A Mid-term Experience with the Cousin Bioring—Adjustable Gastric Band

Background  

Since March 2003, we have used the Cousin Bioring in our laparoscopic gastroplasty procedures for morbid obesity. The Bioring belongs to the new generation of adjustable gastric bands. The aim of this study is to review our experience with this particular type of band.     

Adjustments and Leak Detection of the Adjustable Silicone Gastric Band (ASGB) and Lap-Band™ Adjustable Gastric Band (LAGB) System

Background: The detection of a leakage in the system of the adjustable silicone gastric band (ASGB) may be difficult. Gastrografin injection into the port should be avoided because it acts like a glue and blocks the system. Methods: A syringe containing saline and a syringe containing Thallium-201 chloride is connected to the 4-way stopcock which is connected to the needle. The needle is pushed into the port. The position is confirmed by injection and aspiration of saline. 2 ml of TL-201 chloride (74 MBp) is injected to locate the leakage in the system with planar images with a gamma camera (Elscint SP 6), 30 min, 2, 3, and 24 h after injection. Results: The original ASGB was provided with an injection reservoir which, in our series, was found to be leaking in four cases (3%). Conclusions: Our technique for adjustments and leak detection appears to be simple and effective. Band-related problems such as reservoir leak should disappear with improvement of the material.     

Perioperative Comparison of the MiniMizer ® Extra Band with the Other Laparoscopic Gastric Bands

Background: Laparoscopic adjustable gastric banding is a widely used operation for morbid obesity. The most frequent complications of this operation are band migration and pouch dilatation (slippage). The use of the newly introduced MiniMizer^? Extra band with a unique gastric wall fixation system and a two-degree closure may decrease the postoperative complication rate. Very early (perioperative) results are hereby reported. Methods: From February 2005 through October 2005, 50 classical bands (Obtech-Ethicon, AMI, Midband, Inamed) and 10 MiniMizer^? Extra bands were inserted in our department. Bands were chosen randomly. Complications in the very early postoperative period were studied. Results: No statistically significant differences between surgery times were noted – classical bands mean 36 min (20-60), and MiniMizer^? Extra bands mean 34 min (25-55). No statistically different rates of perioperative complications were noted, with only 2 very minor intraoperative complications in the entire series. Conclusions: The absence of problems in the perioperative period allows the use of the MiniMizer^? Extra band as an alternative to classical bands for short- and long-term comparison.     

Histologic Study of Tissue Reaction to the Gastric Band: Does it Contribute to the Problem of Band Erosion?

Background: One of the major complications of gastric banding is intragastric migration of the band. The frequency ranges from 0.5% to 3.8%, and removal of the band is always required. We undertook a prospective study with the aim to determine the reasons for this significant complication in bariatric surgery. Methods: 480 morbidly obese patients underwent adjustable gastric banding in our Surgical Department, from February 1998 to October 2005. 31 of them were reoperated for different surgical problems, at an average time of 39 months after the bariatric procedure. During the reoperation, some fragments of fibro-adipose tissue in close contact with the band were removed. They were examined, focusing on the following parameters: acute and chronic inflammation, fibrosclerosis, and foreign body granulomatous reaction. Results: Histological assessment showed the presence of acute and chronic inflammation, generally of mild and medium grade; fibrosclerosis was present mostly in a severe form, indicating a biological periprosthesic wall that separates and protects the gastric wall from the band; no cases of foreign body reaction were observed, nor were silicone inclusions found inside the inflammatory cells. Conclusion: The histologic changes of periprosthesic tissue do not appear to account for endoluminal migration of the gastric band. Thus, band erosion could have a closer correlation with other causes, such as infection of the band or intraoperative surgical damage, possibly due to direct mechanical action or to the thermal effect of the electric scalpel.     

3-Year Real-World Outcomes with the Swedish Adjustable Gastric Band™ in France

The study objective was to ascertain outcomes with the Swedish adjustable gastric band (SAGB) on an intention-to-treat basis in multiple centers across the French social health insurance system. SAGB results at 3-year follow-up are reported. The noncomparative, observational, prospective, consecutive cohort study design sought a 500-patient minimum recruitment geographically representative of continental France. Safety (adverse events [AEs], device-related morbidity, and mortality) and effectiveness (change in body mass index [BMI, kilograms per square meter], percentage excess weight loss, comorbidities, quality of life [QoL]) were assessed. Adjustable gastric band survival was calculated. Thirty-one surgeons in 28 multidisciplinary teams/sites enrolled patients between September 2, 2007 and April 30, 2008. SAGB was successfully implanted in 517 patients: 88.0 % female; mean age, 37.5 years; obesity duration, 15.3 years (baseline: mean BMI, 41.0; comorbidities, 773 in 74.3 % of patients; Bariatric Analysis and Reporting Outcome System (BAROS), 1.4; EuroQoL 5-Dimensions (EQ-5D), 0.61; EuroQoL–visual analog scale (EQ–VAS), 52.3). At 3 years: BMI, 32.2 (mean change, ?9.0; p?<?0.0001); excess weight loss, 47.4 %; comorbidities, 161 in 27.2 %; BAROS, 3.6 (+2.2, p?<?0.0001); EQ-5D, 0.84 (+0.22, p?<?0.0001); EQ–VAS, 73.4 (+21.4, p?<?0.0001). SAGB-induced weight loss was associated with substantially improved QoL. One death occurred and was unrelated to the treatment. No AE was reported in 68.3 % of patients, and no confirmed device-related AE in 77.0 %. Overall AE rate was 0.19 per patient year. Device retention was 87.0 %. Analysis of patients lost to follow-up showed a nonsignificant effect on overall study results. In a prospective, consecutive cohort, “real-world”, nationwide study, the Swedish Adjustable Gastric Band was found safe and effective at 3-year follow-up.     

Quality of Life following Laparoscopic Adjustable Gastric Banding – the Swedish Band and the Moorehead-Ardelt Questionnaire

Background: Although weight loss is an important immediate outcome after gastric banding operations, quality of life (QOL) has been shown to be an equally important outcome measure. Methods: From 1996 to May 2002, 125 consecutive patients have been operated laparoscopically for morbid obesity at our institution with the Swedish Adjustable Gastric Band (SAGB). We compared the Moorehead-Ardelt QOL scores of the first 60 patients, operated at a median of 2 years earlier, with a group consisting of the following consecutive 65 patients, who answered the questionnaire preoperatively. Results: The QOL scores among the operated patients were significantly better (P<0.0001, unpaired t-test) on all domains of the Moorehead-Ardelt questionnaire compared to those not yet operated. Conclusions: Laparoscopic banding with the SAGB has been a safe procedure, with satisfactory weight loss and significant improvement in QOL scores 2 years postoperatively.     

Gastric Emptying is not Affected by Sleeve Gastrectomy—Scintigraphic Evaluation of Gastric Emptying after Sleeve Gastrectomy without Removal of the Gastric Antrum

Background  The aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying. Methods  Gastric emptying scintigraphy was performed before and 3 months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5 mCi Tc⁹⁹-labeled sulfur colloid had been added. The meal was consumed within 10 min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240 min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc^99m decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4 h). Results  The mean T 1/2 raw data was 62.39 ± 19.83 and 56.79 ± 18.72 min (p = 0.36, t = −0.92, NS) before and 3 months after LSG, respectively. The T 1/2 linear was 103.64 ± 9.82 and 106.92 ± 14.55, (p = 0.43, t = −0.43, NS), and the linear fit slope 0.48 ± 0.04 and 0.47 ± 0.05 (p = 0.48, t = 0.7, NS). Conclusions  LSG with antrum preservation as performed in this series has no effect on gastric emptying. This work was performed in partial fulfillment of the requirements for a MSc degree of Ronit Tzioni Yehoshua, Sackler Faculty of Medicine, Tel Aviv University, Israel.     

Laparoscopic Repositioning of Heliogast® Gastric Band after Anterior Slippage

Background: Gastric slippage is a well-described complication of gastric banding. The Heliogast? band is equipped with a locking mechanism that enables its straightforward reopening and repositioning. Our experience with Heliogast? band salvage after anterior slippage is reported. Methods: The study sample comprised 418 consecutive patients who underwent 2-step laparoscopic gastric banding with the Lap-Band? first (n=235) followed with the Heliogast? band (n=183). Gastric slippage was diagnosed by symptoms of dysphagia and vomiting and was confirmed with Gastrografin? swallow. Patients who did not respond to conservative treatment were laparoscopically reoperated. In the Heliogast? group, the band was dissected free, unlocked, and repositioned. In the Lap-Band? group, when reopening proved impossible, the band was removed with or without replacement. Results: 10 patients (2.4%) underwent reoperation for anterior slippage, 5 with a Lap-Band? (2.1%) and 5 with a Heliogast? band (2.7%). Band repositioning was feasible in all 5 patients in the Heliogast? group, but in only one of the patients in the Lap-Band? group; in the others, the band was removed. Band repositioning was confirmed radiologically. No postoperative complications were recorded, and all patients were discharged on the first day after surgery. At a median 10 months' follow-up after Heliogast? repositioning, all patients had satisfactory weight loss. Conclusion: Laparoscopic Heliogast? band salvage after anterior slippage is comparatively simple and safe, with excellent postoperative results and no interference with continued weight loss. This constitutes an important means of management for the bariatric surgeon.     

A Rodent Model of Adjustable Gastric Band Surgery—Implications for the Understanding of Underlying Mechanisms

Background  Bariatric surgery is currently the only anti-obesity therapy that can deliver weight loss of up to 20–30% of body weight. Laparoscopic adjustable gastric banding (LAGB) and Roux-en-y gastric bypass are the most commonly performed of these surgeries. The mechanisms by which LAGB initiates an increase in satiety remain completely unknown. The aim of this study is to establish a rodent model of adjustable gastric banding (AGB) that will enable investigation of these mechanisms. Methods  Sprague–Dawley rats were implanted with adjustable gastric bands immediately below the gastro-esophageal junction around the glandular stomach. This band, as in humans, can be inflated via an exteriorized port resulting in an incremental impact on the stomach. Results  Rats with an incremental inflation of the AGB showed a clear stepwise reduction in food intake and body weight. Normal food intake and body weight gain were restored with band deflation. Barium-assisted X-ray of the stomach showed the formation of a small gastric pouch proximal to the inflated band in a manner analogous to the human LAGB. Conclusions  This is the first animal model of the AGB that allows incremental inflation for optimal tightening of the band in the conscious animal with corresponding effects on food intake and body weight. This model will allow measurement of acute and chronic neural and hormonal changes following activation of the band in the conscious animal and will provide the potential to inform and improve surgical approaches that are at the forefront of obesity treatments.     

Outcome after Laparoscopic Adjustable Gastric Banding, Using the Lap-Band® and the Heliogast® Band: A Prospective Randomized Study

Background: A study was performed to assess the usefulness and efficacy of a new type of band (Heliogast?) for laparoscopic adjustable gastric banding (LAGB) for the treatment of morbid obesity, compared with the Lap-Band?. Method: From January to May 2001, a prospective randomized study of 60 LAGB procedures was conducted: group I (n=30), the Lap-Band? system (INAMED); group II (n=30), the Heliogast? band (Hélioscopie). We implanted the devices using the 2-step technique (pars flaccida to peri-gastric) by laparoscopy. Port systems were placed on the rectus sheath and were fixed by non-absorbable sutures. Follow-up of all patients was a minimum of 12 months. Results: There were no differences in operating-time, intra-operative complications, or weight loss during the first 4 weeks after surgery. However, with increasing time, more complications with the Heliogast? band and differences in weight loss favoring the Lap-Band? became significant. Conclusion: Based on the results of this study, we recommend that new bands have independent clinical evaluation before commercialization.     

Band Slippage – a Potentially Life-Threatening Complication after Laparoscopic Adjustable Gastric Banding

Background: Although gastric bands are safe and effective devices, severe late complications may develop in rare cases. Patients: 3 patients were treated for complete dysphagia after slippage of gastric bands. 2 of the patients were admitted for severe dehydration, 1 of whom developed cerebral venous infarction. Ischemia of the gastric pouch occurred in 1 patient. Results: All 3 patients survived after successful medical therapy and surgical removal of the bands. Bariatric reoperations were performed in 2 patients (gastric sleeve resection, gastric bypass). Conclusion: Complete dysphagia on the basis of band slippage represents a life-threatening acute event, which may occur even years after implantation. Patients and doctors should be informed about this long-term risk of gastric banding.     

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.     

Two Hundred Seventy-Five Single-Incision Laparoscopic Gastric Band Insertions: What Have We Learnt?

Single-incision surgery in the morbidly obese patient has not been widely adopted, but remains a popular choice amongst patients. In the bariatric patient, it presents its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here, we present our experience of 275 single-incision laparoscopic gastric bands.Between June 2009 and April 2013, 275 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single incision using a multichannel single port and via a pars flaccida approach. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken.In this series, median operative time was 60 (range 34–170)?min. An additional port was placed in 15 patients (5 %), including two conversions to four-port technique (0.7 %). Of these patients (n?=?15), the majority were male (p?<?0.0001). Reasons for additional port placement included bleeding and anatomical abnormalities. Additional port placement occurred more often within the first 50 cases (5/50, 10 % vs 10/225, 4 %). An umbilical incision resulted in more wound-related complications than a transverse incision in the upper abdomen (p?<?0.001). There were no 30-day mortality and minimal morbidity with two wound infections resulting in band removal.Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity in the morbidly obese patient, and our technique has a high rate of success for all BMIs. Following 275 single-incision band insertions additional port placements were more commonly required in male patients, BMI >45 and earlier in the learning curve.     

Metastatic Adenocarcinoma of the Gastric Pouch 5 Years After Roux-en-Y Gastric Bypass

A 65-year-old male presented 5 years after Roux-en-Y gastric bypass (RYGBP) with cancer of the gastric pouch. At the time of detection, the cancer was already metastatic. This case represents the first reported metastatic gastric adenocarcinoma arising from the gastric pouch following RYGBP.     

Surgical Treatment of Morbid Obesity by Adjustable Gastric Band: the Case for a Conservative Strategy in the Case of Failure – a 9-Year Series

Obesity Surgery - Background: Lapaparoscopic adjustable gastric banding (LAGB) has become a widespread method to treat morbid obesity. Long-term complications and failures require a strategy for...     

Does Gastric Resection Have a Role in the Management of Severe Postfundoplication Gastric Dysfunction?

Background  

Bloating, flatulence, early satiety, and dysphagia resolve in more than 90% of patients early after fundoplication. Gastric dysfunction can persist, however, and a small number of patients develop severe gastric dysfunction (gastroparesis). Management of gastroparesis after antireflux procedures is generally conservative, but gastroparesis can become refractory to medical therapy. The aim of this study was to assess the role of gastric resection in the management of the unusual patient with severe postfundoplication gastric dysfunction.     

Is Roux-en-Y Gastric Bypass Adequate in the Super-Obese?

Background:The outcome after Roux-en-Y gastric bypass (RYGBP) in morbidly obese (MO) (body mass index [BMI] 40-50) was compared with super-obese (SO) (BMI >50) and super-super-obese (SSO) (BMI >60) patients. Methods: A prospective study was conducted in 738 consecutive patients who underwent RYGBP. 483 MO were compared with 184 SO and 70 SSO. Study endpoints included: effect on co-morbid conditions, postoperative morbidity and mortality, and long-term results. Statistical analysis utilized SPSS 11.0. Results: Percentage of males was significantly greater in the SO groups (16.5% vs 13%, P=0.01). Obesity-related conditions were significantly more frequent in the SO groups: sleep apnea (38% vs 17%, P<0.0005), gallstones (23% vs 14%, P=0.013); diabetes (29% vs 17%, P=0.002). Hospital stay was longer in the SO groups (5.7±6.1 days vs 4.6±2.6 days, P=0.024). Wound infection was more frequent in the SO groups (4.7% vs 1.4%, P=0.019). Postoperative mortality was greater in the SSO and SO groups (1.6% and 1.4%) than MO (0%) (P=0.019). Incisional hernia was more frequent in the SO groups (14.1% vs 8.6%; P=0.041). There was no significant difference in percent of excess weight loss (%EWL) between the three groups. EWL >50% at 5 years was: MO 81.5%, SO 87.5%, SSO 80%. The surgery was effective in treating the co-morbid conditions. Conclusion: RYGBP achieved significant durable weight loss and effectively treated co-morbid conditions in SO and SSO patients with acceptable postoperative morbidity and slightly greater mortality than in MO patients.     

Laparoscopic Gastric Bypass with Silicone Band in a Pig Model: Prevention of Anastomotic Dilatation – Feasibility Study

Background: Morbid obesity has become a major global health problem. Surgery remains the only effective treatment for patients with severe obesity, because diet reduction methods and pharmacologic agents have not resulted in long-term weight reduction. Gastric bypass (GBP) can provide adequate weight loss, but after some years, dilatation of the gastric pouch and outlet may lead to weight regain by allowing the patient to increase food intake. Methods: 2 groups of 6 pigs underwent laparoscopic GBP. In the first group, a non-adjustable silicone band (Proring?-band, IOC, Innovative Obesity Care, Saint Etienne, France) was positioned 1 cm proximal to the gastrojejunal anastomosis. In the second group, the device used to stabilize the gastric pouch was an adjustable silicone band (Mid-band?, Medical Innovation Developpement, Villeurbanne, France). Weight loss, complications and histological reaction were evaluated after 3 months. Results: Mortality rate was 25% (cardiac arrythmia in 2 pigs). Conversion rate was 25%. The positioning of the band was more difficult with the Mid-band? because of its larger size and the presence of the catheter. The average weight change in the Proring? group was 15.8 kg (3.5–25.1 kg), and in the Mid-band? group was 12.0 kg (6.2–15.1 kg). Morbidity consisted of one intragastric migration of the Proring? band into the gastrojejunal anastomosis, and one infection of the port in the Mid-band? group treated by removal of the port and antibiotics. Conclusion: Use of silicone devices may be safe and effective in the prevention of pouch or outlet dilatation after GBP.