Combination of Laparoscopic Adjustable Gastric Banding and Gastric Bypass: Current Situation and Future Prospects – Routine Use Not Advised

Although bariatric surgery has proven to be the most effective treatment for morbid obesity, most surgical techniques do have failures. In an effort to improve the reliability, several surgeons started to use a combination of a laparoscopic gastric bypass with an adjustable gastric band. Because of concerns regarding a possible negative outcome, an expert meeting was organized to evaluate the current situation and future application. In total, 104 operations were reported,with several technical variations. The overall complication rate was acceptable, but the percentage of the band erosions was 6.7%, which is too high. The potential advantages (adjustability, maintained access to the stomach and biliary tree, and reversibility) do not compensate for this complication rate. Based on the results and the opinion of the surgeons experienced in this technique, it is concluded that the combination of gastric bypass with an adjustable gastric band to form the pouch is not recommended.     

Factors Determining Conversion from Laparoscopic to Open Roux-en-Y Gastric Bypass

Background: Conversion from laparoscopic to open Roux-en-Y gastric bypass (RYGBP) is expensive and time-consuming. Methods: Data from our first 1,000 laparoscopic RYGBP was entered into a database (Minnesota Database-Bariatric, Exemplo Medical). All patients met NIH criteria for bariatric surgery. Results: 41 (4.1%) of 1,000 consecutive lapRYGBPs were converted to open. Patients requiring conversion to open surgery, analyzed for predictors, revealed: 1) BMI, waist size, and weight all were significantly greater in patients converted to open bypass; 2) Gender: 9 of 109 males (8.3%) and 32 of 891 females (3.6%) were converted (Fischer's exact test, P=0.035); 3) Average age of patients converted was 44.9 compared to 41.3 in the lap group (P=0.02); 4) Conversion was required for 12 large livers (1 palpable preop, 7 had diabetes, 7 had NASH or steatosis); 5) 10 conversions for mechanical/technical reasons – 6 for inability to distend abdominal wall and/or manipulate instruments due to thickness of wall, and 2 due to loss of instruments in abdomen; 6) 9 required conversion for adhesions (2 from previous cholecystectomies with biliary leaks, and 1 from previous transverse colectomy; 7) 4 visceral injuries required conversion (2 stomach, 1 small bowel, 1 esophagus); 8) 3 hemorrhages from spleen with blood loss over 1300 ml required conversion (1 spleen removed, 6 minor not requiring open conversion); 9) 3 conversions were for anomaly/disease (1 malrotation of colon, 1 ovarian teratoma, and 1 intra-thoracic stomach). Conclusion: Steatohepatitis, diabetes mellitus, adhesions from various causes, previous bile leaks, large waist size, BMI, and weight are predictors for conversion to open surgery.     

Literature Review of Comparative Studies of Complications with Swedish Band and Lap-Band®

Background: Gastric restriction is a treatment option for morbid obesity. Currently there are several types of adjustable gastric bands available, with two leading but conceptionally different systems, not just from a technical point of view but also from the long-term complication rates. Methods: A literature search of articles published from January 1997 to December 2002 dealing with prospective or restrospective studies comparing results of treatment with the Swedish band and LapBand? was carried out. Results: 7 comparative studies fulfilled inclusion criteria, with a total of 1,031 patients in the Swedish band (41-597) and 1,305 patients in the Lap-band? groups (34-821). Pouch dilatation/slippage and/or erosion in Swedish vs Lap-band? were reported in the studies as follows: 1 vs 2 in study group 1, 0 vs 9 in study group 2, 0 vs 3 in 3, 3 vs 38 in 4, 0 vs 64 (slippages) and 4 vs 4 (erosions) in group 5. In study 6, 3 vs 3 dilatations and 0 vs 1 erosions were reported. Study 7 found 12 vs 42 long-term complications of this origin. Port-site infections, total reoperation rates and length of hospital stay were also compared. Conclusion:The results of this meta-analysis reveal that fall in BMI is similar with both laparoscopic bands. Long-term complication rates, despite the fact that they have been defined in a similar way in all the included studies, may be higher with more reoperation rates in Lap-band? patients.     

Stroke and Seizure following a Recent Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been an available operation for weight loss for the past decade, and bariatric surgery is increasing in the United States. Careful patient screening and follow-up have been the cornerstone for success against the complexities of morbid obesity. Neurologic complications have occurred, such as polyneuropathy and Wernicke-Korsakoff syndrome. We report an 18-year-old female with morbid obesity, steatohepatitis, tobacco, recreational drug, and oral contraceptive use who at 4 months after LRYGBP experienced a generalized seizure and stroke. She was diagnosed with an acute ischemic stroke, possibly venous infarction. Her postoperative course had been complicated by malnutrition and dehydration, apparently related to nausea from chronic cholecystitis. She had a possible protein-S deficiency. Rare neurologic complications emphasize the importance of postoperative surveillance in these patients.     

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.     

Band Erosion after Laparoscopic Gastric Banding: Occurrence and Results after Conversion to Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding is a popular bariatric operation. Unfortunately, long-term complications such as slippage, infection, and intragastric migration (erosion) may occur. With erosion, band removal is mandatory. Options to prevent weight regain are delayed implantation of a new band, or conversion to another bariatric procedure such as Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion. We present our experience with band erosion and immediate or delayed conversion to RYGBP. Methods: With a multidisciplinary team approach and prospective data collection, a comparison was made between patients with and without band erosion. The patients who were converted to RYGBP for band erosion were analyzed. Results: Gastric banding was performed on 347 patients between 1995 and 2002. Median follow-up is 52 months. Band erosion developed in 24 patients (6.8 %).The latter were heavier before gastric banding (BMI 45.9 vs 43.3, P <0,01). No band had ever been overinflated. Band erosion was diagnosed after a mean of 22.5 months (3-51). At time of diagnosis, mean BMI of 33.5 kg/m² (22.5-48) and average excess weight loss (EWL) of 52.9% (25-97) did not differ from that of the remaining patients at the respective time interval. The band was removed in all cases. Conversion to RYGBP was performed at the same time in 11, and a few months later in 2 patients. Operative morbidity included 1 leak (reoperation) and 4 wound infections. All but 1 patient lost further weight after reoperation, or at least maintained their weight. At last follow-up, mean EWL in relation to the pre-banding weight was 65.1%, and 69.2% of the patients had an EWL >50%, which compares favorably with the results obtained after primary RYGBP. Conclusions: In our series with a median follow-up >4 years, band erosion was more common than usually reported. Band removal with immediate or delayed conversion to RYGBP is feasible with an acceptable morbidity, and prevents weight regain in most cases. These results support further use of this approach for band erosion.     

Modifications of Metabolic and Cardiovascular Risk Factors after Weight Loss Induced by Laparoscopic Gastric Banding

Background: The well-known inverse relation between life expectancy and BMI, particularly in morbid obesity, is presumably in large part due to multiple cardiovascular and metabolic comorbidities. Severely obese patients treated with laparoscopic adjustable silicone gastric banding (LASGB) were evaluated for such risk factors before and 1 year after LASGB. Methods: 130 individuals (age 20-66, BMI 34-59 kg/m²) who underwent LASGB between 1996 and 2000 were studied; 50 of them were available for reevaluation 12 months after surgery. The presence and severity of diabetes (DM), hypertension (HTN), hypercholesterolemia (HC) and hypertriglyceridemia (HT) were assessed before and after surgery. In 18 of them erythrocyte sedimentation rate (ESR) were also measured. Results: Comorbidities were highly prevalent at the initial evaluation: DM 10%, HTN 32%, HC 37%, HT 27%. In the subgroup reevaluated after surgery, prevalence of DM decreased from 15% to 6%, HTN from 37% to 25%, HC from 36% to 25%, and HT from 29% to 13%, with an average BMI loss from 44.1 to 35.9. ESR decreased from a preoperative value of 36.7 ± 22.6 mm/hr to 18.3 ± 11.9 mm/hr at 1 year (p < 0.001). Conclusion: Morbidly obese subjects respond to LASGB with an impressive reduction of comorbidities which is sustained for at least 1 year, well after the initial acute negative energy balance and when weight tends to stabilize. The high prevalence of elevated ESR, which has been considered a strong predictor of coronary mortality, confirms previous reports of its association with obesity, and the clear tendency to normalization with weight loss may represent a further element contributing to lower morbidity.     

Functional gastric bypass with an adjustable gastric band

Background: To create a bond between the technique proposed and the patient, flexibility and adaptability are indispensable.Thus, we devised the functional gastric bypass, which can be activated and deactivated by inflating or deflating the Lap-Band^?. Methods: The Lap-Band^? was positioned according to the standard technique, with the addition of a hand-sewn side-to-side gastroenterostomy between the gastric pouch and the intestine in the form of an Omega loop. Inflation or deflation of the Lap-Band^? allows activation or deactivation of the bypass. From October 1995 to December 2001, 545 Lap-Band^? operations were carried out. Between January 2001 and December 2001, functional gastric bypass was performed on 7 patients. Indications were: 1) prior failed Lap-Band^? treatment; 2) the first-choice operation for patients where non-restrictive surgery may be indicated. Results: There was no morbidity or mortality.The functioning bypass was confirmed radiologically and clinically. Conclusion: In morbid obesity characterized by a variable relationship with food, the flexibility of the functional bypass allows adaptation to changes in the pathology itself and in the individual patient, which other surgical techniques cannot do. Surgical indications, proven feasibility, safety and efficacy await long-term documentation.     

Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity

Background: Since the first laparoscopic adjustable gastric banding (LAGB) operation on September 1, 1993, there have been important publications related to this procedure. The majority of the articles reported surgical technique and short-term results. Long-term results of LAGB are lacking. The authors report long-term data (at least 4 years) from 3 major bariatric centers in Belgium that perform LAGB routinely. Methods: The 3 centers applied the same patient selection criteria, the same standard surgical technique, the same laparoscopic band (Lap-Band?) and the same follow-up program. 763 patients have been enrolled. Sex ratio was 22% male/78% female. Mean age was 34 years, and mean preoperative BMI was 42 kg/m². Results:The follow-up rate was 90%, and the minimum follow-up time was 4 years. The average BMI after 4 years was 30 kg/m². Early complications were: gastric perforation 4 (0.5%); large bowel perforation 1 (0.1%); bleeding 1 (0.1%); and conversion to open 10 (1.3%). Late complications were: erosion 7 (0.9%); total food intolerance 59 (8%); access port problems 20 (2.5%); re-operations 80 (11.1%); death 1 (0.1%). Conclusion: Long-term results of LAGB have been rarely reported, although publications on the procedure are copious. Our long-term data found that BMI evolution is good, the complication and re-operation rates are acceptable and the overall long-term results of the Lap-Band? system are good.     

Current status of non-adjustable gastric banding

Background: The purpose of this study is to review the current status of non-adjustable gastric banding (NGB) and to determine whether this operation is still acceptable in the management of morbid obesity, especially when compared with the adjustable GB (AGB) in long-term results. Materials and Methods: A literature search was conducted of data published on NGB and AGB in Obesity Surgery in the past 12 months or available from other sources, with records of early and late band-related complications, reoperation rate and weight loss in groups reporting ≥100 patients with minimum 3-year postoperative follow-up. Results: 1,812 NGB and 1,968 AGB patients were included. Mean BMI was 42.4 in NGB vs 44.0 in AGB. No statistical difference occurred in the early complication rate (1.4% in NGB vs 1.6% in AGB). A statistical difference was noted in long-term complication rate, (1.9% in NGB vs 6.7% in AGB), and in reoperation rate (3.4% vs 7.2%). There was no difference in excess weight loss at 48 months following both operations (54.2% vs 53.0%). Conclusion: A significant difference in favor of NGB occurred in the long-term reoperation rate. No other differences were identified, other than in band material. NGB is a softer material and therefore, according to computerized images, has greater flexibility in copying gastric peristaltic waves, which may result in less irritation and more physiological behavior by this band.