Minimal-Scar Laparoscopic Adjustable Gastric Banding (LAGB)

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is the most commonly performed bariatric operation in Korea. Occasionally, patients have expressed their dissatisfaction with visible scars on the access port area and other port entries after undergoing LAGB. METHODS: Fifty-one "minimal-scar" LAGB operations were performed beginning in 2006 with a goal of minimizing visible scars, and 31 LAGB operations with a conventional port placement technique were performed previously during the first 3 years of our practice (2003-2005). We retrospectively assessed access port complications and difficulties in saline filling for band adjustment procedures using the two different port access techniques. RESULTS: Operating time, hospital stay, etc., were similar in both groups. The incidences of port complications (infection, seroma, malposition, etc.) were not increased by employing a port in the supraumbilical area using the minimal-scar LAGB technique. CONCLUSIONS: The use of minimal-scar LAGB resulted in a natural-looking and nearly invisible scar around the umbilicus. We submit that it is a feasible and attractive method that facilitates easy access for postoperative band adjustment.     

Gastric Cancer After Laparoscopic Adjustable Gastric Banding

A 63-year-old woman with BMI 46 underwent laparoscopic gastric banding. In the standardized follow-up after 14 and 24 months, the GI series and gastroscopy showed no pathological signs. The patient had hematemesis 32 months after gastric banding, followed by symptoms of obstruction, for which a laparotomy was performed. At operation, peritoneal carcinomatosis due to gastric cancer was found. Symptoms after bariatric procedures can be similar to symptoms of gastric or esophageal cancer. We believe that yearly postoperative gastroscopy is indicated to exclude pathological changes.     

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. Presented at 12th Annual Meeting of IFSO, Porto, Portugal, September 2, 2007.     

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.     

Recurrent Aspiration Pneumonia after Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding is a popular therapeutic option for morbid obesity. Band slippage, pouch enlargement and esophageal dilatation are occasional late complications of this procedure. There are rare reports of recurrent aspiration after banding. We report a 44-year-old female suffering from dysphagia and aspiration pneumonia 2 years after adjustable banding. Her esophagus was dilated to 6 cm, and videocinematography showed a severe achalasia-like disorder.Withdrawal of fluid from the band should be immediate, and relieved the stomal obstruction in this patient. Aspiration pneumonia is a serious late complication, which is easily treated by deflation of the band.     

Adjustable Gastric Banding: Advantages and Disadvantages

Background: Adjustable gastric banding has many advantages in the treatment of severe obesity. Methods: The authors report their experience with open and laparoscopic adjustable gastric banding in the treatment of severe obesity. Results: This procedure presents some risks and complications, which are described. Conclusions: Patients must be well informed about the procedure and accept a strict behavioral therapeutic pattern. Follow-up requires strict surveillance. When the band necessitates increase of pressure, follow-up must be very close in order to avoid a complica- tion that may invalidate this procedure.     

Laparoscopic Adjustable Gastric Banding for Morbid Obesity in a Patient with Situs Inversus Totalis

Laparoscopic surgery with situs inversus may pose particular challenges to the surgeon. We discuss a case of undiagnosed situs inversus totalis in a morbidly obese patient undergoing laparoscopic adjustable gastric banding (LAGB). The patient was a 29-year-old male with a body mass index (BMI) of 56. There was no prior knowledge of his situs inversus totalis, which was only discovered during laparoscopy at the time of surgery. The operative challenges are discussed. LAGB was performed successfully without complication. Postoperative imaging confirmed dextrocardia and situs inversus totalis, as well as correct gastric band position. However, there has been subsequent gastric band erosion and eventual band removal. We discuss the appropriateness of LAGB in this group of patients.     

Laparoscopic Adjustable Silicone Gastric Banding: Technique and Results

Background: Kuzmak's Adjustable Silicone Gastric Banding (ASGB) is the least invasive operation available for morbid obesity, and it is one of the more effective. Based on the know-how gained from performing more than 250 ‘open’ procedures, we have developed an original laparoscopic technique, whose main steps are pouch measurement, limited dissection along the lesser and the greater curvature and the application of the retention sutures. Methods: From September 1993 through October 1994, 30 morbidly obese patients underwent laparoscopic ASGB. Results: Mean operative time was 2 h and the post-operative stay 2-3 days. Only one major perioperative complication (stomach slippage) was observed. The weight loss achieved, reported as a variation of Body Weight, Body Mass Index, per cent Ideal Body Weight and per cent Excess Weight Loss was similar to that obtained with the open procedure. Conclusion: This new approach is a major achievement in bariatric surgery, because it combines the minimal invasiveness of laparoscopy with the reversibility and adjustability of ASGB.     

Experience with Laparoscopic Adjustable Gastric Banding (La-Band System) up to 8 Years

Morbid obesity occurs in 2-5% of the population in Western countries.

Laparoscopic adjustable silicone gastric banding is a minimally invasive, adjustable and reversible procedure for the treatment of morbid obesity.

The lap-band system was evaluated retrospectively in a series of 222 patients. Postoperative outcome and weight loss patterns at up to 8 years follow-up are presented. The most frequent late complications were a leak between the port and the catheter, which occurred in 21 patients (9,4%) and total and irreversible food intolerance due to pouch dilation and/or slippage, which occurred in 13 patients (5,8%). The postoperative BMI reductions are successful and stable after a follow-up of up to 96 months. The lap-band system seems an effective procedure for achieving appreciable and stable weight loss up to 8 years of follow-up and the complications and re-operation rates are acceptable. In 81% of the cases also, the patient is very satisfied with the results of the operation. From the 47,3% who found their quality of life before the operation bad or even devastating, 93% envoy life after the operation like never before.     

Successful Preoperative Diagnosis of a Rare Bowel Obstruction: Cecal Volvulus

Cecal volvulus is an uncommon cause of intestinal obstruction and is rarely diagnosed correctly at the time of presentation. We report a case in an 86-year-old man presented with an abrupt onset of lower abdominal distension, preoperatively diagnosed as cecal volvulus by abdominal CT. Surgery revealed a 20 cm length of the closed-loop that had rotated in a counter-clockwise rotation. A right hemicolectomy with colonic fixation was subsequently performed; early diagnosis enabled this procedure to be performed in a timely fashion. This case demonstrates the need for clinicians to consider cecal volvulus as a possible cause of acute abdomen. Performing abdominal CT studies in such patients may enable early diagnosis and prompt surgical intervention.     

Laparoscopic Adjustable Gastric Banding: A Prospective 4-Year Follow-up Study

Background: A body mass index of ≥40 kg/m² represents clinically severe obesity and warrants operative treatment if requested. The adjustable silicone gastric band and the Swedish adjustable gastric band are recently produced laparoscopic gastric restrictive devices. The aim of this study was to assess all complications linked to both the available gastric bands in a long-term follow-up. Methods: In a prospective study, the effects, complications, and outcomes of this procedure were analyzed. The complications found were divided into early and general complications, and complications correlated to the bands. The technique of laparoscopic adjustable gastric banding is described. Follow-up was performed by the operating team. Results: Between July 1994 and August 1998, the authors operated on 158 patients and performed 102 adjustable silicone gastric bandings and 54 Swedish adjustable gastric bandings. The mean age at surgery was 36 years (range 17-72). The mean preoperative weight was 136 kg (89-230). Of 158 patients who underwent laparoscopic procedures, 156(98%) could be followed up (mean 28 months; duration of follow-up, 6 weeks to 46 months). In early postoperative complications that required operation, one trocar wound hematoma (0.6%) and one wound infection of the port site (0.6%) were observed. The late complications that required reoperation were two pouch dilatations (1.3%), three band leakages (2%), one band migration (0.6%), and one late infection of the port (0.6%). A debanding operation was necessary in one patient because of esophageal dysmotility disorder. No early or late postoperative mortality was registered. The overall reoperation rate is currently about 7%. Conclusion: The operation is safe and effective. Moreover, adjustable gastric banding is fully reversible and is adjustable to the patient's needs. This study verifies the importance of correct operating technique. The authors' study and experience clearly indicate that laparoscopic adjustable gastric banding is an attractive alternative in the surgical treatment of morbid obesity.     

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.     

Small Bowel Obstruction and Internal Hernias during Pregnancy after Gastric Bypass Surgery

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB. In both patients a Petersen’s type IH was found. We reviewed the cases reported in the literature of SBO during pregnancy after RYGB. IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.     

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.     

Enterocutaneous Fistula: a Rare Complication of Laparoscopic Adjustable Gastric Banding

Morbid obesity is a refractory disease with serious co-morbidities. Laparoscopic adjustable gastric banding (LAGB) has generally been a safe and effective method for achieving sustained weight loss. We report a man who presented after LAGB with persistent wound infection at the access port-site, which failed conservative management. Diagnostic laparoscopy found an enterocutaneous fistula from herniated bowel (in a Richter's hernia) into which the catheter had eroded. The small bowel and fascial defect were repaired. The catheter was then clipped and divided, and the port was removed.     

Abdominal Actinomycosis: a Rare Complication after Laparoscopic Gastric Bypass

A 33-year-old, morbidity obese woman underwent a laparoscopic Roux-en-Y gastric bypass in November 2004. She presented 18 months later with a history of recurrent pain in the upper region of the abdomen and severe vomiting. Radiologic and endoscopic evaluations revealed wall thickening in the transverse colon and a solid tumor near the liver. Therefore, a sonography-guided biopsy of the tumor was performed. Cytopathological examination revealed actinomycosis. Thus, therapy with penicillin was started, after which the parameters associated with the infection decreased. The symptoms persisted, however, and the decision was made to operate on the patient to resect the abdominal masses. Nearly 90% of the masses could be removed. Histological analysis showed a fibro-productive inflammation with an actinomycotic etiology. Antibiotic therapy with penicillin was continued for 6 months. Actinomycosis must be considered in the differential diagnosis of patients with abdominal mass, wall thickening of the intestine, and other such symptoms, including abdominal pain following bariatric surgery, even many years after the intervention.     

Comparison of Recovery Time after Open and Laparoscopic Gastric Bypass and Laparoscopic Adjustable Banding

Background: Laparoscopy is believed to reduce recovery time and patient discomfort following bariatric surgical operations. This study tests that hypothesis. Methods: 60 randomly selected bariatric surgery patients, consisting of 20 open Roux-en-Y gastric bypass (RYGBP), 19 lap RYGBP, and 21 laparoscopic adjustable banding, were studied. Outcome measures including hospital length of stay (LOS), days to return to normal activity, days to surgical recovery, and pain medication usage were defined by the patients' subjective responses to a retrospective questionnaire. Overall differences among the three surgeries were first determined using the Kruskal-Wallis test, and then individual comparisons were made between each of the three pairs of operations using a Wilcoxon rank-sum test when a significant difference existed. Results: Patients reported an average LOS of 3.45 days following open RYGBP, 2.47 days following lap RYGBP, and 1.33 days following Lap-Band? surgery. There was little difference in return to normal activity, with open RYGBP patients reporting a 17.55 day delay in return to normal activity, and lap RYGBP reporting an 18.16 day delay. In contrast, Lap-Band? patients responded that the delay was only 7.24 days. Days to recovery were reported to be 29.05 for open RYGBP patients, 21.68 for lap RYGBP patients and 15.81 for Lap-Band? patients. Hospital days (P=0.0002), days to normal activity (P=0.0115), and days to recovery (P<0.0001) differed significantly among the surgery types. Lap and open RYGBP did not differ significantly regarding days to resumption of normal activities. Open RYGBP and banding differed significantly regarding days to recovery (P <0.001). Conclusions: Lap-Band? patients returned to normal activity levels earlier than gastric bypass patient's irrespective of approach. Lap-Band? patients also reported recovering from surgery significantly sooner than open RYGBP patients. Perceived differences in recovery time between open and laparoscopic RYGBP patients did not affect their time to resumption of normal activity.     

Laparoscopic Adjustable Gastric Banding in 1,791 Consecutive Obese Patients: 12-Year Results

Background This study examines 1,791 consecutive laparoscopic adjustable gastric banding (LAGB) procedures with up to 12 years follow-up. Long-term results of LAGB with a high follow-up rate are not common. Methods Between September 1993 and December 2005, 1,791 consecutive patients (75.1% women, mean age 38.7 years, mean weight 127.7 ± 24 kg, mean BMI 46.2 ± 7.7) underwent LAGB by the same surgical team. Perigastric dissection was used in 77.8% of the patients, while subsequently pars flaccida was used in 21.5% and a mixed approach in 0.8%. Data were analyzed according to co-morbidities, conversion, shortand long-term complications and weight loss. Fluoroscopy-guided band adjustments were performed and patients received intensive follow-up. The effects of LAGB on life expectancy were measured in a case/control study involving 821 surgically-treated patients versus 821 treated by medical therapy. Results Most common baseline co-morbidities (%) were hypertension (35.6), osteoarthritis (57.8), diabetes (22), dyslipidemia (27.1), sleep apnea syndrome (31.4), depression (21.2), sweet eating (22.5) and binge eating (18.5). Conversion to open was 1.7%: due to technical difficulties (1.2) and due to intraoperative complications (0.5).Together with the re-positioning of the band, additional surgery was performed in 11.9% of the patients: hiatal hernia repair (2.4), cholecystectomy (7.8) and other procedures (1.7). There was no mortality. Reoperation was required in 106 patients (5.9%): band removal 55 (3.7%), band repositioning 50 (2.7%), and other 1 (0.05%). Port-related complications occurred in 200 patietns (11.2%). 41 patients (2.3%) underwent further surgery due to unsatisfactory results: removal of the band in 12 (0.7%), biliopancreatic diversion in 5 (0.27%) and a biliopancreatic diversion with gastric preservation (“bandinaro”) in 24 (1.3%). Weight in kg was 103.7 ± 21.6, 102.5 ± 22.5, 105.0 ± 23.6, 106.8 ± 24.3, 103.3 ± 26.2 and 101.4 ± 27.1 at 1, 3, 5, 7, 9, 11 years after LAGB. BMI at the same intervals was 37.7 ± 7.1, 37.2 ± 7.2, 38.1 ± 7.6, 38.5 ± 7.9, 37.5 ± 8.5 and 37.7 ± 9.1. The case/control study found a statistically significant difference in survival in favor of the surgically-treated group. Conclusions LAGB can achieve effective, safe and stable long-term weight loss. In experienced hands, the complication rate is low. Follow-up is paramount. Presented at the 11th World Congress of the International Federation for the Surgery of Obesity, Sydney, Australia, September 1, 2006.     

Drain-Associated Intestinal Obstruction after Laparoscopic Gastric Bypass

A rare cause of intestinal obstruction after laparoscopic Roux-en-Y gastric bypass (RYGBP) is reported. A 42-year-old woman developed nausea, vomiting and dilated loops of small bowel upon commencing oral intake the day after RYGBP surgery. A CT scan demonstrated a loop of bowel twisting around the abdominal drainage catheter. After removal of the catheter, the patient’s symptoms immediately resolved and her subsequent course was uneventful. We suggest avoidance of drainage catheters after uncomplicated laparoscopic RYGBP.     

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.