Laparoscopic Adjustable Gastric Banding in Adolescents: The Austrian Experience

Background: Morbid obesity is a rising problem in adolescents in the industrial nations. Up to 25% of children have a body mass index (BMI) higher than the 85th age- and sex-adjusted percentile. Obesity in youth is associated with increased risk for morbidity and mortality in adulthood. In addition, these patients suffer from psychological problems and decreased quality of life. Bariatric procedures have shown effective long-term results in adults, but they are still discussed controversially in adolescent patients. Methods: Between 1998 and 2004, 50 adolescent patients with a mean age of 17.1±2.2 years (range 9-19 years) underwent laparoscopic adjustable gastric banding (LAGB) in Austria. The psychological changes were analyzed by using Moorehead-Ardelt/BAROS questionnaire. Results: The mean BMI decreased from 45.2±7.6 kg/m² at time of surgery to 32.6±6.8 kg/m² after a mean follow-up of 34.7±17.5 months. The mean excess weight loss was 61.4±35.5%. Most of the adolescents showed remarkable improvements in their quality of life. The outcome was regarded as "excellent or very good" in 32 patients, "good" in 12 patients and "fair" in 5 patients. Only one patient noticed no alterations after surgery. Two-thirds of the preoperative co-morbidities resolved, and one-third improved during follow-up. Except for one port dislocation, no peri- or postoperative complications arose. Conclusion: LAGB is an effective and attractive treatment option in very carefully selected obese adolescents, because of its adjustability and the preservation of the gastrointestinal passage. The majority of patients showed a remarkable improvement in their quality of life.     

Laparoscopic Swedish Adjustable Gastric Banding: a Five-Year Prospective Study

Background: Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. However, the long-term complication rate and weight loss are still unclear. Methods: 824 patients underwent a laparoscopic Swedish Adjustable Gastric Banding (SAGB) in a 5-year period. Preoperative data, postoperative weight loss and long-term complications were prospectively obtained for analysis. Results: Mean age of the 824 patients was 43 ± 1 years, with mean preoperative BMI 43 ± 1 kg/m². No intra- or postoperative death occurred in the first 30 postoperative days. Intraoperative conversion rate was 5.2%. Peri-operative complication rate was 1.2%. 97% of the patients were available for follow-up (maximum 5 years). Long-term complications occurred in 191 patients (23.2%). 135 complications (16.4%) were related to the band, and 56 (6.8%) to the access-port or to the tube. Mean excess weight loss was 30, 41, 49, 55 and 57 % after 1, 2, 3, 4 and 5 years respectively. 82.9% of the patients obtained >50% EWL after initial treatment. Conclusions: The results of this study suggest that laparoscopic SAGB can achieve an effective weight loss, with an acceptable mortality and morbidity rate.     

Laparoscopic Adjustable Gastric Banding: Early Experience in 400 Consecutive Patients in the USA

Background: Early experience with 400 consecutive patients who underwent laparoscopic adjustable gastric banding (LAGB) is reported. Methods: From Nov 2002 to Aug 2004, prospective data were collected on 400 consecutive LAGB patients and evaluated retrospectively. Results: There were 354 (88.5%) females and 46 males (11.5%), with mean age 43.6 years and mean BMI 46.2 kg/m 2 . For outpatients (freestanding ambulatory surgery center), mean OR time was 55.4 min in 208 patients (52%), compared to mean inpatient OR time of 70.5 min in 192 patients. Inpatients had a higher BMI (48.2 ± 9.3 SD) than outpatients (43.9 ± 5.7 SD) (P<0.0001). Complications occurred in 35 patients (8.8%). These consisted of 9 slipped bands (2.3%) that were surgically repositioned, 6 port problems (1.5%) that were successfully repaired, 17 patients with temporary stoma occlusion (4.3%) that spontaneously resolved, and 2 bowel perforations (0.5%) that required surgical repair and band removal. One patient died of pneumonia 2 weeks after an uneventful procedure. Average 1-year percent excess weight loss (%EWL) in 138 patients was 48.2%. Patients who had ≤50 kg initial excess weight (n=37, 27%) had a significantly higher %EWL (55.2%) at 1 year than patients who had >50 kg initial excess weight (P=0.0011). Conclusions: LAGB has been safe and effective thus far for the surgical treatment of morbid obesity, and can be performed as an outpatient in select patients.     

Gastrointestinal Quality of Life Following Laparoscopic Adjustable Gastric Banding in Asia

Background: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity. Previous studies in Western countries disclosed a significant improvement in co-morbidities and health-related quality of life. Data from Asia and regarding the specific GI quality of life following LAGB are lacking. Methods: From May 2002 to May 2005, 107 consecutive patients – 48 men and 59 women, with mean age 31.4 years (range 17-57 years) with morbid obesity (mean weight 115.8 kg, range 81-174 kg; mean BMI 41.3 kg/m², range 32.0-59.8 kg/m²) underwent LAGB in a prospective trial. All bands were placed via the pars flaccida technique. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36item questionnaire before LAGB, and at 3, 6, 12 and 24 months after surgery. Results: All procedures were performed laparoscopically with no conversions. There was neither intra-operative complications nor major postoperative complications. Minor complications occurred in 3 patients (2.8%); all were transient stoma obstruction. At follow-up, only one band (0.94%) was removed at 3 months postoperatively because of the patient's intolerance. No gastric slippage occurred. 4 patients (3.7%) had tubing problems and required revision surgery for port adjustment. Mean BMI decreased from 41.3 to 33.1 after 2 years. Percent excess BMI loss averaged 48.1% at 2 years (range 6.7-139.2). All co-morbidities were eliminated significantly. 80% of patients were satisfied with the results at 2 years. However, the GIQLI score remained similar before and after surgery. Preoperative score was 110.8+15 points. The score became 116.2+13, 114.7+13, 108.5+14 and 107.2+17 at 3, 6, 12 and 24 months. The patients had improvement in 3 domains of general health (social, physical and emotional functions), but decrease in the domain of symptoms. Conclusion: Although LAGB was successful in weight loss and resolution of co-morbidities in morbidly obese patients, the GIQLI did not improve. This feature will be the major disadvantage of LAGB.     

Adjustable Gastric Banding in a Multicenter Study in Turkey

Background: Adjustable gastric banding (AGB) is a minimally-invasive approach which allows adjustment of gastric restriction. Methods: The AGB was evaluated retrospectively in a consecutive series at 3 centers. From October 1998 to October 2001, 70 patients (49 women), mean age 34.3 years (18-59) with morbid obesity (preoperative mean BMI 45.2 kg/m²) underwent AGB The open approach was employed in the first 35 patients. Laparoscopic placement was used in the second 35 patients. Complete follow-up has been obtained in all patients. Results: Mean postoperative follow-up has been 18 months (12-39). Mean operative time was 120 minutes in the open approach and 150 minutes in the laparoscopic AGB. Mean hospital stay was 5 days after the open approach and 1.7 days after the laparoscopic surgery. The excess weight loss after 18 months was 59%. Incidence of early postoperative complications was 27.1%, including nausea and vomiting in 8 patients (5 in open approach, 3 in laparoscopic placement), wound infection in 10 patients (all 10 in open approach), and Wernicke's encephalopathy in 1 patient (open approach). Incidence of late complications was 28.5%, and included band migration in 2 patients (both by laparoscopic placement), pouch dilatation in 10 patients (6 in open approach, 4 in laparoscopic placement), incisional hernias in 4 patients (all by open approach), and port infections in 4 patients (all 4 in open approach). Conclusion: AGB has been effective in achieving good weight loss to 3 years follow-up. The ability to adjust the degree of gastric restriction has enabled progressive weight loss.     

Gallstone Formation after Weight Loss following Gastric Banding in Morbidly Obese Dutch Patients

Background: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. Methods: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). Results: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). Conclusions: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.     

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.     

Biliopancreatic Diversion with Duodenal Switch Combined with Laparoscopic Adjustable Gastric Banding

Background: The authors investigated the usefulness of an approach combining biliopancreatic diversion (BPD) with duodenal switch (DS) and laparoscopic adjustable gastric banding (LAGB) in morbidly obese patients. Methods: 258 morbidly obese patients underwent bariatric surgery. 80 underwent gastric bypass (GBP), with an 80-ml pouch, a 120-150-cm common channel and a 350-cm alimentary limb (Group 1). 178 underwent BPD combined with DS-LAGB (Group 2): an 80cm common channel and a 200-cm alimentary limb were created in 68 patients (Subgroup 2a); a 120-cm common channel and a 300-cm alimentary limb were created in 110 patients (Subgroup 2b). Quality of life was assessed using the Moorehead-Ardelt Quality of Life Questionnaire (MA-QLQ). Results: At 2 years, mean BMI and %EWL were 27.8 kg/m² and 77.4 (Group 1), 25.2 kg/m² and 99.6 (Subgroup 2a), and 27.6 kg/m² and 79.3 (Subgroup 2b), respectively. 4 GBP patients regained their weight 2 years after surgery. There was 1 death, not related to surgery in Subgroup 2b. Preoperative MA-QLQ scores were similar between groups; at 2 years, MA-QLQ scores were higher in Subgroups 2a and 2b compared to Group 1 (+2.49 and +2.59 vs +0.98, respectively). Conclusion: Combination bariatric surgery is a safe, effective and durable weight loss option for the treatment of morbid obesity.     

Preoperative Weight Loss by Intragastric Balloon in Super-Obese PatientsTreated with Laparoscopic Gastric Banding: A Case-Control Study

Background: The authors investigated the usefulness of preoperative treatment with the BIB intragastric balloon in super-obese patients before undergoing laparoscopic adjustable gastric banding (LAGB). Methods: The case-control study involved 43 case patients treated with the intragastric balloon followed by LAGB ("Case" group) and 43 sex-, age- and BMI-matched historical controls treated with LAGB alone. Results: Mean length of the intragastric balloon treatment was 164.4±39.7 days, with a fill volume of 609±95 ml. Total complication rate with balloon was 7.0% and percent excess weight loss (%EWL) was 26.1 ± SD 9.3 %. At the time of gastric band placement, both operative time and hospital stay were shorter in patients treated previously with the balloon (Case group) than in the Control group patients. No Case patients required conversion to open surgery or had intraoperative complications. In the Control group, the rate of conversion was 16.3% (P<0.05) and the rate of intraoperative complications was 7.0%. Postoperative follow-up length was 1.1±1.0 years in Case patients and 4.4±1.8 years in Control patients (P<0.001). The %EWL produced by the intragastric balloon in the Case patients was identical to the %EWL observed in the first 6 months after LAGB in the Control group (26.1±9.3 vs 25.3±12.4%). %EWL 6 months after banding was higher in the Case patients than in Controls (33.6±12.5 vs 25.3±12.4%, P<0.01). However, no significant difference in %EWL between the two groups was observed at the subsequent postoperative evaluations. Conclusion: Preoperative treatment with the intragastric balloon reduced the risk of conversion to open surgery and the risk of intraoperative complications in super-obese patients treated with LAGB. Preoperative treatment with the intragastric balloon did not change the total weight loss after LAGB.     

Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super-obese: A Comparative Study of 290 Patients

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.     

Initial Experience with Laparoscopic Adjustable Gastric Banding in Hungary

Background: Laparoscopic adjustable gastric banding (LAGB) was started in Hungary in 1998. We used Lap-Band and SAGB devices. In this study we present our experience through the learning curve. Methods: From Jan 1999 to Dec 2002, 54 patients underwent laparoscopic surgery for morbid obesity in our department, using the Lap-Band? and SAGB. There were 33 men and 21 women, with median age 42 (range 20-64), and preoperative BMI 50 kg/m² (range 41-66). All underwent LAGB, except one patient who had laparoscopic vertical banded gastroplasty.The procedures used the 4-trocar technique. Results: The first patient required reoperation because of gastric rupture from drinking sparkling mineral water despite of our advice. Excluding this, we had no intraoperative or short-term postoperative complications. Mean operating time was 82 minutes (range 55-192), and hospital stay was 3 days. Followup ranges from 1 to 36 months. Mean weight loss was 47 kg at 12 months and 67 kg at 36 months. Mean BMI fell to 29 kg/m². Conclusion:With its safety and effectiveness, LAGB has been a good choice for handling morbidly obese patients in our early experience.     

Impact of Orlistat Therapy on Weight Reduction in Morbidly Obese Patients After Implantation of the Swedish Adjustable Gastric Band

Background: Adjustable gastric banding (AGB) is frequently performed to treat morbid obesity. One problem which can occasionally develop after a restrictive procedure is consumption of a high calorie liquid diet, which may prohibit further weight loss. Orlistat, a newly developed intestinal lipase inhibitor, prevents absorption of about one-third of ingested fat. It is unknown whether patients no longer losing weight after AGB, despite further band restriction, may lose weight with addition of orlistat. Methods: 38 patients were selected who had stopped losing weight 3 months before the initiation of the study, 18±6 months (mean±SEM) after laparoscopic AGB. Subjects were divided into 2 groups, matched for age, sex, filling volume of the band and body mass index (BMI) both at the time of surgery and start of the study (18±6 months after AGB). Results: Patients in group A received dietary counseling and orlistat 120 mg TID for 8 months, while patients in group B received only dietary counseling. During the following 8 months of study, subjects in group A lost 8±3 kg in weight, whereas subjects in group B lost 3±2 kg (p<0.01, months 18 vs 26 of study; p<0.03, group A vs B). In 15 patients from group A the study was further extended 9 months, but interestingly, weight remained stable independent of whether orlistat was continued (n=8) or stopped (n=7). 4 subjects were excluded from the extension study because of additional malabsorptive bypass surgery.Subjects taking orlistat encountered only minor GI side-effects. Conclusion: Orlistat appears to be useful when added in patients after AGB who are no longer losing weight, perhaps due to a high-calorie liquid diet rich in fat.     

A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long-Term Complication and Failure Rates

Background: Since its introduction about 10 years ago, and because of its encouraging early results regarding weight loss and morbidity, laparoscopic gastric banding (LGB) has been considered by many as the treatment of choice for morbid obesity. Few long-term studies have been published. We present our results after up to 8 years (mean 74 months) of follow-up. Methods: Prospective data of patients who had LGB have been collected since 1995, with exclusion of the first 30 patients (learning curve). Major late complications are defined as those requiring band removal (major reoperation), with or without conversion to another procedure. Failure is defined as an excess weight loss (EWL) of <25%, or major reoperation. Results: Between June 1997 and June 2003, LGB was performed in 317 patients, 43 men and 274 women. Mean age was 38 years (19-69), mean weight was 119 kg (79-179), and mean BMI was 43.5 kg/m² (34-78). 97.8% of the patients were available for follow-up after 3 years, 88.2% after 5 years, and 81.5% after 7 years. Overall, 105 (33.1%) of the patients developed late complications, including band erosion in 9.5%, pouch dilatation/slippage in 6.3%, and catheter- or port-related problems in 7.6%. Major reoperation was required in 21.7% of the patients. The mean EWL at 5 years was 58.5% in patients with the band still in place. The failure rate increased from 13.2% after 18 months to 23.8% at 3, 31.5% at 5, and 36.9% at 7 years. Conclusions: LGB appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. Only about 60% of the patients without major complication maintain an acceptable EWL in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.     

Complications after Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Experience with 1,000 Patients over 7 Years

Background: Laparoscopic adjustable gastric banding (LAGB) is considered the least invasive surgical option for morbid obesity. It is less efficient than gastric bypass in weight loss, but has the advantage of being potentially reversible and can improve the quality of life if mortality and morbidity are low. Methods: Between 1996 and 2003, 1,000 patients underwent LAGB. There were 896 women and 104 men with mean age 40.4 years (16.3-66.3). Preoperative mean BMI was 44.3 kg/m². Results: There were no deaths. Cumulative rate of complications was 192 (19.2%). 12 were life-threatening (1.2%): gastric perforation (n=4), acute respiratory distress (n=2), pulmonary embolism (n=2), migration (n=3), and gastric necrosis (n=1). 111 patients required an abdominal reoperation (11.1%) for perforation (n=2), slippage (n=78), migration (n=3), necrosis (n=1), esophageal dilatation (n=2), incisional hernias (n=4) and port problems (n=21). Before October 2000, we used the perigastric technique, and the slippage rate was 24% (91 / 378 ).Then, we changed to the pars flaccida approach and the slippage rate fell to 2% (13 / 622). The pars flaccida approach demonstrated safety in relation to both risks of perforation and slippage. Conclusion: The cumulative complication rate increased to 3-4 years, and then decreased with experience and technical improvement. Concerns of long-term follow-up should be migration and esophageal dilatation, which seem to be rare at 3 years.     

Outcome Predictors in Morbidly Obese Recipients of an Adjustable Gastric Band

Background: The authors investigated the outcome predictors in obese patients who underwent laparoscopic adjustable banding with the Lap-Band?. Methods:The 3-year excess weight loss (EWL) and rate of band-related complications (pouch dilatation and port leackage) were analyzed in 260 morbidly obese patients, according to several possible predictive characteristics. Success rate (EWL >50%), failure rate (EWL < 20%) and weight regain rate (regain of >10%EWL between 1 and 3 yrs) were considered. Results: The Lap-Band? produced a 43.0±22.3% EWL, corresponding to a BMI reduction from 46.6±7.0 to 36.8±6.6 kg/m². Success rate was 35.7%, failure rate was 14.1% and weight regain rate was 20.7%. Pouch dilatation occurred in 32 patients (12.3%), band erosion in 2 (0.8%), port leakage in 74 (28.5%), and port twisting in 2 (0.8%). Major band-related surgery was requested in 11 patients (4.2%) and minor port-related surgery in 62 patients (23.9%). Significant success predictors were found to be age <40 years and BMI <50 kg/m². Significant failure predictors were found to be male sex and non-sweet eating behavior. Significant weight regain predictors were found to be BMI <50 kg/m² and the occurrence of a port leakage. Port leakage was significantly more frequent in women and in patients with BMI <50 kg/m². The prevalence of pouch dilatation was threefold higher in women than in men. Conclusions: Lap-Band? was associated with a good outcome and with a low rate of severe complications. The outcome was more influenced by physiological and technical reasons than by psychological or behavioural factors.     

A Comparison of Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion in Superobesity

Background: Controversy exists regarding the best surgical treatment for superobesity (BMI >50 kg/m²), and a comparison of the 2 most commonly performed procedures in Europe, namely biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB), has not yet been reported. Methods: BPD has been performed in 134 morbidly obese patients since 1996, and as the primary bariatric procedure in 23 superobese patients. 23 sex-matched patients who most closely resembled the age and BMI of the 23 BPD patients were chosen from 1,319 patients who had undergone LAGB since 1996. These groups were compared using appropriate statistical tests. Results: BPD was performed laparoscopically in 12 patients. Median excess weight loss at 24 months was 64.4% following BPD and 48.4% following LAGB. Hospital stay and complication rate were significantly greater with BPD, although the majority of complications were related to the laparotomy wound in patients undergoing open BPD. Rate of resolution of obstructive sleep apnea, hypertension and diabetes mellitus following LAGB was similar to BPD. Conclusion: BPD results in significantly greater weight loss than LAGB in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open BPD.     

Changes in Leptin,Plasminogen Activator Factor and Oxidative Stress in Morbidly Obese Patients following Open and Laparoscopic Swedish Adjustable Gastric Banding

Background: Oxidative stress is increased in obesity, leading to endothelial dysfunction, atherogenesis, and platelet aggregation. The purpose of this study was to determine the effects of weight loss after bariatric surgery on serum lipids, malondialdehyde (MDA, a marker of oxidative stress), oxidized low-density lipoprotein (oxLDL, which is increased in obesity and causes endothelial dysfunction), paraoxonase (PON-1, which inhibits lipid peroxidation), leptin and plasminogen activator inhibitor type-1 (PAI-1, which contributes to a thrombotic state). Methods: 40 morbidly obese patients had insertion of a Swedish adjustable gastric band (SAGB). A lipid profile, MDA, oxLDL, PON-1, leptin and PAI-1 levels were drawn before and 6 months after the operation. 20 patients underwent open (Group 1) and 20 laparoscopic (Group 2) SAGB, to compare the systemic inflammatory response of the two approaches. Results: Patient demographics, indications for surgery, and postoperative results were no different between the groups. Postoperative BMI and concentrations of lipid, MDA, oxLDL, leptin and PAI-1 decreased significantly in both groups. PON-1 activity increased and was negatively correlated with BMI (r=-0.618, P< 0.01), MDA (r=-0.735, P<0.001), oxLDL (r=-0.701, P< 0.01), leptin (r=-0.626, P<0.01) and PAI-1 (r=-0.461, P<0.05). There was a correlation between BMI and MDA (r=0.790, P <0.001), and also leptin (r=0.900, P<0.001) and PAI-1 (r=0.888, P=0.001). There was no correlation between BMI and oxLDL. Conclusion: These findings support the hypothesis that in morbid obesity, weight loss after surgery has positive effects on fibrinolytic function, oxidative stress and antioxidant activity. Both operative approaches had similar effects in this study.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Long-term Results,Late Complications and Quality of Life in a Series of Adjustable Gastric Banding

Background: Adjustable gastric banding is currently the most common bariatric operation. This study is a retrospective analysis of the Finnish experience with this procedure over the last 10 years. Methods: Between March 1993 and June 1999, 123 patients underwent either open (36) or laparoscopic (87) surgery for morbid obesity by the application of an adjustable gastric band. Data on preoperative clinical characteristics and postoperative outcome and weight-loss patterns up to 9 years (mean 55 months) are presented and also evaluated by the Bariatric Analysis and Reporting Outcome System (BAROS). Sex ratio was 31% males / 69% females, mean age 44 years and mean ± SD preoperative BMI 49 ± 8 kg/m² (range 33.6-85.1). Results: During the evaluation period (March 1993 December 2002), 54% of patients experienced postoperative complications requiring hospital treatment ≥ 7 days, and 52% underwent a reoperation. 33% of bands were removed. The most important late complications were esophagitis (30%), obstruction due to slippage / pouch dilatation (21%), incisional hernia (9%) and band erosion (9%).Mean excess weight loss at 1 and 2 year follow-up was 36% and 38%, which later stabilized to 30%. During the evalution period, there were 10 deaths, 2 of which were 30-day deaths, and the remainder were not associated with the band. According to BAROS, the outcome was regarded as "very good" in 3%, "good" in 7%, "fair" in 40% and "failure" in 50%. Conclusion: Our long-term data found that weight reduction is acceptable,but the incidence of late complications and reoperations was high.     

Patient Characteristics Impacting Excess Weight Loss following Laparoscopic Adjustable Gastric Banding

Background: Weight loss is more variable after laparoscopic adjustable gastric banding (LAGB) than after gastric bypass. Subgroup analysis of patients may offer insight into this variability. The aim of our study was to identify preoperative factors that predict outcome. Methods: Demographics, co-morbid conditions and follow-up weight were collected for our 1st 200 LapBand ? patients. Linear regression determined average %EWL. Logistic regression analysis identified factors that impacted %EWL. Result: 200 patients returned for 778 follow-up visits. Median age was 44 years (21-72) and median BMI 45 kg/m² (31-76). 140 (80%) were women. Average %EWL was y % = 0.007 %/day (days since surgery) + 0.12% (correlation coef. 0.4823; P<0.001). %EWL at 1 year was 37%. The best-fit logistic regression model found 7 factors that significantly changed the odds of achieving average %EWL. Older patients, diabetic patients and patients with COPD had greater odds of above average %EWL. Female patients, patients with larger BMIs, asthmatic patients and patients with hypertension had increased odds of below average %EWL. Conclusion: Specific patient characteristics and comorbid conditions significantly altered the odds of achieving satisfactory %EWL following gastric banding.