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.     

Intragastric Stimulation is Ineffective after Failed Adjustable Gastric Banding

Background: Gastric pacing has gained popularity as an effective and safe minimally invasive procedure to treat morbid obesity. This study evaluates the outcome of gastric pacing as a bariatric re-do procedure in patients who developed failure after adjustable gastric banding (AGB) due to band migration. Methods: 8 patients were enrolled in this analysis. After implantation of an AGB, they had developed band failure due to band migration. The implantable gastric stimulator (IGS) was implanted laparoscopically as a second-line operation after gastroscopic removal of the band. Results: Median time (range) from AGB complication to implantation of the IGS was 42 (10.3-50.3) months. During that time, all 8 patients had regained significant weight. All IGS devices could be implanted laparoscopically, without intra- or perioperative complications. The minimal body weight following IGS implantation was reached after 5 (0-12) months. The median observation time was 23 (11.3-27.5) months. 1 year after IGS implantation (n=7), median weight was 116 (98-165) kg, equivalent to a median BMI of 41.1 (36.055.8) kg/m², which is not statistically different to preoperative values and therefore prompted us to stop our ongoing trial. In all but 2 patients, the IGS device was explanted. During the same procedure, patients underwent a gastric sleeve resection (n=4) or a Roux-en-Y gastric bypass (n=2). Conclusion: The implantation of an IGS was an ineffective second-line operation after AGB migration.     

Laparoscopic Adjustable Gastric Banding for Severe Obesity

Background: Morbid obesity is an increasingly common condition with serious associated morbidity and decreased life expectancy. The only treatment with long-term efficacy for this condition is surgical intervention. Laparoscopic adjustable gastric banding (LAGB) is a procedure increasingly performed in European centres and recently approved by the FDA in USA. This article reviews its effectiveness and complications. Methods: A literature search identified relevant articles. Results: LAGB results in approximately 60% (43-78%) excess weight loss at 3 years with improvement in co-morbidities, with perioperative mortality <0.5%. Potential complications include prolapse or pouch dilatation, and port-related complications. Less common complications are intra-operative gastric perforation and band erosion. Rate of reoperation varies greatly between series, and is usually needed for band repositioning or port-related procedures, many of the latter performed under local anesthesia. Conclusion: The available data demonstrate that LAGB is a safe bariatric procedure, and is effective in the short- and medium-term. Results of long-term follow-up are awaited.     

Prevention of Pouch Dilatation after Laparoscopic Adjustable Gastric Banding

Background: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. Methods: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. Results: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. Conclusion: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.     

Short-term Changes in Insulin Resistance following Weight Loss Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding versus Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP) both effectively treat the insulin resistance associated with type 2 diabetes mellitus (T2DM). Restriction of caloric consumption, alterations in the entero-insular axis or weight loss may contribute to lowering insulin resistance after these procedures. The relative importance of these mechanisms, however, following LAGB and LRYGBP remain unclear. The aim of this study was to compare directly the short-term changes in insulin resistance following LAGB and LRYGBP in similar populations of patients. Methods: Patient preference determined operation type. The Homeostasis Model Assessment for Insulin Resistance (HOMA IR) was used to measure insulin resistance. Preoperative values were compared to postoperative levels obtained within 90 days of surgery. Significant differences between groups were tested by ANOVA. Results: There were no significant preoperative differences between groups. The 56 LAGB patients had a mean age of 42.5 years (25.7-63), BMI of 45.5 kg/m² (35-66) and preoperative HOMA IR of 4.1 (1.4-39.2). 75% of LAGB patients were female and 43% had T2DM. The 61 LRYGBP patients had a median age of 39.9 years (22.1-64.3), BMI of 45.0 kg/m² (36-62), and preoperative HOMA IR of 5.0 (0.6-56.5). 79% of LRYGBP patients were women and 44.3% had T2DM. Median follow-up for LAGB patients was 45 days (18-90) and for LRYGBP patients 46 days (8-88 days). LAGB patients had a median of 14.8% excess weight loss (6.9%-37.0%) and LRYGB patients 24.2% (9.8%-51.4%). Postoperative HOMA IR was significantly less after LRYGBP, 2.2 (0.7-12.2), than LAGB, 2.6 (0.8-29.6), although change in HOMA IR was not significantly different. Change in HOMA IR for both groups did not vary with length of follow-up or weight loss but correlated best with preoperative HOMA IR (LAGB r=0.8264; LRYGBP r=0.9711). Conclusions: Both LAGB and LRYGBP significantly improved insulin resistance during the first 3 months following surgery. Both operations generated similar changes in HOMA IR, although postoperative HOMA IR levels were significantly lower after LRYGBP. These findings suggest that caloric restriction plays a significant role in improving insulin resistance after both LAGB and LRYGBP.     

Massive Pericardial Effusion following a Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) is currently the most common bariatric surgical procedure. The most frequent complications of LAGB surgery are pouch dilatation, gastric prolapse, band erosion, stoma obstruction and access-port problems. We report a rare life-threatening case of massive pericardial effusion as a complication of an infected Lap-Band. The management of this condition included subxiphoid pericardial window, removal of the band and later conversion to gastric bypass.     

Exsanguinating Hemorrhage following Gastric Erosion after Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) has become a common bariatric operation, because of its safety, laparoscopic friendliness, acceptable weight loss and absence of long-term adverse nutritional sequelae. Gastric erosion is one of the troublesome complications of gastric banding. The etiology and presentation of erosion remain obscure. We present a patient who complained of persistent pain 6 months after gastric banding. Endoscopy revealed the band to be normally situated, which was also confirmed on upper GI imaging. Despite this, the patient subsequently presented with massive GI hemorrhage and circulatory collapse due to erosion, which necessitated emergency laparotomy with retrieval of the band from within the gastric lumen. This case highlights the possible urgent presentation of erosion after gastric banding, which was hitherto considered to be a more insidious complication. A high index of clinical suspicion remains the mainstay of diagnosis.     

Mechanical Evaluation of a Ruptured Swedish Adjustable Gastric Band

Background: Leakage of a laparoscopically placed Swedish adjustable gastric band (SAGB) was observed 2 1/2 years after placement. The band was evaluated for mechanical inaccuracies by a laboratory. Methods: The ruptured SAGB was investigated microscopically and wall thicknesses were measured. An unused SAGB was tested, both empty and filled, for mechanical deformity after exposure to saline solution. Results: A permanent transformation of the silicone rubber was found, caused by bowing of the device. 2 tears were present at the end of a kink.The mean wall thickness was within acceptable limits. Exposure of the gastric band to saline solution did not cause any sign of permanent deformity of the silicone rubber. Conclusion:The rupture of the gastric band did not seem to be caused by a production error. Long-term deformity, in combination with a continuous dynamic load, may increase the risk of tearing. Long-term follow up is recommended for patients treated with this device.     

Use of Adjustable Silicone Gastric Banding for Revision of Failed Gastric Bariatric Operations

Background: Revision of gastric bariatric operations is sometimes technically difficult and may fail to achieve prolonged weight reduction. The use of the adjustable silicone gastric banding (ASGB) offers a new approach for these revisions. Methods: ASGB was performed as a revisional procedure on 37 patients whose initial bariatric operations were as follows: silastic ring vertical gastroplasty (21), gastric bypass (12), horizontal gastroplasty (3) and vertical banded gastroplasty (1). Results: The length of the procedure varied from 55 to 145 minutes (mean 83 minutes). Intraoperative complications included two fundic tears which were sutured without any postoperative sequelae. Five patients needed reoperation during the first postoperative year due to gastric volvulus (1), tubing tear (1) and development of postoperative ventral hernia (3). BMI fell from 44.8 ± SD 8.07 to 33.4 ± 6.9 kg/m² for patients operated with BMI higher than 35 kg/m² and from 29.2 ± 3.32 to 25.4 ± 2.8 kg/m² for patients operated with BMI lower than 35 kg/m². Conclusions: ASBG can be performed with revisions with an acceptable complication rate and post-operative weight reduction.     

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.     

Conversion of Failed Vertical Banded Gastroplasty to Open Adjustable Gastric Banding

Background: Occasionally, patients with failed vertical banded gastroplasty (VBG) present for secondary treatment. We performed the reoperations using adjustable gastric banding (AGB) technique. Methods: From 1991 to 1997, 80 morbidly obese patients underwent VBG. In 7 (8.7%), staple-line disruption and weight regain were detected within 2 years of follow-up. Conversion to AGB was performed between 1994 and 1998. Meanwhile, another 80 morbidly obese patients underwent primary open AGB. Results: In the 7 patients, staple-line disruption was seen on radiography as a leak of contrast material across the gastric partition. After conversion of "failed" VBGs to AGB, postoperative results have been very satisfactory and similar to those of the primary open AGB group. Conclusions: VBG is a safe technique, although conversion rates were significant. Staple-line disruption constituted the chief cause of insufficient weight loss and frequently indicated the need for further surgery. Our results of the revisional surgery confirm that the reoperations for failed VBG can be performed using AGB technique.     

Adjustable Gastric and Esophagogastric Banding: A Randomized Clinical Trial

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands? were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.     

Band Leakage after Laparoscopic Adjustable Gastric Banding

Background: Laparoscopic adjustable gastric banding is effective in inducing weight loss, as well as being minimally invasive, totally reversible, and adjustable to the patient's needs. Nevertheless, leakage of the adjustable balloon is a known complication. The aim of this study was to assess the incidence and reasons for balloon leakage of the Swedish adjustable gastric band (SAGB). Patients and Methods: Between January 1996 and December 2002, 566 patients (475 women, 91 men) underwent a laparoscopic SAGB implantation. Two groups of patients were analyzed: patients with early postoperative leakage (Group E) and patients with late postoperative leakage (Group L). All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status) were prospectively collected in a computerized data bank. For the detection of gastric band leakage, radiography and the technetium-99m colloid scintigraphy was used. Results: 25 band leakages were observed in 22 patients (4.4%). All these patients had a silent presentation of band leakage, with weight regain and an ability to eat without major restriction. Band leakages in group E were detected during the band filling period after a median follow-up of 8 months and after 30.3 months (P <0.0001) in group L. In group E, all 13 leakages possibly resulted from inappropriate handling of the device during surgery. In 2 cases in group L, a tear of the balloon had occurred where it is fixed to the band. The other 10 bands showed breaks at the edges of the inner side of the balloon. All leakages could be detected by ^99mTc colloid scintigraphy, whereas only 58% of the leakages could be detected by radiography. Conclusion: Band leakage is a rare complication and should be considered if a patient starts to regain weight. Operative failure as well as material defects may account for this complication. The balloon leakage can effectively be detected by ^99mTc colloid-scintigraphy.     

Adjustable Gastric Banding: 5-Year Experience

Background: From 1993 to 1999, 172 patients underwent adjustable silicone gastric banding (ASGB) or laparoscopic adjustable silicone gastric banding (LASGB). In 109 patients the adjustable band was placed via laparoscopy; in the other patients it was placed via laparotomy (prelaparoscopic era, conversions from other bariatric operations, conversions for laparoscopic failure). The conversion rate from laparoscopy to laparotomy was 9.3%, occurring in the early part of our experience. Methods: Mean age was 37.9 years, weight 135 ± 14.8 kg (82-218) and BMI 46.3 ± 5.4 (35.1-69.5). All patients had multiple band adjustments, temporary antisecretive, electrolyte and vitamin therapy, and follow-up per routine. Results: Weight loss at 3 years was 30.2%; mean percent loss of excess weight was 62.5%.There was no mortality.The most important technical complications were: gastric pouch dilatation that required band replacement or removal (5.8 %); mild gastric pouch dilatation reversible with adequate dietary and pharmacological treatment (4.6%); intraoperative gastric perforation (2.3%); band migration (0.6%).The band was removed in 2.3%, with conversion to another bariatric procedure in 1.1%. Conclusions: Results have been satisfactory thus far.     

Gastric Bezoar Complicating Laparoscopic Adjustable Gastric Banding with Band Slippage

Gastric bezoars may develop in the proximal pouch after gastric restriction, eg. by laparoscopic adjustable gastric banding (LAGB). To date, only two centers have reported this rare complication. We report an additional case with band slippage, to emphasize that bezoars should be considered in the differential diagnosis in patients presenting with new onset nausea and vomiting after LAGB.     

Pouch Dilatation after Gastric Banding Causing Gastric Necrosis

Background: Early or late pouch dilatations account for a moderate complication rate after restrictive bariatric operations. Various strategies were developed to prevent or treat pouch dilatations. Methods: A case of necrosis of gastric wall in a concentric dilated pouch following laparoscopic adjustable gastric banding is reported as a severe complication of a conservative treatment attempt. Results: Emergency laparotomy resulted in band removal, partial gastric resection and prolonged hospital stay. Conclusion: Conservative strategies in the treatment of pouch dilatations bear the risk of complications, with both failure of the bariatric procedure and critical clinical course. Indication for early operative reintervention is recommended.     

Adjustable Gastric Banding in an Ambulatory Surgery Center

Background: We report our early experience with 343 consecutive patients who underwent laparoscopic adjustable gastric banding (LAGB) as an outpatient procedure in a self-standing ambulatory surgery center. Methods: Between Apr 2003 and Feb 2005, data was collected prospectively on 343 consecutive patients who underwent LAGB as an outpatient. Results: There were 305 females (88.9%) and 38 males (11.1%), with mean age 43.5 years (±SD 9.9, range 19-67) and mean BMI 44.5 kg/m 2 (±SD 6.1, range 32.7-62.7). Mean operating-room time was 52.9 (±16.3) minutes. 10 complications occurred in 9 patients (2.8%): 5 stoma occlusion, 3 port problems requiring port replacement, 1 superficial wound infection, and 1 colon perforation associated with adhesiolysis requiring band removal. 3 patients required admission to the hospital: 1 for nausea, 1 for observation after bloody nasogastric tube drainage, and 1 for dysphagia due to esophageal spasm. All 9 patients with complications recovered fully. 1-year weight loss data was available in 91 patients; mean percent excess weight lost (%EWL) at 1 year was 45.4% (±17.6). Conclusions: LAGB has become an appropriate outpatient procedure in select patients.     

Adjustable Gastric Banding: Assessment of Safety and Efficacy of Bolus-Filling during Follow-Up

Background: Individual band-filling on demand of the morbidly obese patient is a major advantage of adjustable gastric banding. An increasing number of patients results in an enormous amount of outpatient follow-up visits, which inspired us to compare a stepwise band-filling strategy with a single bolus injection 4 weeks after the operative procedure. Methods: 40 consecutive patients were prospectively randomized in 2 groups. 20 patients (Group A) had stepwise band-filling during 6 monthly ambulant visits. 20 patients (Group B) had a bolus-filling 4 weeks postoperatively and had the next follow-up after another 5 months. Weight loss, complications and procedural costs during follow-up were compared. Results: Patients of both groups did not differ in age, gender or preoperative BMI.There was no significant difference postoperatively in excess weight lost (EWL) after 9 months. Postoperative complications did not differ significantly.By means of bolus-filling, a 60% and 53% reduction in outpatient clinical work was achieved within the 6 and 9 months, respectively. Conclusion: Postoperative management after gastric banding takes advantage of a single bolus-filling during the first postoperative 6 months due to sufficient weight loss, low complication rate but significant reduction of personal, financial and logistic efforts.     

Pregnancies after Adjustable Gastric Banding

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.     

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.