Adjustable Silicone Gastric Banding: Complications in a Personal Series

Background: Morbid obesity is a very severe pathology, deriving partly from a psychological disturbance of nutritional behavior. Besides a behavioral therapeutic approach, surgery appears to be necessary to resolve associated diseases by causing a satisfactory weight loss. Adjustable gastric banding is a less-invasive, potentially reversible procedure that guarantees an optimal quality of life. Methods: The authors have performed Kuzmak's gastric banding since 1992, with the lap-band approach since 1995; 183 patients were submitted to surgery, and 68 of these were operated by the laparoscopic approach. Average body mass index was 45.5 kg/m². The complications were always under control and have decreased since the introduction of the recent lap-band. Results: Gastric banding is still a very young procedure and it is difficult to state definitive results yet. Preliminary results, according to our experience are satisfactory in terms of weight loss, without metabolic changes and without mortality. Conclusions: Our experience is encouraging if patient selection is accurate and rigid.     

The Swedish Adjustable Gastric Banding (SAGB) for Morbid Obesity: 9 Year Experience and a 4-year Follow-up of Patients Operated with a New Adjustable Band

Background: We have developed an adjustable gastric band in which the stoma diameter can be adjusted from the outside. A standardized technique was employed and the application of our band in terms of weight loss and complication rate was evaluated Methods: Between August 1990 and November 1991, 50 patients (15 men and 35 women) were operated on by laparotomy. Their mean age at surgery was 41 (19-60) years. Mean preoperative weight was 134 (106-181) kg and the mean BMI was 46 kg/m² (range 33-59 kg/m²). Results: No patient was lost to follow-up. Four were excluded from the study (brain tumor, pregnancy and two reoperations). The remaining 46 were followed for at least 4 years. At follow-up, mean weight was 80 kg and mean BMI was 27.5 kg/m². The patients had lost a mean of 54 kg. Two patients (4%) had abdominal reoperation because of technical problems. There was one incisional hernia and one minor wound infection, but no other significant complications. Conclusion: This relatively simple method appears to be at least as good as the other operations, and weight loss can be adjusted to patient comfort. Currently, the procedure is being performed laparoscopically.     

Swedish Adjustable Gastric Banding: a Preliminary Experience

Background: The authors have been performing bariatric surgery for 15 years; since February 1992 they have carried out laparoscopic gastric banding (LGB) with a silastic band. Good experience with the LGB combined with everyday laparoscopic activity in their institution persuaded them to try laparoscopic placement of the Swedish adjustable gastric band (SAGB). Methods: The surgical procedure is the same as that for laparoscopic gastric banding except for the use of a 15 mm trocar that is required to introduce the band, and the need to place a port that is connected to the band via a wide loop tube; the port is place subcutaneously and is supported by the lower part of the sternum. The authors do not use any abdominal drain nor a naso-gastric tube. At surgery the band is left empty, and filling is usually not started until 4 weeks after surgery. The patient is immediately mobilized and begins a liquid diet the evening after the operation. The patients are usually discharged from hospital on the first postoperative day. Results: Over 8 months, 24 patients underwent SAGB, with mean BMI 44.69 and mean operating time 45 minutes (range 30-75). No early complications occurred. Preliminary results in this small series show BMIs of 38.65 and 34.60 at 3 and 6 months postoperation. Conclusion: SAGB appears for be a good method for obesity surgery. It is easy to perform and is associated with a low operative risk. Provided that the band is put in the right place, weight loss can be adjusted to patient comfort.     

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.     

Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution

Background: Laparoscopic adjustable gastric banding (LAGB) has been adopted by many bariatric surgeons. It remains under scrutiny, although it represents a major innovation in the treatment of morbid obesity. We present the lessons from the first 500 patients treated in our institution. Methods: From April 1995 to November 1998, 500 patients (421 females, 79 males) underwent an LAGB in our institution: 432 were morbidly obese and 68 were superobese. Mean body mass index (BMI) was 43, and mean excess weight was 51 kg. Results: There have been no deaths. There was one case of gastric perforation reoperated on and three cases of pulmonary and/or abdominal collections treated by drains. Two rings were changed for leakage. One ring was removed for a postoperative sigmoiditis. Three late gastric erosions occurred, requiring re- moval of the ring. Five access- ports have been removed for infection. 25 cases (5%)of pouch dilatation have been observed of which 18 (3.6%) led to reoperation. Mean follow-up was 21 months. Mean excess weight loss was 56% at 1 year, 65% at 2 years, and 64% at 3 years. Conclusion: This favorable outcome led us to propose laparoscopic banding to all our patients instead of stapling gastroplasty. Short-term data should be confirmed by a longer follow-up, but indicate that LAGB should provide good results in terms of weight loss and that there are a limited number of failures. We believe that it should not be regarded just as a first-step procedure but as a final therapy, even for superobese patients.     

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.     

A Simple Band for Gastric Banding

The author has noted that flexible gastric bands have occasionally stenosed the gastric stoma or allowed it to dilate. A band was developed using a soft outer silicone rubber tube over a holding mechanism made out of a nylon cable tie passed within the silicone tube. This simple, easily applied band is rigid, resisting scar contracture and dilatation.     

Adjustable Silicone Gastric Banding and Band Erosion: Personal Experience and Hypotheses

Background: Adjustable silicone gastric banding (ASGB) has been advocated as a minimally invasive procedure that is completely reversible for the surgical treatment of morbid obesity. Band erosion (BE) is one of the possible complications of ASGB. The authors report their experience with BE and discuss its possible causes. Methods: Between February 1993 and February 1998, the authors performed 122 ASGB: 51 open and 71 laparoscopic procedures. Results: Two cases of BE occurred (1.6%). Conclusion: Band erosion is a possible complication of ASGB that is often not diagnosed immediately. Prevention is essential and consists primarily in correct placement of the band. There appears to be only one solution to BE: removal of the band. Placement of a new band after removal is possible; the minimum interval is not known.     

Laparoscopic Adjustable Esophagogastric Banding: a Preliminary Experience

Background: Laparoscopic adjustable gastric banding is an efficient surgical method in the treatment of morbid obesity. In order to reduce the number of complications, we have modified the technique to what we term ‘laparoscopic adjustable esophagogastric banding’. Methods: Between December 1994 and July 1997, 126 laparoscopic adjustable banding procedures were carried out. Of these, 40 underwent a gastric banding operation (group 1), and 86 underwent an esophagogastric banding procedure (group 2). Results: The percentage loss of excess body weight curve was less rapid in group 2 compared to group 1 due to a different strategy in band filling. Follow-up to date shows that no problems with the pouch or the stoma have arisen in the esophagogastric banding group. Conclusions: Laparoscopic adjustable esophagogastric banding is a simpler and safer procedure than laparoscopic adjustable gastric banding. It also works as a very efficient anti-reflux procedure, at least in the short term. It appears to be equally efficient as a weight-reducing operation as gastric banding. Further follow-up of the patients involved is necessary in order to evaluate the results in the longer term.     

Two Years of Practice in Adjustable Silicone Gastric Banding (LAP-BAND™): Evaluation of Variations of Body Mass Index, Percentage Ideal Body Weight and Percentage Excess Body Weight

Background: In the treatment of morbid obesity, surgery had been the only method of obtaining a good and enduring weight loss. Although the procedure of choice is still a matter of debate, among gastric restriction procedures LAP-BAND™ has become our first choice. Methods: We report the results from 62 morbidly obese patients operated in the period October 1994-December 1996. Their characteristics were: mean age 35.6 years, mean body weight 130.6 kg, mean height 162.3 cm, mean body mass index (BMI) 49.9 kg/m², mean percentage ideal body weight (%IBW) 215.7 and mean excess weight (EW) 69.57 kg. Results: Twenty-four months after surgery we found a mean BMI of 39.3, a mean %IBW of 168.6 and a mean % EW loss of 88.5. We removed the band in two patients: one after 9 months because of stoma stenosis and pouch enlargement in a woman who had been lost at follow-up, and the other for gastric slippage occurring after 18 months due to incorrect fixation of the band. Conclusion: Our results led us to consider LAP-BAND™ as the surgical approach for severe obesity among those patients selected for gastric restriction; indeed, it was very safe as well as effective and was rarely followed by complications.     

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.     

Adjustable Silicone Gastric Banding (ASGB): the Italian experience

Adjustable silicone gastric banding (ASGB) is a recently introduced gastric restrictive procedure. From April 1990 to April 1992, 85 patients underwent ASGB at our Department. Patients' characteristics were: 65 females, 20 males, mean age 39.6 years (range 17-60 years); body weight (BW) 127.9 ± 23 kg; % ideal body weight (%IBW) 205 ± 29; body mass index (BMI) 46 ± 7; morbidly obese 68, super-obese 17. Mean follow-up is 353 days. Twelve months after the operation BW was 95.2 ± 23 kg, % loss of excess BW 52.1 ± 22, and %IBW 152.2 ± 30 (45 patients). Mortality rate was zero and postoperative morbidity was insignificant. As late morbidity, we experienced two slippages of the band and six stoma-stenosis with pouch dilatation. Therefore, a surgical revision without removal of the band was performed in eight patients. The band was removed in one patient because of band erosion. In conclusion, ASGB is a safe and effective bariatric procedure. The weight loss is comparable to that produced by more extensive operations. Moreover, ASGB is fully reversible and adjustable to the patients' needs.     

Preparation of Extremely Obese Patients for Laparoscopic Gastric Banding by Gastric Balloon Therapy

Background: In super, super obese patients (body mass index [BMI] >60), especially those with extreme intra-abdominal fat deposition, the technical difficulties in laparoscopic procedures increase. The purpose of this study was to evaluate whether gastric balloon therapy (GBT) can improve the operative conditions for laparoscopic adjustable gastric banding (LAGB) in extremely obese patients. Materials and Methods: From April 1995 to August 1998, 196 LAGBs were performed. In 15 patients (7 female and 8 male), median age 38.8 years (range 17-54), who had been selected as suitable candidates for bariatric surgery, preoperative GBT was studied. Fourteen patients were extremely obese (BMI 60.2 kg/m² [range 58-72]). One 17-year-old boy with BMI 46.6 kg/m² was also treated. The Bioenterics Intragastric Balloon (BIB) was used. The placement, the volume modification, and the removal of the BIB were performed endoscopically. Close follow-up was possible in 14 patients. After balloon removal, 13 patients underwent LAGB. Results: In 14 of 15 cases, GBT was successful. There was only one ballon dysfunction. The mean weight loss was 18.1 kg, and the median duration of balloon therapy was 16.8 weeks. After balloon removal, body weight started to increase. Conclusions: In our experience, the gastric balloon can improve the conditions for laparoscopic surgery in super and in super, super obese patients. There was no conversion to open surgery. The effect of weight loss is much less than immediately after LAGB. However, after failure of all conservative treatments to reduce the preoperative body weight, the GBT seems to be the last possibility.     

Laparoscopic Adjustable Silicone Gastric Banding: Preliminary Results of the University of Naples Experience

Background: Laparoscopic adjustable silicone gastric banding (LASGB) is a minimally invasive surgical procedure indicated for the treatment of patients with morbid obesity. Methods: From January 1996, eight patients successfully underwent the video-laparoscopic procedure. Results: Preoperative body mass index was 44.4 ± 4.7 (range 37.9-53.3). Mean operative time was 255 ± 73 minutes (range 150-360). Mean hospital stay was 3 ± 1 days. Intraoperative complications were absent. Conclusion: Preliminary results have been satisfactory, and encourage us to continue with LASGB.     

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.     

Periprosthesis Sepsis: An Undesirable Complication of Silicone Gastric Banding

Background: Gastric banding is a very satisfactory procedure for the treatment of morbid obesity. The significant incidence of skin suppuration in these patients makes the laparoscopic approach a suitable technique. Regardless of this, in some cases, suppuration can still rarely result. Methods and Results: In four patients the authors observed diffusion of suppuration in both directions along the catheter which connects the port to the band, necessitating band removal and thus invalidating the procedure. Conclusions: Suppuration of port location is an undesirable complication that must be avoided because it may contaminate the entire device system. This complication must be carefully evaluated for a correct diagnosis and an eventual removal of the band.     

Two Cases of Conversion of Vertical Ring Gastroplasty to Adjustable Silicone Gastric Banding

Background: Since May 1995, we have used laparoscopic adjustable silicone gastric banding (ASGB) as an alternative to silastic ring vertical gastroplasty (SRVG) to treat morbid obesity. Moreover, it seemed that ASGB was an appropriate procedure to use when SRVG had failed and no alternative procedure could be attempted again, which occurred in two patients. Because of adhesions, the laparoscopic approach was inappropriate in both cases. The size of the pouch and the staple-line were not obstacles to ASGB. Methods: Case 1 was a 53-year-old woman of 111 kg (BMI = 46) who had SRVG in July 1994. One year later, she had a 54 kg weight loss, but had continuing food intolerance, although malfunction of the pouch or ring could not be found. A removal of the ring was performed in October 1995, and a 10cm diameter silicone band placed. The band was not inflated until she had regained weight 5 months later. Case 2 was a 33-year-old woman of 100 kg (BMI = 40) who had SRVG in March 1994. Weight loss was 45 kg 18 months later; then she gained weight. Endoscopy and barium swallow showed both staple-line disruption and band erosion. Removal of the ring was performed in March 1996, and a 9.75-cm diameter silicone band placed, and inflated at the same time with 2 cc saline. Results: Both patients are doing well. Conclusions: ASGB appeared to be the best alternative when revising an SRVG in cases where a new stapling or the placement of a new ring could have had consequences more serious than the primary complications.     

A Review of Seven Years' Experience with Silicone Gastric Banding

Since January 1983, silicone gastric banding (SGB) has been used with very low morbidity in 311 extremely obese patients to produce and maintain significant weight loss for as long as 7 years. A small meal-sizing pouch with reinforced small stoma is created with placement of the silicone band around the stomach. The basic operative technique involving no cutting or crushing of either the stomach or the small intestines has not changed. Strict quality control of the banding is permitted by specially designed calibration devices and other instruments. To permit correction of changes in stoma diameter occurring with the passage of time, the band was modified in 1986 by adding an adjustable portion (stoma adjustable silicone gastric banding or SASGB). Adjustment to proper size is done percutaneously through the injection port. SASGB allows corrections of most stoma-related problems non-operatively and significantly improved weight loss. One hundred and seventy-three original SGB patients (125 primary, 48 conversion) and 138 SASGB patients (93 primary, 45 conversion) were operated. At 60 months, 65 primary SGB patients averaged 47% excess weight loss (EWL). At 36 months, average EWL was significantly greater for 37 primary SASGB patients than for 94 primary SGB (64.3% vs 49.4%, p = 0.01); 84% of SASGB patients had EWL > 40% and 57% achieved EWL > 60%. SASGB generates weight loss comparable to that produced by more extensive bariatric procedures. Excellent weight loss and maintenance combined with the stoma size non-surgical adjustment ability makes SASGB attractive for use in treating bariatric patients.