Vertical Banded Gastroplasty: First Experience in Russia

Background: The first experience of vertical banded gastroplasty (VBG) in the Russian National Research Center of Surgery is presented. Methods: From November 1992 to October 1996, 24 morbidly obese patients (mean body weight 147.7 kg, BMI 52.1 kg/m²) underwent VBG according to Mason. Results: The early complication rate was 20.8%. The mean excess weight loss (EWL) after weight stabilization (first 12 patients) was 48.0% in the whole group and 53.9% (range 36.0-73.0%) in 10 patients without staple-line disruptions. Significant positive changes in obesity related diseases were noted. Nine of 23 patients presented with incisional hernias some months after operation. Conclusion: The impression of VBG is favorable; however, gaining further experience with the standard techniques and increasing the long-term results are necessary.     

Adjustable Silicone Gastric Banding (ASGB): the Italian experience

Adjustable silicone gastric banding (ASGB) is a recently introduced gastric restrictive procedure. From April 1990 to April 1992, 85 patients underwent ASGB at our Department. Patients' characteristics were: 65 females, 20 males, mean age 39.6 years (range 17-60 years); body weight (BW) 127.9 ± 23 kg; % ideal body weight (%IBW) 205 ± 29; body mass index (BMI) 46 ± 7; morbidly obese 68, super-obese 17. Mean follow-up is 353 days. Twelve months after the operation BW was 95.2 ± 23 kg, % loss of excess BW 52.1 ± 22, and %IBW 152.2 ± 30 (45 patients). Mortality rate was zero and postoperative morbidity was insignificant. As late morbidity, we experienced two slippages of the band and six stoma-stenosis with pouch dilatation. Therefore, a surgical revision without removal of the band was performed in eight patients. The band was removed in one patient because of band erosion. In conclusion, ASGB is a safe and effective bariatric procedure. The weight loss is comparable to that produced by more extensive operations. Moreover, ASGB is fully reversible and adjustable to the patients' needs.     

Vertical banded gastroplasty in the Aegean Region of Turkey

Background: Obesity is increasing in Turkey. The first experience with vertical banded gastroplasty (VBG) with regular intermediate-term follow-up in the Aegean Region of Turkey is presented. Methods: From November 1993 to August 1999, 40 morbidly obese patients underwent VBG. The patients were evaluated on the basis of excess weight loss (EWL) and satisfaction with the operation. Results: Regular follow-up was obtained in 38 patients (95%), with mean follow-up 27.2 months (14-85). Average preoperative body weight (BW) was 141.4 kg (93-238) and body mass index (BMI) was 52.3 kg/m² (41-77.8). Average EWL was 64.1% (21.2-92.3). Average postoperative BW and BMI were 93.3 kg (70-145) and 34.4 kg/m² (25.1-53) respectively. 35 of 38 patients (92%) lost more than 25% of EW and 28 of 38 (73.6%) lost more than 50% of EW. After weight loss, hypertension disappeared or improved in 86% of patients and diabetes resolved in 75%. Sleep apnea disappeared in 100% of patients. The early and late complication rates were 7.9% and 15.8% respectively. 33 of 38 patients (87%) were satisfied with the operation. Conclusion: VBG was safe and effective, resulted in acceptable weight loss, and the vast majority of patients were satisfied.     

Laparoscopic Adjustable Gastric Banding versus Open Vertical Banded Gastroplasty: A Prospective Randomized Trial

Background: Laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) are treatment modalities for morbid obesity. However, few prospective randomized clinical trials (RCT) have been performed to compare both operations. Methods: 100 patients (50 per group) were included in the study. Postoperative outcomes included hospital length of stay (LOS), complications, percent excess weight loss (%EWL), BMI and reduction in total comorbidities. Follow-up in all patients was 2 years. Results: LOS was significantly shorter in the LAGB group. 3 LAGB were converted to open (1 to gastric bypass). Directly after VBG, 3 patients needed relaparotomies due to leakage, of which one (2%) died. After 2 years, 100% follow-up was achieved. BMI and %EWL were significantly decreased in both groups but significantly more in the VBG group compared to the LAGB group (31.0 kg/m² and 70.1% vs 34.6 and 54.9% respectively). Co-morbidities significantly decreased in both groups in time. 2 years after LAGB, 20 patients needed reoperation for pouch dilation/slippage (n=12), band leakage (n=2), band erosion (n=2) and access-port problems (n=4). In the VBG group, 18 patients needed revisional surgery due to staple-line disruption (n=15), narrow outlet (n=2) or insufficient weight loss (n=1). Furthermore, 8 VBG patients developed an incisional hernia. Conclusion: This RCT demonstrates that, despite the initial better weight loss in the VBG group, based on complication rates and clinical outcome, LAGB is preferred. It had a shorter LOS and less postoperative morbidity.     

Use of Adjustable Silicone Gastric Banding for Revision of Failed Gastric Bariatric Operations

Background: Revision of gastric bariatric operations is sometimes technically difficult and may fail to achieve prolonged weight reduction. The use of the adjustable silicone gastric banding (ASGB) offers a new approach for these revisions. Methods: ASGB was performed as a revisional procedure on 37 patients whose initial bariatric operations were as follows: silastic ring vertical gastroplasty (21), gastric bypass (12), horizontal gastroplasty (3) and vertical banded gastroplasty (1). Results: The length of the procedure varied from 55 to 145 minutes (mean 83 minutes). Intraoperative complications included two fundic tears which were sutured without any postoperative sequelae. Five patients needed reoperation during the first postoperative year due to gastric volvulus (1), tubing tear (1) and development of postoperative ventral hernia (3). BMI fell from 44.8 ± SD 8.07 to 33.4 ± 6.9 kg/m² for patients operated with BMI higher than 35 kg/m² and from 29.2 ± 3.32 to 25.4 ± 2.8 kg/m² for patients operated with BMI lower than 35 kg/m². Conclusions: ASBG can be performed with revisions with an acceptable complication rate and post-operative weight reduction.     

Prospective evaluation of biliopancreatic diversion with roux-en-y gastric bypass in the super obese

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 ± 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 ± 7), with an incidence of comorbidities 6 ± 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 ± 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m². Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m², respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.     

A Prospective Comparison of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass in a Non-Superobese Population

Background: In the non-superobese population, consensus is currently unavailable in bariatric surgery. We report the results of a prospective comparison of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in a non-superobese population. Methods: From 1994 to 2000, 179 patients with clinically severe obesity underwent various surgical procedures in our department. During this time a prospective study was undertaken in order to compare VBG with RYGBP in morbidly obese patients with a BMI <50 kg/m². Based on specific criteria including eating behavior, 68 patients were selected to undergo RYGBP and 35 VBG. All patients have undergone complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: All patients have now completed their 5th postoperative year. Mean follow-up period to date is 96.5±12.2 months for VBG and 67.6±11.3 months for RYGBP. 3 patients (8.6%) in the VBG group and 9 patients (13.2%) in the RYGBP group are lost to follow-up. Mean excess weight loss (EWL) was always better in the RYGBP group (P=0.0013). The percentage of failure, defined as EWL <25%, was not significantly different between the two procedures. No statistically significant differences were observed between the 2 groups in the total number of non-metabolic complications, and the only statistically significant difference observed in metabolic complications was vitamin B₁₂ deficiency after RYGBP. Frequency of vomiting was significantly less and quality of eating significantly better in RYGBP than in VBG patients. Conclusion: This prospective long-term study, with nearly complete follow-up, suggests that in the non-superobese population, preoperative eating habits may play a role in choosing the most appropriate bariatric operation for each patient. Although RYGBP is associated with better mean weight loss outcomes, the percentage of patients who achieved and maintained ≥50% EWL after VBG in this pre-selected patient population was not significantly different. Each type of operation has advantages and disadvantages, and, if properly chosen, a purely restrictive procedure can be successful for some patients. Therefore, it can be said that the decision regarding which bariatric procedure to perform in non-superobese patients must be based on in-depth preoperative evaluation as well as the patients' own preferences and outcome expectations.     

Adjustable Gastric Banding in a Public University Hospital: Prospective Analysis of 400 Patients

Background: Laparoscopic application of an adjustable gastric band (LAGB) is considered the least invasive surgical option for morbid obesity. It has the advantage of being potentially reversible and can improve quality of life. Method: Between April 1997 and January 2001, 400 patients underwent LAGB. There were 352 women and 48 men with mean age 40.2 years (16-66). Preoperative mean body weight was 119 kg (85-195) and mean body mass index (BMI) was 43.8 kg/m² (35.1-65.8). Results: Mean operative time was 116 minutes (30-380), and mean hospital stay was 4.55 days (3-42). There was no death. There were 12 conversions (3%). 40 complications required an abdominal reoperation (10%), for perforation (n=2), gastric necrosis (n=1), slippage (n=31), incisional hernia (n=2) and reconnection of the tube (n=4). We noticed 7 pulmonary complications (2 ARDS, 5 atelectasis) and 30 minor problems related to the access port. At 2 years, mean BMI had fallen from 43.8 to 32.7 kg/m² and mean excess weight loss (EWL) was 52.7 % (12-94). Conclusion: LAGB is a very beneficial operation with an acceptable complication rate. EWL is 50% at 2 years if multidisciplinary follow-up remains assiduous. Surveillance for late anterior stomach slippage within the band is essential.     

Three-Year Results of Laparoscopic Vertical Banded Gastroplasty

Background: Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (lap VBG) in 60 obese patients. Patients and Methods: 60 massively obese patients (50 female) with a mean ± SEM body mass index (BMI) of 44.4 ± 1.0 kg/m² were followed up prospectively for an average of 23.0 ± 1.5 months. Lap VBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line, and a stretched polytetrafluoroethylene (Gore-Tex) band was used to reinforce the outlet. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery. Results: Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m² (37.7-65.7) and 5 days (3-13), and 41.9 kg/m² (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m² (24.6-50.7) (n = 9) in the open group and 37.0 kg/m² (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m² (33.8-65.8) and 41.2 kg/m² (32.4-57.8). Conclusions: Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.     

Obesity: An Innately Incurable Disease?

Background: Staple-line disruption is a common complication after vertical banded gastroplasty (VBG). Methods: Of 655 patients who underwent VBG, a hole across the partition developed in 46 (7.02%). Results: The original excellent weight loss from a BMI of 49.2 ± 6.9 kg/m² to 31.9 ± 6.1 kg/m² stopped with staple-line dehiscence, and all 46 patients regained weight, even to their original weight. After operative revision by restapling (n = 24/46) or implantation of an adjustable band (n = 10/46), patients reduced their body weight once more (to BMI 31.2 ± 5.9 or 33.8 ± 5.8). Conclusion: Obese patients need the food-intake reducing operations maintained lifelong; the real cause of obesity is not curable until now, and only the main symptom, “overweight,” can be improved by therapy.     

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Background: Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. Materials and Methods: We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results: Mean age and body mass index (BMI) at the time of revision were 39 ± 9.9 years and 44.0 ± 4.5 kg/m² respectively. No patients were lost to follow-up, and they lost an average of 38.1 ± 10.4% and 44.0 ± 36.3% of excess weight and 49.1 ± 20.9% and 52.0 ± 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 ± 20.5% of excess weight from the combined surgeries in 67 (48–84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. Conclusions: These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.     

Adjustable Silicone Gastric Banding vs Vertical Banded Gastroplasty: a comparison of early results

The Kuzmak adjustable silicone gastric band (ASGB; 33 patients) and the vertical banded gastroplasty (VBG; 91 patients) are compared for weight loss, complication rates, and patient satisfaction. The complexity of the two operations is also compared, using operative time, blood loss, and length of hospitalization. When these three parameters were evaluated, the operations were remarkably similar, although a significant percentage of the ASGB patients left the hospital earlier than the VBG patients. The ASGB group of patients lost 52% of their excess weight (34 kg) and the VBG group 63% (40 kg), with the maximum follow-up being 15 months. Mechanical problems (leaks in the system) occurred in four ASGB patients. This slowed their weight loss and caused dissatisfaction with the procedure. Sixty-four percent of the patients underwent adjustment of the silicone band atleast once during the 15 months. Complications included stomal stenosis in 9% of the ASGB patients vs 1.3% in the VBG patients. There was one staple-line leak, one subphrenic abscess (without a leak), and one retrogastric hematoma in the VBG patients. One death occurred in the ASGB group in a patient who was found at surgery to have unanticipated post-hepatitic cirrhosis. There were no deaths in the VBG group. The conclusion reached is that the ASGB compares favorably with the VBG as a bariatric surgical procedure.     

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BackgroundThe current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m² or BMI >35 kg/m² with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.MethodsAn institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m² and co-morbidities (n = 22) or a BMI of 35–40 kg/m² without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.ResultsThe average BMI for the study group was 36.1 ± 2.6 kg/m² compared with 46.0 ± 7.3 kg/m² for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.ConclusionModerately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m².     

500 Intragastric Balloons: What Happens 5 Years Thereafter?

Background

The BioEnterics Intragastric Balloon (BIB) has been considered an effective, less invasive method for weight loss, as it provides a permanent sensation of satiety. However, various non-randomized studies suggest BIB is a temporary anti-obesity treatment, which induces only a short-term weight loss. The purpose of this study was to present data of 500 obese who, after BIB-induced weight reduction, were followed up for up to 5?years.

Methods

The BioEnterics BIB was used, and remained for 6?months. At 6, 12, and 24?months post-removal (and yearly thereafter), all subjects were contacted for follow-up.

Results

From 500 patients enrolled, 26 were excluded (treatment protocol interruption); 474 thus remained, having initial body weight of 126.16?±?28.32?kg, BMI of 43.73?±?8.39?kg/m², and excess weight (EW) of 61.35?±?25.41. At time of removal, 79 (17%) were excluded as having percent excessive weight loss (EWL) of <20%; the remaining 395 had weight loss of 23.91?±?9.08?kg (18.73%), BMI reduction of 8.34?±?3.14?kg/m² (18.82%), and percent EWL of 42.34?±?19.07. At 6 and 12?months, 387 (98%) and 352 (89%) presented with weight loss of 24.14?±?8.93 and 16.31?±?7.41?kg, BMI reduction of 8.41?±?3.10 and 5.67?±?2.55?kg/m², and percent EWL of 42.73?±?18.87 and 27.71?±?13.40, respectively. At 12 and 24?months, 187 (53%) and 96 (27%) of 352 continued to have percent EWL of >20. Finally, 195 of 474 who completed the 60-month follow-up presented weight loss of 7.26?±?5.41?kg, BMI reduction of 2.53?±?1.85?kg/m², and percent EWL of 12.97?±?8.54. At this time, 46 (23%) retained the percent EWL at >20. In general, those who lost 80% of the total weight lost during the first 3 months of treatment succeeded in maintaining a percent EWL of >20 long term after BIB removal: more precisely, this cutoff point was achieved in 83% at the time of removal and in 53%, 27%, and 23% at 12-, 24-, and 60-month follow-up.

Conclusion

BIB seems to be effective for significant weight loss and maintenance for a long period thereafter, under the absolute prerequisite of patient compliance and behavior change from the very early stages of treatment.     

Laparoscopic ventral incisional hernia repair: A more effective alternative to conventional repair of recurrent incisional hernia

Conventional repair of recurrent ventral incisional hernia is associated with a higher recurrence rate (30%-50%) than repair of primary incisional hernia (11%-20%). Laparoscopic incisional hernia repair (LIHR) can significantly reduce the recurrence rate of primary hernia to less than 5%. In this study, we evaluate the efficacy of repairing recurrent incisional hernia laparoscopically. One-hundred and seventy consecutive patients undergoing LIHR between January 1995 and December 2002 were prospectively reviewed. Patients with recurrent incisional hernia (n = 69) were compared to patients with primary incisional hernia (n = 101). Patient demographics and perioperative and postoperative data were recorded prospectively. Follow-up was obtained from office visits and telephone interviews. Statistical analysis was performed using the Student t test and the x ²test. Results are expressed as means ± standard deviation. The patients with recurrent incisional hernia had a mean of 1.9 ± 1.3 previous repairs, higher body mass index (BMI) (34 ± 6 kg/m² vs. 33 ± 8 kg/m², P = 0.46), larger defect size (123 ± 115 cm² vs. 101 ± 108 cm², P = 0.06), and longer operative time (119 ± 61 minutes vs. 109 ± 44 minutes, P= 0.11). The complication rate was higher in the recurrent group (28% vs. 11%, P = 0.01), but the recurrence rate was not different (7% vs. 5%, P= 0.53). The mean time to recurrence was significantly shorter in the recurrent group (3 ± 2 months vs. 14 ± 7 months, P < 0.0001). The mean follow-up interval was 19 ± 18 months in the recurrent group and 27 ± 20 months in the primary group. Although laparoscopic repair of recurrent incisional hernia resulted in a higher recurrence and complication rate than laparoscopic repair of primary incisional hernia, the rates were lower than those reported for conventional repair of recurrent incisional hernia. Laparoscopic repair of recurrent incisional hernia is an effective alternative to conventional repair. Supported in part by Tyco/US Surgical Corporation through an educational grant to the University of Kentucky Center for Minimally Invasive Surgery.     

Italian Group for Lap-Band System®: Results of Multicenter Study on Patients with BMI ≤35 kg/m2

Background: The Lap-Band System? is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI ≤ 35. We report the Italian multicentre experience with BMI ≤ 35 kg/m² over the last 5 years. Patients and Methods: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System?. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI ≤ 35 were selected. Data were expressed as mean ± SD except as otherwise indicated. Results: 225 (6.8%) out of 3,319 Lap-Band? patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19±11.8, range 17-66 years, mean BMI 33.9±1.1, range 25.1-35 kg/m², mean excess weight 29.5±7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1±2.15, 29.7±2.19, 28.7±3.8, 26.7±4.3, 27.9±3.2, and 28.2±0.9 kg/m² respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. Conclusions: Although surgical indications for BMI ≤ 35 remain questionable, the Lap-Band? in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.     

An Adjustable Vertical Banded Gastroplasty does not Eliminate the Risk of Staple-line Disruption

Background: The two main reasons for reoperation after vertical banded gastroplasty (VBG) in the treatment of obesity are staple-line disruption and stomal stenosis. Patients: Seven morbidly obese patients of mean (±SEM) body mass index (BMI) 43.7 ± 1.9 kg/m² treated with an adjustable vertical banded gastroplasty (AVBG). Results: No complications of the band system were reported. Weight-loss [BMI at 2 years follow-up 33.9 ± 6.9 kg/m² (n = 5)] was equivalent to that seen after VBG with a fixed band. Two of the patients developed staple-line disruption at 18 and 24 months after surgery. Conclusion: AVBG allows adjustment of the stoma, but staple-line disruption was common in this small series. It is possible that an excessive filling of the band in order to achieve excess weight loss results in a high pressure in the upper pouch which increases the risk of staple-line disruption.     

Vertical Banded Gastroplasty: 6 Years Experience at a Center in Poland

Background: Vertical banded gastroplasty (VBG) has been performed in our department as a restrictive operation for treatment of morbid obesity. We assessed efficacy, safety, and quality of life (QoL) after VBG, based on our 6-year experience. Methods: 101 patients with >1 year follow-up who underwent VBG between January 1998 and May 2003, were retrospectively studied. Mean age was 41 years, and mean preoperative BMI was 51.3 kg/m² . Almost 60% of the patients suffered from hypertension, and 25% were diabetic. Postoperative QoL was determined with the BAROS questionnaire. Data concerning weight loss and co-morbidities were collected during the postoperative visits. Results: 87.2% of patients achieved ≥ 50% EWL. 86 patients (85.2%) responded to the BAROS questionnaire. >90% of the patients analyzed according to BAROS, reported improvement in QoL after VBG. No patient reported deterioration in health or well-being after the VBG. Anti-hypertensive medication was discontinued in 26 patients (56.5%) and decreased in the other 15 hypertensive patients (32.6%). 35% of diabetic patients did not require further treatment, while a further 40% had their insulin doses decreased or were switched to oral drugs. Early complications occurred in 4.65%, and consisted of an evisceration, pulmonary embolus and gastric leak. Late complications occurred in 20.9%, and included bleeding from peptic ulcer, incisional hernia, stomal stenosis and staple-line disruption (3.5%). There have been no deaths. Conclusion: VBG provided significant weight reduction and improved QoL in the vast majority of morbidly obese patients. Patients with diabetes and hypertension benefitted because these co-morbidities were improved or disappeared with the weight loss.     

Bariatric Re-operations: Are They Preventable?

Background: Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. Methods: From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 ±11 years, mean original weight 151.3 ± 44.3 kg, mean BMI 58.4±16.9 kg/m2 and mean excess body weight (EBW) 94.4±43.5 kg. Mean height was 161±7.7 cm, and 15 patients were female (88.2%).The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Results: Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP,1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Conclusion: Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.     

Revisional Bariatric Surgery Following Failed Primary Laparoscopic Sleeve Gastrectomy: A Systematic Review

Revisional bariatric surgery following laparoscopic sleeve gastrectomy (LSG) failure presents a clinical challenge for the bariatric surgeon. Limited evidence exists in selecting the appropriate revisional operation: laparoscopic gastric bypass (LGB), laparoscopic re-sleeve gastrectomy (LRSG), or other surgical intervention (OSI), to address weight regain. We systematically reviewed the literature to assess the efficacy of existing revisional surgery. A comprehensive search of electronic databases (e.g., Medline, Embase, Scopus, Web of Science, and the Cochrane Library) was completed. All randomized controlled trials, non-randomized comparison study, and case series were included. Eleven primary studies (218 patients) were identified and included in the systematic review. Studies were grouped into three main categories: LGB, LRSG, and OSI. Preoperative body mass index (BMI) was 41.9 kg/m² (LGB), 38.5 kg/m² (LRSG), and 44.4 kg/m² (OSI). After conversion to LGB, BMI decreased to 33.7 and 35.7 kg/m² at 12 and 24 months of follow-up, respectively. Excess weight loss (EWL) was 60 and 48 % over the same periods. After LRSG, BMI decreased to 30.4 and 35.3 kg/m² with corresponding EWL of 68 and 44 %, at 12 and 24 months, respectively. After OSI, BMI decreased to 27.3 kg/m² with an EWL of 75 % at 24-month follow-up but could not be analyzed due to incomplete data collection in primary studies. Both LGB and LRSG achieve effective weight loss following failed LSG. The less technically challenging nature of LRSG may be more widely applicable. Further research is required to elicit sustainability in long-term weight loss benefits.