Laparoscopic adjustable gastric banding

Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality

Background: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB.

Methods: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY).

Results: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m². The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention.

Conclusions: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Is it possible to improve long-term results of laparoscopic adjustable gastric banding with appropriate patient selection?

Introduction

The gastric band is still offered as a good bariatric option for highly motivated and carefully selected patients. The question is whether this faith is justified or not.

Aim

To assess long-term clinical outcomes of patients who underwent laparoscopic adjustable gastric banding (LAGB) at a single bariatric center and to examine variables associated with patients’ adherence to scheduled postoperative appointments.

Material and methods

A retrospective review of patients who underwent LAGB between 2004 and 2009 was performed. The initial cohort included 167 patients. Data regarding sex, age, preoperative weight, hometown population and distance from the bariatric center, and gastric band volume were collected. Compliance was measured as the number of postoperative appointments. Clinical outcome was defined as percent excess weight loss (%EWL) at the end of the observation period or at band removal.

Results

The LAGB was performed in 167 patients between 2004 and 2009. The mean follow-up time was 90 ±24 months. Five (3%) patients were lost to follow-up; 37 (22.2%) had their band removed. The remaining 125 (74.8%) patients retained their bands and were included in the analysis. The mean %EWL was 33.0 ±26.6%. Thirty-one (18.6%) patients achieved %EWL > 50%.

Conclusions

This study found that LAGB was not an effective bariatric procedure in long-term observation. Only 25% of 125 patients who maintained a functioning band achieved %EWL > 50%. Compliance was the only independent prognostic factor for weight loss. Other factors had no influence on outcome.

Hepatic left lobe volume is a sensitive index of metabolic improvement in obese women after gastric banding

BACKGROUND

Nonalcoholic fatty liver disease is a common finding in obese subjects. Increasing evidence has been provided suggesting that it represents the hepatic component of the metabolic syndrome.

OBJECTIVE

Aim of this longitudinal study was to evaluate the relationships between several anthropometric measures, including the hepatic left lobe volume (HLLV), and various indicators of the metabolic syndrome in a cohort of severely obese women before and after laparoscopic adjustable gastric banding (LAGB).

STUDY DESIGN AND RESULTS

Seventy-five obese women (mean age 45 ± 10 years and body mass index (BMI) 42.5 ± 4.8 kg m(-2)) underwent LAGB and completed an average (± s.d.) post-surgical follow-up of 24 ± 6 months. Determination of HLLV, subcutaneous and intra-abdominal fat (IAF) was based on ultrasound. The principal component statistical analysis applied to pre-operative measurements, highlighted HLLV as a parameter that clustered with serum insulin, IAF, serum glucose and uric acid, along with triglycerides (TGs), alkaline phosphatase and high-density lipoprotein cholesterol. After LAGB, the average reduction of BMI was 23%, 12% for subcutaneous fat (SCF), 42% for HLLV and 40% for visceral fat. Among body weight, BMI, SCF, IAF and HLLV, reduction of the latter was an independent predictor of reduction of serum transaminases and γ-Glutamyltransferase, glucose, insulin and TGs.

CONCLUSIONS

In severely obese women: (i) HLLV is a sensitive indicator of ectopic fat deposition, clustering with parameters defining the metabolic syndrome; (ii) weight loss achieved by LAGB is associated with a reduction of liver volume as estimated by HLLV; (iii) among various anthropometric parameters measured, reduction of HLLV that follows LAGB represents the best single predictor of improvement of various cardiometabolic risk factors.

Is gastro-gastric fixation suture necessary in laparoscopic adjustable gastric banding? A prospective randomized study

BACKGROUND

The reason for gastro-gastric suture (GGS) in laparoscopic adjustable gastric banding (LAGB) is to prevent migration, slippage, and pouch dilatation. Despite various suturing techniques, these complications are still quite common. In our study, we prospectively randomized patients for GGS and analyzed outcome.

METHODS

Between September 2006 and February 2008, eighty patients were randomized before LAGB procedure with pars flaccida technique. Forty patients had GGS for band fixation (Group 1), and 40 patients did not (Group 2). Groups were compared for length of surgery (LOS), length of hospital stay (LOHS), early and late complications, and percent of excess weight loss (%EWL). Mann-Whitney U test was used to define statistical differences between groups. P<.05 was accepted as significant.

RESULTS

Mean body mass index (BMI) of groups 1 and 2 were 43.3±4.9 and 42.2±4.3 kg/m(2), respectively. Mean LOHS was 29.2±9.3 and 25.2±10.5 hours in groups 1 and 2, respectively. There was no statistically significant difference between groups 1 and 2 in comparison of %EWL (P=.344 and P=.132, respectively). There was a significant difference in LOS between groups, and it was shorter in group 2 (P<.05). In terms of complications, slippage rate was higher, migration and port complications were lower in group 2 although not statistically significant (P>.05). Pouch dilatation rate was similar in both groups.

CONCLUSIONS

LOS is shorter without GGS. There is no difference in rates of slippage, migration, pouch dilatation complications, and %EWL between either approach. In light of our findings, we think that routine use of GGSs should be revisited.

A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs

BACKGROUND

Gastric bypass and adjustable gastric banding are the 2 most commonly performed bariatric procedures for the treatment of morbid obesity. The aim of this study was to compare the outcomes, quality of life, and costs of laparoscopic gastric bypass versus laparoscopic gastric banding.

STUDY DESIGN

Between 2002 and 2007, 250 patients with a body mass index of 35 to 60 kg/m2 were randomly assigned to gastric bypass or gastric banding. After exclusion, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Outcome measures included demographic data, operative time, blood loss, length of hospital stay, morbidity, mortality, early and late reoperation rate, weight loss, changes in quality of life, and cost. Treatment failure was defined as losing less than 20% of excess weight or conversion to another bariatric operation for failure of weight loss.

RESULTS

There were no deaths at 90 days in either group. The mean body mass index was higher in the gastric bypass group (47.5 vs. 45.5 kg/m2, respectively, P < 0.01) while the mean age was higher in the gastric band group (45 vs. 41 years, respectively, P < 0.01). Compared with gastric banding, operative blood loss was higher and the mean operative time and length of stay were longer in the gastric bypass group. The 30-day complication rate was higher after gastric bypass (21.6% vs. 7.0% for gastric band); however, there were no life-threatening complications such as leaks or sepsis. The most frequent late complication in the gastric bypass group was stricture (14.3%). The 1-year mortality was 0.9% for the gastric bypass group and 0% for the gastric band group. The percent of excess weight loss at 4 years was higher in the gastric bypass group (68 ± 19% vs. 45 ± 28%, respectively, P < 0.05). Treatment failure occurred in 16.7% of the patients who underwent gastric banding and in 0% of those who underwent gastric bypass, with male gender being a predictive factor for poor weight loss after gastric banding. At 1-year postsurgery, quality of life improved in both groups to that of US norms. The total cost was higher for gastric bypass as compared with gastric banding procedure ($12,310 vs. $10,766, respectively, P < 0.01).

CONCLUSIONS

Laparoscopic gastric bypass and gastric banding are both safe and effective approaches for the treatment of morbid obesity. Gastric bypass resulted in better weight loss at medium- and long-term follow-up but was associated with more perioperative and late complications and a higher 30-day readmission rate. There was a wide variation in weight loss after gastric banding with a small proportion of patients considered as treatment failure, and male gender was a predictive factor for poor weight loss.

Safety, efficacy, and durability of laparoscopic adjustable gastric banding in a single surgeon U.S. community practice

BACKGROUND

Although laparoscopic adjustable gastric banding (LAGB) has been increasing in popularity, controversy is ongoing in regard to its efficacy, safety and durability. Particular concern exists now that this technique is being adapted in the community setting. We report a single surgeon's experience of LAGB in a community practice serving a medium-size Midwest town in the United States.

METHODS

From March 30, 2004 to December 2, 2009, 442 patients underwent LAGB (77% women; mean age 47 years, range 18-71; mean body mass index 47 kg/m(2), range 35-78). The maximal number of primary procedures performed in a 12-month period was 105. Follow-up information was available for 94% of patients.

RESULTS

The perioperative mortality rate was 0%. The average percentage of excess weight loss was 27% at 6 months (n = 384), 38% at 12 months (n = 301), 44% at 18 months (n = 260), 48% at 24 months (n = 190), 51% at 36 months (n = 135), 58% at 48 months (n = 66), and 60% at 60 months (n = 31). By 60 months, 10% had failed to lose ≥25% of their excess body weight. The explantation rate was 1.8%. Gastric prolapse occurred in 2.0% of patients and erosion in 0.4% of patients.

CONCLUSION

LAGB can be done safely in a community setting with acceptable weight loss and low failure rates. LAGB is less technical than other procedures; however, the results depend heavily on meticulous long-term follow-up. We have proposed a strategy that has been effective in the community setting.

Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up

BACKGROUND

Studies have shown that type 2 diabetes (T2DM) improves or resolves shortly after Roux-en-Y gastric bypass (RYGB). Few data are available on T2DM recurrence or the effect of weight regain on T2DM status.

METHODS

A review of 42 RYGB patients with T2DM and >or=3 years of follow-up and laboratory data was performed. Postoperative weight loss and T2DM status was assessed. Recurrence or worsening was defined as hemoglobin A1c >6.0% and fasting glucose >124 mg/dL and/or medication required after remission or improvement. Patients whose T2DM recurred or worsened were compared with those whose did not, and patients whose T2DM improved were compared with those whose T2DM resolved.

RESULTS

T2DM had either resolved or improved in all patients (64% and 36%, respectively); 24% (10) recurred or worsened. The patients with recurrence or worsening had had a lower preoperative body mass index than those without recurrence or worsening (47.9 versus 52.9 kg/m2; P = .05), regained a greater percentage of their lost weight (37.7% versus 15.4%; P = .002), had a greater weight loss failure rate (63% versus 14%; P = .03), and had greater postoperative glucose levels (138 versus 102 mg/dL; P = .0002). Patients who required insulin or oral medication before RYGB were more likely to experience improvement rather than resolution (92% versus 8%, P <or=.0001; and 85% versus 15%; P = .0006, respectively).

CONCLUSION

Our results have shown that beyond 3 years after RYGB, the incidence of T2DM recurrence or worsening in patients with initial resolution or improvement was significant. In our patients, a greater likelihood of recurrence or worsening of T2DM was associated with a lower preoperative body mass index. Before widespread acceptance of bariatric surgery as a definitive treatment for those with T2DM can be achieved, additional study of this recurrence phenomenon is indicated.

Intra-gastric band erosion from an un-inflated Lap-Band: a case report

The increasing prevalence of morbid obesity is of public health concern throughout the world, and surgical intervention seems to offer the only long-term solution to the problem. Gastric banding is one of the available options in the bariatric armamentarium. As more Lap-Bands are being inserted, intragastric erosion is increasingly being encountered as a major complication. The case of a 40-year-old man with intra-gastric band erosion is presented with the band never having been inflated, suggesting that additional factors may play a role in the development of erosions. The presentation, diagnostic modalities, and pathognomomic findings are discussed.

Laparoscopic adjustable gastric banding in adolescent: safety and efficacy

BACKGROUND

Obesity prevalence is rapidly increasing among children and adolescents worldwide. It is considered one of the most alarming public health issues facing the world today. The adult experience has demonstrated that surgery is the only effective means of achieving persistent weight loss in obese patients. However, little is known about bariatric surgery in children and adolescents. The aim of this study is to evaluate the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in this group of patients.

METHODS

A retrospective review included all children and adolescents who underwent LAGB from January 2003 to December 2005.

RESULTS

Fifty-one patients underwent LAGB. The mean age was 16.8 years (range, 9-19), and the mean body mass index was 49.9 kg/m2 (range, 38-63). Mean excess weight loss was 42% at 6 months and 60% at 1 year follow-up. The most prevalent comorbidities were obstructive sleep apnea, limited physical activities, hypertension, and diabetes mellitus. Band adjustments were performed under fluoroscopic guidance in 5 patients and direct access as a clinic procedure in the remaining. One patient required port repositioning under fluoroscopic guidance. The mean follow-up was 16 months (range, 3-34). There was no mortality or significant postoperative complications.

CONCLUSION

The absence of significant nutritional deficiency, the continued adjustability, and potential reversibility of LAGB make it the safest, least invasive, and most effective bariatric surgery that can be offered to the young and adolescent population.

Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years

OBJECTIVE

To complete a long-term (>10 years) follow-up of patients undergoing isolated roux-en-Y gastric bypass for severe obesity.

BACKGROUND

Long-term results of gastric bypass in patients followed for longer than 10 years is not reported in the literature.

METHODS

Accurate weights were recorded on 228 of 272 (83.8%) of patients at a mean of 11.4 years (range, 4.7-14.9 years) after surgery. Results were documented on an individual basis for both long- and short-limb gastric bypass and compared with results at the nadir BMI and % excess weight loss (%EWL) at 5 years and >10 years post surgery.

RESULTS

There was a significant (P < 0.0001) increase in BMI in both morbidly obese (BMI < 50 kg/m) and super obese patients (BMI > 50 kg/m) from the nadir to 5 years and from 5 to 10 years. The super obese lost more rapidly from time zero and gained more rapidly after reaching the lowest weight at approximately 2 years than the morbidly obese patients. There was no difference in results between the long- and short-limb operations. There was a significant increase in failures and decrease in excellent results at 10 years when compared with 5 years. The failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients and 34.9% for super obese patients.

CONCLUSIONS

The gastric bypass limb length does not impact long-term weight loss. Significant weight gain occurs continuously in patients after reaching the nadir weight following gastric bypass. Despite this weight gain, the long-term mortality remains low at 3.1%.

Outcomes after laparoscopic adjustable gastric band repositioning for slippage or pouch dilation

BACKGROUND

Slippage and pouch dilation are the most common surgical complications after laparoscopic adjustable gastric banding, yet few reports have described the specific outcomes after band repositioning for these complications. The objective of this study was to examine the intermediate outcomes of our patients who underwent band repositioning for slippage or pouch dilation.

METHODS

From October 2000 to December 2005, 1275 patients underwent laparoscopic adjustable gastric banding at our center. Of these, we retrospectively reviewed the data of the first 40 consecutive patients (92.5% women, mean age 41.7 years, mean preoperative weight 123.3 kg [range 86.2-180.5], mean body mass index 44.8 kg/m2 [range 34.6-66.4]) who presented with anterior slippage (52.5%), posterior slippage (20%), or pouch dilation (27.5%, 7 with associated hiatal hernias) that required band repositioning (95%) or explantation (5%).

RESULTS

The average time between laparoscopic adjustable gastric banding and reoperation was 22.9 months. Before band repositioning, the mean weight was 91.5 kg, mean body mass index was 33.2 kg/m(2), and mean percentage of excess weight loss was 49.4% (range 1-79.8%). One patient had a recurrent anterior slippage that required a second band repositioning. Two bands were explanted, one for intraoperative gastric perforation and one at the patient's request. The mean percentage of excess weight loss after band repositioning was 48.1% (range 18.2-77.4%) at an average follow-up of 17.6 months (range 6-36). To date, 38 (95%) of the 40 patients have functioning bands. Co-morbidity resolution was seen in 3 (60%) of 5 patients with diabetes, 13 (65%) of 20 with hypertension, and 8 (72%) of 11 with sleep apnea.

CONCLUSION

Laparoscopic band repositioning can result in preservation of most of the initial weight loss and co-morbidity resolution.

Three-year follow-up weight loss results for patients undergoing laparoscopic adjustable gastric banding at a major university medical center: does the weight loss persist?

BACKGROUND

Very few large United States series with long-term data after laparoscopic adjustable gastric banding (LAGB) have been published. Here, we present results of 409 consecutive LAGBs performed at a major United States medical center.

METHODS

Charts were retrospectively reviewed for perioperative morbidity, mortality, and repeat operations. Weight loss data were collected during band adjustments.

RESULTS

Mean age of patients was 42 years. Mean preoperative weight and body mass index (BMI) were 142.4 kg and 50.6 kg/m2, respectively. There was 1 fatal myocardial infarction and 4 nonfatal pulmonary emboli. There were 50 (12%) repeat operations resulting in 16 (4%) bands being removed. Mean excess weight loss was 23.7%, 44.3%, 48.0%, and 53.3% with <1 year, 1 to 2 years, 2 to 3 years, and >3 years of follow-up, respectively.

CONCLUSIONS

Three-year follow-up data demonstrated continued weight loss in patients after LAGB. The relative safety and continued adjustability of LAGB make it an appealing option for long-term weight loss.