Five-year weight loss experience of outpatients receiving laparoscopic adjustable gastric band surgery

Efficacy and Safety of Sleeve Gastrectomy or One Anastomosis Gastric Bypass Conversion Following Adjustable Gastric Banding

BACKGROUND

Given revision or conversion surgery is required in up to 60% of patients who had adjustable gastric band (LAGB), we compared safety and efficacy of sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB) as conversion surgical procedures in patients with suboptimal response or weight recurrence following LAGB.

METHODS

Conversion surgery was performed in 335 patients between 2016 and 2020. Weight loss, early and late-stage complications, and comorbidity outcomes were reviewed and analyzed.

RESULTS

One hundred and sixty-three patients underwent cSG (BMI: 38.3 ± 8.3 kg/m²), and 172 patients underwent cOAGB (BMI: 45.2 ± 9.3 kg/m²). Percent total body weight loss (%TWL) was 28.7 ± 9.9% at 12 months, 30.3 ± 12.8% at 2 years, 31.0 ± 14.5% at 3 years, and 31.1 ± 14.7% at 4 years following OAGB, which was significantly higher than SG; 18.4 ± 8.7%, 18.8 ± 9.8%, 19.3 ± 11.1%, and 16.9 ± 10.9%, respectively (p < 0.0001). Remission of comorbidities, regardless of conversion procedure type, was 20.8% for hypertension (HT), 52% for dyslipidemia (DLD), 60% for type 2 diabetes (DM), 64% for non-alcoholic steatohepatitis (NASH), and 76% for insulin resistance (IR).There were no leaks or deaths following SG or OAGB. A twofold greater frequency of complications was seen in the OAGB group vs SG group (15.1% and 6.7%, respectively).

CONCLUSION

Significant weight loss, acceptable complication rates, and similar remission of comorbidities were seen regardless of the type of conversion procedure. Prospective randomized clinical trials are recommended for further elucidation of long-term outcomes.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding

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Although most complications following LAGB are confined to the stomach and port site, some may envolve the entire bowel causing extensive damage.

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One must be wary of the presentation of long term complications, as it may initially present as an unrelated pathology, such as acute pancreatitis.

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Long term complications may be asymptomatic for years despite extensice damage, including multiple contained perforations.

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The surgical procedure performed to treat long term complications should be planned and performed by physicians experienced in foregut surgery.

Introduction

Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported.

Presentation of case

A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum.

Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21.

Discussion

Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature.

Conclusion

Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Laparoscopic Adjustable Gastric Banding-Should a Second Chance Be Given?

Background

Obesity is a chronic relapsing-remitting disease and a global pandemic, being associated with multiple comorbidities. Laparoscopic adjustable gastric banding (LAGB) is one of the safest surgical procedures used for the treatment of obesity, and even though its popularity has been decreasing over time, it still remains an option for a certain group of patients, producing considerable weight loss and improvement in obesity-associated comorbidities.

Methods

The aim of this study was to evaluate the impact of weight loss following LAGB on obesity-associated comorbidities, and to identify factors that could predict better response to surgery, and patient sub-groups exhibiting greatest benefit. A total of 99 severely obese patients (81.2% women, mean age 44.19 ± 10.94 years, mean body mass index (BMI) 51.84 ± 8.77 kg/m²) underwent LAGB in a single institution. Results obtained 1, 2, and 5 years postoperatively were compared with the pre-operative values using SPPS software version 20.

Results

A significant drop in BMI was recorded throughout the follow-up period, as well as in A1c and triglycerides, with greatest improvement seen 2 years after surgery (51.8 ± 8.7 kg/m² vs 42.3 ± 9.2 kg/m², p < 0.05, 55.5 ± 19.1 mmol/mol vs 45.8 ± 13.7 mmol/mol, p < 0.05, and 2.2 ± 1.7 mmol/l vs 1.5 ± 0.6 mmol/l). Better outcomes were seen in younger patients, with lower duration of diabetes before surgery, and lower pre-operative systolic blood pressure.

Conclusions

Younger age, lower degree of obesity, and lower severity of comorbidities at the time of surgery can be important predictors of successful weight loss, making this group of patients the ideal candidates for LAGB.

Polygenic risk score for predicting weight loss after bariatric surgery

BACKGROUND

The extent of weight loss among patients undergoing bariatric surgery is highly variable. Herein, we tested the contribution of genetic background to such interindividual variability after biliopancreatic diversion with duodenal switch.

METHODS

Percentage of excess body weight loss (%EBWL) was monitored in 865 patients over a period of 48 months after bariatric surgery, and two polygenic risk scores were constructed with 186 and 11 (PRS186 and PRS11) single nucleotide polymorphisms previously associated with body mass index (BMI).

RESULTS

The accuracy of the %EBWL logistic prediction model - including initial BMI, age, sex, and surgery modality, and assessed as the area under the receiver operating characteristics (ROC) curve adjusted for optimism (AUCadj = 0.867) - significantly increased after the inclusion of PRS186 (ΔAUCadj = 0.021; 95% CI of the difference [95% CIdiff] = 0.005-0.038) but not PRS11 (ΔAUCadj= 0.008; 95% CIdiff= -0.003-0.019). The overall fit of the longitudinal linear mixed model for %EBWL showed a significant increase after addition of PRS186 (-2 log-likelihood = 12.3; P = 0.002) and PRS11 (-2 log-likelihood = 9.9; P = 0.007). A significant interaction with postsurgery time was found for PRS186 (β = -0.003; P = 0.008) and PRS11 (β = -0.008; P = 0.03). The inclusion of PRS186 and PRS11 in the model improved the cost-effectiveness of bariatric surgery by reducing the percentage of false negatives from 20.4% to 10.9% and 10.2%, respectively.

CONCLUSION

These results revealed that genetic background has a significant impact on weight loss after biliopancreatic diversion with duodenal switch. Likewise, the improvement in weight loss prediction after addition of polygenic risk scores is cost-effective, suggesting that genetic testing could potentially be used in the presurgical assessment of patients with severe obesity.

FUNDING

Heart and Stroke Foundation of Canada (G-17-0016627) and Canada Research Chair in Genomics Applied to Nutrition and Metabolic Health (no. 950-231-580).

Prevalence of All-Cause Mortality and Suicide among Bariatric Surgery Cohorts: A Meta-Analysis

INTRODUCTION

Prior meta-analysis has reported mortality rates among post-operative bariatric patients, but they have not considered psychiatric factors like suicide contributing to mortality.

OBJECTIVES

The current meta-analysis aims to determine the pooled prevalence for mortality and suicide amongst cohorts using reported suicides post bariatric surgery. It is also the aim of the current meta-analytical study to determine moderators that could account for the heterogeneity found.

RESULTS

In our study, the pooled prevalence of mortality in the studies which reported suicidal mortality was 1.8% and the prevalence of suicide was 0.3%. Mean body mass index (BMI) and the duration of follow-up appear to be significant moderators.

CONCLUSIONS

Given the prevalence of suicide post bariatric surgery, it is highly important for bariatric teams to consider both the medical and psychiatric well-being of individuals pre- and post-operatively.

Utilization of Public System for Gastric Bands Placed by Private Providers: a 4-Year Population-Based Analysis in Ontario, Canada

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

Medium and long-term results of gastric banding: outcomes from a large private clinic in UK

Background

Laparoscopic adjustable gastric band (LAGB) has been an established bariatric procedure for the last three decades and was, for many years, the first-choice procedure for the treatment of chronic obesity. However, more recently, the popularity of the LAGB has been in sharp decline and has been replaced by other procedures such as the Roux-En-Y gastric bypass and sleeve gastrectomy. A key driver in this decline has been the high revision and early explanation rates reported in some studies.

Methods

This was a retrospective study of 2246 patients who underwent LAGB at a large private clinic in the UK between June 2004 and October 2014.

Results

2246 patients were included in the study; 1945 (84.6%) were women. All patients were followed up for 2 years following their procedure and subsequent follow up was at the discretion of patients. Mean follow up duration was 43.7 +/− 29.3 months. Operative mortality was zero and there were no in-hospital returns to theatre. Mean preoperative weight and body mass index (BMI) were 111.2 ± 22.1 kg and 39.9 ± 6.7 kg/m² respectively. Mean excess % BMI loss at 1-, 2-, 5- and 8-years of follow-up was 43.1 ± 25.4, 47.9 ± 31.9, 52.4 ± 41.7 and 57.1% ± 28.6 respectively. There was no significant difference in mean excess % BMI loss between those < 50 or ≥ 50 years old (p value = 0.23) or between patients with an initial BMI of < or ≥ 50 kg/m² (p value = 0.65). Complications over nine years occurred in 130 (5.8%) patients and included: 39 (1.7%) slippage or pouch dilatation, 2 (0.04%) erosions and 76 (3.4%) problems related to the access port or LAGB tubing. The overall re-operation rate for LAGB complications was 4.2% over 9 years with a LAGB explantation rate of 1.5%. 39 LAGBs were converted to a sleeve or gastric bypass procedure, 11 of these due to complications.

Conclusion

This is the first study to report on LAGB outcomes from a private clinic in the UK. LAGB is a safe procedure, which delivers significant and durable weight loss with acceptable complications rates and low re-operation rate.

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.

The Importance of Dog Ownership: Implications for Long-Term Weight Reduction After Gastric Banding

Gastric banding (GB) is considered an option to support weight loss for individuals who are unable to lose weight through diet and exercise alone. Exercise is an important element of maintaining gradual weight loss following GB. Dog walking may be one method to encourage exercise and contribute to continued weight loss. Over a 5-year period, 24 individuals aged between 31 and 58 years (21 female; 12 dog-owners) were weighed at 7 time points. Intention to treat MANOVA analysis showed both groups lost a significant amount of weight, F(6, 17) = 15.7, P = .001, η_p² = .85, but no difference was observed between dog owners and non-dog owners, F(6, 17) = 0.66, P = .68, η_p² = .19, although from 24 months postbanding, data indicated dog owners appear to weigh less than non-dog owners. Further longitudinal research is warranted beyond 5 year post-GB; and encouraging exercise through dog walking may be a useful adjunct to increasing activity and promoting weight loss following GB.

Endoscopic Devices for Obesity

The obesity epidemic, recognized by the World Health Organization in 1997, refers to the rising incidence of obesity worldwide. Lifestyle modification and pharmacotherapy are often ineffective long-term solutions; bariatric surgery remains the gold standard for long-term obesity weight loss. Despite the reported benefits, it has been estimated that only 1% of obese patients will undergo surgery. Endoscopic treatment for obesity represents a potential cost-effective, accessible, minimally invasive procedure that can function as a bridge or alternative intervention to bariatric surgery. We review the current endoscopic bariatric devices including space occupying devices, endoscopic gastroplasty, aspiration technology, post-bariatric surgery endoscopic revision, and obesity-related NOTES procedures. Given the diverse devices already FDA approved and in development, we discuss the future directions of endoscopic therapies for obesity.

Regional Variations in the Public Delivery of Bariatric Surgery: An Evaluation of the Center of Excellence Model

OBJECTIVE

We evaluated regional access to bariatric surgery within the high-volume, center of excellence (COE) model of Ontario, Canada.

BACKGROUND

In 2009, Ontario implemented Canada's first regionalized bariatric surgical care system based on a COE. Because of this, a small number of COEs service a large population and geographic area.

METHODS

This study identified all patients older than 18 years, who received bariatric surgery from April 2009 to March 2012. Morbid obesity-adjusted rates of surgery were then calculated for each neighborhood, and a cluster analysis was performed to determine aggregation of neighborhoods with significantly higher (hot spots) or lower (cold spots) rates of surgery. Ordinal logistic regression was used to identify independent predictors of neighborhood access.

RESULTS

The cluster analysis identified 49 cold spot neighborhoods, representing 1.7 million people. Forty of these neighborhoods lie within a relatively small area that contains 3 of the 4 COEs. In the multivariate analysis, for every 100 km from the nearest COE, neighborhoods were 0.88 times as likely to live in a hot spot [95% CI (confidence interval): 0.80-0.97; P = 0.012]. In addition, having a bariatric facility within the same administrative health region as the neighborhood made it almost twice as likely to be a hot spot, odds ratio = 1.75 (95% CI: 1.10-2.79; P = 0.018). Low neighborhood socioeconomic status was not associated with decreased delivery of care.

CONCLUSIONS

This study identified an unequal delivery of bariatric surgery within Ontario. Both longer distances and not having a bariatric facility within the same health region had significant negative effects. Further research into patient attitudes and referral patterns is required to better characterize these disparities.

Laparoscopic adjustable gastric band: 4-year experience and learning curve

Background and Objectives:

Laparoscopic adjustable gastric banding has become the most popular procedure for the treatment of morbid obesity in Europe. The objectives of this series are to report the results of the 4-year experience of a single surgeon and to define the learning curve.

Methods:

A retrospective review of 156 patients who underwent laparoscopic adjustable gastric banding between October 2006 and May 2010 was performed. Patients were separated into 3 groups: group 1 comprised the first 50 patients; group 2 comprised the second 50 patients; and group 3 comprised the last group of patients, with a total of 56 patients.

Results:

The male-to-female ratio was 1:4 (33 male and 133 female patients). The mean age was 38 years (range, 17–62 years). The mean preoperative body mass index was 44.9 kg/m². The mean percent excess weight loss was 41.7% at the 1-year follow-up visit (153 patients, 98%), 49.7% at the 2-year follow-up visit (147 patients, 94%), and 50.2% at the 3-year follow-up visit (127 patients, 81%). The overall complication rate and major complication rate were 15.4% and 3.2%, respectively. There were no deaths. Percent excess weight loss, length of hospitalization (in days), and complication rates were compared among the 3 groups. No significant differences were noted among the groups except in the number of complications (P < .001), but all data were clearly improved in groups 2 and 3.

Conclusions:

The analyses in this study have documented one more time that laparoscopic adjustable gastric banding is an effective procedure for the treatment of morbid obesity, achieving >50% excess weight loss at 3 years. It is a procedure with certain complications even when performed by a surgeon with previous experience in laparoscopic surgery. According to our subset analysis, the learning curve is at least 50 procedures.

Laparoscopic adjustable gastric banding reduces subcutaneous adipose tissue and blood inflammation in nondiabetic morbidly obese individuals

BACKGROUND

Significant and sustained excess weight loss (EWL) appears to reduce the risk of obesity-related comorbidities (insulin resistance, hyperlipidemia, and inflammation), but this has been primarily shown in adult diabetic obese patients. We evaluated whether the EWL obtained 3 years after laparoscopic adjustable gastric banding (LAGB) improves the metabolic phenotype in nondiabetic morbidly obese (NDMO) individuals from south Italy.

METHODS

Serum and subcutaneous adipose tissue (SAT) samples from 20 obese individuals (median BMI=41.5 kg/m(2)) before (T0) and after LAGB (T1) and from 10 controls (median BMI=22.8 kg/m(2)) were taken. Serum leptin, adiponectin, C reactive protein (CRP), and main analyte levels were evaluated by routine methods or immunoassay. In SAT, adipocyte size was measured by hematoxylin/eosin staining, cluster of differentiation 68 (CD68) macrophage infiltration marker by immunohistochemistry, and adiponectin, adiponectin receptors 1 and 2, and interleukin 6 (IL6) messenger RNAs by qRT-PCR.

RESULTS

The average EWL was 66.7 %, and CRP, triglycerides, hepatic markers, leptin levels, homeostasis model assessment, and the leptin/adiponectin ratio were lower (p<0.05) at T1 than at T0. The expression of small adipocytes and adiponectin was increased (p<0.05), and inflammation markers (CD68 and IL6) decreased (p<0.05) at T1 vs. T0. At linear regression multivariate analysis, over 90 % (R (2)=0.905) of EWL (dependent variable) was explained by CD68, adiponectinemia, triglyceridemia, CRP, and total protein levels.

CONCLUSIONS

The EWL obtained 3 years after LAGB resulted in an improvement of lipid metabolism and a reduction of inflammation in NDMO patients, thereby decreasing the risk of obesity-associated diseases.

Long-Term outcomes and experience of laparoscopic adjustable gastric banding: one center's results in China

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB), as one major bariatric surgery for treatment of obesity, results in ineffective long-term weight loss and a high reoperation rate. The objective of this study was to evaluate the long-term effects of LAGB on the weight loss outcomes and reoperation rates of obese patients with different body mass index (BMI) levels in China.

METHODS

A retrospective study was performed to review the follow-up data of obese patients who underwent LAGB at Shanghai Changhai Hospital between November 2003 and May 2013. The main outcomes included weight loss, percentage excess weight loss (%EWL), reoperation rate, and reasons for reoperation.

RESULTS

A total of 254 LAGB procedures were performed in our hospital. By the end of May 2013, 145 Chinese patients (57.8%) were followed up, 99 patients with BMI ≥ 35 kg/m(2) (high BMI group) and 46 patients with BMI < 35 kg/m(2) (low BMI group). In the high BMI group, the mean %EWL was > 25% within 5 years postoperatively, but it decreased to less than 25% after 5 years. However, in the low BMI group, the mean %EWL at each time point was over 50%. The reoperation rate was 33.1%; it was 17.4% in the low BMI group and 34.3% in the high BMI group.

CONCLUSION

LAGB is more effective with a lower reoperation rate for obese patients with a BMI < 35 kg/m(2) compared to BMI ≥ 35 kg/m(2) in our population.

Medical tourism and bariatric surgery: who pays?

INTRODUCTION

The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic.

METHODS

A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated costs. A threshold analysis was used to compare costs of medical tourism to those from our institution.

RESULTS

A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate ≤ 28% (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta.

CONCLUSIONS

Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country.

Acute appendicitis as a rare complication of gastric band

Laparoscopic adjustable gastric banding is a common and effective minimally invasive procedure in the treatment of morbid obesity. Common complications of the procedure include productive burping, ulceration, gastritis, erosion, slippage, problems with the port, bleeding and infection. We report a case of acute appendicitis caused by gastric banding in a female patient. Gastric band encircled the appendix causing lumen obstruction and infection. The patient developed symptoms of topical acute peritonitis and an appendisectomy was performed.