Intragastric gastric band migration: erosion: an analysis of multicenter experience on 177 patients.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has proven to be a safe and effective surgical treatment for morbid obesity. It can be a simple, fast, reversible, anatomy-preserving procedure. Despite these advantages, its long-term efficacy came into question by the occurrence of complications such as intragastric band migration. Consistent information regarding this complication is still lacking. Treatment for migration is still being debated as well. Most of the inconsistencies of these data stem from the very low number of patients reported in single-center experiences or case reports. Lack of multicenter experience is evident. The aim of this study was to perform a retrospective analysis of data on intragastric migration in a large multicenter cohort of patients who underwent LAGB. METHODS: A retrospective multicenter study on LAGB patients was performed. Data had been entered into a prospective database of the Italian Group for LapBand(®) (GILB) since January 1997. Pars flaccida and perigastric positioning were considered along with different kinds of gastric bands by the same manufacturer. Time of diagnosis, mean body mass index (BMI), presentation symptoms, and conservative and surgical therapy of intragastric migration were considered. RESULTS: From January 1997 to December 2009, a total of 6,839 patients underwent LAGB and their data were recorded [5,660 females, 1,179 males; mean age 38.5 ± 18.2 years (range 21-62 years); mean BMI = 46.7 ± 7.7 kg/m(2) (range 37.3-68.3); excess weight (EW) 61.8 ± 25.4 kg (range 36-130); %EW 91.1 ± 32.4 % (range 21-112 %)]. A total of 177 of 6,839 (2.5 %) intragastric erosions were observed. According to the postoperative time of follow-up, the diagnosis of intragastric migration was made in 74 (41.8 %), 14 (7.9 %), 38 (21.4 %), 40 (22.6 %), 6 (3.4 %), and 4 (2.2 %) banded patients at 6-12, 24, 36, 48, 60, and 72 months after banding, respectively. Most of intragastric band migration during the first 2 years occurred in bands with no or a few milliliters of filling. In patients with late erosion, the bands were adjusted several times; no band was overfilled but one was filled to the maximum or submaximum with a maximum of two adjustments. Erosions diagnosed during the first 24 months were related to the experience of the surgical staff, while late erosions were not. CONCLUSIONS: Intragastric band migration or band erosion is a rare, disturbing, and usually not life-threatening complication of gastric banding. Its pathogenesis is probably linked to different mechanisms in early (technical failure in retrogastric passage) or late (band management) presentation. It is usually asymptomatic and there is no pathognomonic presentation. A wide range of therapeutic options are available, from simple endoscopic or laparoscopic removal to early or late band replacement or other bariatric procedure. More experience and more studies are needed to lower its presentation rate and definitively clarify its pathogenesis to address the right therapeutic option.

Laparoscopic adjustable gastric banding via pars flaccida versus perigastric positioning: technique, complications, and results in 2,549 patients.

AIM: Retrospective multicenter analysis of the results of two different approaches for band positioning: perigastric and pars flaccida. METHODS: Data were collected from the database of the Italian Group for LapBand (GILB). Patients operated from January 2001 to December 2004 were selected according to criteria of case-control studies to compare two different band positioning techniques: perigastric (PG group) and pars flaccida (PF group). Demographics, laparotomic conversion, postoperative complications, and weight loss parameters were considered. Data are expressed as mean +/- standard deviation. RESULTS: 2,549 patients underwent the LapBand System procedure [age: 40 +/- 11.7 years; sex: 2,130 female, 419 male; body mass index (BMI): 46.4 +/- 6.9 kg/m(2); excess weight (EW): 60.1 +/- 23.6 kg; %EW: 90.1 +/- 32.4]. During this period 1,343/2,549 (52.7%) were operated via the pars flaccida (PF group) and 1,206/2,549 (47.3%) via the perigastric approach (PG group). Demographics for both groups were similar. Thirty-day mortality was absent in both groups. Operative time was significantly longer in the PG group (80 +/- 20 min versus 60 +/- 40 min; p < 0.05). Hospital stay was similar in the two groups (2 +/- 2 days). Laparotomic conversion was significantly higher in the PG group (6 versus 2 patients; p < 0.001). Overall postoperative complication rate was 172/2,549 (6.7%) and was linked to gastric pouch dilation/slippage (67/172), intragastric migration/erosion (17/172), and tube/port failure (88/172). Gastric pouch dilation and intragastric migration were significantly more frequent in the PG group: 47 versus 20 (p < 0.001) and 12 versus 5 (p < 0.001), respectively. Patients eligible for minimum 3-year follow-up were 1,118/1,206 (PG group) and 1,079/1,343 (PF group). Mean BMI was 33.8 +/- 12.1 kg/m(2) (PG group) and 32.4 +/- 11.7 kg/m(2) (PF group) (p = ns), and mean percentage excess weight loss (%EWL) was 47.2 +/- 25.4 and 48.9 +/- 13.2 in PG and PF groups, respectively (p = ns). CONCLUSIONS: Significant improvement in LapBand System results with regard to laparotomic conversion and postoperative complication rate, with similar weight loss results, was observed in the pars flaccida group.

Bariatric surgery improves atherogenic LDL profile by triglyceride reduction.

BACKGROUND: Small dense low-density lipoprotein (LDL) are atherogenic particles frequently observed in obese patients. Fatty acids modulate LDL. Objective of this study was to determine the relations between plasma phospholipid fatty acid composition and the presence of small dense LDL particles in morbidly obese patients treated with laparoscopic gastric banding (LAGB). METHODS: Small dense LDL, plasma lipids, lipoproteins, apoproteins, and phospholipid fatty acid composition (a marker of dietary fatty acid intake) were quantified before and 12 months after surgery in four men and 11 women who were morbidly obese and (BMI > 40 kg/m(2)) eligible for surgery, consecutively treated with LAGB at the Department of Medical and Surgical Sciences of the University of Padova. RESULTS: BMI was 48.3 +/- 4.8 kg/m(2) before and 36.1 +/- 5.5 kg/m(2) after LAGB. Plasma triglycerides and apoprotein E levels significantly decreased, while HDL cholesterol significantly increased after LAGB. A reduction of small dense LDL with an increase of LDL relative flotation (0.34 +/- 0.04 before vs 0.38 +/- 0.03 after LAGB, p < 0.001) was also observed. These modifications were neither related to weight reduction nor to changes in phospholipid fatty acid composition, but they were associated to triglyceride reduction, which explained 76.7% of the LDL relative flotation variation. CONCLUSION: Weight loss obtained by LAGB in morbidly obese subjects was accompanied by triglyceride reduction, high-density lipoprotein increase, and an improvement of the atherogenic LDL profile. Triglyceride reduction, but not the extent of weight loss or dietary fatty acid modifications, is the determinant of modifications of LDL physical properties in these patients.

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.

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.

National survey for bariatric procedures in adolescents: Long time follow-up.

INTRODUCTION: The role of bariatric surgery and its role in adolescent is still under discussion worldwide. The aim of this study is to report an Italian survey for bariatric procedures in adolescents and the outcome with a medium and long-term follow-up. MATERIALS AND METHODS: We retrospectively analyzed consecutive data added into the Italian register of the society for bariatric surgery(period 2000-2010). We evaluated all patients treated in a 10-year period with a mean follow-up of 3 years. Inclusion and exclusion criteria were created. All patients were aged between 13 and 18 years. We evaluated and compared clinical data. RESULTS: After reviewing medical charts, 173 patients were considered for the study; 85 patients were treated with adjustable gastric band (AGB), 47 with intragastric balloon (IB), 26 with sleeve gastrectomy (SG) and other 15 patients with malabsorptive techniques (MT). Among clinical data, there was a statistical difference in terms of %excess weight loss (%EWL) between techniques only after 1 year post-procedure; at 5 years, considering the percentage of patients studied, sleeve gastrectomy had the best %EWL respect to other non malabsorptive techniques (p<0.05); at 5 year more than 90% resolved their comorbidities especially hypertension, dyspnea, orthopedic problems and dyspnea. CONCLUSIONS: This study is the first reporting a national survey in adolescent; more than 80% of patients are followed until 5 years post-op but only few patients (less than 5%) until 10 years. Our results demonstrated that sleeve gastrectomy in adolescent is safe and had a better %EWL respect to other non-malabsorptive bariatric procedures. LEVEL OF EVIDENCE: level III.

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.

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.

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.

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.

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.

Avoiding postoperative complications with the LAP-BAND system.

The most frequently occurring complications associated with the LAP-BAND (INAMED Health, Santa Barbara, CA) include gastric prolapse, stoma obstruction, esophageal and gastric pouch dilatation, erosion, and access port problems. This article describes the causes of these complications and details some points for their prevention and treatment. As techniques for placement of the LAP-BAND have evolved, complication rates have declined. For example, occurrence of gastric prolapse was reduced from the initially reported rates of 22% to less than 5%. The emergence of many problems, such as gastric pouch dilatation or prolapse, can be minimized with proper operative technique and close postoperative management and follow-up. As with other major surgical procedures, particularly those performed in the bariatric population, complications associated with the LAP-BAND system are unavoidable but are rarely life-threatening if managed appropriately. Surgeons and patients should adopt strategies that will help avoid complications and be sensitive to any indication of their emergence.

Patient management after LAP-BAND placement.

Severe obesity is a chronic disease requiring continuing care. Optimal outcomes of laparoscopic adjustable gastric banding using the LAP-BAND (INAMED Health, Santa Barbara, CA) depend on accurate placement of the band and excellent postplacement care, which requires a long-term commitment from both the patient and the bariatric surgical team. Adjustability is a key feature of the LAP-BAND system, and knowing when and how much to adjust requires careful judgment. Two methods of approaching the art of adjustment are described: the office adjustment and the radiologic adjustment. A properly placed and adjusted band produces prolonged satiety after a small meal, facilitating a major reduction in dietary intake leading to weight loss. Healthy food choices, increased activity and exercise, and the behavioral changes necessary to achieve these are essential elements of all weight loss programs. The LAP-BAND program is no exception. Follow-up requires monitoring of the comorbidities of obesity and metabolic and nutritional status. Communication and collaboration with the patient's primary care provider are important. All of the elements above are necessary to provide the comprehensive care that contributes to optimal patient outcomes.