The effectiveness of adjustable gastric banding: a retrospective 6-year U.S. follow-up study

Pseudoachalasia: a diagnostic challenge. When to consider and how to manage?

Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.

Role of imaging in assessment and detection of complications after bariatric surgery

Background

Bariatric surgery is performed to control morbid obesity secondary to failed medical approaches. Practical knowledge of post-surgical anatomy allows accurate interpretation of imaging findings related to normal post-surgical anatomy and common post-surgical complications.

The purpose of this study was to highlight the role of imaging in the assessment and detection of complications after bariatric surgery.

Results

This prospective study included 49 patients who had bariatric surgery. Sleeve gastrectomy was the most common bariatric surgery. The leak was the commonest complication (12%). The sensitivity of upper GI series for diagnosis of post-operative complication after bariatric surgery was 70% and specificity 94% while the sensitivity of CT study was 95% and specificity 95%.

Conclusion

CT has a golden role in the diagnosis of post-operative complications. Both post-contrast CT and upper GI series should be used in diagnosing complications following bariatric surgery. US is useful for diagnosis of a superficial problem.

'The rollercoaster of follow-up care' after bariatric surgery: a rapid review and qualitative synthesis

Benefits of bariatric surgery for obesity related comorbidities are well established. However, in the longer term, patients can become vulnerable to procedure specific problems, experience weight regain and continue to need monitoring and management of comorbidities. Effective longer term follow-up is vital due to these complex needs post-surgery. Current guidance recommends annual long-term follow-up after bariatric surgery. However, attendance can be low, and failure to attend is associated with poorer outcomes. Understanding patients' experiences and needs is central to the delivery of effective care. This rapid review has synthesized the current qualitative literature on patient experiences of healthcare professional (HCP) led follow-up from 12 months after bariatric surgery. A recurring theme was the need for more and extended follow-up care, particularly psychological support. Enablers to attending follow-up care were patient self-efficacy as well as HCP factors such as a non-judgemental attitude, knowledge and continuity of care. Barriers included unrealistic patient expectations and perceived lack of HCP expertise. Some preferences were expressed including patient initiated access to HCPs and more information preoperatively to prepare for potential post-surgery issues. Insights gained from this work will help identify areas for improvement to care in order to optimize longer term outcomes.

Abdominal Contouring and Combining Procedures

The abdomen is the most common area of concern among patients with massive weight loss (MWL). Abdominal contouring techniques in the MWL population include panniculectomy, standard abdominoplasty, fleur-de-lis abdominoplasty, reverse abdominoplasty and various combinations of these techniques as part of circumferential procedures such as, circumferential abdominoplasty, and lower body lift. The authors believe that the optimal surgical approach to the abdomen is an integration of the patient aesthetic preferences and the surgeon assessment and experience. The authors recommend to limit total body reconstruction of MWL patients to 2 stages, and include the abdominal area in the first stage.

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.

The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults

BACKGROUND

Several studies have been investigated to find the long-term effect of bariatric surgery on weight loss; nevertheless, a meta-analysis can detailedly demonstrate the effect of bariatric surgery on weight in morbidly obese patients. This study aimed to assess the long- and very long-term effects of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) on weight loss in adults.

METHODS

An electronic search using PubMed, Scopus, and Google scholar databases was performed for all English-language articles up to May 15, 2016 with no publication date restriction. Outcome was long-term (≥5-10 years) and very long-term (≥10 years) weight reduction that reported as the mean %EWL and changes in BMI from baseline.

RESULTS

Eighty articles with 87 arms were included in this meta-analysis. The excess weight loss percentage (%EWL) was 47.94% and 47.43% after LAGB at ≥5 and ≥10 years, respectively. After LRYGB the %EWL was 62.58% at ≥5 years and 63.52% at ≥10 years. It was 53.25% at ≥5 years after LSG. Results of subgroup analyses have indicated that LRYGB leads to higher %EWL in America and Asia compared with Europe. Meta-regression analyses have shown that there is no significant association between %EWL and baseline age, BMI and length of follow-up after three procedures. However, there is a positive association between gender and %EWL after LRYGB (β = 1.24). No publication bias was found.

CONCLUSIONS

These findings suggest that LRYGB is an effective procedure in morbidly obese patients that leads to sustainable weight loss over the long- and very long-term periods in compared with LAGB and LSG.

Update on bariatric surgical procedures and an introduction to the implantable weight loss device: the Maestro Rechargeable System

There are many different methods of treating obesity, ranging from various medical options to several surgical therapies. This paper briefly summarizes current surgical options for weight loss with a focus on one of the newest US Food and Drug Administration-approved devices for surgical weight loss therapy, the Maestro Rechargeable System. Also known as the vagal blocking for obesity control implantable device, this tool blocks vagal nerve activity to induce weight loss.

Guidelines for the follow-up of patients undergoing bariatric surgery

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow-up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow-up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi-professional subgroup, which included patient representatives, to develop bariatric surgery follow-up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow-up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long-term follow-up are important.

Endoscopic Devices for Obesity

The obesity epidemic, recognized by the World Health Organization in 1997, refers to the rising incidence of obesity worldwide. Lifestyle modification and pharmacotherapy are often ineffective long-term solutions; bariatric surgery remains the gold standard for long-term obesity weight loss. Despite the reported benefits, it has been estimated that only 1% of obese patients will undergo surgery. Endoscopic treatment for obesity represents a potential cost-effective, accessible, minimally invasive procedure that can function as a bridge or alternative intervention to bariatric surgery. We review the current endoscopic bariatric devices including space occupying devices, endoscopic gastroplasty, aspiration technology, post-bariatric surgery endoscopic revision, and obesity-related NOTES procedures. Given the diverse devices already FDA approved and in development, we discuss the future directions of endoscopic therapies for obesity.

Effectiveness and Safety of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding in Morbidly Obese Patients: a Multicenter, Retrospective, Matched Cohort Study

BACKGROUND

Laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most performed procedures worldwide (92 %) nowadays. However, comparative clinical trials are scarce in literature. The objective of this study was to compare the effectiveness and safety of the three most performed bariatric procedures.

METHODS

A multicenter, retrospective, matched cohort study was conducted. Patients were eligible for analysis when a primary procedure was performed between 2007 and 2010 in one of the two specialized bariatric centers. Primary outcome was weight loss, expressed in the percentage excess weight loss (%EWL). Secondary outcome parameters are hospital stay, complication rate, and revisional surgery.

RESULTS

In total, 735 patients, 245 in each group, were included for analysis. The groups were comparable for age and gender after matching. Mean postoperative follow-up was 3.1 ± 1.2 years. LAGB patients showed less %EWL compared to LSG and LRYGB at all postoperative follow-up visits. LRYGB showed a %EWL of 71 ± 20 % compared to LSG (76 ± 23 %; p=0.008) after 1-year follow-up; thereafter, no significant difference was observed. After 3 years of follow-up, LAGB showed a higher complication rate compared to LSG and LRYGB (p<0.05). Revisional surgery after LAGB was needed in 21 %, while 9 % of the LSG underwent conversion to RYGB.

CONCLUSIONS

LRYGB is a safe and effective treatment in morbid obese patients with good long-term outcomes. LSG seems to be an appropriate alternative as a definitive procedure, in terms of weight reduction and complication rate. LAGB is inferior to both LRYGB and LSG.

Weight loss outcomes among patients referred after primary bariatric procedure

BACKGROUND

Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere.

METHODS

We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management.

RESULTS

Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001).

CONCLUSIONS

Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Patients' perspectives on laparoscopic adjustable gastric banding (LAGB) aftercare attendance: qualitative assessment

BACKGROUND

Despite recognition of the importance of laparoscopic adjustable gastric banding (LAGB) aftercare for optimal surgical outcomes and the failure of some patients to attend regularly, factors influencing LAGB aftercare attrition have not been thoroughly examined in the literature.

METHODS

Patients' perspectives on LAGB aftercare attendance were explored using a qualitative research methodology. Twenty-four LAGB patients who either (1) did not attend aftercare (n = 12) or (2) attended aftercare regularly (n = 12) were interviewed. Data were analysed using grounded theory methods.

RESULTS

Four common processes emerged from patients' descriptions: (1) barriers to attendance, (2) purely medical service, (3) non-patient centred approach, and (4) behavioural and psychological aspects of behavioural changes. Regular attendees typically reported (1) a commitment to aftercare, (2) a need to make the band work, (3) regular monitoring motivated attendance, and (4) happiness with the improved health. Non-regular attendees perceived (1) that aftercare is more relevant early on after the surgery, (2) insufficient follow-up from the centre, (3) failure and shame, (4) not comfortable to be vulnerable, and (5) an intention to reconnect.

CONCLUSIONS

Patients perceive LAGB post-operative medical management to be professional, effective, and valuable. Patients' difficulty to actively participate during aftercare visits contributes to reduced satisfaction and a range of compromised outcomes. Management of LAGB post-operative patients may be improved with the use of patient-centred strategies that encourage patients' active participation. Further research is required to evaluate the emerged themes and determine whether interventions targeting identified barriers enhance attendance and improve outcomes.

Sustained weight loss after gastric banding revision for pouch-related problems

OBJECTIVE

To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months.

BACKGROUND

There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose.

METHODS

A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation.

RESULTS

Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision.

CONCLUSIONS

Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes

BACKGROUND

Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups.

METHODS

We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality.

RESULTS

A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths.

CONCLUSIONS

SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

Efficacy and safety of the adjustable gastric band - pooled interim analysis of the APEX and HERO studies at 48 weeks

OBJECTIVE

This 48 week combined analysis reports safety and clinical effectiveness of the LAP-BAND AP * laparoscopic adjustable gastric band (LAGB) in severely obese patients enrolled in the 5 year, prospective, observational, open-label APEX (NCT00501085) and HERO (NCT00953173) studies.

METHODS

The studies enrolled 1620 patients (APEX: N = 514; HERO: N = 1106), 1140 patients in the US (including all APEX patients), and 480 patients in the European Union (EU), Canada or Australia. APEX and HERO are non-randomized, non-comparator, open-label studies with differences in study management practices and follow-up. Notably, laboratory data were not collected during the APEX study.

RESULTS

After 48 weeks, mean (SD) percentage weight loss (%WL) was for APEX: 18.7% (7.9); HERO-US: 17.9% (8.5); HERO-EU: 16.5% (10.3); HERO-Canada: 13.4% (8.9); and HERO-Australia: 12.3% (6.9). After 48 weeks, there were no significant differences in %WL for APEX vs. HERO-US. After 48 weeks in the combined analysis (APEX + HERO): (1) patients without vs. with type 2 diabetes at baseline had greater %WL (18% [8.7] vs. 16% [8.5], p = 0.002); (2) female patients had greater %WL vs. male patients (17.9% [8.5] vs. 15.9% [9.3], p = 0.003); (3) younger patients had greater %WL vs. older patients (<50 years: 17.8% [8.7] vs. ≥50 years: 16.7% [8.6], p = 0.035); (4) baseline BMI did not affect %WL (≤35 to ≤45 kg/m(2): 17.7% [8.4] vs. >45 kg/m(2): 17.1% [9.1], p = 0.272). Device-related serious adverse events and adverse events were reported in 1.9% and 17.7% of patients, respectively. Revision and explantation surgeries were carried out on 3.4% and 2.3% of patients, respectively during the 48 weeks of follow-up.

CONCLUSIONS

This analysis demonstrates the effective weight loss and safety profile of the current LAGB system, with US patients achieving better weight loss than patients from outside the US.

Nutrition care for patients with weight regain after bariatric surgery

Achieving optimal weight outcomes for patients with obesity is important to the management of their chronic disease. All interventions present risks for weight regain. Bariatric surgery is the most efficacious treatment, producing greater weight losses that are sustained over more time compared to lifestyle interventions. However, approximately 20-30% of patients do not achieve successful weight outcomes, and patients may experience a regain of 20-25% of their lost weight. This paper reviews several factors that influence weight regain after bariatric surgery, including type of surgery, food tolerance, energy requirements, drivers to eat, errors in estimating intake, adherence, food and beverage choices, and patient knowledge. A comprehensive multidisciplinary approach can provide the best care for patients with weight regain. Nutrition care by a registered dietitian is recommended for all bariatric surgery patients. Nutrition diagnoses and interventions are discussed. Regular monitoring of weight status and early intervention may help prevent significant weight regain.

Laparoscopic adjustable gastric band survival in a high-volume bariatric unit

Background

Although laparoscopic adjustable gastric bands (LAGBs) have been shown to be efficacious, their long-term usefulness has been questioned. This study examined the fate of LAGBs in a unit with over a decade of experience in their use. Patient factors related to the need for, and timing of, band removal were investigated.

Methods

A prospectively maintained database was used to identify all patients with a LAGB. Patient demographics, need for band removal and band survival were examined. Logistic regression modelling was done and Kaplan–Meier curves were calculated for band survival.

Results

Between 2000 and 2012, 674 bands were placed in 665 patients. Of these, 143 (21·2 per cent) were removed. There was no difference in rates of removal by sex (P = 0·910). The highest rates of removal were in patients aged less than 40 years (26·7 per cent), and those with a BMI greater than 60 kg/m2 (28·6 per cent). Earlier band removal was seen in younger patients (P = 0·002). Rates of removal increased linearly by earlier year of placement. Of bands placed 4 or more years previously, 35·0 per cent required removal. Eighty-three patients (58·0 per cent) who had a LAGB removed went on to have a further bariatric procedure (band to bypass, 66; band to sleeve, 17).

Conclusion

Even in experienced hands LAGB does not appear to be a definitive solution. In a large number of patients there appears to be a finite ‘band life’, with the majority of patients requiring conversion to a further bariatric procedure.

Presented in part to a meeting of the British Obesity and Metabolic Surgery Society, Glasgow, UK, January 2013, as an oral presentation for which it was awarded the council prize; published in abstract form as Br J Surg 2013; 100(Suppl 3): 2

Reduction in Framingham risk of cardiovascular disease in obese patients undergoing laparoscopic adjustable gastric banding

Background

Obesity is a major risk factor for cardiovascular disease (CVD), with weight loss offering improvement in CVD risk factors.

Aims

To examine whether weight loss in laparoscopic adjustable gastric band (LAGB)-treated obese patients is associated with meaningful reductions in estimated 10- and 30- year Framingham CVD risk 12–15 months post-LAGB.

Methods

Obese adult patients [body mass index (BMI) ≥30 kg/m²] treated with LAGB were identified in a large US healthcare database. Patients without CVD at baseline and with measures of BMI, systolic blood pressure, diabetes, and smoking status at baseline and follow-up were eligible. Non-LAGB patients were propensity score matched to LAGB patients on baseline BMI, age, and gender. Estimated 10- and 30-year risk of developing CVD using office-based data, including BMI, was calculated at baseline and 12–15 months follow-up.

Results

Mean BMI in LAGB patients (n = 647, average age 45.66 years, 81.1% female) decreased from 42.7 to 33.4 kg/m² (P < 0.0001), with 35.4% no longer obese; 10- and 30-year estimated CVD risk decreased from 10.8 to 7.6% (P < 0.0001) and 44.34 to 32.30% (P < 0.0001), respectively, 12–15 months post-LAGB. Improvements were significantly greater than in non-LAGB patients (N = 4,295) (P < 0.0001). In the subset with lipid data (n = 74), improvements in total (−20.6 mg/dL; P < 0.05) and high-density lipoprotein (+10.6 mg/dL, P < 0.0001) cholesterol 1 year post-LAGB were also observed.

Conclusions

Data from a US healthcare database show that individuals undergoing LAGB have significant weight loss and reductions in estimated 10- to 30-year CVD risk within 1 year post-LAGB.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Benefit-risk paradigm for clinical trial design of obesity devices: FDA proposal

Diet and exercise, except in controlled circumstances, have not been shown to provide effective and prolonged weight loss for the majority of those who are obese. Several older drugs intended to reduce weight have been withdrawn from the market, and the new drugs show only modest weight loss. Surgical intervention, specifically procedures that alter the normal gastrointestinal anatomy, does provide prolonged periods of sustained weight loss, with rebound weight gain over time. A variety of medical devices to assist in weight reduction have been studied, but only two are legally marketed devices for obesity. The authors propose a new paradigm for devices intended to treat obesity, based on a benefit-risk determination, with the hope to provide sponsors an a priori tool for systematic assessment of the risks associated with the devices intended for treatment of obesity and to suggest appropriate levels of benefit for devices with different risk levels. The paradigm is not intended to determine the class of a device from a regulatory perspective. This approach was conceived at a Food and Drug Administration (FDA) co-sponsored workshop in October, 2011 and formally presented to an FDA advisory panel for discussion in May 2012.

Safety and efficacy of the LAP-BAND AP® adjustable gastric band in the treatment of obesity: results at 2 years

BACKGROUND

The objective of this analysis is to report interim, 2-year results for morbidly obese patients who have undergone laparoscopic adjustable gastric banding in the LAP-BAND AP® EXperience (APEX) trial.

METHODS

The APEX trial is an ongoing, multicenter, prospective, open-label, 5-year study of the LAP-BAND AP® System (LBAP) in 517 morbidly obese patients at 50 clinical centers in the United States. Last observation carried forward was used in the analyses of change in body weight and comorbid conditions, and observed data were analyzed for the Obesity and Weight-Loss Quality of Life (OWLQOL) questionnaire. Changes in body weight, percent weight loss, percent excess weight loss, body mass index (BMI), OWLQOL score, remission or improvement in obesity-related comorbid conditions, and adverse events were reported.

RESULTS

At baseline, 81.5% of patients were female, and 85.8% were white. The mean age was 42.5 years, and the mean BMI was 44.0 kg/m(2). More than 85% of patients had ≥ 1 obesity-related comorbidity. At 2 years, the mean BMI change was -8.5 kg/m(2), and the mean percent weight loss was -19.3%. Responses to all questions on the OWLQOL questionnaire had a mean improvement of 54% (range, 26%-67%) at 2 years. Obesity-related comorbid conditions were remitted or improved in the majority of patients at 2 years, including type 2 diabetes mellitus (96%), hypertension (91%), gastroesophageal reflux disease (91%), hyperlipidemia (77%), obstructive sleep apnea (86%), depression (75%), and osteoarthritis (93%). The LBAP and its implantation were well tolerated, with 19.1% and 6.0% of patients reporting device-related adverse events or serious device-related adverse events, respectively.

CONCLUSION

The LBAP safely and effectively facilitated weight loss in morbidly obese patients, with clinically meaningful improvements in quality of life and obesity-related comorbidities. The durability of these results will be further described with additional follow-up through 5 years.

TRIAL REGISTRATION

www.ClinicalTrials.gov identifier NCT00501085.

Laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding is one of several weight loss procedures in the bariatric surgeon's armamentarium to treat morbid obesity. Laparoscopic gastric banding has the lowest perioperative risk compared to laparoscopic gastric bypass, sleeve gastrectomy, and duodenal switch (Buchwald et al., JAMA 292:1724-1737, 2004). The adjustable gastric band results in approximately 50% excess weight loss at 5 years (O'Brien and Dixon,J Laparoendosc Adv Surg Tech A 13:265-270, 2003). In the long-term, reoperation rates can be high with the percentage of reoperations varying enormously in reported studies from 2% to 80% (Schouten et al., Surg Obes Relat Dis 7:99-109, 2011), although with changes in technique, reoperation rates after gastric banding have decreased (O'Brien et al., Obes Surg 15:820-826, 2005). Aftercare is critical to the success of the banded patient, in terms of adjusting the band as well as monitoring the patient's symptoms (Weichman et al., Surg Endosc 25:397-403, 2011). Several studies have shown that patients who are seen more than six to seven times in the first postoperative year have better weight loss.

Patients' experience and outcomes after laparoscopic adjustable gastric banding in Washington state

BACKGROUND

There is very little evidence regarding the real world experience and outcomes after laparoscopic adjustable gastric banding (LAGB). Our objective was to estimate the amount of postoperative weight loss, change in co-morbidity status, and complications after LAGB. The setting was LAGB surgical centers in Washington state.

METHODS

A cross-sectional survey was developed to collect primary data from patients who had undergone LAGB in Washington state from 2004 to 2010. The survey contained questions on patient characteristics, weight change, co-morbidities, and complications after LAGB surgery. We used descriptive and other statistical tests to evaluate our key research questions by the period since LAGB.

RESULTS

A total of 1556 surveys were sent out, and 790 were returned (response rate 50.8%). Responders were categorized into 4 groups according to the follow-up period: <2, 2-3, 3-4, and >4 years. The corresponding average body mass index reduction in each group was 21.0%, 22.5%, 21.3%, and 20.4%. Of the respondents, 21.7%, 34.8%, 44.6%, and 38.7% indicated they did not have any adjustments in the year preceding the survey. The percentage of respondents who had undergone additional operations related to LAGB was 8.6%. Specifically, 3.6% of the respondents had undergone either band removal or conversion to another type of bariatric operation.

CONCLUSION

We found that although LAGB appeared to be beneficial for weight reduction and improving co-morbidities, the underuse of band adjustments and significant rate of treatment failure might limit the long-term effectiveness of LAGB.

Bariatric surgical anatomy and mechanisms of action

Because bariatric surgery is becoming increasingly common, gastroenterologists need to be familiar with the surgical and endoscopic anatomy of the operations in use today. This review focuses on the 4 most commonly performed bariatric operations in the United States: Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. The anatomy and mechanism of action of each procedure is discussed and illustrated. Emphasis is placed on the endoscopic anatomy, with review of the commonly encountered complications. Emerging techniques and devices are reviewed.