONS

Although IT inhibits the GI transit time, the earlier interaction between undigested nutrients and interpositioned ileum promotes gut hormone secretion and thus reduces body weight and alleviates hyperglycemia. A decrease of GI transit of IT rats exacerbates the antidiabetic effects.

A comparative study of eating behaviours within and between conventional metabolic (bariatric) surgery procedures

AIMS AND OBJECTIVES

To compare eating behaviours within and between gastric bypass, sleeve gastrectomy and gastric band procedures and to investigate associations between eating behaviours and body weight.

BACKGROUND

Eating behaviours are subjective constructs representing physiological need and the hedonic need to eat. After metabolic surgery, eating behaviours have been observed to change. Little is known about whether eating behaviour change differs according to the metabolic procedure performed.

DESIGN

Adults (n = 204) with severe obesity from three countries were followed 1 year after metabolic surgical procedures (n = 121).

METHODS

We measured eating behaviours using the Three-Factor Eating Questionnaire and used linear mixed models to compare eating behaviours within and between three procedure groups. We complied with the STROBE checklist for reporting observational studies.

RESULTS

Within groups, there were statistically significant increases in restraint and decreases in disinhibition and hunger. Between groups, we observed differences in disinhibition associated with the band procedure. There were no significant differences between any group for body weight or body mass index a year post-surgery. Disinhibition was the only eating behaviour associated with body weight, body mass index and the per cent of weight loss.

CONCLUSIONS

Eating behaviours in adults with severe obesity who underwent any of the three metabolic procedures were associated with eating behaviour change 1 year post-surgery. Disinhibition was the only eating behaviour that was associated with body weight.

RELEVANCE TO CLINICAL PRACTICE

Irrespective of the procedure, we found participants had a statistically significant increase in restraint and decreases in disinhibition and hunger 1 year post-surgery. Despite the significant reduction in disinhibition within the band group, this behaviour was more pronounced post-surgery compared with other groups. Although the reduction in hunger showed the greatest change, it was not associated with weight outcomes. This is relevant clinical knowledge for nurses who support bariatric surgical patients.

Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) patients have substantially altered anatomy. The mechanism of rapid gastric emptying and the role of esophageal contractile function in esophago-gastric transit has not been defined. We aimed to determine the mechanisms of esophago-gastric transit and role of esophageal function following sleeve gastrectomy.

METHODS

Prospective study of twenty-six asymptomatic participants post SG underwent nuclear scintigraphy and high-resolution manometry. Fourteen had semi-solid stress barium to model the emptying process. Concurrent video fluoroscopy and manometry were performed on 7 participants.

RESULTS

Demographic data are as follows: age 45.3 ± 15.0 years, 73.1% female, excess weight loss 62.2 ± 28.1% at 8 months. Scintigraphy showed rapid gastric emptying (24.4 ± 11.4 vs. 75.80 ± 45.19 min in control, p < 0.001) with 35.24 ± 17.12% of bolus transited into small bowel on initial frame. Triggered deglutitive reflux was common (54.4% vs. 18.2%, p = 0.017). Stress barium delineated separate vertical and antral gastric compartments with cyclical emptying of 8 stages, including reflux-induced repeated esophageal peristalsis. During manometry, ramping effects were noted, with sequential swallows producing sustained isobaric pressurizations in proximal stomach (33.6 ± 29.5 mmHg). Video fluoroscopy showed individual esophageal peristalsis generating pressurizations at 5.0 ± 1.4 cm below lower esophageal sphincter (LES), at amplitude of 31.6 ± 13.1 mmHg, associated with intragastric transit. Pressurizations were sustained for 17.3 ± 8.2 s, similar to the prolonged LES contraction (18.5 ± 9.0 s, p = 0.355).

CONCLUSIONS

Repeated esophageal peristaltic contractions induced isobaric pressurization of proximal stomach, thus providing the drive to pressurize and empty the vertical compartment of the gastric sleeve. Transit following SG appeared to be esophageal-mediated and followed a distinct cycle with strong associations with reflux.

Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding

INTRODUCTION

A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB).

METHODS

Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating).

RESULTS

Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery.

CONCLUSION

These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.

Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding

Introduction

Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up.

Methods

Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented.

Results

Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/− duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques.

Conclusion

All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.

Mechanisms of Weight Loss After Sleeve Gastrectomy and Adjustable Gastric Banding: Far More Than Just Restriction

Obesity has reached global epidemic proportions in recent decades. Bariatric surgery is currently accepted as most effective in alleviating morbid obesity and related disorders. Sleeve gastrectomy (SG) and adjustable gastric banding (AGB) have gained popularity since the beginning of this century because of their efficacy, safety, and simplicity. SG, in particular, has emerged as the most popular bariatric procedure because of its simpler concept and shorter operative time compared with gastric bypass. Caloric restriction, however, cannot account for the sustained weight loss and improved glucose metabolism seen following SG and AGB. Other mechanisms, including changes in gastrointestinal hormone secretion, rearrangement of hypothalamic and vagal control, alteration in energy expenditure, and re-regulation of bile acid metabolism and the intestinal flora environment, are thought to contribute to the postoperative benefits. This review focuses on clinical and experimental literature addressing the potential mechanisms for SG and AGB procedures in human and animal models. Understanding such mechanisms can provide important insight into how current gastric restrictive procedures work and how future treatments of obesity, both surgical and nonsurgical, can be developed.

Food Intake and Eating Behavior After Bariatric Surgery

Obesity is an escalating global chronic disease. Bariatric surgery is a very efficacious treatment for obesity and its comorbidities. Alterations to gastrointestinal anatomy during bariatric surgery result in neurological and physiological changes affecting hypothalamic signaling, gut hormones, bile acids, and gut microbiota, which coalesce to exert a profound influence on eating behavior. A thorough understanding of the mechanisms underlying eating behavior is essential in the management of patients after bariatric surgery. Studies investigating candidate mechanisms have expanded dramatically in the last decade. Herein we review the proposed mechanisms governing changes in eating behavior, food intake, and body weight after bariatric surgery. Additive or synergistic effects of both conditioned and unconditioned factors likely account for the complete picture of changes in eating behavior. Considered application of strategies designed to support the underlying principles governing changes in eating behavior holds promise as a means of optimizing responses to surgery and long-term outcomes.

The Physiology and Pathophysiology of Gastroesophageal Reflux in Patients with Laparoscopic Adjustable Gastric Band

INTRODUCTION

The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group.

METHODS

High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement.

RESULTS

The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010).

CONCLUSIONS

Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.

Laparoscopic Adjustable Gastric Band Slippage Rates Following Laparoscopic Gastric Band Insertion: a Single Centre Experience

INTRODUCTION

Laparoscopic adjustable gastric bands (LAGB) are placed around the superior aspect of the stomach to aid weight loss and co-morbidity resolution in morbidly obese patients. Slippage of the LAGB from its original position to lower in the fundus of the stomach leads to gastric obstruction, and sometimes ischaemia or perforation, necessitating LAGB repositioning or removal. This study aimed to identify the incidence of LAGB slippage, as well as predisposing factors that may influence its development.

METHODS

All LAGBs inserted at one centre, via a pars flaccida technique, by four Bariatric specialist consultants, were reviewed utilising a prospectively maintained Bariatric database, computer records and case notes review.

RESULTS

Seven hundred nineteen LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip rate 3.1 %). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 years slip vs. 45 years non-slip; p = 0.027), higher median total excess weight loss (64 % slip vs. 36 % non-slip; p < 0.001) and higher mean excess weight loss per month (2.41 % slip vs. 1.00 % non-slip; p < 0.001). There was no significant effect by sex, BMI at insertion or band type.

CONCLUSIONS

Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Endoscopic Bariatric and Metabolic Therapies: Surgical Analogues and Mechanisms of Action

Obesity is a worsening pandemic with numerous related comorbid illnesses. Conservative management including lifestyle modification and medications have limited efficacy. In contradistinction, bariatric surgery is effective, however, with substantial cost and non-negligible morbidity and mortality. As such, a small percentage of eligible patients undergo surgery. Over the past decade, endoscopic bariatric and metabolic therapies have been introduced as a less invasive option for the treatment of obesity and its related comorbid illnesses. This article reviews major endoscopic bariatric and metabolic therapies, their surgical analogues, and proposed mechanisms of action. Clinical trial data for each device also are discussed.

The use of adjustable gastric bands for management of severe and complex obesity

BACKGROUND

Obesity levels in the UK have reached a sustained high and ∼4% of the population would be candidates for bariatric surgery based upon current UK NICE guidelines, which has important implications for Clinical Commissioning Groups.

SOURCES OF DATA

Summary data from Cochrane systematic reviews, randomized controlled trials (RCTs) and cohort studies.

AREAS OF AGREEMENT

Currently, the only treatment that offers significant and durable weight loss for those with severe and complex obesity is surgery. Three operations account for 95% of all bariatric surgery in the UK, but the NHS offers surgery to only a small fraction of those who could benefit. Laparoscopic adjustable gastric banding (gastric banding) has potentially the lowest risk and up-front costs of the three procedures.

AREAS OF CONTROVERSY

Reliable Level 1 evidence of the relative effectiveness of the operations is lacking.

GROWING POINTS

As a point intervention, weight loss surgery together with the chronic disease management strategy for obesity can prevent significant future disease and mortality, and the NHS should embrace both.

AREAS TIMELY FOR DEVELOPING RESEARCH

Better RCT evidence is needed including clinical effectiveness and economic analysis to answer the important question 'which is the best of the three operations most frequently performed?' This review considers the current evidence for gastric banding for the treatment of severe and complex obesity.

Controversies in bariatric surgery

BACKGROUND

There are many controversies related to bariatric surgery. This review explores selected areas.

METHODS

A combination of randomized clinical trials (RCTs), systematic reviews and expert opinion have been brought together to highlight areas of importance or conflict.

RESULTS AND CONCLUSION

Metabolic surgery is an increasingly preferred term rather than bariatric or obesity surgery. Reporting should be standardized to include appropriate weight measures, valid disease measures and data on loss to follow-up. There are many putative mechanisms of effect of key bariatric procedures, but satiety and early satiation appear central. Weight loss must be durable. Long-term outcome studies (more than 10-year follow-up) show that biliopancreatic diversion is most effective, with 72 per cent excess weight loss (EWL). Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding (LAGB) are equally effective, with 54 per cent EWL. There are no long-term data on vertical sleeve gastrectomy. Type II diabetes is a common and serious disease, usually associated with increased weight. Multiple RCTs have shown that bariatric surgery provides clear benefits over continuing with non-surgical therapies. The earlier the treatment, the more likely and durable will be the remission. Bariatric surgery should be available to all who are obese (body mass index over 30 kg/m(2) ). LAGB, a safe, effective, reversible outpatient procedure, is the author's preferred primary option.

The role of bariatric surgery in the treatment of diabetes

The obesity epidemic contributes to approximately 44% of the world's type 2 diabetes burden. Bariatric surgery is an effective treatment for type 2 diabetes mellitus in patients with morbid obesity as it improves glycaemia, blood pressure, lipids and inflammation. This review describes the evidence supporting the addition of bariatric surgery to the treatment algorithms used by diabetologists. We emphasize the need to view bariatric surgery as an adjuvant therapy which should not be used instead of but rather together with best medical therapy.

Intensive medical weight loss or laparoscopic adjustable gastric banding in the treatment of mild to moderate obesity: long-term follow-up of a prospective randomised trial

BACKGROUND

Proven short-term effectiveness of obesity therapy should be re-evaluated in the long-term. The objective of this paper is to determine the long-term (10 years) outcome for patients from a randomised controlled trial (RCT).

METHODS

A RCT in 2002 compared laparoscopic adjustable gastric band (LAGB) for obesity with non-surgical therapy. Follow-up has been conducted at 10 years. Eighty patients (BMI 30-35) were randomised to a non-surgical or a surgical program. Outcome data are available on 37 (92.5 %) of the surgical patients and 27 (62.5 %) of the non-surgical patients at 10 years.

RESULTS

Weight change, the metabolic syndrome, quality of life, adverse events and direct costs of the surgical cohort were the main results of the study. A durable weight loss is present in the surgical group with a mean (SD) 10-year weight loss of 14.1 (7.7) kg (63.4 % EWL), better than the non-surgical group (mean (SD) = 0.4 (10.5) kg; p < 0.001). The metabolic syndrome was reduced from 14 to 4 of the 37 patients who completed 10 years within the LAGB groups. Proximal gastric enlargements occurred in 17 (30 %) of the 57 who had LAGB and removal of the band occurred in 7 (12 %). The annual maintenance costs including additional surgery was AUD $765 per patient per year.

CONCLUSIONS

Bariatric surgery with the LAGB can achieve long-term weight reduction which is better than a program of non-surgical therapy. There is also a sustained reduction of the metabolic syndrome. There is a significant maintenance requirement after LAGB.

Airway management concerns in patient with gastric banding procedures

Laparoscopic adjustable gastric band (LAGB) is considered a relatively safe and effective treatment for obesity. Even after weight loss patients with LAGB are at increased risk of pulmonary aspiration during induction of general anaesthesia, possibly due to LAGB-induced anatomical and functional changes. We present a case of aspiration in a patient with LAGB following significant weight loss and 14 h of preoperative fasting and review the literature. In the presence of LAGB we propose specific anaesthesia management at least consisting of anti-Trendelenburg positioning; avoidance of mask-ventilation; use of the local rapid sequence induction strategy with endotracheal intubation and fully awake extubation.

Effects of RYGB on energy expenditure, appetite and glycaemic control: a randomized controlled clinical trial

OBJECTIVES

Increased energy expenditure (EE) has been proposed as an important mechanism for weight loss following Roux-en-Y gastric bypass (RYGB). However, this has never been investigated in a controlled setting independent of changes in energy balance. Similarly, only few studies have investigated the effect of RYGB on glycaemic control per se. Here, we investigated the effect of RYGB on EE, appetite, glycaemic control and specific signalling molecules compared with a control group in comparable negative energy balance.

SUBJECTS/METHODS

Obese normal glucose-tolerant participants were randomized to receive RYGB after 8 (n=14) or 12 weeks (n=14). The protocol included a visit at week 0 and three visits (weeks 7, 11 and 78) where 24-h EE, appetite and blood parameters were assessed. Participants followed a low-calorie diet from weeks 0-11, with those operated at week 12 serving as a control group for those operated at week 8.

RESULTS

Compared with controls, RYGB-operated participants had lower body composition-adjusted 24-h EE and basal EE 3 weeks postoperatively (both P<0.05) but EE parameters at week 78 were not different from preoperative values (week 7). Surgery changed the postprandial response of glucagon-like peptide-1 (GLP-1), peptide YY3-36 (PYY), ghrelin, cholecystokinin, fibroblast growth factor-19 and bile acids (all P<0.05). Particularly, increases in GLP-1, PYY and decreases in ghrelin were associated with decreased appetite. None of HOMA-IR (homeostasis model assessment-estimated insulin resistance), Matsuda index, the insulinogenic index, the disposition index and fasting hepatic insulin clearance were different between the groups, but RYGB operated had lower fasting glucose (P<0.05) and the postprandial glucose profile was shifted to the left (P<0.01).

CONCLUSIONS

Our data do not support that EE is increased after RYGB. More likely, RYGB promotes weight loss by reducing appetite, partly mediated by changes in gastrointestinal hormone secretion. Furthermore, we found that the early changes in glycaemic control after RYGB is to a large extent mediated by caloric restriction.

Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature

OBJECTIVE

To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery.

BACKGROUND

Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures.

METHODS

We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years.

RESULTS

A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL.

CONCLUSIONS

The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.

[Adjustable gastric band as surgical treatment for morbid obesity. Are worldwide results reproducibles in Spain?]

INTRODUCTION

Adjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference.

MATERIAL AND METHODS

A program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results.

RESULTS

A total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years.

CONCLUSIONS

The results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country.

Upper gastrointestinal symptoms in obese patients and their outcomes after bariatric surgery

Obesity is considered an important risk factor for the development of gastrointestinal (GI) disorders, likely through alterations of GI motility. Even though gastroesophageal reflux disease is the condition mainly studied at present, the prevalence of other upper GI symptoms is also augmented in obese patients. Owing to their chronic trend, these disorders have a bearing on public spending and their correct diagnosis would avoid unnecessary cost-consuming investigations. Furthermore, bariatric surgery dramatically changes GI anatomy and physiology, influencing GI symptom outcomes. The aim of this review is to categorize the available results in a pathophysiological framework in an attempt to set up the correct clinical GI management of obese patients before and after bariatric surgery. This would be helpful in tentatively reducing their considerable economic burden on public health services.

Gastric bypass surgery is followed by lowered blood pressure and increased diuresis - long term results from the Swedish Obese Subjects (SOS) study

Objective

To compare two bariatric surgical principles with regard to effects on blood pressure and salt intake.

Background

In most patients bariatric surgery induces a sustained weight loss and a reduced cardiovascular risk profile but the long-term effect on blood pressure is uncertain.

Methods

Cohort study with data from the prospective, controlled Swedish Obese Subjects (SOS) study involving 480 primary health care centres and 25 surgical departments in Sweden. Obese patients treated with non-surgical methods (Controls, n = 1636 and n = 1132 at 2 y and 10 y follow up, respectively) were compared to patients treated with gastric bypass (GBP, n = 245 and n = 277, respectively) or purely restrictive procedures (vertical banded gastroplasty or gastric banding; VBG/B, n = 1534 and n = 1064, respectively).

Results

At long-term follow-up (median 10 y) GBP was associated with lowered systolic (mean: −5.1 mm Hg) and diastolic pressure (−5.6 mmHg) differing significantly from both VBG/B (−1.5 and −2.1 mmHg, respectively; p<0.001) and Controls (+1.2 and −3.8 mmHg, respectively; p<0.01). Diurnal urinary output was +100 ml (P<0.05) and +170 ml (P<0.001) higher in GBP subjects than in weight-loss matched VBG/B subjects at the 2 y and 10 y follow-ups, respectively. Urinary output was linearly associated with blood pressure only after GBP and these patients consumed approximately 1 g salt per day more at the follow-ups than did VBG/B (P<0.01).

Conclusions

The purely restrictive techniques VBG/B exerted a transient blood pressure lowering effect, whereas gastric bypass was associated with a sustained blood pressure reduction and an increased diuresis. The daily salt consumption was higher after gastric bypass than after restrictive bariatric surgery.

Effect of source of funding on weight loss up to 3 years after gastric banding

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is a popular choice for patients seeking weight loss surgery. Since behavioural change appears to play a role in weight loss outcomes we postulated that publicly funded patients might not do as well as self-payers. This series examines the effect of public funding versus self-pay on patients undergoing LAGB over 1, 2 and 3 years.

METHODS

Consecutive non-randomised cohort series of patient undergoing LAGB over 5 years (September 2003 to December 2008) in a single unit. Age, sex, funding route, body mass index (BMI) and complications were recorded. Per cent excess weight loss (EWL) and the Reinhold criterion for success (proportion achieving 50 % EWL) were assessed.

RESULTS

Ninety-nine patients were publicly funded, and 250 patients were self-payers. Initial BMI was significantly higher in publicly funded patients (46.6 vs. 42.3 kg/m(2), p < 0.001) with a higher proportion of males (22.2 vs. 6.0 %, p < 0.001). Mean % EWL was significantly less for publicly funded patients at 1 year (38.1 vs. 53.5 %, p < 0.001) and 2 years (49.6 vs. 64.1 %, p < 0.001), but not at 3 years (59.7 vs. 61.8 %, p = 0.784). Fewer publicly funded patients achieved 50 % EWL at 1 year (24.5 vs. 50.2 %, p < 0.001), but with no significant difference at 2 years (54.8 vs. 67.0 %, p = 0.140) or 3 years (55.2 vs. 66.0 %, p = 0.349).

CONCLUSIONS

Self-pay patients initially achieved more % EWL and greater success in reaching 50 % EWL after LAGB, but this difference was not maintained. The results suggest that patient motivation, using self-pay as a surrogate marker, may affect early results, but the operation itself is the main determinant of weight loss at 3 years.

Effect of vertical sleeve gastrectomy on food selection and satiation in rats

Vertical sleeve gastrectomy (VSG) is a restrictive procedure that reduces food intake to produce weight loss. Here we assess volume and nutrient effects on the ingestive behavior of VSG and sham surgery animals. Rats given access to Ensure or pelleted chow were used to determine if liquid foods would adversely affect weight loss after surgery. Volume effects were studied by altering the caloric density of Ensure, and dietary preferences for fat and carbohydrate (sucrose) were assessed using a two-bottle test. c-Fos was used to measure neuronal activation in the nucleus of the solitary tract and area postrema in response to intragastric infusions of water, sucrose, or Intralipid. The degree of colocalization with catecholaminergic neurons was also assessed. VSG rats did not show the expected preference for a liquid diet over chow and lacked dietary preferences for fat seen in shams. Preferences for carbohydrate/sucrose solutions were unaffected by surgery. Meal size was reduced by VSG; however, VSG rats were able to alter their volume of intake to compensate for changes in caloric density, and intragastric infusions of water produced similar levels of neuronal activation among VSG, sham, and pair-fed rats. In comparison, nutrient-induced c-Fos activation was substantially increased by VSG. Colocalization between c-Fos and catecholaminergic-expressing neurons was similar among rats treated with water, sucrose, or Intralipid. VSG alters nutrient sensing in a manner that lowers the threshold for satiety and reduces fat preference to induce and maintain weight loss.

Review article: the impact of bariatric surgery on gastrointestinal motility

BACKGROUND

Obesity is a major medical problem worldwide. Different treatment modalities have emerged to treat obese patients, but the best long-term results are achieved with bariatric surgery. Currently, the interventions most commonly performed are laparoscopic adjustable gastric banding (LAGB), Roux-en-Y- gastric bypass (RYGB) and sleeve gastrectomy.

AIM

To review the gastrointestinal motor complications associated with each of these types of bariatric interventions and the clinical implications of such complications.

METHODS

Search of medical database (PubMed) on English-language articles from January 1996 to March 2011. The search terms used were laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), roux-en-Y-gastric bypass (RYGB), using the AND operator with the terms: complications, motility, GERD, reflux, gastric emptying, esophagitis, dysphagia.

RESULTS

Of the three bariatric interventions reviewed, LAGB was the most studied. Most studies reported short follow-up, of ≤ 1 year. Oesophageal motor dysfunction is the most common motility complication following the bariatric interventions that were reviewed and is mainly observed after LAGB. Some data suggest that oesophageal motor function testing predicts development of post-operative symptoms and oesophageal dilation. RYGB offers protection from gastro-oesophageal reflux. Sleeve gastrectomy was the least studied and was associated with an acceleration of gastric emptying.

CONCLUSIONS

The effects of these interventions on GI motility should be considered when selecting patients for bariatric surgery. There is scant information regarding the overall effect of sleeve gastrectomy on gastro-oesophageal reflux patterns and oesophageal motility.

Surgical approaches to the treatment of obesity

Bariatric surgery, through its efficacy and improved safety, is emerging as an important and broadly available treatment for people with severe and complex obesity that has not responded adequately to other therapy. Established procedures, such as Roux-en-Y gastric bypass and adjustable gastric banding, account for more than 80% of bariatric surgical procedures globally. Sleeve gastrectomy has emerged as a stand-alone procedure. Truly malabsoptive procedures, such as biliopancreatic diversion and its duodenal switch variant, have a diminishing role as primary procedures, but remain an option for patients who do not respond adequately to less disruptive procedures. The procedures vary considerably in their postoperative morbidity and mortality; pattern and extent of weight loss; nature and severity of long-term complications; and nutritional requirements and risks. There is no perfect procedure--an informed risk and benefit assessment should be made by each patient. Gastroenterologists also need to be familiar with the risks and benefits of current and emerging procedures as they are likely to be increasingly involved in the integrated care of these patients.