Reduction in Slippage with 11-cm Lap-Band® and Change of Gastric Banding Technique

A Novel Auxiliary Device for Preventing Band Slippage After Laparoscopic Adjustable Gastric Banding: Infra-Band Fixation Using S-Loop

BACKGROUND

Band slippage is known to be a troublesome complication of laparoscopic adjustable gastric banding (LAGB), often requiring surgical intervention. To prevent band slippage, a new auxiliary device "S-loop" was developed.

METHODS

From July 2010 to January 2014, a total of 814 LAGBs were performed by a single surgeon. The patients were divided into two groups based on the application of S-loop: conventional LAGB group (n = 378) and S-loop group (n = 436). The operative outcomes were compared between the two groups.

RESULTS

The mean operative time and the length of hospital stay were significantly longer in the conventional LAGB group than in the S-loop group (64.3 minutes versus 57.1 minutes; P < .001 and 5.0 hours versus 3.6 hours; P < .001, respectively). The complications occurred in 7.1% of the conventional LAGB group and 1.6% in the S-loop group (P < .001). Slippage was the most common complication: 13 cases were observed in the conventional LAGB group, whereas no slippage was observed in the S-loop group.

CONCLUSION

Infra-band fixation using S-loop is a simple and effective method for preventing band slippage compared with the conventional LAGB.

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.

Is fixation during gastric banding necessary? A randomised clinical study

Anterior fixation via a gastro-gastric suture in laparoscopic adjustable gastric banding (LAGB) is commonly performed to prevent band-related complications. However, the necessity of this common technique has never been proven. Not fixing the band would be time sparing and would reduce adhesions on the stomach and probably make revisional surgery easier. This study was conceived as a 3-year randomised clinical trial to test the safety and efficacy of the non-fixation technique. From December 2006 to December 2007, 81 patients undergoing LAGB were randomly distributed into two groups: group A, with gastro-gastric sutures (n = 41) and group B, without gastro-gastric fixation (n = 40). The two groups were equivalent regarding initial body mass index (BMI), age and sex ratio. The main outcome was postoperative complications and secondary outcomes were operative time and weight loss expressed by the percentage of excess BMI loss (%EBMIL). All patients were prospectively followed up for 2 years. The mean preoperative BMI was 42.5 kg/m² (35-56). All patients were available for follow-up at 2 years. The mean overall preoperative time was 82 ± 20 min for the fixation group and 72 ± 20 min for the non-fixation group (p = 0.13). The mean hospital stay was 4.1 ± 1.5 days (no significant difference between the two groups). The 2-year %EBMIL was 35.9 for group A and 39.4 for group B (p = NS). The mean BMI at 2 years was 36.3 and 36.1, respectively, with no statistical difference. We observed three early band slippages in the non-fixation group and none in the fixation group. Three bands were removed during the second year of follow-up for causes other than band slippage (no significant difference between the two groups). This study was interrupted before a statistical significance could be reached, under the general agreement of all participating surgeons, because of the three unexpected early band slippages. For the patients who did not suffer from this complication, we did not observe any differences between the two groups in terms of late complications and weight loss. The operative time was shorter in the non-fixation group. This randomised clinical trial suggests that care should be taken when not fixating the LAGB because of the risk of early postoperative band slippage. We suggest that fixing the LAGB by gastro-gastric sutures should remain common practice.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts

BACKGROUND

No long-term, international, multicenter studies of the effectiveness and safety of the SAGB in morbid obesity have been previously published. The objective of this study was to assess the effectiveness and safety of the Swedish Adjustable Gastric Band (SAGB) at 6 bariatric centers in Australia, Europe, and Brazil, with < or =5 years of follow-up; the effect on patient covariates; and changes in co-morbidity.

METHODS

A 2-phase study design was used, involving both retrospective and prospective data. SAGB was implanted by way of the pars flaccida 1, 3, and 5 years previously. The retrospective phase entailed a review of the records. The prospective phase included a subset of eligible patients who agreed to undergo additional clinical assessments. The percentage of excess weight loss (%EWL), patient level predictors, change in co-morbidities, and complications were analyzed.

RESULTS

A total of 481 patients in 3 mutually exclusive follow-up cohorts (1 yr, n = 200; 3 yr, n = 184; 5 yr, n = 97) participated in the present study. Of these 481 patients, 339 (1 yr, n = 139; 3 yr, n = 131; 5 yr, n = 69) underwent prospective evaluations. The mean %EWL was 43.5% + or - 21.8%, 57.7% + or - 25.9%, and 49.8% + or - 27.6% and the mean change in body mass index was -7.64, -10.75, and -9.52 in the 1-, 3-, and 5-year cohorts, respectively (P <.001). Gender and age did not predict the %EWL; however, a greater preoperative body mass index was inversely related to the %EWL. Longer postimplantation times were associated with greater improvement in co-morbidities and with greater frequencies of reoperation. Fewer than 15% of the patients in the 5-year cohort had undergone band removal and 10% required band revisions. No fatal or life-threatening complications occurred.

CONCLUSION

SAGB is safe and effective in inducing weight loss and improvement of co-morbidities in morbidly obese patients at international bariatric centers at 1, 3, and 5 years postoperatively.

Adjustable laparoscopic gastric banding: demonstrated on multidetector computed tomography with multiplanar reformation and 3-dimensional imaging

Laparoscopic adjustable gastric banding (LAGB) is a widely performed surgical procedure for morbid obesity in Europe and Australia. An upper gastrointestinal examination is usually used to assess for band placement and possible complications. Computed tomography (CT) is not used routinely but may be beneficial to evaluate LAGB and possible complications. Also, LAGB may be incidentally demonstrated on CT. We report 2 patients with LAGB that was well demonstrated on multidetector CT with multiplanar reformation and 3-dimensional imaging.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Ten years experience with laparoscopic adjustable gastric banding

BACKGROUND

Gastric banding is a safe and efficient bariatric procedure. We report here the results of 591 consecutive gastric bandings in terms of excess weight loss with up to 10 years follow-up and the complications.

METHODS

Between June 1996 and September 2006, 591 patients underwent laparoscopic adjustable gastric banding (LAGB) by the same surgeon (JB). Of these patients, 69.2% were women. Mean age was 33.6 years +/- 10.7 and mean BMI was 41.95 kg/m2 +/- 8.7. Patients were reviewed monthly for the first 6 months, every 2 months for the next 6 months, and yearly thereafter. Excess weight loss was calculated at 6 months and 1, 2, 4, 6, 8, and 10 years.

RESULTS

Six hundred eleven bands were implanted in 591 patients. Fifty-one patients (8.6%) had band removal due to a complication. Mean follow-up was 35 +/- 2 months. Percentage of excess weight loss was 45.8% +/- 27.4 at 6 months, 66.7% +/- 30.3 at 1 year, 72.6% +/- 28.8 at 2 years, 75.9% +/- 27.4 at 4 years, 82.8% +/- 32.6 at 6 years, 82.3% +/- 25.1 at 8 years, and 82.7% +/- 4.2 at 10 years. Complications encountered were band failure (9.3%), slippage (5.3%), erosion (4.6%), infection (2.4%), high band position (1.9%), and others (2.8%). Complication rate was 23.3% overall but dropped to 2.5% when calculated on the second half of the patients.

CONCLUSION

LAGB is a safe and efficient bariatric procedure. With experience, the complication rate drops to a very low level. Close follow-up can further increase its efficacy.

Radiological assessment of complications after laparoscopic suprabursal adjustable gastric banding for morbid obesity

BACKGROUND

The purpose of this study was to investigate the clinical impact of radiological assessment on delivery of therapy in patients with laparoscopic adjustable gastric banding for morbid obesity who have developed gastroesophageal symptoms or have inadequate excess weight loss.

METHODS

Institutional review board approval and informed consent were obtained from all patients. Suprabursal banding was performed in 373 patients who underwent 869 upper gastrointestinal series. The control group comprised 59 asymptomatic subjects from the study population with satisfactory weight loss at follow-up.

RESULTS

There were no intra-operative deaths or gastric perforations. A small gastric pouch was found above the band in 13 (22.03%) of the 59 control subjects; the upper limit of the gastric pouch volume was 9.85 ml (mathematical formula for a sphere used). The main postoperative complications included: 21 of 373 (5.63%) gastric portions above the band with a mean volume of 137.98 ml and narrowed stoma of 0.99 mm; 15 of 373 (4.02%) gastric portions above the band with a mean volume of 33.27 ml and open stoma of 4.95 mm; and 16 of 373 (4.28%) tubing disconnection and displacement into the peritoneal cavity. Twenty-one of 21 narrowed-stoma and eight of 15 open-stoma gastric portions underwent repeat surgery, upward herniation of the stomach (from below the band) being found in all 29 cases.

CONCLUSION

Our main findings following the use of the suprabursal approach for surgical band positioning suggest that repeat surgery may be worthwhile for all gastric upper portions >10 ml in patients with gastroesophageal symptoms or inadequate excess weight loss.

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

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

Prospective Study of a Two-Stage Operative Concept in the Treatment of Morbid Obesity: Primary Lap-Band® Followed if Needed by Sleeve Gastrectomy with Duodenal Switch

BACKGROUND

We investigated the success rate of a two-stage operative concept for treatment of morbid obesity: primary laparoscopic adjustable gastric banding (LAGB, Lap-Band) for all morbidly obese patients, followed by sleeve gastrectomy with biliopancreatic diversion (duodenal switch or DS) in case of failure.

METHODS

From Dec 1996 to May 2004, 366 consecutive patients (female 78%, mean age 41 (17-66) years, BMI 44.3 (35-75) kg/m2 were prospectively evaluated, using the two-stage operative concept. The follow-up rate after a mean of 4.1 (1-8.4) years was 98%. Primary outcome measure was BAROS score, defined according to weight loss, quality of life, reduction in co-morbidities, complications and re-operations.

RESULTS

A very good-to-excellent result was found in 118 patients (32%), 141 (39%) had a good results, 76 (21%) a fair result, and 31 (8%) were failures. 39 patients needed re-banding due to slippage, 68 a DS, and 11 patients had band removal. Early morbidity of the Lap-Band was 3.8%, that of DS 13%, and mortality was zero. The excess weight loss at last follow-up of all the patients was 44% (40% after Lap-Band/rebanding, and 82% 2 years after DS).

CONCLUSION

The two-stage concept with primary LAGB, followed by DS in case of failure, leads to a good result in 71% of morbidly obese patients. LAGB alone does not appear to be an adequate procedure for every morbidly obese patient.

Expression and localization of melanocortin-1 receptor in human adipose tissues of severely obese patients

OBJECTIVE

The melanocortin system is a key regulator in the hypothalamus of energy intake and expenditure. It is frequently linked with obesity and apparently modulates sympathetic outflow to white adipose tissues. The role of the melanocortins within adipose tissues, however, is not entirely clear. This study was aimed at determining the quantitative expression of the five melanocortin receptors (MC1-R to MC5-R) in subcutaneous and omental fat of obese patients and non-obese subjects.

RESEARCH METHODS AND PROCEDURES

Expression of MC1-R to MC5-R, proopiomelanocortin, agouti signaling protein, leptin, leptin receptor, and uncoupling protein-1 was investigated in human fat samples by quantitative reverse transcription-polymerase chain reaction. MC1-R expression was also studied in preadipocytes, adipocytes, and monocytic THP-1 cells and by immunohistochemical localization in adipose tissues.

RESULTS

Notable expression was found for MC1-R, whereas no mRNA for MC2-R and MC3-R was detected; MC4-R and MC5-R mRNA was occasionally detectable but at very low levels. MC1-R mRNA in subcutaneous fat was increased in obese patients as compared with controls; omental fat of both groups had slightly higher MC1-R expression than subcutaneous fat and did not differ between patient groups. Immunohistochemical analysis of the MC1-R in adipose tissue sections showed that MC1-R expression was higher in macrophages but also present in adipocytes.

DISCUSSION

The expression of MC1-R and the lack of MC2-R in human adipose tissues indicate that the melanocortins may regulate cell proliferation and/or inflammatory signals rather than lipolysis. Also, the increased expression of MC1-R in subcutaneous fat of obese subjects may reflect one aspect of the pathophysiology of obesity.