Laparoscopic adjustable gastric banding

Gut microbiome: Linking together obesity, bariatric surgery and associated clinical outcomes under a single focus

Obesity is increasingly prevalent in the post-industrial era, with increased mortality rates. The gut microbiota has a central role in immunological, nutritional and metabolism mediated functions, and due to its multiplexity, it is considered an independent organ. Modern high-throughput sequencing techniques have allowed phylogenetic exploration and quantitative analyses of gut microbiome and improved our current understanding of the gut microbiota in health and disease. Its role in obesity and its changes following bariatric surgery have been highlighted in several studies. According to current literature, obesity is linked to a particular microbiota profile that grants the host an augmented potential for calorie release, while limited diversity of gut microbiome has also been observed. Moreover, bariatric surgery procedures represent effective interventions for sustained weight loss and restore a healthier microbiota, contributing to the observed fat mass reduction and lean mass increase. However, newer evidence has shown that gut microbiota is only partially recovered following bariatric surgery. Moreover, several targets including FGF15/19 (a gut-derived peptide), could be responsible for the favorable metabolic changes of bariatric surgery. More randomized controlled trials and larger prospective studies that include well-defined cohorts are required to better identify associations between gut microbiota, obesity, and bariatric surgery.

Computer-aided Veress needle guidance using endoscopic optical coherence tomography and convolutional neural networks

During laparoscopic surgery, the Veress needle is commonly used in pneumoperitoneum establishment. Precise placement of the Veress needle is still a challenge for the surgeon. In this study, a computer-aided endoscopic optical coherence tomography (OCT) system was developed to effectively and safely guide Veress needle insertion. This endoscopic system was tested by imaging subcutaneous fat, muscle, abdominal space, and the small intestine from swine samples to simulate the surgical process, including the situation with small intestine injury. Each tissue layer was visualized in OCT images with unique features and subsequently used to develop a system for automatic localization of the Veress needle tip by identifying tissue layers (or spaces) and estimating the needle-to-tissue distance. We used convolutional neural networks (CNNs) in automatic tissue classification and distance estimation. The average testing accuracy in tissue classification was 98.53 ± 0.39%, and the average testing relative error in distance estimation reached 4.42 ± 0.56% (36.09 ± 4.92 μm).

Food Intake and Eating Behavior After Bariatric Surgery

Obesity is an escalating global chronic disease. Bariatric surgery is a very efficacious treatment for obesity and its comorbidities. Alterations to gastrointestinal anatomy during bariatric surgery result in neurological and physiological changes affecting hypothalamic signaling, gut hormones, bile acids, and gut microbiota, which coalesce to exert a profound influence on eating behavior. A thorough understanding of the mechanisms underlying eating behavior is essential in the management of patients after bariatric surgery. Studies investigating candidate mechanisms have expanded dramatically in the last decade. Herein we review the proposed mechanisms governing changes in eating behavior, food intake, and body weight after bariatric surgery. Additive or synergistic effects of both conditioned and unconditioned factors likely account for the complete picture of changes in eating behavior. Considered application of strategies designed to support the underlying principles governing changes in eating behavior holds promise as a means of optimizing responses to surgery and long-term outcomes.

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.

Intraabdominal Trocar-Free Vacuum Liver Retractor for Laparoscopic Sleeve Gastrectomy (Video)

PURPOSE

Retraction of the liver is essential in laparoscopic sleeve gastrectomy. Recently, a new internal liver retractor, the LiVac® device, has been introduced. The current video report (run-time 7:26 min) seeks to demonstrate the efficacy and safety of the LiVac® trocar-free liver retractor in laparoscopic sleeve gastrectomy.

MATERIALS AND METHODS

The LiVac® retractor is inserted besides an abdominal trocar and uses the vacuum system of the operating room without the need for specific devices. The liver is retracted without the need of an assistant or extra trocars.

RESULTS

The present case is a laparoscopic sleeve gastrectomy in a 30-year-old woman with morbid obesity (BMI 45.3 kg/m(2)). The LiVac® retractor provided an excellent view of the operative field. No problems or device-related complications occured during the procedure.

CONCLUSIONS

The LiVac liver retractor was easy to applicate in the presented case and provided a good exposure of the operative field.

Intra-abdominal Trocar-Free Vacuum Liver Retractor for Upper-Gastrointestinal Surgery

Background. In laparoscopic upper-gastrointestinal (GI) surgery, an adequate retraction of the liver is crucial. Especially in single-port surgery and obese patients, problems may occur during liver retraction. The current study seeks to evaluate the efficacy and safety of the LiVac trocar-free liver retractor in laparoscopic upper-GI surgery. Methods. The present study is a nonrandomized dual-center clinical series describing our preliminary results using the LiVac system for liver retraction. The primary end points of the present study included the effectiveness and safety of the LiVac device as well as complications and documentation of problems with the device during surgery. Results. The device was used in 11 patients for simple and complex laparoscopic procedures. The mean age of the study population was 59.6 years (SD = 20.6; range = 30-84). There were 6 female and 5 male patients with a mean body mass index (BMI) of 31.9 kg/m2 (SD = 8.1; range = 26.0-45.3). The efficacy of the device was excellent in all cases, reducing the number of trocars needed. There were no device-related complications. Conclusion. The LiVac liver retractor is easy to use and provides a good exposure of the operative field in upper-GI laparoscopic surgery, even in obese patients with a high BMI.

Laparoscopic Treatment of a Large Gastric Pouch Following Gastric Band Slippage

INTRODUCTION

Gastric band slippage with formation of a gastric pouch is a frequent complication after gastric banding. There is no consensus on the treatment of this condition, which differs within and between centers. Here, we describe our treatment of a large gastric pouch after gastric band slippage. Despite removal of the band, the pouch caused oral feeding intolerance.

METHODS

The video shows our treatment of large gastric pouch following gastric banding and surgical revision. A 45-year-old woman with history of gastric banding was referred to our center for persistent oral feeding intolerance following gastric band removal.

RESULTS

We found that a large gastric pouch was responsible for extrinsic compression and thus required revisional surgery after optimization of the patient's nutritional status. Video endoscopy revealed a large gastric pouch, which was responsible for oral feeding intolerance. Intra-operative exploration then revealed major adhesions, which had probably caused the pouch to form. During surgery that was somewhat analogous to sleeve gastrectomy, we removed the adhesions and resected the gastric pouch. The operating time was 70 min. An uneventful postoperative course enabled rapid discharge (on postoperative day 2).

CONCLUSION

The formation of a large gastric pouch is a rare complication of chronic gastric band slippage. Following nutritional optimization, surgery is required.

Multicenter Randomized Study of Obesity Treatment with Minimally Invasive Injection of Hyaluronic Acid Versus and Combined with Intragastric Balloon

BACKGROUND

Research into minimally invasive techniques is worthwhile for greater acceptance in bariatric surgery, a useful first step being to evaluate the combination of these with current procedures. We suggest that intragastric balloon (IGB) can be performed with hyaluronic acid (HA) injections at the level of the gastroesophageal junction.

METHODS

A submucosal restriction is created by circular injection of an absorbable material within a defined area based on endoscopic anatomy. We included 101 patients in a prospective multicenter randomized trial, with average body mass index (BMI) 33.4 (range 27-44), treated from April 2010 to April 2012 by IGB and/or HA injection, sequentially, and followed for two more years. Patients were divided into group 1 (IGB alone), group 2 (IGB followed by HA at IGB removal, at 6 months), and group 3 (HA and IGB at 6 months).

RESULTS

BMI loss at 6 months was inferior in the HA group (32 patients) compared with the IGB groups (68 patients) (2.1 ± 0.4 versus 3.4 ± 0.3, p < 0.05). The efficacy of IGB alone compared with combined treatments (groups 2 and 3) was significantly inferior at 18 months only, but the impact of the treatment sequence (HA before or after IGB) on BMI loss was not statistically significant, although in favor of HA first.

CONCLUSIONS

This study did not demonstrate the efficacy of HA injections as an obesity treatment.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

BACKGROUND

Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years.

PATIENTS AND METHODS

Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months.

RESULTS

The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months.

CONCLUSIONS

If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

Laparoscopic adjustable gastric banding in adolescents

Gastric band placement developed as a means of limiting the amount of solid food that enters the stomach, relying on the principle of reducing caloric intake by reducing food volume. By making it difficult for a patient to swallow a large bite of food, one ideally could learn to change eating behavior to take smaller bites and eat more slowly in order to avoid the unpleasant sensation of food backing up at the level of the restriction. Limiting intake should result in weight loss. This article reviews the history of gastric band surgery, the operation and follow-up care, complications associated with gastric banding, and results to date.

The evolution of minimally invasive bariatric surgery

BACKGROUND

Obesity is a pandemic associated with significant morbidity and mortality. This historical article charts the progress of successful strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a précis of the reported outcome data following minimally invasive bariatric procedures.

METHODS

A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques.

RESULTS

This article charts the progression of early weight loss strategies, from early dietary modifications and pharmacologic interventions to initial techniques in small bowel bypass procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures.

CONCLUSIONS

A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.

Best Practice Guidelines in Pediatric/Adolescent Weight Loss Surgery

OBJECTIVE

To establish evidence-based guidelines for best practices in pediatric/adolescent weight loss surgery (WLS).

RESEARCH METHODS AND PROCEDURES

We carried out a systematic search of English-language literature in MEDLINE on WLS performed on children and adolescents. Key words were used to narrow the field for a selective review of abstracts. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence-based models. Eight pertinent case series, published between 1980 and 2004, were identified and reviewed. These data were supplemented with expert opinions and literature on WLS in adults.

RESULTS

Recommendations focused on patient safety, reduction of medical errors, systems improvements, credentialing, and future research. We developed evidence-based criteria for eligibility, assessment, treatment, and follow-up; recommended surgical procedures based on the best available evidence; and established minimum guideline requirements for data collection.

DISCUSSION

Lack of adequate data and gaps in knowledge were cited as important reasons for caution. Physiological status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery. Data collection and peer review were also identified as important issues in the delivery of best practice care.

A 5-year experience with laparoscopic adjustable gastric banding--focus on outcomes, complications, and their management

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) remains the most popular surgical modality for obesity management in Europe. The aim of this publication is to present a 5-year experience in obesity treatment with LAGB operation with the assessment of outcomes, frequency of complications, and their management. Management of the band-related complications is crucial for continuous obesity treatments, despite the fact of initial failure, allowing further excess weight loss in patients with morbid obesity.

METHODS

One hundred sixty patients underwent the LAGB procedure with standard pars flaccida technique during the years 2005-2009. A retrospective analysis of the data was performed; chi-squared test and Student's t test at the level of significance of p < 0.05 were used. Information on reoperations was gathered from hospital case notes.

RESULTS

In the presented group, the mean body mass index (BMI) was 48.13 kg/m(2) (33.46-83.04 kg/m(2); standard deviation [SD] ±8.45). Of the patients, 36.2% had super morbid obesity with BMI >50 kg/m(2). The mean observation period reached 549 days (31-2,026 days; SD ±390.1), with the mean number of control visits of 4.2 (1-12). The mean percentage of excess weight loss during the observation period was 34% (from -9.9% to 85.1%; SD ±20.6), with the mean body mass reduction of 24.4 kg. Complications appeared in 30 patients (20.1%). Twenty-four patients (16.1%) required reoperation. There were no mortalities recorded.

CONCLUSIONS

The mean operative time of 59 min was relatively short. Morbidity and mortality rates were comparable to many published series. Failure or complications of LAGB did not stop the obesity treatment. Most of the band-related complications occurred late and could be provided for laparoscopically.

The history and evolution of bariatric surgical procedures

The search for the ideal weight loss operation began more than 50 years ago. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Variations, alterations, and modifications of these original procedures, combined with intense efforts to follow and document outcomes, have led to the evolution of modern bariatric surgery. More recent research has focused on the hormonal and metabolic effects of these procedures. These discoveries at the cellular level will help develop possible mechanisms of weight loss and comorbidity reduction beyond the traditional explanation of reduced food consumption and malabsorption.

Access-port fixation on the left pectoral fascia in laparoscopic adjustable gastric banding

Access-port (AP) complications after laparoscopic adjustable gastric banding (LAGB) are often seen but seldom reported in literature. AP complications requiring additional surgery is reported in 3.6% to 24% of LAGB patients (Susmallian et al. Obes. Surg, 4:128–131, 2003; Peterli et al. Obes. Surg., 12(6):851–856, 2002; Busetto et al. Obes. Surg., 12:83–92, 2002; Mittermair et al. Obes. Surg., 19:446–450, 2009; Holeczy et al. Obes. Surg., 9:453–455, 1999; Bueter et al. Arch. Surg., 393:199–205, 2008; Launay-Savary et al. Obes Surg, 18:1406–1410, 2008; Balsiger et al. J. Gastrointest. Surg., 11:1470–1477, 2007; Szold and Abu-Abeid Surg. Endosc., 16:230–233, 2002). We evaluated the effect of fixing the AP on the pectoral fascia using the Velocity™ Injection Port on complication and re-operation rate. From January 2005 till October 2007, 619 LAGB procedures were performed using the SAGB QuickClose™. All procedures were performed by three dedicated surgeons using the pars flaccida technique. APs were placed on the fascia of the pectoral muscle using an infra-mammary incision. The AP device was fixed on the fascia using the Velocity™ Injection Port and Applier. Data was obtained retrospectively and records of 619 consecutive patients were reviewed for access-port complications. Sixty-eight AP complications were observed. Complications could be divided in four categories. Discomfort was reported in 30 patients, seven needing additional surgery. Infection contributed to 11 patients needing surgical removal of the device. Fourteen Patients with superficial infection were treated conservatively. Nine patients had inaccessible APs. Ultrasound-guided access was required in three patients. The remainder needed surgical relocation of the AP. Leakage of the tube was observed in four patients all of which needed revisional surgery. Our experience shows that fixation of the AP on the left pectoral fascia using the Velocity™ leads to a readily accessible AP with good anaesthetic and aesthetic results. In our series, 68 (11%) complications were recorded, of which 28 (4.5%) needed additional surgery.

Long-term results of bariatric restrictive procedures: a prospective study

Laparoscopic adjustable gastric banding (LAGB) and vertical-banded gastroplasty (VBG) are surgical treatment modalities for morbid obesity. This prospective study describes the long-term results of LAGB and VBG. One hundred patients were included in the study. Fifty patients underwent LAGB and 50 patients, open VBG. Study parameters were weight loss, changes in obesity-related comorbidities, long-term complications, re-operations including conversions to other bariatric procedures and laboratory parameters including vitamin status. From 91 patients (91%), data were obtained with a mean follow-up duration of 84 months (7 years). Weight loss [percent excess weight loss (EWL)] was significantly more after VBG compared with LAGB, 66% versus 54%, respectively. All comorbidities significantly decreased in both groups. Long-term complications after VBG were mainly staple line disruption (54%) and incisional hernia (27%). After LAGB, the most frequent complications were pouch dilatation (21%) and anterior slippage (17%). Major re-operations after VBG were performed in 60% of patients. All re-operations following were conversions to Roux-en-Y gastric bypass (RYGB). In the LAGB group, 33% of patients had a refixation or replacement of the band, and 11% underwent conversion to another bariatric procedure. There were no significant differences in weight loss between patients with or without re-interventions. No vitamin deficiencies were present after 7 years, although supplement usage was inconsistent. This long-term follow-up study confirms the high occurrence of late complications after restrictive bariatric surgery. The failure rate of 65% after VBG is too high, and this procedure is not performed anymore in our institution. The re-operation rate after LAGB is decreasing as a result of new techniques and materials. Results of the re-operations are good with sustained weight loss and reduction in comorbidities. However, in order to achieve these results, a durable and complete follow-up after restrictive procedures is imperative.

Long-term results and complications following adjustable gastric banding

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 +/- 6 kg/m(2). BMI after 1, 5, 7, 9, and 10 years was 33 +/- 6, 30 +/- 6, 31 +/- 6, 32 +/- 7, and 31 +/- 7 kg/m(2), respectively. Mean excess weight loss after 1 year was 57.1 +/- 23.0% and after 5, 7, 9, and 10 years 73.2 +/- 29.6%, 65.9 +/- 29.3%, 61.8 +/- 32.8%, and 64.0 +/- 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.

Laparoscopic adjustable gastric banding (LAGB): surgical results and 5-year follow-up

BACKGROUND

LAGB is a technique increasingly used in the USA. The aim of this study is to analyze the 5-year outcome in terms of weight loss and complications.

METHOD

We reviewed our prospective electronic database for all patients undergoing LAGB between 2002 and 2007. We assessed weight progression, complications, and reoperations.

RESULTS

We performed 199 cases during this period (70.4% females). Mean age was 37.8 ± 12.4 years. Preoperative body mass index (BMI) was 36.0 ± 3.8 kg/m(2). Preoperative comorbidities were dyslipidemia in 52.3%, insulin resistance in 30.7%, arterial hypertension in 24.6%, and type 2 diabetes in 5.5%. There were no conversions to open technique. Early complications were observed in two patients (1%): one hemoperitoneum and one ileitis. Mortality was 0%. Late complication rate was 33.6% (18.0% related to the band). Reoperation was required in 40 patients (20.1%). Laparoscopic repositioning was done in seven patients, and port/reservoir revision was done in five patients. Band removal was required in 28 patients, due to inadequate weight loss in 9, slippage in 9, gastric erosion in 1, bowel obstruction in 1, acute stomach dilatation in 1, and food intolerance in 7. Twenty of these patients underwent revisional surgery: sleeve gastrectomy in 12 and laparoscopic Roux-en-Y gastric bypass in 8 cases. Unrelated band complication was seen in 15.6%, mainly due to anemia (7.5%), alopecia (4.5%), and cholelithiasis (3.5%). With a median follow-up of 48 months (1-72 months), 75, 60, and 95% of patients were available for follow-up at 1, 3, and 5 years, respectively. Mean percent excess weight loss (%EWL) at 1, 3, and 5 years was 58.8 ± 30.0%, 56.8 ± 35.0%, and 58.4 ± 46.6%, respectively. However, failure rate (%EWL <50%) at 1, 3, and 5 years was 40.4, 43.5, and 46.3%, respectively.

CONCLUSIONS

LAGB has low perioperative morbidity. However, its late complications are significant, and inadequate weight loss can be as high as 46.3% after 5 years.

Metabolic and nutritional changes after bariatric surgery

Bariatric surgery is the most durable intervention for severe obesity. Appropriate candidates for surgery include those with a body mass index over 40 kg/m(2), or those with a BMI over 35 kg/m(2) who also have weight-related comorbidities. Bariatric procedures are categorized as restrictive, where food intake is limited by a small gastric 'pouch'; malabsorptive, where the length of intestine available for nutrient absorption is decreased; or a combination of both. Although pure malabsorptive procedures, such as the now-historical jejunoileal bypass, achieve greater weight loss than restrictive procedures, they are generally associated with more postoperative metabolic problems. The Roux-en-Y gastric bypass is currently considered the gold standard bariatric procedure for most patients. It results in excellent weight loss with minimal complications, but does require life-long vitamin supplementation. Compliance with vitamins and supplements is also mandatory after malabsorptive procedures. With these procedures, decreased oral intake, as well as altered absorption of nutrients from the GI tract, results in potentially low blood levels of a variety of micronutrients, especially iron, vitamin B12 and folate. Bariatric surgery also improves the comorbid conditions that are associated with obesity, such as diabetes, hypertension, dyslipidemia, obstructive sleep apnea, obesity hypoventilation, gastroesophageal reflux disease, asthma, venous stasis, polycystic ovary syndrome and pseudotumor cerebri. The resolution of diabetes is secondary to weight loss and may also be due to alteration of the enteroinsular axis.

Past, present, and future: Critical analysis of use of gastric bands in obese patients

Adjustable gastric banding (AGB) is quickly becoming the most popular bariatric operation performed in the United States and Canada. Patients are particularly fond of the simplicity of the tool, the relatively low morbidity of the surgery, the quick recovery, and overall results. The gastric band has evolved over its 35-year history into a very successful adjustable tool used to restrict food consumption and limit caloric intake. The percent of excessive weight loss after banding can range from 30%-60% and depends on the time out from surgery. Along with weight loss, there is good resolution of the co-morbid conditions that are associated with excess weight and improvements in quality of life demonstrated after banding. Nutrition and follow up are extremely important after banding to ensure good compliance and adequate weight loss. Failure to follow the postoperative diet, exercise regiment, or mechanical failure of the band can lead to failure to lose adequate weight. While there are particular early and late complications associated with this surgery, the safety profile of the AGB is very appealing when compared to other bariatric operations. As we continue to reduce the morbidity of the procedure, the simple adjustable band concept has a lot of potential to remain a primary technique of maintaining long term weight loss. In conclusion, AGB has and continues to play an important role in the treatment of morbid obesity. It offers reasonably good weight loss results with very little morbidity, and the future of the adjustable band is bright.

The gastric band: first-choice procedure for obesity surgery

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its development, clinical outcomes, and future role. We also address current controversies, including a comparison of LAGB with Roux-en-Y gastric bypass (RYGBP). At present LAGB seems to be increasing in popularity in the United States, whereas in Europe there seems to be a trend away from gastric banding toward RYGBP. Optimal outcomes after LAGB are a function of correct laparoscopic technique, an experienced surgical team, a well-engineered device, and intensive long-term follow-up. The majority of studies show that LAGB is an extremely safe and effective procedure, with an operative mortality of 0-0.1% and excess weight loss (%EWL) of 50-60%. Commensurate with this degree of weight loss, almost all studies show substantial improvements in obesity-related co-morbidities, such as hypertension, type II diabetes, and dyslipidemia. In addition, LAGB has been shown to be both safe and effective in the super-obese, in adolescents, and in older patients and can be delivered as an ambulatory procedure. Operative mortality and early complication rates are significantly higher for RYGBP and, whilst gastric bypass results in greater weight loss than LAGB in the first 2 years, at 3 years and beyond the difference appears to be less marked. Overall, LAGB provides a safe, effective intervention for obese patients and remains our first-choice procedure for bariatric surgery.

Fundamentals of cardiometabolic risk factor reduction: achieving and maintaining weight loss with pharmacotherapy or bariatric surgery

Obesity is a major health problem in the United States and many other countries because of its high prevalence and causal relationship with serious medical comorbidities. The therapeutic options currently available to help obese patients lose weight are: (1) therapeutic lifestyle change (behavioral, dietary, and physical activity modification); (2) pharmacotherapy; and (3) bariatric surgery. Lifestyle modification is the first therapeutic choice; however, achieving a successful long-term weight loss with lifestyle intervention alone is difficult. There is increasing interest, therefore, in the use of pharmacotherapy and surgery to treat obesity. Although there are a number of antiobesity medications available, the only medications approved in the United States for long-term treatment of obesity are sibutramine and orlistat. Use of these medications results in 3% to 5% more weight loss compared with placebo after 1 year. Bariatric surgery is an effective weight loss option for obese patients, but it is restricted to patients who are considered morbidly obese (ie, with a body mass index [BMI] > or =40 kg/m(2) or a BMI of 35-39.9 kg/m(2) with > or =1 severe obesity-related medical complication).

Preliminary results of the laparoscopic adjustable gastric banding procedure by a new generation of silicone band: MIDBAND

BACKGROUND

The surgical treatment of morbid obesity by laparoscopic adjustable gastric banding has become a "gold standard" in Europe. Currently, five types of silicone bands are used in the majority of countries performing bariatric surgery.

METHODS

The MIDBAND was introduced to the European market in 2000. It is placed around the stomach using the Pars Flaccida technique described by Forsell. A prospective multicentric study on 113 cases was carried out to evaluate technical feasibility, complications, and the midterm weight loss outcomes (2 years).

RESULTS

The percentage of excess body weight loss was 52.58% at 2 years. Perioperative mortality was nil and the complication rate was low (slippage <2%).

CONCLUSION

These encouraging results require longer-term studies to validate this procedure.

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.

[Interest of upper digestive tract study preoperatively to prevent in patients carrying a gastric ban. About two cases]

We report the case of a female patient with gastric band who had aspiration pneumonia after anaesthetic induction for a plastic surgery. In another similar case, we discovered preoperatively, oesogastric stasis with gastric strangulation. After deflation of the gastric band the anaesthetic procedure was uneventful.

Band and port-related morbidity after bariatric surgery: an underestimated problem

OBJECTIVE

To evaluate the magnitude of the morbidity related to the system used for gastric banding Methods Between January 1997 and December 2004, 286 consecutive patients underwent laparoscopic gastric banding (LAGB) in one center. We used 4 models of LapBand 9.75, 10, 11 and Vanguard with pars flacida route. Recalibration of band was performed in our consultation unit without systematic radiologic control. We considered four kinds of complication: port displacement, port rupture, band rupture and others problems.

RESULTS

The mean follow up was 3.3+/-2.8 years with a median 2.9 years. Complications occurred within a mean time of 2.2+/-1.9 years. For the models vanguard and size 11, there were no rupture and 15 (27.7%) displacements whereas for size 9.75 and 10 there were 39 ruptures (14.7%) and 15 (5.6%) displacements. Types of complications were related to the bands used i.e. more port displacements for the models vanguard and size 11 and more band and port ruptures for the models size 9.75 and 10. But when we considered the respective follow up according to the type of band these differences were no longer significant. Moreover rupture rate was significantly high but decreased after March 2002 because of changing of junction between port and catheter. Mean excess weight loss (35.2+/-27.7%) was not different in group whether the patients were reoperated or not.

CONCLUSION

Band and port related morbidity is an important aspect of bariatric surgery. We have to pay attention to material evolution and to our follow up for calibration. Some new recent technical advancement could improve the management of these patients.

Gastric banding at the Royal Brisbane and Women's Hospital: trials and tribulations of a public service

BACKGROUND

The Royal Brisbane and Women's Hospital provides the only gastric banding service for the public to the state of Queensland. Our patients are potentially a different group from the previously reported Australian series with respect to weight, comorbidities and ease of follow up and we therefore present this series of public patient for comparison of medium-term results.

METHODS

The service consists of a dedicated fortnightly clinic. Patients are referred from within the hospital and also from other health services throughout Queensland and northern New South Wales. Resources allow a limited number of gastric bands to be placed annually. At follow up, measurement of weight is carried out and band adjustments made as necessary. Data are collected prospectively on a dedicated database (LapBase; AccessMed, Melbourne, Australia).

RESULTS

Sixty-nine laparoscopic gastric bands (Lap Band; Inamed Health, Santa Barbara, CA, USA) have been placed as a public service at Royal Brisbane and Women's Hospital since August 2001 in 50 women and 19 men. The mean body mass index (BMI) at surgery was 53 kg/m2 (range 33-81 kg/m2). The mean percentage of excess bodyweight lost at 1, 2 and 3 years is 38.5, 45.7 and 57.9%, respectively. The mean BMI has reduced from the baseline of 53 to 44.5 at 1 year, 41.8 at 2 years and 38.6 at 3 years. The waiting list currently contains 103 patients with a mean BMI of 53 kg/m2 and 250 new referrals are on a waiting list for initial review.

CONCLUSION

A banding service for the public is a unique experience. The BMI is greater than in other published series; diverse geographic origin of the patients creates difficulties with review and there are limited surgical resources. The Royal Brisbane and Women's Hospital is leading the way towards a multidisciplinary clinic approach to managing obesity. However, more resources will be required to have an effect on overall public health.

Complications of antiobesity surgery

Bariatric surgery is an effective long-term treatment for patients who suffer from morbid obesity, the incidence of which is increasing in North America. Laparoscopic gastric bypass and laparoscopic adjustable gastric band placement are the two commonly performed bariatric procedures. This article discusses the indications for bariatric surgery and the early and late complications associated with these two procedures. Laparoscopic biliopancreatic diversion and laparoscopic sleeve gastrectomy are also briefly discussed.

Outcome and Complications after Laparoscopic Swedish Adjustable Gastric Banding: 5-Year Results of a Prospective Clinical Trial

BACKGROUND

Bariatric surgery is currently the only effective treatment for morbid obesity in terms of inducing and maintaining satisfactory weight loss and decreasing weight-related co-morbidities. A study was conducted to assess the effects, complications and outcome after laparoscopic Swedish adjustable gastric banding (SAGB) to 5 years.

METHODS

Between June 1998 and December 2005, all patients with implantation of a SAGB were enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications and re-operation rate.

RESULTS

SAGB was performed in 128 patients (87 female, 41 male). Mean age was 40.2 +/- 5.3 years, with mean preoperative BMI 44.5 +/- 3.9 kg/m2. Overall mortality was 0%. Patient follow-up was 94.5%. BMI after 1, 2 and 5 years was 35.7 +/- 3.7 kg/m2 (P < 0.005), 33.7 +/- 3.8 kg/m2 (P < 0.001) and 31.8 +/- 3.8 kg/m2 (P < 0.001), respectively. Mean EWL after 1, 2 and 5 years was 33.3 +/- 6.8% (P < 0.005), 45.5 +/- 6.4% (P < 0.001) and 57.4 +/- 6.5% (P < 0.001), respectively. The nonresponder rate (EWL < 30%) after 2 and 5 years was 17.0% and 6.8%, respectively. The early complication rate (< 30 d) was 6.25% (8/128), with 5 minor and 3 major complications. Late complications (> 30 d) occurred in 10.9% (14/128), of whom 2 were minor and 12 were major complications. The overall re-operation rate was 11.7% (15/128).

CONCLUSIONS

At 5-year follow-up, laparoscopic SAGB is a safe and effective surgical treatment for morbid obesity. Our results appear to confirm that SAGB is a safer surgical treatment regarding rate and severity of complications compared with gastric bypass and malabsorptive procedures.

Surgery for obesity: a review of the current state of the art and future directions

The number of patients undergoing surgery for the treatment of obesity, and the proportion of the health care budget dedicated to this health problem, is growing exponentially. There are several competing surgical approaches for the management of morbid obesity. We review the literature relating to four of these: gastric bypass, biliopancreatic diversion, gastric banding, and gastric pacing. Our review finds that while enhancing the malabsorptive activity of these procedures may induce an incremental increase in excess body weight loss, the proportion of patients who fail to lose more than 50% of their excess body weight is similar no matter how radical is the surgery performed. There is little guidance from the literature as to appropriate patient selection for the varying procedures, and anonymously reported registries have yet to show that patients who undergo bariatric surgery have enhanced longevity. To date, the bariatric surgical community has not conducted adequately powered randomized prospective trials to elucidate key elements of the surgical procedure such as optimal bypass length, to determine whether mixed operations are superior to those that offer intake restriction only, and to define what constitutes success after bariatric surgery. As a public health measure, bariatric surgery in the United States is being pursued in an irrational manner, being concentrated in areas where there are fewer morbidly obese patients, and used disproportionately among the population of white obese females.

Hyperoxaluria in kidney stone formers treated with modern bariatric surgery

PURPOSE

Nephrolithiasis and renal failure secondary to severe hyperoxaluria were complications of jejunoileal bypass for obesity, leading to the discontinuation of this procedure in the United States in 1980. Bariatric procedures currently in use have not been adequately evaluated for this complication.

MATERIALS AND METHODS

We compared 24-hour urine chemistry studies of 132 patients with nephrolithiasis who had undergone bariatric surgery with the urine chemistry studies of patients who had undergone jejunoileal bypass, those with routine kidney stones and normal subjects. The primary aim was to determine if hyperoxaluria developed in patients who underwent bariatric surgery and had kidney stones as had been seen with jejunoileal bypass.

RESULTS

Patients who have undergone modern bariatric surgery had an adjusted mean urine oxalate excretion of 83 mg per day compared to 39 mg per day for routine kidney stone formers and 34 mg per day for normal subjects (p <0.001 for both comparisons), but not quite as high as that found in patients treated with jejunoileal bypass (102 mg per day, p <0.001). Urine supersaturation of calcium oxalate, the main driving force for calcium oxalate stone formation, was higher in patients treated with bariatric surgery compared to routine kidney stone formers and normal subjects (p <0.001 for both comparisons).

CONCLUSIONS

Hyperoxaluria is the most significant abnormality of urine chemistry studies in patients with kidney stones who have undergone bariatric surgery. Many of these patients have a degree of hyperoxaluria that could lead to kidney failure. Further studies are required to determine the prevalence of this problem in patients who have undergone bariatric surgery.