Role of a Minimally Invasive Approach in the Management of Laparoscopic Adjustable Gastric Banding Postoperative Complications

Obesity treatment by Bioenterics intragastric balloon: Iranian results

We studied the effectiveness, tolerability and safety of Bioenteric Intragastric Balloon (BIB) for treatment of obesity in Iranian population. 52 patients (46 female (88.5%), mean age: 35.5 ±10, mean body weight: 107.6±25.4 kg) referred to two major training hospitals in Tehran, Iran, after evaluation by a multidisciplinary team, underwent endoscopic BIB placement under unconscious sedation. BIB was removed after 6 months and patients were discharged with drug therapy and 1000 kcal diet. Weight and Body Mass Index (BMI) were assessed at baseline, 6 months and 1 year after BIB insertion. The mean weight and BMI at baseline were 107.6±25.4 kg and 39.4±7.9 kg/m2; 6 months after balloon placement, they were 88.7±21.9 kg and 32.5±7.4 kg and 6 months after balloon removal, they were 93.4±21.9kg and 34.85±8.2 kg/m2 respectively. The weight decline was statistically significant throughout the study and follow up with p value <0.001. The most frequent side effects were nausea and vomiting which were resolved in the majority of cases by one week. No major complications, such as death, gastric obstruction, gastric or esophageal perforation, or balloon displacement occurred in our study. BIB is a safe, effective and well-tolerated treatment of obesity, but its effects are temporary, so it should be accompanied and followed by other methods to achieve sustained weight reduction.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": a multicenter study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy).

METHODS

A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months.

RESULTS

The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group.

CONCLUSION

Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss.

Let loose technique, an option in band migration

Obesity is nowadays a serious worldwide public health problem. In order to give patients a better quality of live, there are now medical and surgical treatments that may be offered to those patients. Since 2005, the Hospital de Santarém has been doing bariatric surgery. From 77 procedures with laparoscopic adjustable gastric banding, there were three cases of migration. The authors propose a new procedure to deal with migrations, according to a classification for band migration, as an alternative to a removal by laparoscopy or laparotomy. Let loose technique is a procedure that can be used in patients with band migration beyond the angle of Treitz and without other associated complications. It is consist of removing the port under local anaesthesia, leaving the insufflations' tube, hospitalization for monitoring the patient and awaiting for the elimination of the band with faeces. It's less costly and with minimal risks for patient. The first results are satisfactory and encouraging.

Endoscopic solutions for weight loss

PURPOSE OF REVIEW

Gastroenterologists will likely play a critical role in the treatment of obesity and its comorbidities, as novel endoluminal approaches demonstrate their safety and efficacy over the coming years. Understanding the relative advantages and shortcomings of the endoscopic tools and procedures currently under investigation will provide the gastroenterologist with valuable insight into the future of endoscopic procedures for weight loss.

RECENT FINDINGS

Endoscopic restrictive procedures, intestinal sleeves, and intragastric balloons have demonstrated short-term efficacy in inducing weight reduction and in reversing the comorbidities of obesity with an acceptable risk profile. Several endoscopic tools have also demonstrated effectiveness as revisional tools for reversing weight gain after bariatric surgery.

SUMMARY

A plethora of endoscopic tools and procedures are under investigation for primary and revisional obesity management, and these may offer new weight loss options to a variety of different patient populations.

Revision laparoscopic gastric bypass: an effective approach following failure of primary bariatric procedures

BACKGROUND

The laparoscopic approach plays an important role in the primary surgical management of morbid obesity. This study evaluated the potential role of the laparoscopic approach to revision Roux-en-Y gastric bypass (LRYGB) in the management of selected patients who fail to lose adequate weight or regain weight after primary bariatric surgery.

METHODS

Revision LRYGB was carried out to remedy early or delayed failure of primary bariatric procedures. Patients who underwent laparoscopic revision surgery to re-establish a functioning gastric band were not included in this report. The results are presented as mean (SD).

RESULTS

Between April 2002 and March 2009, 21 patients underwent 21 laparoscopic revision procedures. The initial bariatric operations were laparoscopic gastric band (n = 10), open vertical banded gastroplasty (n = 6), open Magenstrasse and Mill (n = 2), open gastric bypass with pouch dilatation (n = 2), and open gastric band (n = 1). All revision procedures were completed laparoscopically and included conversion to LRYGB (n = 19), and others (n = 2). The postoperative hospital stay was 2.0 (1.3) days. The anastomotic leak, morbidity, and mortality rates were 0%, 4.8%, and 0% respectively. At a follow-up of 12.9 (7.9) months, the prerevision body mass index has decreased significantly from 43.9 (7.4) to 32.7 (6.6) kg/m(2) (p < 0.001) with a percentage excess weight loss of 61.1 (21.2).

CONCLUSIONS

The laparoscopic approach to revision Roux-en-Y gastric bypass is safe and effective even in patients with previous open bariatric surgery and is associated with rapid recovery and short hospital stay.

Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.

METHODS

A retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.

RESULTS

Of 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.

CONCLUSION

Although reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system

BACKGROUND

The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse.

METHODS

The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus.

RESULTS

Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve.

CONCLUSION

The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

[Intragastric migration of adjustable gastroplasty bands]

BACKGROUND

The incidence of morbid obesity is increasing in France; adjustable gastric banding has become the most common surgical treatment.

PATIENTS

We report seven cases of patients who presented with gastric erosion as a complication of gastric banding; this occurred at a mean interval of 4 years following the initial bariatric procedure.

RESULTS

In six cases, repair was performed laparoscopically; one case required conversion to an open laparotomy approach. There was no mortality but morbidity occurred in 57% of cases: pleural effusion (two) and wound abscess (two).

CONCLUSION

Gastric erosion and migration of adjustable gastric rings can occur at a long interval after laparoscopic gastric banding. Long-term follow-up is necessary in all such patients.

Clinical experience of transoral suturing for an endoluminal vertical gastroplasty: 1-year follow-up in 64 patients

BACKGROUND

Bariatric surgery for severe obesity has demonstrated significant health benefits, but it is not without complications. Transoral approaches to weight loss offer a minimally invasive option.

OBJECTIVE

To evaluate the safety and feasibility of a transoral suturing procedure for weight loss.

DESIGN

Single-center, uncontrolled study with a 1-year follow-up.

SETTING

Hospital de Clinicas, Caracas, Venezuela.

PATIENTS

Sixty-four patients (mean age [SD] 31.5 +/- 10.1 years, range 16-62 years; mean (SD) preoperative body mass index [BMI] 39.9 +/- 5.1 kg/m(2), range 28.0-60.2 kg/m(2)) were enrolled between 2003 and 2005.

INTERVENTION

Endoluminal vertical gastroplasty by using a continuous suture pattern to treat obesity.

MAIN OUTCOME MEASUREMENTS

Short-term complication monitoring and patient weight before the procedure and at 1, 3, and 12 months after the procedure.

RESULTS

The outpatient procedures were performed in approximately 45 minutes. Patients had a significant reduction in BMI at 12 months (mean [SD] BMI 39.9 +/- 5.1 kg/m(2) vs 30.6 +/- 4.7 kg/m(2); P < .001) and a percentage of excess weight loss (%EWL) (SD) of 21.1 +/- 6.2, 39.6 +/- 11.3, and 58.1 +/- 19.9 at 1, 3, and 12 months, respectively. By comparing the study's subpopulations, group I (baseline BMI >or=40 kg/m(2), n = 33), group II (baseline BMI 35-40 kg/m(2), n = 19), and group III (baseline BMI <35 kg/m(2), n = 12) demonstrated a %EWL (SD) of 48.9 +/- 10.7, 56.5 +/- 13.9, and 85.1 +/- 24.0, respectively, at 12 months after the procedure (P = .037 when comparing group I vs II; P < .001 when comparing group II vs III and group I vs III). No patients experienced any serious adverse events.

LIMITATIONS

This study represents a single center's clinical experience, with no sham control.

CONCLUSIONS

Endoluminal vertical gastroplasty by using a continuous suture pattern is associated with significant weight loss. Additional studies are needed to demonstrate the procedure's long-term safety and efficacy.

Laparoscopic transgastric removal of eroded adjustable band: a novel approach

Gastric erosion is a well-known complication of laparoscopic adjustable gastric band (LAGB) placement for morbid obesity. We describe a novel approach for the removal of an eroded band through a laparoscopic gastrotomy with subsequent intraluminal division and removal of the band. A 67-year-old woman with a body mass index of 35.5 kg/m2 was seen 1 year after LAGB placement performed outside the United States. She had developed dysphagia and regurgitation of undigested food a few months after the procedure. The LAGB had been adjusted twice by her primary surgeons and was completely deflated once her symptoms began. The patient failed to improve and was subsequently referred to our institution where an upper endoscopy revealed intragastric band erosion. The patient was taken to the operating room for LAGB removal; however, standard laparoscopic and endoscopic attempts at band retrieval were unsuccessful. We then attempted a novel laparoscopic technique. An anterior gastrotomy was created, distal to the area of erosion, to facilitate easy intraluminal band division and removal. The gastrotomy was repaired, and a leak test was performed. A postoperative Gastrografin upper gastrointestinal series showed no extravasation. The patient began a diet, was discharged, and was seen in follow-up with complete resolution of her symptoms. The results of this case have shown that laparoscopic transgastric removal of an eroded gastric band is safe and feasible when standard endoscopic and laparoscopic techniques fail.

Surgery for morbid obesity

The prevalence of morbid obesity in the UK population is rising, bringing with it increased levels of cardiovascular disease, diabetes, arthritis and early mortality. The overall cost to the health service is high, and is set to increase over the coming decades as the overweight population ages. Dietary, lifestyle and pharmacological interventions offer at best reasonable, short-term weight reduction and often fail. Surgical intervention is a safe and effective means of delivering marked long-term weight reduction. This article compares and contrasts the options available for surgical treatment of morbid obesity based on a review of the current literature.

Device-Related Reoperations after Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) is considered a relatively safe weight loss procedure with low morbidity. When complications occur, obstruction, erosion, and port malfunction require reoperation. We retrospectively reviewed our experience with 270 consecutive patients who underwent LAGB. Device-related reoperations were performed in 26 (10%) patients. Reoperations were related to the band in 13, to port/tubing in 11, and related to both in 2 patients. Of the 15 band-related problems, it was removed in 5 (2%): slippage (3), intra-abdominal abscess (1), and during emergent operation for bleeding duodenal ulcer (1). Revision or immediate replacement was performed in 10 (4%): slippage (5), obstruction (4), and leak from the reservoir (1). Port/tubing problems were the reason for reoperations in 13 (5%): infection (5), crack at tubing-port connection (6), and port rotation (2). Port removal for infection was followed later by port replacement (average 9 months). Overall, slippage occurred in 8 (3%), obstruction in 4 (1.5%), leak from reservoir in 7 (3%), and infection in 5 (2%) patients. Fifteen device-related problems occurred during our first 100 cases and 12 subsequently ( P = 0.057). Permanent LapBand loss was only 5 per cent, leading to overall rate of 95 per cent of LapBand preservation as a restrictive device.