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.     

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/m² to 41.5 kg/m². 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.     

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.     

Patient and Parent Perspectives of Adolescent Laparoscopic Adjustable Gastric Banding (LAGB)

Background

Adolescent obesity is a significant global health challenge and severely obese adolescents commonly experience serious medical and psychosocial challenges. Consequently, severe adolescent obesity is increasingly being treated surgically. The limited available research examining the effectiveness of adolescent bariatric surgery focuses primarily on bio-medical outcomes. There is a need for a more comprehensive understanding of the behavioural, emotional and social factors which affect adolescents’ and parents’ experience of weight loss surgery.

Methods

Patient and parents’ perspectives of adolescent LAGB were examined using a qualitative research methodology. Individual, semi-structured interviews were conducted with eight adolescent patients and five parents. Thematic analysis was used to identify key themes in the qualitative data.

Results

Patients and parents generally considered adolescent laparoscopic adjustable gastric banding (LAGB) to be a life-changing experience, resulting in physical and mental health benefits. Factors considered to facilitate weight loss following surgery included parental support and adherence to treatment guidelines. Many adolescents reported experiencing surgical weight loss stigma and challenging interpersonal outcomes after weight loss for which they felt unprepared.

Conclusions

Patients and parents perceived LAGB positively. There are opportunities to improve both the experience and outcomes of adolescent LAGB through parental education and enhancements to surgical aftercare programmes.

     

Reduction in Co-morbidities 4 Years after Laparoscopic Adjustable Gastric Banding

Background: We investigated the reduction in co-morbidities following laparoscopic adjustable silicone gastric banding (LAGB). Methods: Between December 1996 and October 2002, 295 patients with mean BMI 45 kg/m² were operated (79% women, average age 41 years). Mean follow-up was 44 months. Reduction in co-morbidity was scaled relative to the preoperative co-morbidity level as having been cured, improved, unchanged, or worsened. Patients needing reoperations were analyzed separately. Results: The preoperative frequencies of co-morbidities were as follows: hypertension 52%, diabetes 20%, dyspnea 85%, peripheral edema 63%, sleep apnea 36%, arthralgia 89%, reflux 57%, reduced selfesteem 95%, reduced general physical performance 96%, hyperlipidemia 39%, hyperuricemia 36%, and menstrual problems 22%. Excess weight loss after 1 year was 40%, after 2 years 46%, after 3 years 47%, and after 4 years 54%. After 4 years, the rate of cure/improvement of the co-morbiditites were: hypertension 58% / 42%, diabetes 75% / 8%, dyspnea 85% / 12%, arthralgia 52% / 24%, reflux 79% / 11%, self-esteem 45% / 39%, and general physical performance 58% / 33%. We also found an improvement in stress incontinence, sleep apnea, peripheral edema, and regulation of menstruation. Greater weight loss was associated with greater reduction in dyspnea, arthralgia, self-esteem, and physical performance. Hypertension, diabetes, reflux, and edema improved independent of the amount of weight loss. Reoperated patients undergoing either rebanding or biliopancreatic diversion with duodenal switch had similar weight loss and reduction in co-morbidities as did patients treated with LAGB only. Conclusion: With moderate weight loss following LAGB, co-morbidities were cured in 50-80% or improved in 10-40% of all patients.     

Laparoscopic Adjustable Silicone Gastric Banding vs Laparoscopic Vertical Banded Gastroplasty in Morbidly Obese Patients: Long-Term Results of a Prospective Randomized Controlled Clinical Trial

Background  Aim of the study is to present long-term results of a prospective randomized single-institution clinical trial comparing laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbid obesity. Methods  A total of 100 morbidly obese patients (body mass index 40 to 50 kg/m²) were randomized to LASGB (n = 49) or LVBG (n = 51) and followed up for a minimum of 7 years. Results  Mean operative time was 65.4 min in LASGBs and 94.2 min in LVBGs (p < 0.05); mean hospital stay was 3.7 and 6.6 days, respectively (p < 0.05). Late complication rates were 36.7% in LASGBs vs 15.7% in LVBGs at 3 years (p < 0.05), 46.9% vs 43.1% at 5 years (NS), and 55.1% vs 47.1% at 7 years (NS). Late reoperation rates were 28.6% in LASGBs and 2.0% in LVBGs at 3 years (p < 0.001), 38.8% and 2.0% at 5 years (p < 0.001), and 46.9% and 7.8% at 7 years (p < 0.001). Excess weight loss in LASGBs was 41.8% at 3 years, 33.2% at 5 years, and 29.9% at 7 years; excess weight loss in LVBGs was 60.9%, 57%, and 53.1%, respectively (p < 0.05). Conclusions  This study demonstrates that in a carefully selected group of patients, LVBG is significantly more effective than LASGB in terms of late complications, late reoperations, and long-term results on weight loss.     

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.     

Long-Term Pulmonary Complications after Laparoscopic Adjustable Gastric Banding

Early pulmonary complications following laparoscopic adjustable gastric banding (LAGB) have been rare, while long-term pulmonary complications have not been reported. Herein, we report two patients who presented 2 and 3 years after LAGB with unexpected pulmonary complications. The first patient had aspiration pneumonia secondary to stomal obstruction and esophageal reflux. The second patient had left lobar pneumonia, in which the connecting catheter appeared as a linear structure within the consolidation. This may be due to migration of the connecting catheter through the diaphragm, piercing lung parenchyma. Both complications presented as asthma-like symptoms. Diagnosis could have been missed if not evaluated properly. A high index of suspicion and long-term follow-up are important for diagnosing such complications after LAGB.     

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.     

Development of a Measure of Barriers to Laparoscopic Adjustable Gastric Banding (LAGB) Aftercare Attendance

Background

Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been thoroughly explored. The aim of the current study was to describe the scale development, explore the factor structure and evaluate the psychometric properties of the Gastric Banding Aftercare Attendance Questionnaire (GBAAQ)—a tool that measures barriers to aftercare attendance in LAGB patients.

Methods

One hundred and eighty-three participants completed the GBAAQ; 107 regular attendees and 76 non-attendees.

Results

A factor analysis identified four factors (Treatment Approach, Time Constraints, Stress and Pressures, Uncomfortable Participating) that demonstrated good known-groups validity and internal consistency.

Conclusions

Although further validation is needed, the results of the present study provide preliminary support for the validity of the GBAAQ. Knowledge about the barriers to LAGB aftercare attendance can be used to identify those most at risk of non-attendance and can inform strategies aimed at reducing non-attendance.

     

Disruption of the Leptin-Insulin Relationship in Obese Men 24 Hours after Laparoscopic Adjustable Silicone Gastric Banding

Background:The placement of a band to attain a tiny stomach pouch has been reported to produce early satiety in patients undergoing gastric banding. The adipocyte-derived hormone, leptin, has been shown to decrease both food intake and body weight. The aim of the present study was to assess the potential involvement of acute changes in leptin concentrations following laparoscopic adjustable silicone gastric banding (LASGB). Methods:The study groups comprised obese male patients undergoing bariatric surgery by LASGB and overweight men undergoing laparoscopic Nissen fundoplication (NFd). Blood was drawn before surgery and 24 hours postoperatively for glucose, insulin and leptin measurements. Results: In both experimental groups, a statistically significant decrease was observed in pre- and postsurgery glucose (LASGB 111 ± 8 vs 99 ± 6 mg/dl, P<0.01; NFd 107 ± 7 vs 98 ± 5 mg/d, P<0.01) and insulin concentrations (LASGB 39.8 ± 11.9 vs 32.9 ± 10.3 U/l, P<0.01; NFd 13.2 ± 3.3 vs 12.2 ± 2.9 U/l, P<0.05). However, no significant differences were observed when the percent change from pre-surgery values was analysed between both groups. Following surgery, an increase in leptin concentrations was observed in the LASGB group (23.5 ± 4.7 vs 37.5 ± 6.8 μg/l, P<0.001) whereas a small decrease was evident in the NFd patients (12.9 ± 4.6 vs 8.9 ± 2.2 μg/l, P<0.01). Conclusion: These findings strongly suggest that the short-term increase observed in plasma leptin concentrations following LASGB may play a key role in triggering an early satiety signal due to the modi fication of the gastrointestinal anatomy and physiology.     

Laparoscopic Placement of Adjustable Silicone Gastric Banding: Early Experience

Background: the authors describe a laparoscopic technique for the positioning of stoma adjustable silicone gastric banding (SASGB), which respects the main steps of the open procedure. Methods: (1) patient position: supine with thighs abducted and 30° reverse Trendelenburg; (2) Four 10 mm trocars (supra-umbilical, sub-xiphoid, right upper quadrant, left upper quadrant) and an 18 mm trocar (left subcostal); (3) exposure of the subcardial area; (4) measurement of the pouch; (5) dissection of the lesser and greater curvatures; (6) retrogastric tunnel; (7) introduction and placement of the band; (8) band closure and stoma calibration; (9) retention sutures. Results: results obtained in a first (1992) series of five patients who underwent the laparoscopic application of the regular SASGB and results of a second series (1993-1994) of seven patients in whom the new LAP-ASGB was utilized are reported. Conclusion: this new approach can represent a major achievement in bariatric surgery, as it combines the minimal invasiveness of the laparoscopic approach with the reversibility of SASGB.     

Outcomes of Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding in Adolescents

Background

The goal of this study is to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese adolescents.

Methods

We performed a retrospective review of all adolescents between the ages of 15 and 19 who underwent LAGB or LRYGB at our university affiliated Bariatric Center of Excellence from 2002 to 2011. Postsurgical weight loss at 1, 3, 6, 12, 18, and 24?months was noted and expressed as percentage of excess weight loss (% EWL).

Results

Thirty-two patients underwent LRYGB and 23 underwent LAGB. The LAGB group was younger (18.6?±?0.6 versus 17.2?±?1.5) than the LRYGB group. Other preoperative demographic factors including body mass index, gender, ethnicity, and comorbidities were similar between the two groups. The average % EWL was superior in the LRYGB group compared to the LAGB group at all time points studied (p?<?0.05), although at 2-year follow-up, only 16?% (5/32) LRYGB and 30?% (7/23) LAGB patients were available for follow-up. Three patients with type II diabetes mellitus underwent LRYGB and all experienced remission of their diabetes. The number of complications requiring interventions was similar between the two groups.

Conclusions

In our study, adolescents undergoing LRYGB achieved superior weight loss compared to LAGB in the short-term follow-up. The complication rate for LAGB was similar compared to LRYGB. More studies are needed to monitor the long-term effects of these operations on adolescents before definitive recommendations can be made.     

Outpatient Laparoscopic Adjustable Gastric Banding in Super-obese Patients

Background Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity that is well suited to outpatient surgery. Super-obese patients (BMI ≥50) are often viewed as higher risk patients, with their surgical procedures limited to hospital operating-rooms. We report our experience performing LAGB for super-obese patients in a freestanding ambulatory surgery center and describe the program elements that make this feasible and safe. Methods Database records containing 1,780 consecutive patients from program inception (November 2002 to November 2006) were searched for patients with a BMI >49.9 undergoing an outpatient LAGB and reviewed to identify complications. Results 320 super-obese patients underwent an outpatient LAGB.Mean preoperative weight was 155.2 kg (range 112.3–220.5 kg), and mean BMI was 55.4 kg/m² (range 50.0–71.1 kg/m²). 53 patients (16.6%) had BMI >60. There were no deaths, significant cardiopulmonary complications, significant intraoperative bleeding, conversion to open laparotomy, or hospital admissions. 3 patients (0.1%) developed gastric edema causing transient obstruction, and 1 developed a delayed colon perforation from electrocautery incurred during adhesiolysis. No complication arose or was more difficult to manage as a result of the procedure being done on an outpatient basis. Conclusions Outpatient LAGB can be safely performed in super-obese patients with a complication rate similar to lower BMI patients. Patient selection and preoperative preparation are essential to achieve excellent outcomes. The decision to offer an outpatient LAGB should rest on the overall physiological condition rather than BMI or weight alone.     

Laparoscopic Staged Adjustable Gastric Banding and Liver Resection in Morbidly Obese Patient

We report the case of a 34-year old morbidly obese female, with a history of polycystic ovarian syndrome and birth control pill therapy, who underwent laparoscopic gastric banding. On laparoscopic exploration, a 4-cm liver neoplasm that was missed by preoperative ultrasound was incidentally found. The intraoperative biopsy was suggestive for a benign lesion of hepatocellular origin but could not make the differential diagnosis between focal nodular hyperplasia and adenoma. The neoplasm had atypical features on postoperative magnetic resonance imaging and was suggestive of liver adenoma. Six months after laparoscopic gastric banding, the patient presented with a weight loss of 24 kg and consented to liver resection. A laparoscopic resection of liver segment 3 was performed. Atypical liver neoplasms are subject to potential degeneration, rupture, and bleeding; therefore, they should be treated surgically to allow final diagnosis and potential cure of the disease. In this case, a staged approach was effective in obtaining substantial weight loss and a lesser degree of liver steatosis to enable the performance of a laparoscopic liver resection.     

Laparoscopic Adjustable Silicone Gastric Banding (Lap-Band®): How To Avoid Comlications

Background: The laparoscopic application of LAPBAND is gaining widespread acceptance as a gastric restrictive procedure. At the same time the reported morbidities (i.e., gastric perforation, stomach and/or band slippage) are cause for some concern. Methods: From September 1993 until May 1997, 260 patients underwent LAP-BAND at the Department of Surgery at the University of Padova, Italy. Results: The mortality rate was zero and the morbidity rate requiring reoperation was 3.4% (stomach slippage, gastric perforation, erosion). In order to avoid complications the key points of the technique are reviewed: (1) reference points for dissection (equator of the balloon, left crus); (2) retrogastric tunnel within the layers of the phrenogastric ligament; (3) embedment of the band; (4) proper outlet calibration; and (5) retention sutures. Conclusions: Attention to technical details is of paramount importance for a safe, standardized and effective operation.     

Changes in Body Image Disturbance in Morbidly Obese Patients 1 Year after Laparoscopic Adjustable Gastric Banding

Background The effectiveness of post-surgical weight loss in improving body image disturbance (BID) in morbidly obese patients is still unclear. Providing multidimensional measures of BID and controlling for the effect of co-morbid eating psychopathology may help to clarify this issue. This preliminary study explores whether 1) BID improves 1 year after laparoscopic adjustable gastric banding (LAGB), and whether 2) such improvement is related to post-surgical BMI and/or eating disorder reduction. BID was multidimensionally assessed by means of the Body Uneasiness Test(BUT). Methods 35 obese subjects (mean BMI 45.5) were evaluated prior to and 1 year after LAGB using the BUT, and a standardized interview and questionnaire to assess eating psychopathology. BID and eating habit changes during follow-up were also investigated. Postoperative BUT values were entered as outcome measures (dependent variables) in a series of stepwise multiple regression analyses; BMI and binge eating reduction, baseline BUT scores, gender, age, and age of onset of obesity were tested as independent variables. Results Some aspects of BID (body image overconcern and related avoidance behaviors, compulsive self-monitoring, and overall severity of BID) improved following LAGB, while others (weight phobia, depersonalization, and uneasiness toward body parts) did not. The post-surgical lower levels of the former were predicted by the overall decrease in binge eating symptoms, irrespective of BMI reduction, age, gender, and age of onset of obesity. Conclusions LAGB may ameliorate some BID aspects in morbidly obese patients, and an improvement in eating behaviors may contribute to this effect.     

Stoma Adjustable Silicone Gastric Banding: Results in 111 Consecutive Patients

From April 1990 through December 1992, 111 patients (80 females, 31 males, mean age 38 years, range 16-60) underwent stoma adjustable silicone gastric banding (SASGB) at the Department of Surgery, University Hospital, Padua, Italy. Patients' characteristics were: mean height 166 ± 8 cm; mean body weight (BW) 129.1 ± 21.6 kg; mean body mass index (BMI) 46.4 ± 6.3 kg/m²; mean percentage of ideal body weight (%IBW) 206.2 ± 27. Eighty-eight patients were morbidly obese and 23 super obese. All patients were available for follow-up. Median follow-up was 18.8 months (range 12-44). At 1 year (103 patients), mean postoperative BW, BMI, %IBW and excess weight lost (%EWL) were 101.5 ± 20 kg, 36.5 ± 6 kg/m², 164 ± 30 and 40.8 ± 19 respectively; at 2 years (58 patients) 92.3 ± 19 kg, 33.1 ± 6 kg/m², 148.8 ± 28, 52 ± 23, respectively, and at 3 years (26 patients) 86.9 ± 14 kg, 31.4 ± 5 kg/m², 141.5 ± 25 and 63.6 ± 20 respectively. The overall postoperative mortality rate was zero and the early morbidity rate 9%. Late complications were band slippage (two patients), stoma stenosis with pouch dilatation (seven patients), band erosion (one patient), reservoir leakage (three patients) and reservoir infection (two patients). Surgical revision was performed in ten (9%) patients, two of whom required band removal. Most complications occurred in patients who underwent SASGB during our initial experience. Our findings confirm that SASGB is a safe and effective surgical means of achieving weight reduction.