Laparoscopic adjustable gastric banding, the past, the present and the future

Italian guidelines for the management of adult individuals with overweight and obesity and metabolic comorbidities that are resistant to behavioral treatment

AIM

This guideline (GL) is aimed at providing a clinical practice reference for the management of adult patients with overweight or obesity associated with metabolic complications who are resistant to lifestyle modification.

METHODS

Surgeons, endocrinologists, gastroenterologists, psychologists, pharmacologists, a general practitioner, a nutritionist, a nurse and a patients' representative acted as multi-disciplinary panel. This GL has been developed following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A systematic review and network meta-analysis was performed by a methodologic group. For each question, the panel identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for clinical practice recommendations. Consensus on the direction (for or against) and strength (strong or conditional) of recommendations was reached through a majority vote.

RESULTS

The present GL provides recommendations about the role of both pharmacological and surgical treatment for the clinical management of the adult patient population with BMI > 27 kg/m2 and < 40 kg/m2 associated with weight-related metabolic comorbidities, resistant to lifestyle changes. The panel: suggests the timely implementation of therapeutic interventions in addition to diet and physical activity; recommends the use of semaglutide 2.4 mg/week and suggests liraglutide 3 mg/day in patients with obesity or overweight also affected by diabetes or pre-diabetes; recommends semaglutide 2.4 mg/week in patients with obesity or overweight also affected by non-alcoholic fatty liver disease; recommends semaglutide 2.4 mg/week as first-line drug in patients with obesity or overweight that require a larger weight loss to reduce comorbidities; suggests the use of orlistat in patients with obesity or overweight also affected by hypertriglyceridemia that assume high-calorie and high-fat diet; suggests the use of naltrexone/bupropion combination in patients with obesity or overweight, with emotional eating; recommends surgical intervention (sleeve gastrectomy, Roux-en-Y gastric bypass, or metabolic gastric bypass/gastric bypass with single anastomosis/gastric mini bypass in patients with BMI ≥ 35 kg/m2 who are suitable for metabolic surgery; and suggests gastric banding as a possible, though less effective, surgical alternative.

CONCLUSION

The present GL is directed to all physicians addressing people with obesity-working in hospitals, territorial services or private practice-and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.

Roux-en-Y gastric bypass and sleeve gastrectomy as revisional bariatric procedures after adjustable gastric banding: a retrospective cohort study

INTRODUCTION

The frequency of revisional bariatric surgery is increasing, but its effectiveness and safety are not yet fully established. The aim of our study was to compare short-term outcomes of primary (pRYGB and pSG) and revisional bariatric surgeries (rRYGB and rSG).

METHODS

We performed a retrospective cohort study assessing all patients submitted to primary and revisional (after a failed AGB) RYGB and SG in 2019. Each patient was followed-up at 6 months and 12 months after surgery. We compared pRYGB vs. rRYGB, pSG vs. rSG and rRYGB vs. rSG on weight loss, surgical complications, and resolution of comorbidities.

RESULTS

We assessed 494 patients, of which 18.8% had undergone a revisional procedure. Higher weight loss at 6 and 12 months was observed in patients undergoing primary vs. revisional procedures. Patients submitted to rRYGB lost more weight than those with rSG (%EWL 12 months = 82.6% vs. 69.0%, p < 0.001). Regarding the resolution of obesity-related comorbidities, diabetes resolution was more frequent in pRYGB than rRYGB (54.2% vs. 25.0%; p = 0.038). Also, 41.7% of the patients who underwent rRYGB had dyslipidemia resolution vs. 0% from the rSG group (p = 0.035). Dyslipidemia resolution was also more common in pSG vs. rSG (68.6% vs. 0.0%; p = 0.001). No significant differences in surgical complications were found.

CONCLUSION

Revisional bariatric surgery is effective and safe treating obesity and related comorbidities after AGB. Primary procedures appear to be associated with better weight loss outcomes. Further prospective studies are needed to better understand the role of revisional bariatric surgery.

Significance of Hormone Alteration Following Bariatric Surgery

The prevalence of obesity has increased significantly over the last several decades, and with its increase comes a wide variety of comorbidities, such as diabetes and cardiovascular disease. Traditionally, diet and exercise have been prescribed for individuals to try and regain control of their weight and health status. Despite this successful method, the compliance rate is significantly below the desired amount. Over the last few decades, a new treatment has been offered to significantly decrease an individual's weight to an optimal BMI between 18 and 25 kg/m2. Bariatric surgery has been proposed to be the most appropriate treatment for obesity, and there are several different types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), adjustable gastric band (AGB), and sleeve gastrectomy (SG). Hormones may be significantly involved in losing and maintaining weight loss. This paper aims to evaluate hormone changes in appetite suppression, appetite activation, glycemic control, and lipid metabolism and how these impact overall weight loss concerning the most prominent surgeries. The hormones assessed were ghrelin, insulin, leptin, GLP-1, PYY, and adiponectin, and their levels before and after each surgery were compared. RYGB is one of the most successful types of bariatric surgeries, and this correlates with it having the most suppressed levels of ghrelin, insulin, and leptin following surgery with a slow return to normal. RYGB has also led to the most significant increased levels of PYY, pre- and post-prandial GLP-1, and adiponectin. Hormones following SG followed the hormone trend after RYGB but were not as prominent. BDP-DS has the highest success rate. However, numerous adverse effects have limited the amount of studies assessing the surgery. What was present was not as significant as RYGB, possibly due to manipulation.

Obesity management for cardiovascular disease prevention

Background

Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies.

Methods

A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects.

Results

This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1].

Conclusion

Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

Cardiovascular Effects of Weight Loss in Obese Patients with Diabetes: Is Bariatric Surgery the Additional Arrow in the Quiver?

Obesity is an increasingly widespread disease worldwide because of lifestyle changes. It is associated with an increased risk of cardiovascular disease, primarily type 2 diabetes mellitus, with an increase in major cardiovascular adverse events. Bariatric surgery has been shown to be able to reduce the incidence of obesity-related cardiovascular disease and thus overall mortality. This result has been shown to be the result of hormonal and metabolic effects induced by post-surgical anatomical changes, with important effects on multiple hormonal and molecular axes that make this treatment more effective than conservative therapy in determining a marked improvement in the patient's cardiovascular risk profile. This review, therefore, aimed to examine the surgical techniques currently available and how these might be responsible not only for weight loss but also for metabolic improvement and cardiovascular benefits in patients undergoing such procedures.

Small Bowel Obstruction Secondary to Laparoscopic Adjustable Gastric Band Connecting Tube Intertwinement Within the Mesentery: A Case Report

Laparoscopic adjustable gastric banding (LAGB) is a technique used for the surgical management of morbid obesity. This report illustrates the case of a 46-year-old African American woman who presented with a rare case of small bowel obstruction (SBO) two years post-LAGB placement. SBO, in this case, was a result of LAGB connecting tube intertwinement within the mesentery, accompanied by adhesions. The patient was diagnosed clinically and radiologically by computed tomography (CT) scan, which showed high-grade SBO. Initially, an exploratory laparoscopy was conducted, which soon transformed into an exploratory laparotomy when the cause of obstruction was seen to be the intertwinement of the connecting tube of the gastric band with the mesentery. With the rise of bariatric procedures to combat the epidemic of obesity in American society, this rare complication secondary to one of the most widely performed procedures beckons the attention of bariatric surgeons, emergency personnel, and device manufacturers.

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.

The Role of Devices in the Management of Pediatric Obesity

PURPOSE OF REVIEW

Approximately 20% of children and adolescents in the USA suffer from obesity with significant long-term effects well into adulthood. Metabolic and bariatric surgery, although well adopted in the adult population, has been underutilized in children.

RECENT FINDINGS

There are four categories of weight loss devices regulated by the Food and Drug Administration for use in adults - gastric bands, gastric balloon systems, electrical stimulation systems, and gastric emptying systems. In this commentary we discuss the role these devices may play in increasing the adoption of procedural intervention for severe obesity in children and adolescents.

Minimally Invasive Revisional Bariatric Surgery in a MBSAQIP Accredited High-Volume Center

Background

With the rising number of bariatric surgeries performed annually, there has also been an increase in revisional bariatric surgeries (RBS). The aim of this study is to evaluate the safety and postoperative outcomes of RBS performed with a minimally invasive approach.

Methods

Retrospective analysis on a prospectively collected database of patients who underwent minimally invasive RBS between 2012 and 2019. Primary endpoints were conversion rate, major morbidity, mortality, and 30-day reoperation rate. Comparative analysis of laparoscopic adjustable gastric banding (LAGB) conversion to sleeve gastrectomy (SG) vs. conversion to Roux-en-Y gastric bypass (RYGB) was performed.

Results

A total of 221 patients underwent minimally invasive RBS, 137 (62%) laparoscopically and 84 (38%) robotically. The most common RBS were LAGB to SG (59.3%) and LAGB to RYGB conversions (16.7%). The main indication was weight loss failure (88.7%). Conversion rate, major morbidity, and mortality were 0.9, 3.2, and 0.4%, respectively. Urgent reoperation was required in 3.2% of cases. Total weight loss at 1 and 2-years follow- were 14.3 and 17.3%, respectively. Comparative analysis of LAGB conversion to SG vs. RYGB showed similar major morbidity (SG: 2.3% vs. RYGB 0%, p = 1). Greater total weight loss was achieved in LAGB to RYGB conversions at 1-year (SG: 14.8% vs. RYGB 25.3%, p < 0.001).

Conclusions

Minimally invasive RBS can be performed safely in a broad patient population with low conversion and complication rates, and improved weight loss outcomes. LAGB to RYGB conversions are associated with greater weight loss. Further randomized trials are needed to draw more conclusive recommendations.

Recent Technical Developments in the Field of Laparoscopic Surgery: A Literature Review

The benefits of laparoscopic surgery (LS) include a speedy recovery, shorter duration of hospital stay, minimal postoperative pain, discomfort and disabilities, and better cosmetic outcomes (less scarring) that help an individual to resume normal daily activities and return to work. A comprehensive literature search on laparoscopic surgeries was conducted using different Internet-based search engines and databases from August 2021 to October 2021. The search was limited to articles published in the English language and those published between years 2005 and 2021. A total of 126 articles were initially identified. Two independent reviewers thoroughly examined the quality and content of the articles. Articles with duplicate data were excluded, and the remaining articles were screened and assessed by the titles and abstracts. After a vigorous assessment, we included data from 49 articles for this review process. Bibliographic management was done using the software “EndNote” (Thomson Reuters, New York, NY, USA).

It was concluded that LS has become the technique of choice for virtually every kind of abdominal surgery, evident by numerous scholarly publications in this field. Level I evidence demonstrating the advantage of LS over open surgery has been reported for numerous operations, including fundoplication for gastroesophageal regurgitation disease, bariatric surgery for weight loss, and cancer resection. Advanced LS has subsequently been expanded to include hepatectomy, pancreatectomy, urology, and gynecology. Patients who are at risk of having elevated abdominal pressure during LS, however, should proceed with care. Recent advances in natural orifice transluminal endoscopic surgery, single-incision laparoscopic surgery, and robot-assisted laparoscopic surgery are promising.

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.

Which predictors could effect on remission of type 2 diabetes mellitus after the metabolic surgery: A general perspective of current studies?

BACKGROUND

The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus (T2DM). Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM. There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM, but remission rates of T2DM after metabolic surgery can display great variability.

AIM

To discuss the most commonly used surgical options including vertical sleeve gastrectomy, adjustable gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

METHODS

We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures.

RESULTS

In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patient with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

CONCLUSION

In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patients with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

Potential positive effects of bariatric surgery on healthcare resource utilisation

BACKGROUND

To determine whether a bariatric surgical procedure is associated with a reduction in healthcare utilisation among patients with obesity and high pre-procedural healthcare needs.

METHODS

Design: Retrospective cohort study.

SETTING

Tertiary Victorian public hospital.

PARTICIPANTS

Twenty-nine adults who underwent publicly funded primary bariatric surgery between 2008 and 2018 at the Alfred Hospital, Melbourne and had high resource use over the year prior to surgery, defined as at least two of ≥3 hospital admissions, ≥7 inpatient bed days for obesity-related co-morbidities or inpatient hospital costs ≥$10 000.

MAIN OUTCOME MEASURES

Change in inpatient and outpatient resource use.

RESULTS

After 1 year following bariatric surgery, total hospital bed days decreased from 663 to 80 and the median (Q1, Q3) per patient decreased from 7 (4.5, 15) to 5 (2.25, 9.75) (p = 0.001) and the total number of hospital admissions fell from 118 to 67 (p < 0.001). The median cost of inpatient care decreased from $11 405 ($4408, $22251) to $3974 ($0, $4325) per annum (p < 0.001). The total and median number of outpatient attendances did not significantly change 12 months after bariatric surgery, but the demand for outpatient services unrelated to bariatric surgery declined by a median of four visits per patient (p = 0.013).

CONCLUSIONS

The evidence from this small pilot study suggests that Bariatric surgery has the potential to decrease resource use and inpatient hospital costs over a 1-year time frame for obese patients with high resource use. These data will be used to design a prospective randomised controlled trial to provide more definitive information on this important issue.

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.