Long-term complications requiring reoperations after laparoscopic adjustable gastric banding: a systematic review

Revisional One-Step Bariatric Surgical Techniques After Unsuccessful Laparoscopic Gastric Band: A Retrospective Cohort Study with 2-Year Follow-up

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has high reported rates of revision due to poor weight loss (WL) and high complication rates. Yet, there is yet to be a consensus on the best revisional procedure after unsuccessful LAGB, and studies comparing different revisional procedures after LAGB are still needed.

METHODS

This was a retrospective cohort study that compared the outcomes of one-step revisional Roux-en-Y gastric bypass (rRYGB), one-anastomosis gastric bypass (rOAGB), or laparoscopic sleeve gastrectomy (rLSG) after LAGB. WL, complications, resolution of associated medical conditions, and food tolerance were assessed with a post hoc pairwise comparison one-way analysis of variance (ANOVA) throughout a 2-year follow-up.

RESULTS

The final analysis included 102 (rRYGB), 80 (rOAGB), and 70 (rLSG) patients. After 2 years, an equal percentage of excess weight loss was observed in rOAGB and rRYGB (both >90%; p=0.998), significantly higher than that in rLSG (83.6%; p<0.001). In our study, no leaks were observed. rRYGB had higher complication rates according to the Clavien-Dindo classification (10.8% vs. 3.75% and 5.7% in rOAGB and rLSG, respectively, p=0.754), and re-operations were not statistically significant. Food tolerance was comparable between rOAGB and rRYGB (p = 0.987), and both had significantly better food tolerance than rLSG (p<0.001). The study cohorts had comparable resolution rates for associated medical problems (p>0.60).

CONCLUSION

rOAGB and rRYGB had better outcomes after LAGB than rLSG regarding WL, feasibility, food tolerance, and safety. rOAGB had significantly higher rates of nutritional deficiencies.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication

BACKGROUND

Significant controversy exists regarding the indications and outcomes after laparoscopic adjustable gastric banding (LAGB) conversions to laparoscopic sleeve gastrectomy (LSG).

AIM

To comprehensively determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes.

METHODS

Six hundred revision LSG (RLSG) and 1200 controls (primary LSG (PLSG)) were included. Patient demographics, complications, follow-up, and patient-completed questionnaires were collected.

RESULTS

RLSG vs controls; females 87% vs 78.8%, age 45 ± 19.4 vs 40.6 ± 10.6 years, p = 0.561; baseline weight 119.7 ± 26.2 vs 120.6 ± 26.5 kg p = 0.961). Follow-up was 87% vs 89.3%. Weight loss in RLSG at 5 years, 22.9% vs 29.6% TBWL, p = 0.001, 10 years: 19.5% vs 27% TBWL, p = 0.001. RLSG had more complications (4.8 vs 2.0% RR 2.4, p = 0.001), re-admissions (4.3 vs 2.4% RR 1.8, p = 0.012), staple line leaks (2.5 vs 0.9%, p = 0.003). Eroded bands and baseline weight were independent predictors of complications after RLSG. Long-term re-operation rate was 7.3% for RLSG compared to 3.2% in controls. Severe oesophageal dysmotility predicted poor weight loss. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034).

CONCLUSION

RLSG provides long-term weight loss, although peri-operative complications are significantly elevated compared to PLSG. Longer-term re-operation rates are elevated compared to PLSG. Four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.

Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Gastric band slippage in pregnancy: A diagnostic dilemma

Pregnancy after laparoscopic adjusted gastric banding (LAGB) is thought to be safe and lowers the risk for maternal obstetric complications, without causing a difference in birth weight or a higher incidence of neonatal complications. Even though LAGB complications in pregnancy are rare, they are often severe and can cause significant maternal and neonatal morbidity. This report outlines the case of a pregnant 32-year-old female with gastric band slippage in the third trimester and provides a summary of the literature on LAGB complications in pregnancy and their management.

Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: A systematic review and network meta-analysis

BACKGROUND

revisional bariatric surgery is gaining increasing interest as long term follow-up studies demonstrate an elevated failure rate of primary surgery due to insufficient weight loss, weight regain or complications. This particularly concerns restrictive bariatric surgery which has been widely adopted from the '80s till present through different procedures, notably vertical banded gastroplasty, laparoscopic adjusted gastric banding and sleeve gastrectomy. The aim of this study is to define which revisional bariatric procedure performs the best after failure of primary restrictive surgery.

METHODS

a systematic review and network meta-analysis of 39 studies was conducted following the PRISMA guidelines and the Cochrane protocol.

RESULTS

biliopancreatic diversion with duodenal switch guarantees the best results in terms of weight loss (1 and 3-years %TWL MD: 12.38 and 28.42) followed by single-anastomosis duodenoileal bypass (9.24 and 19.13), one-anastomosis gastric bypass (7.16 and 13.1), and Roux-en-Y gastric bypass (4.68 and 7.3) compared to re-sleeve gastrectomy. Duodenal switch and Roux-en-Y gastric bypass are associated to an increased risk of late major morbidity (OR: 3.07 and 2.11 respectively) compared to re-sleeve gastrectomy while no significant difference was highlighted for the other procedures. Re-sleeve gastrectomy is the revisional intervention most frequently burdened by weight recidivism; compared to it, patients undergoing single-anastomosis duodenoileal bypass have the lowest risk of weight regain (OR: 0.07).

CONCLUSION

considering the analyzed outcomes altogether, single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are the most performing revisional procedures after failure of restrictive surgery due to satisfying short and mid-term weight loss and low early and late morbidity. Moreover, single-anastomosis duodenoileal bypass has low risk of weight recidivism.

Gastroesophageal Reflux Disease and the Patient with Obesity

Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.

Effectiveness and Safety of Adjustable Gastric Banding in Morbidly Obese Patients After 5 Years of Follow-up

Obesity is a civilization disease that promotes the emergence and development of many diseases, such as type II diabetes, cardiovascular, and some cancers. It directly affects the length and quality of life. The purpose of this retrospective study was to show the short- and long-term results of weight loss after laparoscopic adjustable gastric banding (LAGB) as well as to assess the results of the procedure and the percentage of reoperations. Case series analysis included 228 subsequent patients who underwent LAGB due to obesity. In the postoperative period, there was a gradual reduction in body weight, especially in the first 24 months after surgery. After 3 years, no further weight reduction was observed, and sometimes, a slight increase in weight was observed 5 years after surgery; the trend in weight reduction over the entire time period was significant. A similar result was found for percentage of BMI loss (%BMIL) and percentage of excess body weight loss (%EWL), especially in the first 36 months after surgery. Our study confirmed the good early results and low effectiveness of laparoscopic adjustable gastric banding in the long-term treatment of pathological obesity. On the other hand, the simplicity and safety of the procedure, the minimal effects of malnutrition, the low number of early complications, and the total reversibility or conversion procedure for any other bariatric surgery are the strengths of laparoscopic adjustable gastric banding for a selected group of patients.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

Background

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

Materials and Methods

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

Results

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

Conclusion

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

Graphical abstract

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Anaemia and Related Nutritional Deficiencies in Chinese Patients with Obesity, 12 Months Following Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a predominant bariatric procedure at present. However, data are scarce regarding the nutritional impact of this procedure on Chinese patients. This study aimed to evaluate the prevalence of nutritional deficiency after LSG in Chinese patients.

METHODS

Eighty-two patients with obesity were recruited from the Second Xiangya Hospital of Central South University, and all patients underwent LSG and completed the visit.

RESULTS

Compared with the baseline, the serum albumin levels increased significantly at 1-12 months (P<0.001) after surgery, and the hypoalbuminemia rate decreased from 8.5% to 0% throughout the study (P=0.063). Anaemia was present in 7.3% of all patients before surgery, and its prevalence increased to 11.0% at 12 months post-operation (P=0.109). The anaemia rate of fertile females was higher than that of males (21.4% vs 2.3%, P=0.036). No significant changes were found in vitamin B12 deficiency throughout the study (0% vs 3.8%, P=1.0). The increases in the folate deficiency were only discovered in the female group (3.7% vs 20%, P=0.031) and the obese without type 2 diabetes (T2D) group after LSG (27.3% vs 47.1%, P=0.031). A decrease in the ferritin levels and an increase in iron deficiency at 12 months post-surgery were found among all patients.

CONCLUSION

Based on 12 months of follow-up, LSG is effective in controlling metabolic syndrome and has a modest effect on nutritional deficiencies, which suggests that LSG is an effective and comparably safe procedure for Chinese patients considering nutritional deficiencies at 12 months post-surgery.

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.

Is there an indication left for gastric band? A single center experience on 178 patients with a follow-up of 10 years

Background

Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL < 25%) and rate of band removal.

Methods

Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss.

Results

After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL < 25), 32 (18%) had an insufficient weight loss (25 < %EWL < 50) and 34 (19.1%) underwent band removal. Among these, 6 (3.4%) were removed for complications and 28 (15.7%) for insufficient weight loss. Weight regain occurred in 38 out of 144 (26.4%) subjects with the band in place at 10 years. Only one case of early vomiting with readmission for medical treatment was recorded. Slippage, erosion/migration and port/tube complications occurred in 4 (2.2%), 2(1.1%) and 9(5%) cases respectively.

Conclusion

LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

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.

Reoperations After Bariatric Surgery in 26 Years of Follow-up of the Swedish Obese Subjects Study

Importance

Bariatric surgery is an established treatment for obesity, but knowledge on the long-term incidence of revisional surgery is scarce.

Objective

To determine the incidence and type of revisional surgery after bariatric surgery in 26 years of follow-up of participants in the Swedish Obese Subjects (SOS) study.

Design, Setting, and Participants

The SOS study is a prospective nonrandomized controlled study comparing bariatric surgery (banding, vertical banded gastroplasty [VBG], and gastric bypass [GBP]) with usual care. The bariatric surgeries in the SOS study were conducted at 25 public surgical departments in Sweden. Men with body mass index values of 34 or higher and women with body mass indexes of 38 or higher were recruited to the surgery group of the SOS study between September 1, 1987, and January 31, 2001, and follow-up continued until December 31, 2014. Data analysis occurred from November 2016 to April 2018.

Interventions

Banding, VBG, or GBP.

Main Outcomes and Measures

Revisional surgeries, analyzed using data from questionnaires, hospital records, and the Swedish National Patient register through December 31, 2014.

Results

A total of 2010 participants underwent surgery. The age range was 37 to 60 years. A total of 376 participants underwent banding (18.7%), while 1365 had VBG (67.9%) and 266 had GBP (13.2%). During a median follow-up of 19 years, 559 participants (27.8%) underwent first-time revisional surgery, including 354 conversions to other bariatric procedures (17.6%), 114 corrective surgeries (5.6%), and 91 reversals to normal anatomy (4.5%). Revisional surgeries (conversions, corrective surgery, and reversals) were common after banding (153 of 376 [40.7%]) and VBG (386 of 1365 [28.3%]) but relatively rare after GBP (20 of 266 [7.5%]). Patients who had banding and VBG primarily underwent conversions to GBP or reversals. Incidence of reversals was 5 times higher after banding than after VBG (40.7% vs 7.5%; unadjusted hazard ratio, 5.19 [95% CI, 3.43-7.87]; P < .001). Corrective surgeries were equally common irrespective of the index surgery (72 of 1365 patients who had VBG [5.3%]; 23 of 376 patients who had banding [6.1%]; 19 of 266 patients who had GBP [7.1%]). Revisional surgery indications, including inadequate weight loss, band-associated complications (migration, stenosis, and slippage), staple-line disruptions, and postsurgical morbidity, varied depending on index surgery subgroup. Most corrections occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period.

Conclusions and Relevance

Corrective surgeries occur mainly within the first 10 years and with similar incidences across all 3 surgical subgroups, but indications varied. Conversions (mainly to GBP) and reversals occurred after many years and were most frequent after banding and VBG, reflecting a higher overall revisional surgery demand after these operations.

More than an Anti-diabetic Bariatric Surgery, Metabolic Surgery Alleviates Systemic and Local Inflammation in Obesity

Obesity, associated with increased risk of type 2 diabetes (T2D), cardiovascular disease, and hepatic steatosis et al., has become a major global health problem. Recently, obesity has been proven to be under a status of low-grade, chronic inflammation, which contributes to insulin resistance and T2D. Bariatric surgery is currently an effective treatment for the control of morbid obesity and T2D, which impels ongoing efforts to clarify physiological and molecular mechanisms mediating these benefits. The correlation between obesity, inflammation, and T2D has been revealed to a certain extent, and studies have shed light on the effect of bariatric surgery on inflammatory status of subjects with obesity. Based on recent findings, this review focuses on the relationship between inflammation, obesity, and bariatric surgery.

Abdominal viscus penetration by laparoscopic-adjustable gastric band tubing: case report and review

Laparoscopic-adjustable gastric band (LAGB) complications are increasingly recognised as follow-up time increases. These are most commonly related to the gastric band or port site, but complications of the connecting tubing are also reported. We present a case of LAGB tubing penetration through the transverse colon causing abdominal sepsis in a complex surgical abdomen and review prior published cases of abdominal viscus penetration by LAGB tubing. Like complications involving all LAGB components, these often present with non-specific abdominal signs and symptoms and undergo abdominal CT as an early investigation. This makes knowledge of normal and pathological imaging features of LAGB components important in radiology practice.

Assessing the Safety and Efficacy of Converting Laparoscopic Gastric Band to Sleeve Gastrectomy: A Rural Tertiary Center's Experience

Gastric banding for surgical treatment of morbid obesity has a complication rate of 20 to 50 per cent. Complications include band erosion, band slippage, and failed weight loss. One salvage procedure used is the laparoscopic sleeve gastrectomy. We aimed to compare our results between single-stage and two-stage conversation of gastric band with sleeve gastrectomy. We performed a retrospective review of 27 gastric band patients converted to sleeve gastrectomy. Hospital length of stay, surgical complications, and weight loss were compared. Twelve patients had a two-stage conversion and 15 patients had a single-stage conversion. There were no surgical complications in either group. There was a significant reduction in BMI after conversion, starting at one month and continuing forward to 12 months. The average BMI reduction over the two-year follow-up period was 8.19. There was no significant difference in length of hospital stay between the groups. Single-stage conversion of gastric band to sleeve gastrectomy does not lead to increased hospital length of stay or surgical morbidity. In the presence of gastric band slip or erosion, a two-stage approach is preferable. Conversion resulted in statistically significant weight loss in all patients.

Gastric Banding: Complications Identified by CT

PURPOSE

Laparoscopic adjustable gastric banding (LAGB) used to be a common procedure at the turn of the century and is still frequently encountered on CT scans in common clinical practice. Our aim is to present the frequency and spectrum of complication associated with LAGB, as observed in CT.

MATERIALS AND METHODS

After approval of our institutional review board, a retrospective search for LAGB in CT interpretations using the term "band" between December 2011 and April 2017 was conducted. CT scans were reviewed to identify complications. The findings were divided into two groups: symptomatic, in which the complications caused acute symptoms for which CT scans were conducted, and incidental, in which complications were incidentally identified. The frequency of complications was calculated.

RESULTS

We identified 160 patients who underwent LAGB and performed a CT scan. Complications were identified in 69/160 (43.1%) patients, with a total of 83 findings: 47/160 (29.4%) esophageal dilatation, 13/160 (8.2%) pulmonary complications, 6/160 (3.8%) abdominal abscesses, 5/160 (3.1%) small bowel obstructions, 4/160 (2.5%) intragastric band erosions, 4/160 (2.5%) tube disconnections, 3/160 (1.9%) port site and tube course infections, and 1/160 (0.6%) small pouch bezoars. When compared with patients' referral notes, 38/83 (45.8%) of the findings were associated with acute symptoms, whereas 45/83 (54.2%) of the findings were incidental. Eighteen percent of the incidental complications were clinically important.

CONCLUSION

Complications were found in 43% of CT scans of patients who underwent LAGB; less than half of the findings were symptomatic. Some of the incidentally identified complications had substantial clinical importance.

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss.

OBJECTIVE

To compare the weight loss results of these 2 surgeries.

SETTING

University hospital, United States.

METHODS

A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations.

RESULTS

The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087).

CONCLUSION

Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.

Laparoscopic Adjustable Gastric Banding After Failed Roux-En-Y Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is associated with approximately 25 % weight loss failure, resulting in insufficient weight loss or weight regain. Strategies of revisional surgery focus on alteration of limb length, pouch or stoma size. Altering pouch size and outlet by adding laparoscopic adjustable gastric band (LAGB) might initiate further weight loss. The goal of this study is to review the safety and efficacy of LAGB after failed RYGB in a retrospective cohort of patients in our institute.

METHODS

Patients with secondary LAGB (n = 44) were studied between May 2012 and January 2015. Demographics, effects on weight loss and complications were analysed.

RESULTS

Mean age and body mass index (BMI) at time of LAGB was 45.8 ± 8.2 years and 37.2 ± 5.4 kg/m², respectively. Mean interval between RYGB and LAGB was 2.6 ± 1.3 years. Mean follow-up was 14 ± 7.9 months, with 25 % loss to follow-up at 12 months. Due to LAGB, patients lost an additional 17.6 % ± 28.3 % excess weight. Patients with weight regain after initial weight loss success showed more excess weight loss (EWL) compared to patients whom never reached 50% EWL after RYGB. Overall complication and reoperation rates were 30 and 21 %, respectively, with 16 % band removal. One fatality due to septic shock following band erosion was observed.

CONCLUSION

In this largest published cohort, secondary banding of failed RYGB provides only limited additional weight loss. Furthermore, this technique is associated with high morbidity and reoperation rates. A significant difference in effect was found between patients with weight loss failure and weight regain. Larger prospective series are necessary to evaluate if the modest benefits are worth the risks of secondary LAGB.

Bariatric Surgery in China: How Is This New Concept Going?

BACKGROUND

Obesity has become an epidemic in developing countries including China. The use of bariatric surgery to treat obesity has grown in popularity worldwide, but it is still a new concept in China. This study aims to investigate the trends in bariatric surgery in China.

METHODS

An electronic search of the MEDLINE, EMBASE, and Chinese National Knowledge Infrastructure was conducted to select studies for this survey.

RESULTS

A total of 7779 bariatric procedures were reported from 2001 to 2015, most of which (89.2 %) were performed in the most recent 5 years. Further, 70.9 % of all procedures were performed to treat obesity and related comorbidities, defined as metabolic surgery. The data showed 89.4 % of all operations were performed laparoscopically. The absolute number of bariatric surgeries increased 148.7 times in the last 5 years compared to the 2001-2005 period. The percentage of laparoscopic Roux-en-Y gastric bypasses performed increased from 0 to 62.2 %, and the percentage of laparoscopic sleeve gastrectomies from 0 to 12.7 %. The percentage of laparoscopic adjustable gastric bands increased dramatically from 0 to 73.3 % in the 2006-2010 period, but it dropped quickly to 12.9 % in the 2011-2015 period. Most operations (66.7 %) were conducted in the East area, which is the most developed economic region in China. There was limited surgical innovation or original research reported in China.

CONCLUSIONS

Bariatric surgery is still at an early stage in China, but is now experiencing an explosive growth. A national registry system needs to be established to record and provide precise data.

Abdominal tuberculosis after removal of an adjustable gastric band - report of an unusual case

Laparoscopic adjustable gastric banding (LAGB) is the third most popular bariatric procedure. Despite its reversibility and minimal invasiveness, band infection affects 1.2% of patients. We present a case of a 25-year-old, obese woman who was experiencing malaise and feverishness 3 years after gastric band placement. Due to port site infection the port was removed, which did not improve the patient’s condition. After 2 years the band was removed via laparotomy with a minor surgical site infection reported. The patient returned 2 weeks after discharge with signs of sepsis. After ruling out pulmonary causes, an exploratory laparotomy was performed, revealing granulomatous peritonitis. Standard histopathological examinations, broncho-alveolar lavage culture and DNA tests along with microbiological cultures were inconclusive. Broad-spectrum antibiotics and antifungal and antiparasitic agents did not improve the patient’s condition. Mycobacterium tuberculosis DNA was discovered in a greater omentum specimen. The patient was treated with isoniazid, rifampicin, pyrazinamide and streptomycin for four months.

Long-term outcome of laparoscopic adjustable gastric banding (LAGB): results of a Swiss single-center study of 405 patients with up to 18 years' follow-up

BACKGROUND

In the past, laparoscopic adjustable gastric banding (LAGB) seemed to be a promising bariatric procedure. However, many studies showed high rates of reoperation due to complications or insufficient weight loss. There is a lack of long-term studies with follow-up beyond 15 years.

OBJECTIVE

To conduct long-term follow-up of patients after LAGB and analyze their weight loss as a primary endpoint.

SETTING

Tertiary referral center for bariatric surgery, St. Claraspital, Switzerland.

METHODS

A retrospective analysis of prospectively collected clinical data in a cohort of 405 patients having undergone LAGB was performed.

RESULTS

A total of 405 patients (age 41±10 years, body mass index [BMI] 44.3±6 kg/m²) were treated with LAGB between 1996 and 2010. Mean follow-up was 13±3 years, with a follow-up rate of 85% (range 8-18 years), corresponding to 343 patients. One hundred patients exceeded 15-year follow-up. In 216 patients (63%), sleeve gastrectomy, gastric bypass, or biliopancreatic diversion with duodenal switch was performed as revisional surgery. Twenty-seven patients (8%) refused revisional surgery after band removal. Finally, 100 patients (29%) still have the band in place, with a mean BMI of 35±7 kg/m², corresponding to an excess BMI loss of 48±27%. Among these, the failure rate was 25%, according to the Bariatric Analysis and Reporting Outcome System (BAROS); 50% had a good to excellent outcome.

CONCLUSION

More than 10 years after LAGB, 71% of patients lost their bands and only 15% of the 343 followed patients with the band in place have a good to excellent result, according to BAROS.

Comparison of Reinforcement Techniques Using Suture on Staple-Line in Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy is a common procedure in recent years for treatment of morbid obesity however leak from staple-line is its main challenging complication. Despite numerous studies regarding leak after sleeve gastrectomy, there is still no conclusion on reinforcement of staple-line in this procedure. The purpose of this study was to compare two methods of oversewing staple-line versus no reinforcement.

METHODS

Resected stomachs of 30 patients undergoing laparoscopic sleeve gastrectomy were evaluated for bursting pressure immediately after extraction from the abdomen. Reinforcement technique was applied in random order to 3 segments of the staple-line on each specimen: continuous Lembert's sutures, continuous through-and-through sutures, and no reinforcement. Bursting pressure was determined by injection of methylene blue solution into lumen of resected stomach and recording pressure at which leakage occurs. Location of leak, intragastric pressure, and volume at first leak were recorded.

RESULTS

Baseline characteristics of patients were similar in randomized groups for order of reinforcement technique. Mean ischemia time of specimens was 17.4 ± 10.4 min. No leaks were observed in segments reinforced with Lembert's oversewing technique. The through-and-through reinforcement segments were first to leak in 21 out of 30 cases (70 %) with mean leak pressure of 570 mmHg and mean leak volume of 399 ml. Leakage occurred in 9 segments (30 %) with no reinforcement with a leak pressure of 329 mmHg and volume of 380 ml.

CONCLUSIONS

In vitro, Lembert's suture reinforcement technique on stapled human stomach is associated with less leakage rate in comparison to through-and-through reinforcement and non-reinforced staple-line.