Treatment of massive super-obesity with laparoscopic adjustable gastric banding

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Looking into the profile of those who succeed in losing weight with an intragastric balloon

BACKGROUND

Weight loss by means of an intragastric balloon is an advantageous procedure, as usage of such a balloon is minimally invasive and of minimal operational risk. Nevertheless, despite the encouraging results referred in to large population studies, its success rate as a treatment option is still questionable. The aim of this study was to classify and analyze all parameters recorded in a database of a treatment protocol concerning obese individuals handled by an intragastric balloon, in an attempt to delineate the comparable profile of those who succeeded to lose weight and those who failed.

SUBJECTS AND METHODS

Retrospective data collection, including demographic and anthropometric data, social and psychological factors, educational status, and attendance at sessions and the exercise program, was conducted. Using as a criterion for grouping the percentage of excess weight loss (%EWL), the successful (%EWL ≥50%) and the poor (%EWL ≤20%) responders were identified.

RESULTS

In total, 583 patients were assessed. Initial and ideal body weight (BW), initial body mass index (BMI), and excess weight were significantly lower in the %EWL ≥50% group (P<.001). Upon balloon removal, both groups exhibited a significant difference regarding BW, BW lost, BMI, and %EWL (P<.001). Advanced age (odds ratio [OR]=1.06; P<.001), female gender (OR=3.31; P<.001), basic educational level (OR=3.12; P<.001), and single or divorced marital status (OR=6.00; P<.001) were identified as the most powerful determinants of %EWL ≥50%. Moreover, attendance at more than four monthly interviews and strict exercise program commitment contributed significantly to a favorable outcome.

CONCLUSIONS

Our findings could serve as an initial step for further research into factors possibly contributing to the early identification of those individuals who will notably benefit from usage of an intragastric balloon regarding BW loss.

Outcome after laparoscopic gastric bypass for super-super obese patients

GOAL

The surgical treatment of the super-super obese (SSO), defined by a body mass index (BMI) superior or equal to 60 kg/m2, is difficult. The goal of this study was to evaluate the results of laparoscopic gastric bypass (LGBP) in this setting.

PATIENTS AND METHODS

Between June 2005 and December 2011, 20 SSO patients underwent LGBP by one surgeon. Postoperative complications, weight loss, evolution of co-morbidities and quality of life were analyzed. The Bariatric Analysis and Reporting Outcome System (BAROS) was used to classify outcomes.

RESULTS

There were 15 women and five men (median age: 37.5 years). Median BMI was 63 kg/m2. Median duration of operation was 180 minutes. One patient was converted to laparotomy. Three complications occurred: one grade I, one grade II and one grade V. The median excess weight loss was 47.1% at 12 months, 55.3% at 24 months, 53.3% at 36 months and 55.3% at 48 months. Among the patients with a follow-up of at least 12 months (n=17), the median quality of life score was 1.75 and the median BAROS score was 5.75. Arterial hypertension and type II diabetes resolved or improved in all patients and sleep apnea resolved in almost half of patients (43%).

CONCLUSIONS

LGBP appears feasible and effective for SSO, both in terms of weight loss and improvement of co-morbidities and quality of life as well, with a low rate of postoperative complications.

Patterns of surgical weight loss and resolution of metabolic abnormalities in superobese bariatric adolescents

PURPOSE

The aim of the study was to compare the baseline and the 18-month follow-up for weight and metabolic characteristics of superobese (SO) (body mass index [BMI] ≥50 kg/m(2)) and morbidly obese (MO) (BMI <50 kg/m(2)) adolescents who participated in a prospective longitudinal study of gastric banding delivered in an adolescent multidisciplinary treatment program.

METHODS

Clinical information was extracted from an institutional review board-approved database of bariatric adolescents. Fasting cytokine and acute phase protein serum levels were analyzed by enzyme-linked immunosorbent assay. Liver histopathologies were assessed using the Kleiner's classification score.

RESULTS

Other than BMI, MO (n = 11) and SO (n = 7) patients have similar degree of insulin resistance, dyslipidemia, and nonalcoholic fatty liver disease. Serum C-reactive protein (10.2 ± 5.6 SO vs 4 ± 3.9 μg/mL MO [P < .02]) and leptin (71 ± 31 SO vs 45 ± 28 MO ng/mL [P = .04]) were more elevated in SO patients. Although weight loss is similar (30 ± 19 kg MO vs 28 ± 12 kg SO, P = .8 at 18 months; mean percent change in BMI, 22.8% ± 11.6% vs 20.5% ± 10.3% SO, P = .2), SO patients has less resolution of insulin resistance and dyslipidemia but experienced significantly improved health-related quality of life.

CONCLUSIONS

The SO adolescents demonstrate equivalent short-term weight loss and improved quality of life but delayed metabolic response to a gastric banding-based weight loss treatment program compared with MO patients, illustrating the importance of early referral for timely intervention of MO patients.

Safety and effectiveness of bariatric surgery: Roux-en-y gastric bypass is superior to gastric banding in the management of morbidly obese patients: a response

Background

The recent article by Guller, Klein, Hagen was reviewed and discussed by the authors of this response to critically analyze the validity of the conclusions, at a time when patients and providers depend on peer reviewed data to guide their health care choices. The authors of this response all have high volume bariatric surgery practices encompassing experience with both gastric bypass and gastric banding, and have made significant contributions to the peer reviewed literature. We examined the assumptions of the paper, reviewed the main articles cited, provided more evidence from articles that were included in the materials and methods of the paper, but not cited, and challenge the conclusion that Roux-en-Y gastric bypass is superior to gastric banding.

Results and discussion

The paper by Guller et al was subject to significant bias. The authors did not demonstrate an understanding of gastric banding, selectively included data with unfavorable results towards gastric banding, did not provide equal critique to the literature on gastric bypass, and deliberately excluded much of the favorable data on gastric banding.

Conclusion

The paper's conclusion that gastric bypass is the procedure of choice is biased, unsubstantiated, not supported by the current literature and represents a disservice to the scientific and health care community.

Best practice updates for surgical care in weight loss surgery

To update evidence-based best practice guidelines for surgical care in weight loss surgery (WLS). Systematic search of English-language literature on WLS in MEDLINE, EMBASE, and the Cochrane Library between April 2004 and May 2007. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Evidence-based best practice recommendations from the most recent literature on surgical methods and technologies, risks and benefits, outcomes, and surgeon qualifications and credentialing. We identified >135 articles; the 65 most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in WLS are required to address rapid changes in surgical techniques and patient demographics. Key factors in patient safety include surgical risk factors, type of procedure, surgeon training, and facility certification.

Laparoscopic single-site surgery for placement of adjustable gastric band--a series of 22 cases

BACKGROUND

We present a series of 22 patients who underwent laparoendoscopic single-site (LESS) surgery for placement of an adjustable gastric band at a U.S. university hospital.

METHODS

From December 2007 to December 2008, LESS surgery, through a transumbilical incision, to place an adjustable gastric band was performed on 22 patients under institutional review board approval. Multiple ports were placed through a single incision in the umbilicus to allow for liver retraction, visualization, and the working instruments. None of the critical steps of the standard pars flaccida technique were altered.

RESULTS

A total of 22 patients were carefully selected and included 20 women and 2 men, with an age range of 18-67 years (mean 42). The mean body mass index was 42 kg/m(2) (range 35-45). The exclusion criteria included hepatomegaly, central obesity, previous abdominal surgery, and super-obesity. The mean operative time was 84 minutes (range 53-111). All patients were discharged home within the 23-hour admission, and no perioperative complications were noted. In addition, no wound-related complications developed. One patient required conversion to conventional laparoscopy. No intraoperative or postoperative complications occurred.

CONCLUSION

In our experience, LESS surgery for adjustable gastric band placement shows this technique to be both feasible and safe in selected patients to date. Although technical limitations exist that will be improved on, additional studies are needed to compare LESS surgery for placement of an adjustable gastric band with traditional laparoscopic techniques.

Laparoscopic single-site surgery for placement of an adjustable gastric band: initial experience

BACKGROUND

Laparoendoscopic single-site (LESS) surgery for cholecystectomy and appendectomy are described in the literature. The benefits of these procedures compared with traditional laparoscopic approaches have yet to be determined. To date, no series of LESS surgeries for placement of an adjustable gastric band has been published or documented. This study aimed to determine the safety and feasibility of LESS surgery for placement of an adjustable gastric band.

METHODS

From December 2007 to June 2008, LESS surgery to place an adjustable gastric band via a transumbilical incision was performed for 10 patients with institutional review board approval. Essentially, multiple ports were placed through a single incision in the umbilicus to allow for liver retraction, visualization, and working instruments. All critical steps using a standard pars flaccida technique were performed without alteration.

RESULTS

For this study, 10 patients (9 women and 1 man) were carefully selected. These patients ranged in age from 32 to 61 years (mean, 47 years) and had a mean body mass index (BMI) of 42 kg/m2 (range, 35-45 kg/m2). The patients were selected for absence of both hepatomegaly and central obesity. Superobese patients were not considered for inclusion in the study. The mean operative time was 1 h and 10 min (range, 53 min to 1 h and 48 min). All the patients were discharged home within 23 h of admission, and no perioperative complications were noted. In addition, no wound-related complications occurred. Notably, only 2 of the 10 patients required the use of narcotic analgesia after discharge from the recovery room. There were no intra- or postoperative complications.

CONCLUSIONS

In our experience, LESS surgery for adjustable gastric banding shows this technique to be both feasible and safe for selected patients. Although technical limitations exist that will be improved upon, further studies are needed to compare LESS surgery for placement of an adjustable gastric band with traditional laparoscopic techniques.

Comparison of those who succeed in losing significant excessive weight after bariatric surgery and those who fail

BACKGROUND

Gastric bypass and adjustable gastric banding currently are the most commonly performed weight loss surgeries. The results are encouraging for most patients, but some patients have a better experience than others. This report aims to define differences between those who succeeded and those that failed to lose significant excessive weight after bariatric surgery.

METHODS

The authors retrospectively reviewed their database over the past 4 years. They studied 484 bariatric patients who had 1 year of follow-up evaluation. Success was defined as more than 50% excess weight loss (EWL) and failure as less than 30% EWL. Student's t-tests were performed between the groups of bypass patients, band patients, men, women, whites, and minorities.

RESULTS

An overall success rate of 58% and a failure rate of 15% were observed. The successful group was significantly younger. The starting body mass index (BMI) was significantly lower for the successful band patients. The starting excess weight was significantly less in both the successful band and bypass groups, as was the starting weight. The successful whites were significantly younger, and the starting BMI was significantly lower in the successful minority group. The unsuccessful bypass patients and whites were significantly taller than the successful group. Gender was not a significant variable in success or failure regardless of procedure.

CONCLUSION

Without consideration for the procedure performed, the patients who successfully lost weight were younger. The unsuccessful band patients had a higher starting BMI, whereas the successful band and bypass patients had lower average starting and excess weights. The successful bypass patients were significantly shorter. Among whites, the successful patients were significantly younger and shorter. The successful minorities had a lower starting BMI. These variables give further insight into the complexity of successful excess weight loss.

[Laparoscopic gastric banding--where are the limits?]

Die Kriterien zur Indikation fÜr ein Gastric Banding (GB) oder einen Bypass sind in den bekannten Leitlinien nur unscharf definiert und orientieren sich meist am BMI der Patienten. In der vorliegenden Arbeitwerden neben dem BMI auch die Rolle von hormonalen Mediatoren, die mit der morbiden Adipositasverbunden sind, die KomplikationstrÄchtigkeit und die Langzeitresultatedes GB dem laparoskopischen Gastric Bypass gegenÜbergestellt, um gegebenenfalls Grenzen des GB aufzuzeigen. Laparoscopic Gastric Banding - Where Are the Limits? The criteria for the indication of gastric banding (GB) or bypass in morbidly obese patients are poorly defined in the available guidelines and usually rely on the BMI of the patients. In this study, the role of the BMI and of hormonal mediators associated with morbid obesity are outlined. Furthermore, the complications and long-termresults of GB are analyzed and compared with laparoscopic gastric bypass in order to define the limits of GB.

Stoma obstruction after laparoscopic adjustable gastric banding for morbid obesity: report of two cases and treatment options

Laparoscopic adjustable gastric band is one of the surgical options available for morbid obesity in the current century. Its popularity is gained by its proven efficacy with a reported low incidence of the intraoperative as well as the postoperative complications. Stomal obstruction post-laparoscopic adjustable gastric band (LAGB) has been under reported in the English literature. We report this complication in two patients and discuss two different simple modalities of treatment. Post-LAGB complications are numerous, dealing with their complications have a steeping curve. Educating the patients postoperatively in regard to food ingestion manner is a must and should prevent such complication.

Failure of adjustable gastric banding: starting BMI of 46 kg/m2 is a fulcrum of success and failure

BACKGROUND

To determine the body mass index (BMI) located at the fulcrum of success and failure in a prospective study conducted at the University of Texas Health Science Center at Houston. On average, our patients whose percentage of excess weight loss (%EWL) was >50% at 1 year had a significantly lower BMI than those with <30% EWL.

METHODS

We prospectively collected the weight loss data for 430 patients who had had an adjustable gastric band placed. We stratified the %EWL within 1 year for patients with a BMI of 30-59 kg/m2. A line was generated for the %EWL over time for BMI groups of 30-39, 40-49, and 50-59 kg/m(2) and compared with the average %EWL over time. The y-intercepts of the resulting four lines were graphed against the average BMI for each group.

RESULTS

The generated y-intercept line had an R2 of .9237. Using the equation of this line and the known y-intercept for the average, we solved for x, resulting in a BMI of 46 kg/m2. Patients with a BMI <46 kg/m2 had a 50% EWL at 1 year, and those with a BMI >46 kg/m2 had only a 33% EWL at 1 year. The %EWL between the groups was significantly different at all measured intervals (P <.0001).

CONCLUSION

A BMI of 46 kg/m2 identifies those at high risk of failure to lose a significant percentage of excess weight after adjustable gastric banding and who require closer follow-up. Furthermore, patients who have a BMI >46 kg/m2 should be advised that their weight loss might be suboptimal at 1 year.

Ten years experience with laparoscopic adjustable gastric banding

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Metabolic outcomes of obese diabetic patients following laparoscopic adjustable gastric banding

INTRODUCTION

Obesity is an independent risk factor in the development of diabetes. Weight loss surgery is the most effective treatment of morbid obesity. This study examines the effect of gastric banding on metabolic profile in diabetics.

METHODS

Between April 2003 and November 2007, 1,335 patients underwent laparoscopic adjustable gastric banding. Metabolic profile was examined on a subset of 254 patients. Of these, 122 were diabetic. Data collection included body mass index, weight, blood pressure, HbA1c, fasting glucose, total serum cholesterol, triglyceride, and medications taken for blood pressure and diabetes both preoperatively and 1 year postoperatively.

RESULTS

Comorbid conditions in the diabetic patients included hypercholesterolemia (49.3%), hypertriglyceridemia (53.8%) and hypertension (92%). In 1 year, mean BMI reduced from 52.9 kg/m(2) to 41.5 kg/m(2). Of the patients, 93.1% experienced an improvement in fasting glucose levels and 75.4% patients an improvement in HbA1c levels at the end of 1 year. All patients experienced a decrease in insulin requirements, and 36.6% were able to totally discontinue using it. Of the patients, 100% showed improvement in their triglyceride level, and 90.9% showed improvement in their total cholesterol level. The mean arterial pressure improved in 87.5% of the patients.

CONCLUSION

The metabolic syndrome associated with morbid obesity is difficult to adequately control with medication. Laparoscopic gastric banding can be considered a potentially curative treatment option in the management of this syndrome.

Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

BACKGROUND

We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve.

METHODS

The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospital's electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge.

RESULTS

A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality.

CONCLUSION

Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.