Improvement of Lipid Profile after One-Anastomosis Gastric Bypass Compared to Sleeve Gastrectomy.

Fewer studies compared the improvement of plasma lipid levels after different types of surgery, in particular compared to one-anastomosis gastric bypass (OAGB). The aim of our study was to investigate how laparoscopic sleeve gastrectomy (LSG) and OAGB impact on weight loss and lipid profile 18 months after surgery, in patients with severe obesity. Forty-six patients treated with OAGB were matched to eighty-eight patients submitted to LSG. Weight loss after OAGB (33.2%) was more evident than after LSG (29.6%) (p = 0.024). The difference in the prevalence of dyslipidemia showed a statistically significant reduction only after OAGB (61% versus 22%, p < 0.001). After adjustment for delta body mass index (BMI), age and sex, we demonstrated a statistically significant decrease of the differences between the changes before and after (delta Δ) the two surgery procedures: Δ total cholesterol values (p < 0.001), Δ low density lipoprotein-cholesterol values (p < 0.001) and Δ triglycerides values (p = 0.007). Patients with severe obesity undergoing to OAGB presented a better improvement of lipid plasma values than LSG patients. The reduction of lipid plasma levels was independent of the significant decrease of BMI after surgery, of age and of sex.

Predicting Responses to Bariatric and Metabolic Surgery.

PURPOSE OF REVIEW: Bariatric surgery is today the most effective therapy for weight loss and reduction of comorbidity burden in patients with severe obesity. However, bariatric surgery does not benefit equally all the patients. A consistent variability in outcomes has been observed. Predicting responses to bariatric surgery could be an important tool in clinical practice, by improving patients' selection or by identifying patients in which more aggressive follow-up and post-operative intervention should be applied. Predictive factors for weight loss, weight regain, diabetes remission and recurrence are briefly reviewed in this paper. RECENT FINDINGS: Many pre-operative factors have been proposed as negative or positive predictors of body weight reduction after surgery. However, none of these factors has been consistently demonstrated to have a sufficiently strong predictive power to influence eligibility to bariatric surgery itself. Weight regain can occur after bariatric surgery and its probability seems to be more influenced by post-operative behavioral factors than by pre-operative predictors. Several effective scores have been developed to predict diabetes remission after surgery, however long-term maintenance and diabetes recurrence after surgery seem again more influenced by post-operative behaviors and weight loss maintenance. In general, more attention and active interventions to pre-operative and post-operative eating behaviors and lifestyle modifications are probably more important at the clinical level than the search of pre-operative predictors of long-term outcomes.

The gastric band: first-choice procedure for obesity surgery.

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its development, clinical outcomes, and future role. We also address current controversies, including a comparison of LAGB with Roux-en-Y gastric bypass (RYGBP). At present LAGB seems to be increasing in popularity in the United States, whereas in Europe there seems to be a trend away from gastric banding toward RYGBP. Optimal outcomes after LAGB are a function of correct laparoscopic technique, an experienced surgical team, a well-engineered device, and intensive long-term follow-up. The majority of studies show that LAGB is an extremely safe and effective procedure, with an operative mortality of 0-0.1% and excess weight loss (%EWL) of 50-60%. Commensurate with this degree of weight loss, almost all studies show substantial improvements in obesity-related co-morbidities, such as hypertension, type II diabetes, and dyslipidemia. In addition, LAGB has been shown to be both safe and effective in the super-obese, in adolescents, and in older patients and can be delivered as an ambulatory procedure. Operative mortality and early complication rates are significantly higher for RYGBP and, whilst gastric bypass results in greater weight loss than LAGB in the first 2 years, at 3 years and beyond the difference appears to be less marked. Overall, LAGB provides a safe, effective intervention for obese patients and remains our first-choice procedure for bariatric surgery.

Preoperative psychological testing--another form of prejudice.

Preoperative psychological screening of bariatric surgery candidates has become routine, and a significant proportion of patients have their surgery deferred as a consequence. If psychological testing is being used as a form of preoperative triage, both patients and surgeons are entitled to know whether there is sufficient evidence to justify its use in this way. We define the argument for psychological screening as consisting of four premises (p1-p4) and a conclusion (C) as follows: (p1) A significant minority of obese patients will not be successful in losing weight following bariatric surgery-the "failure" group; (p2) A significant minority of patients will exhibit abnormal psychological profiles during preoperative testing; (p3) The majority of individuals referred to in (p2) will be found in group (p1) i.e., abnormal psychological profiles identified preoperatively predict less favorable weight loss outcomes postoperatively; (p4) Identifying patients with adverse psychological profiles preoperatively would allow either exclusion of those at high risk of failure or provide a more secure rationale for targeted pre- and postoperative support; (C) Psychological screening should be part of the routine preoperative assessment for patients undergoing obesity surgery. We reviewed the literature to find evidence to support the premises and show that (p1) can be justified but that (p2) is problematic and can only be accepted in a heavily qualified version. We find no evidence for (p3) and since (p4) and (C) are predicated on (p3), the argument clearly fails. There is no evidence to suggest that preoperative psychological screening can predict postoperative outcomes and no justification for using such testing as a means of discriminating between candidates presenting themselves for bariatric surgery.

Medium and long-term results of gastric banding: outcomes from a large private clinic in UK.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) has been an established bariatric procedure for the last three decades and was, for many years, the first-choice procedure for the treatment of chronic obesity. However, more recently, the popularity of the LAGB has been in sharp decline and has been replaced by other procedures such as the Roux-En-Y gastric bypass and sleeve gastrectomy. A key driver in this decline has been the high revision and early explanation rates reported in some studies. METHODS: This was a retrospective study of 2246 patients who underwent LAGB at a large private clinic in the UK between June 2004 and October 2014. RESULTS: 2246 patients were included in the study; 1945 (84.6%) were women. All patients were followed up for 2 years following their procedure and subsequent follow up was at the discretion of patients. Mean follow up duration was 43.7 +/- 29.3 months. Operative mortality was zero and there were no in-hospital returns to theatre. Mean preoperative weight and body mass index (BMI) were 111.2 ± 22.1 kg and 39.9 ± 6.7 kg/m2 respectively. Mean excess % BMI loss at 1-, 2-, 5- and 8-years of follow-up was 43.1 ± 25.4, 47.9 ± 31.9, 52.4 ± 41.7 and 57.1% ± 28.6 respectively. There was no significant difference in mean excess % BMI loss between those < 50 or ≥ 50 years old (p value = 0.23) or between patients with an initial BMI of < or ≥ 50 kg/m2 (p value = 0.65). Complications over nine years occurred in 130 (5.8%) patients and included: 39 (1.7%) slippage or pouch dilatation, 2 (0.04%) erosions and 76 (3.4%) problems related to the access port or LAGB tubing. The overall re-operation rate for LAGB complications was 4.2% over 9 years with a LAGB explantation rate of 1.5%. 39 LAGBs were converted to a sleeve or gastric bypass procedure, 11 of these due to complications. CONCLUSION: This is the first study to report on LAGB outcomes from a private clinic in the UK. LAGB is a safe procedure, which delivers significant and durable weight loss with acceptable complications rates and low re-operation rate.

Laparoendoscopic Percutaneous Endoscopic Gastrostomy in Adults.

BACKGROUND: Since its introduction, the placement of percutaneous endoscopic gastrostomy (PEG) has been increasing in the Western countries. Nevertheless, it is not always possible to perform this operation. Laparoscopic-assisted endoscopic gastrostomy (LAPEG) is an effective alternative solution. MATERIALS AND METHODS: Indication to PEG placement was established only for people who required a nutritional support of >4 weeks and without metastatic carcinoma. Sixteen patients underwent LAPEG after the failure of the original PEG operation. Two trocars of 5 mm and one of 12 mm were used, and a fourth trocar of 5 mm was placed when necessary to lift the liver. In four cases a gastrotomy was performed, in seven patients it was not necessary. When PEG was placed, the stomach was not fixed with stitches to the abdominal wall. RESULTS: Sixteen patients were selected for LAPEG and were all successful; in one case it was necessary to replace the PEG, and the same procedure was performed again. Median age was 73 years. Placement of laparoscopic PEG was not associated with other surgical procedures. Nutritional feeding started the day after for patients with sutureless technique and 2 days after in patients with gastrotomy. CONCLUSION: LAPEG is a safe technique with a low complication rate. It should be considered a minimal alternative in all cases where the placement of PEG is not possible.

Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results.

BACKGROUND: This study examines 1,791 consecutive laparoscopic adjustable gastric banding (LAGB) procedures with up to 12 years follow-up. Long-term results of LAGB with a high follow-up rate are not common. METHODS: Between September 1993 and December 2005, 1,791 consecutive patients (75.1% women, mean age 38.7 years, mean weight 127.7 +/- 24 kg, mean BMI 46.2 +/- 7.7) underwent LAGB by the same surgical team. Perigastric dissection was used in 77.8% of the patients, while subsequently pars flaccida was used in 21.5% and a mixed approach in 0.8%. Data were analyzed according to co-morbidities, conversion, short- and long-term complications and weight loss. Fluoroscopy-guided band adjustments were performed and patients received intensive follow-up. The effects of LAGB on life expectancy were measured in a case/control study involving 821 surgically-treated patients versus 821 treated by medical therapy. RESULTS: Most common baseline co-morbidities (%) were hypertension (35.6), osteoarthritis (57.8), diabetes (22), dyslipidemia (27.1), sleep apnea syndrome (31.4), depression (21.2), sweet eating (22.5) and binge eating (18.5). Conversion to open was 1.7%: due to technical difficulties (1.2) and due to intraoperative complications (0.5). Together with the re-positioning of the band, additional surgery was performed in 11.9% of the patients: hiatal hernia repair (2.4), cholecystectomy (7.8) and other procedures (1.7). There was no mortality. Reoperation was required in 106 patients (5.9%): band removal 55 (3.7%), band repositioning 50 (2.7 %), and other 1 (0.05 %). Port-related complications occurred in 200 patients (11.2%). 41 patients (2.3%) underwent further surgery due to unsatisfactory results: removal of the band in 12 (0.7%), biliopancreatic diversion in 5 (0.27%) and a biliopancreatic diversion with gastric preservation ("bandinaro") in 24 (1.3%). Weight in kg was 103.7 +/- 21.6, 102.5 +/- 22.5, 105.0 +/- 23.6, 106.8 +/- 24.3, 103.3 +/- 26.2 and 101.4 +/- 27.1 at 1, 3, 5, 7, 9, 11 years after LAGB. BMI at the same intervals was 37.7 +/- 7.1, 37.2 +/- 7.2, 38.1 +/- 7.6, 38.5 +/- 7.9, 37.5 +/- 8.5 and 37.7 +/- 9.1. The case/control study found a statistically significant difference in survival in favor of the surgically-treated group. CONCLUSIONS: LAGB can achieve effective, safe and stable long-term weight loss. In experienced hands, the complication rate is low. Follow-up is paramount.

Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls.

BACKGROUND: To compare the mortality rate of obese patients treated by laparoscopic gastric banding (LAGB) with the mortality rate of matched obese patients observed at medical centers. The net effect of bariatric surgery on total mortality is still controversial. Gastric bypass has been shown to reduce the relative risk of death, but similar data with LABG are still lacking. METHODS: The surgical series was composed of 821 patients with a body mass index (BMI) >40 kg/m(2) consecutively treated with LAGB at Padova University, Italy. The reference group was composed of 821 gender-, age-, and BMI-matched patients selected from a sample of 4681 adults with a BMI >40 kg/m(2) observed at 6 Italian medical centers not using surgical therapy. RESULTS: The mean follow-up was 5.6 +/- 1.9 and 7.2 +/- 1.2 years in the surgical and reference group, respectively. The vital status was known in 97.6% of the surgical group (8 deaths) and in 97.4% of the reference group (36 deaths). In the surgical group, the percentage of excess weight loss was 39.8% +/- 17.9% 1 year after LAGB and 37.2% +/- 23.8% 5 years after LAGB. The rate of late revisional surgery was 12.2%. Survival was estimated using the Kaplan-Meier method, and the differences between the 2 groups were evaluated using the log-rank test. The survival rate was significantly greater in the surgical group (P = 0.0004). On multivariate Cox analysis, the 5-year relative risk of death in the surgical group, adjusted for gender, age, and baseline BMI, was 0.36 (95% confidence interval 0.16-0.80). CONCLUSION: LAGB was associated with a 0% operative mortality rate and 40% stable excess weight loss. LAGB patients had a 5-year 60% lower risk of death than comparable morbidly obese patients.

Complications of laparoscopic gastric banding: detection and treatment.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) is acknownledged as a popular and effective surgical option in the management of obesity and related metabolic diseases. This procedure is a remarkably safe operation from both a general surgical and bariatric perspective. It facilitates brief hospitalization and can be performed by single incision. METHODS: We analyzed the most common LAGB complications as intraoperative and postoperative gastric perforation, stomach slippage/dilatation, port/tubing complications and intragastric band migration which occurred in our long decades clinical experience. Detection, treatment and rate of presentation of each complication was evaluated. RESULTS: LAGB showed good long term results in terms of weight loss and resolution of obesity related diseases. Moreover, mortality due to obesity and related diseases appeared significantly lower in LAGB patients than in medically treated patients. CONCLUSION: Gastric Banding has a very low rate of early and late complications; these are also less severe when compared to more invasive procedures and are likely to be managed with mini-invasive techniques. In any case referral to a bariatric surgeon is deemed appropriate. KEY WORDS: Complication, Laparoscopic gastric banding, Morbid obesity.

Impact of the feedback provided by a gastric electrical stimulation system on eating behavior and physical activity levels.

OBJECTIVE: The closed-loop gastric electrical stimulation (CLGES) abiliti® system provides tailored gastric electrical stimulation activated by food entry into the stomach and sensor-based data to medical professionals. The aim of this study was to analyze behavior changes using sensor-based food intake and activity data in participants treated with the CLGES system. METHODS: Food intake and activity data (3D accelerometer) were downloaded at baseline and monthly/bimonthly for 12 months in a subset of patients with obesity (N = 45) participating in a multicenter trial with CLGES. Measured food intake parameters included the number of intakes during allowed and disallowed periods, nighttime intakes, and between-meal snacks (average/d). Activity parameters included time in different levels of physical activity (min/d), sleep/sedentary (h/d), and estimated energy expenditure (EE). RESULTS: Weight loss at 12 months averaged 15.7 ± 7.7% of the baseline body weight. Stable reduction in the number of disallowed meals and between-meal snacks (P < 0.05), an increase in all levels of physical activity (P < 0.001), and an increase in activity-based EE (303 ± 53 kcal/d on average, P < 0.001) were seen. CONCLUSIONS: Significant improvement in eating and activity was seen in participants. It is hypothesized that feedback of the sensor-based data induced behavioral changes and contributed to weight loss in patients treated with CLGES.

Complications Following the Mini/One Anastomosis Gastric Bypass (MGB/OAGB): a Multi-institutional Survey on 2678 Patients with a Mid-term (5 Years) Follow-up.

BACKGROUND: In recent years, several articles have reported considerable results with the Mini/One Anastomosis Gastric Bypass (MGB/OAGB) in terms of both weight loss and resolution of comorbidities. Despite those positive reports, some controversies still limit the widespread acceptance of this procedure. Therefore, a multicenter retrospective study, with the aim to investigate complications following this procedure, has been designed. PATIENTS AND METHODS: To report the complications rate following the MGB/OAGB and their management, and to assess the role of this approach in determining eventual complications related especially to the loop reconstruction, in the early and late postoperative periods, the clinical records of 2678 patients who underwent MGB/OAGB between 2006 and 2015 have been studied. RESULTS: Intraoperative and early complications rates were 0.5 and 3.1%, respectively. Follow-up at 5 years was 62.6%. Late complications rate was 10.1%. A statistical correlation was found for perioperative bleeding both with operative time (p < 0.001) or a learning curve of less than 50 cases (p < 0.001). A statistical correlation was found for postoperative duodenal-gastro-esophageal reflux (DGER) with a preexisting gastro-esophageal-reflux disease (GERD) or with a gastric pouch shorter than 9 cm, (p < 0.001 and p = 0.001), respectively. An excessive weight loss correlated with a biliopancreatic limb longer than 250 cm (p < 0.001). CONCLUSIONS: Our results confirm MGB/OAGB to be a reliable bariatric procedure. According to other large and long-term published series, MGB/OAGB seems to compare very favorably, in terms of complication rate, with two mainstream procedures as standard Roux-en-Y gastric bypass (RYGBP) and laparoscopic sleeve gastrectomy (LSG).

High ghrelin concentration is not a predictor of less weight loss in morbidly obese women treated with laparoscopic adjustable gastric banding.

BACKGROUND: We analyzed the role of high plasma ghrelin concentrations at surgery as a negative predictor of weight loss in morbidly obese patients treated with laparoscopic gastric banding (LAGB). METHODS: Fasting plasma ghrelin concentrations were measured in 113 women before LAGB, and 16 of them were identified as having ghrelin concentrations clearly higher than expected according to the BMI levels. The 2-year postoperative outcome of these 16 patients was compared to the outcome of the remaining subjects. RESULTS: Mean fasting plasma ghrelin concentration in the group with hyperghrelinemia was 82.3+/-23.1 pg/ml and in women with normal ghrelin was 27.1+/-11.3 pg/ml (P<0.001). No differences in age, age at onset of obesity or degree of obesity were observed between the two groups. Women with hyperghrelinemia had a weight gain during the waiting time similar to women with normal ghrelin. The prevalence of comorbidities and eating behavior disturbances was similar in the two groups, but depression was 2.5 fold more prevalent in the hyperghrelinemic women than in the women with normal ghrelin. The %EWL after LAGB surgery was similar in women with high and normal ghrelin concentrations, with no differences in levels of postoperative band filling. No differences in band-related complications or revisional surgery rate were observed between the two groups. CONCLUSION: A high fasting ghrelin concentration at baseline did not significantly affect the outcome after LAGB in morbidly obese women, in terms of weight loss and complications rate.

Weight loss and postoperative complications in morbidly obese patients with binge eating disorder treated by laparoscopic adjustable gastric banding.

BACKGROUND: The authors investigated the outcome of morbidly obese patients with binge eating disorder (BED) treated surgically with laparoscopic adjustable gastric banding. METHODS: The 5-year outcomes of 130 patients with BED and 249 patients without BED are described. The diagnosis of BED was made preoperatively and all patients with BED were supported with psychological therapy. RESULTS: Patients with and without BED had similar BMI levels before surgery. More patients with than without BED had depressive symptoms and associated minor disturbances of eating behavior (night eating and grazing). Percent excess weight loss (%EWL) in the first 5 years after surgery was similar in patients with and without BED. The percentage of BED patients showing %EWL >50% at the 5-year evaluation was 23.1, and 25.7% in non-BED patients. The percentage of patients showing weight regain in the last 4 years of follow-up was similar in binge eaters (20.8%) and in non-binge eaters (22.5%). The 5-year frequency of gastric pouch and esophageal dilatation was significantly higher in binge eaters than in non-binge eaters (25.4 vs 17.7 %, P<0.05 and 10.0 vs 4.8%, P<0.05, respectively). Binge eaters underwent a higher number of postoperative band adjustments than non-binge eaters (3.0+/-2.1 vs 2.6+/-1.9, P<0.05) and the maximum band fill after surgery was higher in the BED patients than in non-BED patients (3.2+/-1.2 vs 2.8+/-1.3 ml, P<0.01). CONCLUSION: Morbidly obese patients with BED supported by adequate psychological treatment can have good outcomes after gastric banding.

The Gastric Band That Is Not to Be : Efficacy, Safety and Performance of the Easyband™: a Multicenter Experience.

BACKGROUND: Access port problems after laparoscopic adjustable gastric banding can be significant complications. The Easyband™ is an innovative type of gastric band, whose internal diameter can be adjusted by a telemetrically activated motor. The aim of this study was to evaluate safety, efficacy and performance of the Easyband™. METHODS: A total of 110 morbidly obese patients were prospectively enrolled. The Easyband™ was implanted laparoscopically by experienced bariatric surgeons in six different hospital locations. Patient characteristics, surgery details, postoperative weight loss, and complications were recorded. Follow-up lasted 2 years. RESULTS: Follow-up was completed by 78.2 % of the patients. Surgeons rated 71 % of each aspect of Easyband™ implantation as "easy" or "very easy". Adjustments were successful in 91 % of the attempts. One or more adverse events occurred in 79.1 % of the patients. Thirty-six serious adverse events were reported, of which 50 % was device-related. One or more functional tests failed in 20.9 % of the devices, 8.2 % passed after a repeated test. A reintervention was necessary in 15.5 % of the patients. Mean weight loss after 2 years was 24.2 ± 14.0 kg, mean excess weight loss was 46.1 ± 24 %. CONCLUSION: Excess weight loss with the Easyband™ was comparable with other gastric banding devices. Adjustment of the device was simple, non-invasive and more acceptable to patients than with a standard access port. However, a high incidence of device-related problems requiring surgical explantation occurred. The Easyband™ represents a major advance in gastric band design, but significant technical problems need to be resolved before further implants can be recommended.

Treatment of morbid obesity with the Transcend Implantable Gastric Stimulator (IGS): a prospective survey.

BACKGROUND: The implantable gastric stimulator (IGS), a pacemaker-like device, has been found to be safe and effective to induce and maintain weight loss. We present our experience with 20 morbidly obese patients. METHODS: Between September 20 and November 22, 2002, 20 patients (F/M 12/8), mean age 40.3 years (23-62) underwent IGS implantation. Mean BMI was 40.9 (33.9-48.2), mean weight 115.0 kg (87.0-137.0) and mean excess weight (EW) 51.3 kg (35.6-70.1).Co-morbitidies were: 3 cases of hypertension, 1 diabetes, 1 dislipidemia and 1 depression. Mean operative time was 58.5 min (37-85). The IGS was actived 30 days after implantation. Patients were advised to follow a low calorie diet and behavior modification (to avoid fat and to ingest more liquids during meals, to chew slowly, to eat vegetables before main meals, and to perform exercise daily). RESULTS: Mean +/- standard error percent excess weight loss (%EWL) was: 10.6+/-1.8 at 1 month; 15.0+/-2.3 at 2 months; 16.6+/-2.6 at 3 months; 18.1+/-3.5 at 4 months; 15.5+/-3.5 at 6 months; 18.9+/-3.5 at 8 months; and 23.8+/-5.0 at 10 months. There were no intra-operative surgical or long-term complications. There were 3 intra-operative gastric penetrations, observed by gastroscopy, without sequelae. One patient with hypertension ceased his medical therapy at the 4th month. CONCLUSION: IGS can be implanted laparoscopically with minimal perioperative complications. The observed weight loss is comparable to other noninvasive procedures. If weight loss is maintained, IGS could be considered as a first choice therapy in the treatment of morbid obesity in selected patients.

Postoperative management of laparoscopic gastric banding.

BACKGROUND: The authors investigated the postoperative management of morbidly obese patients treated by laparoscopic adjustable gastric banding (LAGB) with the Lap-Band System. METHODS: The 3-year postoperative band management is presented in 379 morbidly obese patients, divided according to intra-operative band filling and quartiles of maximum postoperative band filling. RESULTS: LAGB resulted in a 40.8 +/- 24.5 percent excess weight loss (%EWL). Stoma stenosis occurred in 87 patients (23.0%), pouch dilatation in 52 (13.7%) and esophageal dilatation in 22 (5.8%). Most band-related complications were controlled by simple band deflation. The mean number of postoperative band adjustments was 2.3 +/- 1.7, and mean maximum band filling after surgery was 2.8 +/- 1.2 ml. Weight loss at 3 years was identical in 205 patients who had the band completely unfilled at surgery and in 174 patients who had the band filled with 1 to 3 ml of sterile saline. The rate of band-related complications was significantly lower in the first group. No differences in %EWL were observed between quartiles of maximum band filling after surgery. The rate of band-related complications increased with increasing levels of postoperative maximum band filling. In patients with the band filled with < 3.0 ml of sterile saline at 6 months, the inflation of further saline produced a dose-related increase in the rate of weight loss. In patients with the band filled with > 3.0 ml of sterile saline at 6 months, the inflation of further saline was associated with a reduced %EWL. CONCLUSION: Postoperative adjustability of the Lap-Band was useful in the treatment of band-related complications and was able to significantly influence the rate of weight loss. On the other hand, aggressive postoperative band filling was associated with an increased rate of complications.

Preoperative weight loss by intragastric balloon in super-obese patients treated 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.

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 leakage) 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.

Progress in implantable gastric stimulation: summary of results of the European multi-center study.

BACKGROUND: The Implantable Gastric Stimulator (IGS(R)), a pacemaker-like device, has been found to be safe and effective to induce and maintain weight loss. The LOSS (Laparoscopic Obesity Stimulation Survey) is a prospective non-randomized trial which enrolled 69 patients involving 11 investigator centers in 5 European Countries. In 19 patients, ghrelin was analyzed. METHODS: Between January 2002 and December 2003, 69 patients (F/M 49/20), mean age 41 years (18-65) underwent IGS implantation. Mean BMI was 41 (35-57), mean weight 115.0 kg (65-160) and mean excess weight (EW) 52 kg (13-89). The IGS was actived 30 days after implantation. In a subset of 19 patients studied further, 0, 6, and 12 months appetite and satiety score were evaluated and 0 and 6 months ghrelin profile was analyzed. RESULTS: The mean +/- standard error %EWL was: 8.6+/-1.8 at 1 month, 15.8+/-2.3 at 3 months, 17.8+/-2.6 at 6 months, 21.0+/-3.5 at 10 months, and 21.0+/-5.0 at 15 months. There were no intraoperative surgical or long-term complications. 7 intra-operative gastric penetrations occurred, observed by gastroscopy, without sequelae. 1 patient required a reoperation to remove a retained lead needle. In the subset of 19 patients, appetite was reduced and post-prandial and inter-prandial satiety was increased after IGS implantation. In the 19 patients, despite weight reduction, ghrelin did not increase. CONCLUSION: IGS can be implanted laparoscopically with minimal perioperative complications. Appetite is reduced and satiety is increased after the implantation. Ghrelin levels could be one of the mechanisms explaining weight loss and weight maintenance in IGS patients. If weight loss is maintained, IGS could be considered a good option for selected patients.

An adjustable silicone gastric band for laparoscopic treatment of morbid obesity--technique and results.

The laparoscopic application of an adjustable silicone gastric band (Lap-Band System, Bioenterics, Carpinteria, CA) (Fig. 1), based on a similar device introduced by Kuzmak in 1986, is gaining widespread acceptance as a gastric restrictive procedure in treatment of morbid obesity. The advantage of an operation that does not open the gastrointestinal tract and can be performed laparoscopically is obvious. This procedure, using the laparoscopic approach , has been performed in our institutions since 1992. The goals of this article are to describe both our standardized surgical technique that minimized the morbidity rate and its results.