Pouch Volume,Stoma Diameter and Weight Loss in Swedish Adjustable Gastric Banding (SAGB)

Background: Weight loss appears to be inversely related to pouch volume following gastric restriction procedures for morbid obesity. The aim of this study was to investigate the changes in pouch volume with time and the relationship between pouch volume and stoma diameter and subsequent weight loss following the Swedish Adjustable Gastric Banding (SAGB). Methods: During 1990 50 patients were operated upon. Their mean BMI at surgery was 46 and at 2 years 28. We followed these patients with endoscopy at 6 weeks and 3, 18 and 24 months after surgery. During endoscopy pouch volume was estimated according to a standardized classification system and measured stoma diameter using balloon catheters. Results: The results indicate that the pouch dilates during the first few months after surgery but that the size thereafter is fairly stable. There is also a relationship between pouch volume and subsequent weight loss. Pouch volume seems to be the primary determinator for weight loss. Conclusion: The smaller the pouch the greater the weight loss. Reduction of the stoma diameter is a good instrument for regulating the degree and speed of weight loss in patients with small pouches, but much less powerful in patients with large pouches.     

The Swedish Adjustable Gastric Banding (SAGB) for morbid obesity — Weight loss, complications, pouch volume, and stoma diameter in a four-year follow-up

Summary Background: We have developed an adjustable gastric band in which the stoma diameter can be adjusted from the outside. The aim of this study was to evaluate the new standardized operating technique with our band in terms of weight loss and complication rate. Another aim of this study was to investigate the changes in pouch volume with time and the relationship between pouch volume and stoma diameter, and subsequent weight loss following the placement of the Swedish Adjustable Gastric Band (SAGB). Methods: Between August 1990 and November 1991, 50 patients (15 men and 35 women) were operated on by laparotomy. Mean preoperative weight was 134 (106–181) kg and the mean BMI was 46 (33–59) kg/m². During endoscopy, pouch volume was estimated according to a standardized classification system, and the stoma diameter was measured using balloon catheters. Results: At follow-up, mean weight was 80 kg and mean BMI was 27.5 kg/m². The patients had lost a mean of 54 kg. 2 patients (4%) had abdominal reoperation because of technical problems. There was 1 incisional hernia and 1 minor wound infection, but no other significant complications. We found that pouch volume was of crucial importance. If the pouch is small enough, regulation of the stoma diameter is an important tool for steering weight loss dynamics. If the pouch is too big, further narrowing of the stoma will not lead to additional weight loss. Conclusions: This relatively simple method appears to be at least as good as the other operations, and weight loss can be adjusted to patient comfort. Currently, the procedure is being performed laparoscopically.      

Alternative Technique for Creation of a Proximal Gastric Pouch in Laparoscopic Adjustable Silicone Gastric Banding

Background: Laparoscopic adjustable silicone gastric banding (LASGB) has become a widely used procedure for the treatment of morbid obesity. The original operation, as described by Kuzmak, has been subjected to modifications. Construction of a proximal gastric pouch is an important part of the operation. Until now, we used the technique of Niville. Since this was often complicated by gastric bleeding and/or serosal tears, we developed a new technique to construct a pouch. Surgical Technique: A new technique, using a thread previously fixed to that portion of the fundus that will be used to construct the pouch, is described. Conclusion: A safe and easy adaptation of the LASGB technique is proposed to create the gastric pouch.     

Symmetrical Pouch Dilatation After Laparoscopic Adjustable Gastric Banding: Incidence and Management

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has commonly been complicated by the problem of band slippage or prolapse. Since popularization of the pars flaccida approach and improved anterior fixation, it is our impression that the problem of symmetrical dilatation of the proximal gastric pouch has become more important. METHODS: We have reviewed the results of a series of 425 LAGB all performed by the pars flaccida approach from June 2003 to October 2007 to analyze the incidence and implications of this new pattern. RESULTS: There were no posterior prolapses, 2 anterior prolapses, and 17 cases of symmetrical pouch dilatation (SPD) (revision rate 4.4%). Teenage patients had a 22% revision rate for SPD. All revisions were completed laparoscopically with no mortality, no significant complications, and a median hospital stay of 1 day. The median weight loss following revisional surgery was not significantly different from the background cohort. CONCLUSION: SPD is the most common reason for revision of LAGB in this series. We postulate that SPD is caused by excessive pressure in the proximal gastric pouch. This may be generated either by eating too quickly or too large a volume or excessive tightening of the band. The radial forces in the pouch may ultimately cause pressure on the phrenoesophageal ligament and a secondary hiatal hernia.     

Complications Following Swedish Adjustable Gastric Banding: A Long-Term Follow-up

Background: The Swedish adjustable gastric band (SAGB) has been in use since 1985. The aim of this study was to analyze short and long-term complications linked to the SAGB. Materials and Methods: Between August 1990 and December 1996, we operated on a series of 326 patients (78 men and 248 women) at the Huddinge University Hospital and the Norra ?lvsborg County Hospital. The mean age of patients at surgery was 40 years (range 19-62). The mean preoperative weight was 125 kg (range 81-181). The mean excess weight was 80%. Results: The mean time of follow-up was 28 months (range 6-76). Complications requiring reoperation included two (0.6%) band dislocations, six (1.8%) band leakages, and 16 (4.6%) band migrations-erosions. The most common reason for abdominal reoperation, band migration, was attributed to overfilling of the band system. In the patients in whom migration occurred, the bands had been filled with a mean volume of 12.6 ml fluid. In the remaining patients, the mean volume was 8.7 ml. The most common complication not requiring reoperation was reflux disease (4.7%). In cases with a small pouch, this complication did not seem to be a serious problem. The mean excess weight loss in the 296 patients without complications was 68%. Conclusion: The overall long-term complication rate following SAGB is reasonable. With improved operating technique and closer follow-up, it should be possible to reduce the complication rate further. Reoperation because of band migration appears to be related to overfilling of the system and should therefore be avoidable in most cases.     

Late Pouch Dilation after Laparoscopic Adjustable Gastric and Esophagogastric Banding: Incidence, Treatment, and Outcome

Background: Pathologic late pouch dilation is the most frequent complication following gastric banding procedures for morbid obesity. In this study, possible predictive factors were sought. The treatment of these complications and the final outcome are discussed. Methods: Between December 1994 and December 1997, 171 patients underwent laparoscopic adjustable banding for morbid obesity. 40 patients underwent classic gastric banding (Group 1), and 131 patients underwent esophagogastric banding (Group 2). Results: Pouch dilation developed in 6 patients (15%) in Group 1 and 12 patients (9.2%) in Group 2. There were no significant predictive factors, although the complication occurred more frequently in patients with presurgical hiatus hernia. The type of dilation was different for each group, as was the surgical treatment. Laparoscopic repositioning of the band was always possible and was uncomplicated. The long-term outcome has been good, and weight loss has been maintained. Conclusions: A frequent complication following banding procedures for morbid obesity is pathologic late pouch dilation. In experienced hands, when appropriate surgical treatment is carried out, this is not a major problem. Nevertheless, efforts should be made to decrease the number of late dilations.     

Band Erosion Following Gastric Banding: How to Treat It

Background Intragastric band migration is an unusual but major long-term complication of gastric banding: its frequency ranges from 0.5–3.8% and always requires removal of the band. Different laparoscopic, laparotomic or endoscopic methods are currently used for band removal. Methods 571 morbidly obese patients underwent adjustable gastric banding from February 1998 to July 2006. Band erosion occurred in 3 patients (0.52%). In addition, 6 such patients were referred to our Department from other hospitals. To remove the migrated band, in most patients we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation). Results In 7 of the 9 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparoscopy. In another case, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 2 patients, we had to remove the band surgically – in one case for port-site infection with subphrenic abscess, and in the other case for complete band migration into the jejunum associated with acute pancreatitis, cholelithiasis and choledocholithiasis. Conclusion The Gastric Band Cutter, when used, was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be the procedure of choice for band erosion, because it allows earlier patient discharge and avoids a surgical operation. It is advisable to perform the endoscopic removal in the operating theater, because of possible complications of the procedure.     

Gastric Emptying of Semisolids and Pouch Motility Following Laparoscopic Adjustable Gastric Banding

Background  Laparoscopic adjustable gastric banding (LAGB) has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. We performed a pilot study to evaluate gastric emptying of semisolid meals and antral motility following LAGB. Methods  Gastric emptying half-time was compared in normal volunteers and morbidly obese patients before and 6–12 months after LAGB using sulfur colloid-labeled semisolid meals. Results  There was no difference in mean age between groups. Women were prevalent in the group of obese patients. BMI was higher in patients before surgery (p < 0.001). Patients following LAGB demonstrated prolonged gastric pouch emptying (T1/2 = 36.6 ± 9.8 min) compared to subjects without surgery (23.8 ± 4.7 min) and healthy volunteers (22.8 ± 6.8 min; p < 0.001). Similar gastric contractility was found all groups (3.3 ± 0.4; p = 0.968). No cases of band slippage or pouch dilatation were observed during mean follow-up of 11.4 months. Conclusions  A standard normal gastric pouch emptying rate of semisolids in asymptomatic patients after LAGB was established. Postoperative prolongation of gastric emptying is a matter of mechanical delay without gastric pouch denervation. This study provides a first step of future functional evaluation of complications following this type of bariatric surgery.     

Numerical Analysis of Pouch Filling and Emptying After Laparoscopic Gastric Banding Surgery

Background Previous studies have indicated that pouch volume and stoma size are two important factors related to weight loss after laparoscopic gastric banding in morbid obese patients. We hypothesized that there was association among the wall stress, pouch volume, and stoma size in a model for the filling and emptying phases of the pouch. Methods A numerical pouch model with variable pouch volume and stoma size was generated. Uniaxial tensile testing was performed on fundus strips from fresh pig stomach and the mass flow of filling and emptying of the pouch was simulated numerically. Results There was an overall qualitative agreement on the volume change between the simulated results and the clinical recording. Increasing the pouch volume size from 22 to 105 ml caused a decrease of the maximum circumferential stress from 14.14 to 11.80 kPa and the maximum longitudinal stress from 9.87 to 6.70 kPa in the pouch wall at the same degree of filling. Decreasing the stoma diameter from 27 to 10 mm caused an increase of the maximum circumferential stress from 11.46 to 12.78 kPa and a decrease of the maximum longitudinal stress from 10.34 to 8.69 kPa. Conclusion Both the pouch volume and stoma size are important determinants of mechanical wall stress, wall strain, and pouch emptying and hence may affect satiety and weight loss. This information may be important in understanding the mechanical behavior of pouches and for the development of more advanced numerical models in the clinical management of the surgery.     

Markers of Bone and Calcium Metabolism Following Gastric Bypass and Laparoscopic Adjustable Gastric Banding

BACKGROUND: Several studies have suggested that morbid obesity is associated with vitamin D deficiency and elevated parathyroid hormone (PTH). Studies have also suggested that there is an increase in vitamin D deficiency, bone resorption, and elevated PTH after gastric bypass surgery. Few studies have evaluated markers of bone and calcium metabolism after laparoscopic adjustable gastric banding or compared these results to those after gastric bypass. METHODS: Data on all patients undergoing primary gastric bypass (GBP; n = 979) and laparoscopic adjustable gastric banding (LAGB; n = 269) procedures at a tertiary-referral center from June 1996 through March 2005 were reviewed from a prospective database. Only patients with 25OH vitamin D levels available were included in this study (n = 534; GBP = 403, LAGB = 131). All patients were advised to take at least 1,200 mg calcium and 800-1,200 IU of vitamin D daily before and subsequent to their operation. Markers for bone metabolism [25OH Vitamin D, corrected serum calcium, alkaline phosphatase (AP), and PTH] were evaluated preoperatively and 3, 6, 12, and 24 months postoperatively. An analysis of variance and chi-square were performed to determine differences between the operative groups. Linear regression analysis was performed to evaluate the relationship between preoperative body mass index (BMI) and 25OH vitamin D and PTH levels and between percent excess weight loss and 25OH vitamin D and PTH after surgery. RESULTS: Sixty-four percent of all patients presented with vitamin D deficiency (<20 ng/ml) and 14% presented with elevated PTH preoperatively. Mean 25OH vitamin D levels and AP levels increased significantly after GBP surgery (vitamin D, 17 to 25 ng/ml 12 months post-op; AP, 80 to 90 IU/L 24 months post-op). Corrected calcium levels remained within normal limits and showed no change over time after both procedures. AP levels significantly increased from 76 IU/l preoperatively to 82 IU/l 6 months after LAGB surgery and then decreased to 59 IU/l 24 months after LAGB surgery. Linear regression analysis of preoperative vitamin D, PTH, and BMI values showed a significant positive relationship between initial BMI and PTH (r = 0.29) and a significant negative relationship between vitamin D and initial BMI (r = -0.19). A significant positive linear relationship between vitamin D and percent excess weight loss was evident 12 and 24 months after GBP surgery (r = 0.39 and 0.57, respectively). A negative relationship was evident between PTH and vitamin D 6 months after GBP surgery (r = -0.35) and 12 months after LAGB surgery (r = -0.61). CONCLUSIONS: These findings suggest that morbid obesity is associated with vitamin D deficiency, and elevated PTH and with adequate supplementation, GBP, and particularly LAGB, patients can improve their bone metabolism abnormalities related to obesity. Furthermore, adequate supplementation for GBP patients may attenuate the increased risk for bone loss associated with malabsorption from the bypass.     

Preliminary Results of the Laparoscopic Adjustable Gastric Banding Procedure by a New Generation of Silicone Band: MIDBAND

Background

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

Methods

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

Results

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

Conclusion

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

Assessment of the Outcome of Laparoscopic Nonadjustable Gastric Banding and Stoma Adjustable Gastric Banding: Surgeon's and Patient's View

Background: The results of nonadjustable gastric banding (NAGB) and stoma adjustable gastric banding (SAGB) in the treatment of morbid obesity are compared. Of 300 patients operated laparoscopically with NAGB since 1993 and of 25 with SAGB since 1994, 65 in the NAGB and 11 in the SAGB group were available for a 3-year follow-up study. Methods: For assessment of the outcome of our laparoscopic approach in terms of weight loss, length of hospitalization, immediate and late postoperative wound complications, postoperative changes in the band and pouch area, were compared in patients from both groups. The patient's opinion on the outcome of the operation and the quality of postoperative digestion was recorded. Results: There was no significant difference in the length of hospital stay and wound complication rate in the two groups or the weight loss at 36 months after surgery. There was a statistically significant lower incidence of postoperative food intolerance and vomiting and a lower rate of immediate and long-term reoperation rate in the SAGB group. Conclusion: SAGB is a method with less postoperative complications in food intolerance and vomiting in comparison with NAGB.     

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

BACKGROUND: Bariatric surgery is currently the only effective treatment for morbid obesity in terms of inducing and maintaining satisfactory weight loss and decreasing weight-related co-morbidities. A study was conducted to assess the effects, complications and outcome after laparoscopic Swedish adjustable gastric banding (SAGB) to 5 years. METHODS: Between June 1998 and December 2005, all patients with implantation of a SAGB were enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications and re-operation rate. RESULTS: SAGB was performed in 128 patients (87 female, 41 male). Mean age was 40.2 +/- 5.3 years, with mean preoperative BMI 44.5 +/- 3.9 kg/m2. Overall mortality was 0%. Patient follow-up was 94.5%. BMI after 1, 2 and 5 years was 35.7 +/- 3.7 kg/m2 (P < 0.005), 33.7 +/- 3.8 kg/m2 (P < 0.001) and 31.8 +/- 3.8 kg/m2 (P < 0.001), respectively. Mean EWL after 1, 2 and 5 years was 33.3 +/- 6.8% (P < 0.005), 45.5 +/- 6.4% (P < 0.001) and 57.4 +/- 6.5% (P < 0.001), respectively. The nonresponder rate (EWL < 30%) after 2 and 5 years was 17.0% and 6.8%, respectively. The early complication rate (< 30 d) was 6.25% (8/128), with 5 minor and 3 major complications. Late complications (> 30 d) occurred in 10.9% (14/128), of whom 2 were minor and 12 were major complications. The overall re-operation rate was 11.7% (15/128). CONCLUSIONS: At 5-year follow-up, laparoscopic SAGB is a safe and effective surgical treatment for morbid obesity. Our results appear to confirm that SAGB is a safer surgical treatment regarding rate and severity of complications compared with gastric bypass and malabsorptive procedures.     

Prospective Evaluation and 7-Year Follow-up of Swedish Adjustable Gastric Banding in Adults with Extreme Obesity

Background Swedish adjustable gastric banding (SAGB) is a widespread laparoscopic procedure in bariatric surgery. Few long-term data is available. Aim To determine long-term outcome after SAGB in 196 patients studied prospectively. Patients and Methods 196 patients, 40 men, and 156 women have been operated from 1996 to 2005. Age was 38 ± 1 (mean ± sem) years. Mean follow-up was 63 ± 2 months. Results Hospital morbidity was 3% (0.5% early reoperation); mortality was 0. Late complications were band migration (1%), leakage (5%), slipping (4%), or pouch dilatation (8%). Minor reoperations (tube replacement, port-related, and hernias) were needed in 7.5%. Cumulative major reoperation rate reached 32%. Eighteen percent had a band replacement; 14% had removal of band anatomy. Late mortality was 0.5%. Exactly 7 years after SAGB, BMI decreased from 45 ± 1 kg/m² to 33 ± 1 kg/m², and excess weight loss (EWL) was 61 ± 4%. Sixty-eight percent of the patients reached ≥50% EWL. Conclusion In 14% of the patients, the band anatomy had to be removed. Seven years of intact band anatomy leads to a successful EWL of 61 ± 4% and to EWL of ≥50% in 68%. However, cumulative major reoperation rate of 32% in 7 years makes it mandatory to offer and discuss other bariatric procedures to the respective patients. Presented at the 48th Annual Meeting of the Society for Surgery of the Alimentary Tract, Washington, DC, from May 19 to 23, 2007 and published as an abstract in Gastroenterology 2007;132:A-837.     

Modification of Gastric Banding,Using a Fundal Suture

Many forms of gastric banding have been described and high reoperation rates reported. These can be mainly attributed to excess vomiting associated both with and without stenosis. Reflux oesophagitis and the ‘sump’ effect may be other causes. This paper examines the problems associated with banding leading to revisional surgery and introduces a new technique, ‘fundal supporting suture’, to correct these problems. Preliminary results on 126 bandings without the modification and 22 with the modification are presented.     

Measurement of Functional Pouch Volume following the Gastric Bypass Procedure

Background: The cottage cheese test was developed in an attempt to find a simple way to measure functional pouch volume and to better understand the fate of the tiny proximal pouch following the gastric bypass procedure. Methods: Our patients were asked to eat cottage cheese in a structured fashion before their return visits from 3 months to 2 years postoperatively. Results: We found there was a step-wise progression of increase in functional pouch volume with statistical significance between each time interval. Also, we compared the patients' excess weight loss at 1, 2, and 3 years postoperatively to their pouch size at 1 year postoperatively. Although there is a wide range (2.5-9.0 oz) of pouch sizes at 1 year, there is no significant difference in excess weight loss between the smaller and larger pouches. Conclusions: The pouches enlarge by the orderly process of hyperplasia. Within the 2.5-9 oz volume variation, the pouch volume alone is not a predictor of weight loss. Rather, how the patient uses the pouch/tool, in addition to the other behavior modifications, determines the degree of weight loss. This data strongly suggests that the surgeon's understanding of and teaching of the optimal use of the pouch/tool may be more important than previously thought.     

Results and Complications of Laparoscopic Adjustable Gastric Banding: An Early and Intermediate Experience

Background: Laparoscopic adjustable silicone gastric banding (LASGB) has been performed as the initial procedure for weight reduction in the authors' institution for the past 22 months. The efficacy and safety of the procedure were studied. Methods: Patients were followed up prospectively during the perioperative and long-term course and for complications. Results: 391 patients, aged 16-72 years, with a mean body mass index (BMI) of 43.1 (range 33-66) were operated on. The laparoscopic procedure was completed in all but four. The mean operative time was 78 min (range 36-165), and the mean postoperative hospital stay was 1.2 days (range 1-8). There were four (1%) intraoperative complications: pneumothorax in one patient, bleeding in two patients, and injury to the stomach in one. Early postoperative complications were subphrenic abscess in two patients and band malposition in five. Of the patients operated on, 356 (91%) were available for follow-up. Over an average follow-up period of 13 months (range 1-22), band slippage occurred in 16 patients (4.1%), resistant port infection in 1, and longstanding pain in the port area in 9. There were 2 cases of port migration. A total of 26 (6.4%) reoperations were performed: early band repositioning (5), bleeding port site (1), late band repositioning (13), band removal (5), and local relocation of the port (2). All abdominal operations were performed laparoscopically. During the 18-month follow-up, the average BMI dropped from 43.1 to 29.8. Conclusion: LASGB is a safe procedure, with low early complication rates. Most reoperations may be performed laparoscopically, with subsequent low morbidity and short hospitalizations. On intermediate-term follow-up it seems to be an effective bariatric procedure.     

Impact of Laparoscopic Adjustable Gastric Banding on Obesity Co-morbidities in the Medium- and Long-Term

Background The authors evaluated the impact of laparoscopic adjustable gastric banding (LAGB) on obesity-associated diseases in a series at 3 to 8 years postoperatively, namely diabetes, pulmonary disease, hypertension and knee joint pain. Methods 145 morbidly obese patients underwent LAGB with mean age 38 years and preoperative BMI 48.5 kg/m2 (range 34–77). Changes in BMI and excess BMI loss (EBL) were evaluated. Results 138 of the 145 patients (95%) were available for full follow-up. At last follow-up, BMI had dropped to 34.0 ± 6.4 SD kg/m², and mean EBL was 61.9 ± 26.1%. Prevalence of obesity-associated disease was significantly reduced: diabetes decreased from 10% to 4%, treatment-requiring pulmonary disease from 15% to 5%, hypertension from 43% to 27%, and knee pain from 47% to 38%. Conclusion Following gastric banding, >75% of patients suffering from obesity-related disease had significant decrease or resolution of their co-morbidities.     

Comparison of Weight Loss and Morbidity after Gastric Bypass and Gastric Banding. A Single Center European Experience

Background Gastric bypass and gastric banding are widely used to treat morbid obesity and both procedures offer certain advantages. The indication for these two treatment options continue to be subject to debate. Methods A single-center case-controlled matched-pair cohort study was performed. Fifty-three primary gastric bypass patients (GB) operated between January 2002 and May 2005 were matched by gender, age, race, and initial bodyweight to 53 patients who underwent laparoscopic adjustable gastric banding (LAGB) in the same time period. Results Both groups were comparable regarding age, race, gender, preoperative body mass index, and excessive weight. Severe early complications occurred in six patients (11.3%) in the GB group and were not seen in the LAGB group. Severe late complications occurred in three patients (5.7%) in the GB group and one patient (1.9%) in the LAGB group. No mortality occurred in either group. Weight loss was significantly lower in the LAGB group than in the GB group at all time points during the follow-up. Significantly more patients were treated successfully (excess weight loss >50%) in the GB group than in the LAGB group. After 2 years, 76% of the patients in the GB group were treated successfully versus 40% of the patients in the LAGB group (P = 0.03). Conclusion Gastric bypass and gastric banding are safe and without mortality. Gastric bypass is more effective in terms of weight loss and the number of successfully treated patients. Gastric banding is a procedure with less severe complications.