Laparoscopic adjustable gastric banding for patients with body mass index of

BACKGROUND: Many mild-to-moderately obese individuals (body mass index [BMI] 30-35 kg/m(2)) have serious diseases related to their obesity. Nonoperative therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 1996 and 2004, 93 patients with a BMI of 30-35 kg/m(2) underwent laparoscopic adjustable gastric banding with the LAP-BAND. All patients were referred by their primary physician, entered into a comprehensive bariatric surgery program at one Australian center, and operated on by one surgeon. Data on all patients were collected prospectively and entered into an electronic registry. The study parameters included preoperative age, gender, BMI, presence of co-morbidities, percentage of excess weight loss, and resolution of co-morbidities. RESULTS: The mean age was 44.6 years (range 16-76), mean weight was 98 kg, and the mean BMI was 32.7 kg/m(2) (range 30-34). Of the 93 patients, 42 (45%) had co-morbidities, including asthma, diabetes, hypertension, and sleep apnea. The proportion of patients in follow-up was 79%, 85%, and 89% at 1, 2, and 3 years, respectively. The mean weight was reduced to 71 kg at 1 year, 72 kg at 2 years, and 72 kg at 3 years. The mean BMI was reduced to 27.2 +/- 2.2, 27.3 +/- 3.1, and 27.6 +/- 3.7 kg/m(2), respectively, and the mean percentage of excess weight loss was 57.9% +/- 24.5%, 57.6 +/- 29.3%, and 53.8% +/- 32.8% at 1, 2, and 3 years, respectively. At 3 years, the BMI was 18-24 kg/m(2) in 34%, 25-29 kg/m(2) in 51%, and 30-35 kg/m(2) in 10%. At 3 years, the percentage of excess weight loss was <25% in 10%, 25-50% in 24%, 50-75% in 51%, and >75% in 10%. The co-morbidities improved or completely resolved in most patients. No mortality occurred. CONCLUSION: We are very encouraged by this series of low BMI patients treated with the LAP-BAND. Their weight loss has been good, the complications have been minimal, and the co-morbidities have partially or wholly resolved. With additional study, it is reasonable to expect the weight guidelines for bariatric surgery to be altered to include patients with a BMI of 30-35 kg/m(2).

U.S. experience with 749 laparoscopic adjustable gastric bands: intermediate outcomes.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) has consistently been shown to be a safe and effective treatment for morbid obesity, especially in Europe and Australia. Data from the U.S. regarding the LAGB has been insufficient. This study reveals our experience with 749 primary LAGB over a 3-year period in a U.S. university teaching hospital. METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study include preoperative age, BMI, gender, race, conversion rate, operative time, hospital stay, percent excess weight loss (%EWL) and postoperative complications. Annual esophagrams were performed RESULTS: From July 2001 through September 2004, 749 patients (531 females, 218 males) underwent LAGB for the treatment of morbid obesity. There were 630 Caucasians, 61 African-Americans, and 49 Latin Americans, with a mean age of 42.3 (range 18, 72 years) and mean BMI of 46.0 +/- 7.0 (range 35, 91.5 kg/m(2)). There was one conversion to open (0.1%). Median operative time and hospital stay were 60 minutes and 23 hours, respectively. The mean %EWL at 1 year, 2 years, and 3 years was 44.4 (+/-17.8), 51.8 (+/-20.9), and 52.0 (+/-19.6), respectively. There were no mortalities. Postoperative complications occurred in 12.8% of patients: 1.5% acute postoperative band obstruction, 0.9% wound infection, 2.9% gastric prolapse ("slip"), 2.0% concentric pouch dilatation (without slip), 0.8% aspiration pneumonia, 2.4% port/tubing problems, 0.3% severe esophageal dilatation/dysmotility (reversible), and 1.5% overall band removal. CONCLUSION: These American results substantiate the data from abroad that LAGB is a safe and effective treatment for morbid obesity.

Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is increasingly recommended to women of reproductive age. For continued use, LAGB needs to be proven to be safe and well-tolerated during pregnancy. Maternal obesity is a well-recognized risk factor for gestational diabetes, maternal hypertension and is more likely to result in instrumental delivery or caesarean section. Weight control with the LAGB may reduce the incidence of these complications. METHODS: An observational study was conducted of the LAGB in pregnancy, including a study comparing outcomes of LAGB pregnancies with previous non-LAGB pregnancies. Women who had had successful LAGB pregnancies were identified from a computerized database. A telephone questionnaire was used to collect the additional outcome data needed and was administered by an independent medical practitioner. RESULTS: 49 LAGB and 31 previous non-LAGB pregnancies were included. 2 LAGBs (4%) required removal during pregnancy. Mean maternal weight gain was significantly reduced in the LAGB group, 3.7 kg vs 15.6 kg (P <0.0001), with no effect on fetal weight, 3.31 vs 3.53 kg, or neonatal complications, 4% and 3%. The incidence of gestational diabetes, 8 and 27% (P =0.048), and hypertension, 8 and 22.5% (P =0.06) was significantly reduced in the LAGB group. The overall complication rate during pregnancy for LAGB was 20.4% and 52% for non-LAGB (P =0.0037) CONCLUSION: LAGB is safe and well-tolerated during pregnancy with a lower incidence of gestational diabetes and maternal hypertension. LAGB can be safely recommended to morbidly obese women of childbearing age.

Lessons learned from laparoscopic gastric banding for morbid obesity.

BACKGROUND: Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. METHODS: We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. RESULTS: At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. CONCLUSIONS: We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice.

Laparoscopic adjustable gastric banding for massive superobesity ( > 60 body mass index kg/m2).

Surgery for massive super obesity is a formidable challenge. No existing open or laparoscopic procedure reduces BMI below 30 from a starting point above 55. Laparoscopic adjustable gastric banding has been used to treat 76 massive super obese patients with a BMI > 60 kgs/m2. Median weight was 193 kgs +/-34.7 kgs (154-335 kgs). Five patients had a BMI > 100 kgs/m2. There was neither mortality nor pulmonary emboli. hospital stay was 3 days (1-6 days). Excess weight loss was 46.69 +/-10.5 at 1 year; 59.14 +/- 11.7% at 3 years and 61 +/- 15.1% at 5 years. At 2 years, 84% of the patients had greater than 50% excess weight loss and this was maintained at 3, 4, and 5 years. BMI fell from 69 +/- 6.2 to 49 +/- 7.73 at 1 year to 37 +/- 4.45 at 3 years and this was maintained at 4 and 5 years. BMI in 13 patients with > 5 year follow up was 35.09 +/- 53 kgs/m2 (27-44). Weight loss with laparoscopic adjustable gastric banding in this group of massive super obese patients has been similar to all other surgical techniques with reduction of BMI from 69 to 33 kgs/m2 at 3 years. The relative safety of the Lapband avoids bowel surgery in these very big patients, suggesting that laparoscopic adjustable gastric banding is a valid surgical approach to these difficult patients.

The poor quality of information about laparoscopy on the World Wide Web as indexed by popular search engines.

BACKGROUND: This study was undertaken to determine the quality of information on the Internet regarding laparoscopy. METHODS: Four popular World Wide Web search engines were used with the key word "laparoscopy." Advertisements, patient- or physician-directed information, and controversial material were noted. RESULTS: A total of 14,030 Web pages were found, but only 104 were unique Web sites. The majority of the sites were duplicate pages, subpages within a main Web page, or dead links. Twenty-eight of the 104 pages had a medical product for sale, 26 were patient-directed, 23 were written by a physician or group of physicians, and six represented corporations. The remaining 21 were "miscellaneous." The 46 pages containing educational material were critically reviewed. At least one of the senior authors found that 32 of the pages contained controversial or misleading statements. All of the three senior authors (LKN, NAO, GAF) independently agreed that 17 of the 46 pages contained controversial information. CONCLUSION: The World Wide Web is not a reliable source for patient or physician information about laparoscopy. Authenticating medical information on the World Wide Web is a difficult task, and no government or surgical society has taken the lead in regulating what is presented as fact on the World Wide Web.

Laparoscopic cholecystectomy.

A consecutive series of 220 laparoscopic cholecystectomies (June 1990 to May 1991) is presented. These were the author's initial experience of the technique. Procedures were elective (205) and acute (15), including 3 gangrenous cholecystitis and 4 empyema. There were 166 females and 34 males, 12-75 years, weighing 44-115 kg. Forty-eight patients had prior abdominal surgery. Two hundred and eleven patients had successful laparoscopic cholecystectomies, 6 open cholecystectomies and 3 mini-laparotomies to remove split stones. None of the last 120 cases were opened. Operating time ranged from 20 min to 3 h 20 min. There were 4 serious complications: 2 bile leaks from the gall-bladder bed and 2 jejunal injuries (Veres needle and 5 mm trocar). Sixty-one patients were discharged the next day, 29 on day 2, 5 on day 3, 4 on day 4, 1 on day 5, 1 on day 22 and 1 on day 27. At two weeks follow-up all but 2 patients had fully recovered.

Laparoscopic inguinal hernia repair.

Between March 1991 and May 1994, 444 laparoscopic inguinal hernia repairs were undertaken in 375 patients: 386 transperitoneal and 58 extraperitoneal. During a follow-up period of 20.5 months (range 1-38) there have been three recurrences at 6, 7 and 12 months, all direct and all after transperitoneal repair. A total of 52 patients were treated as a day case (< 6 h), 317 patients spent less than 24 h in hospital and four patients were discharged on the second postoperative day. Operating time for transperitoneal hernia repair was 27 min (range 10-68) and extraperitoneal repair, 29 min (range 11-48). Short-term complications occurred in 18 patients: six haematomas, four seromas, one urinary retention and seven suffered persistent groin pain. Six patients have had neuralgia, three have had mesh removed and three further patients had individual clips removed from within the inguinal canal. There have been two adhesive small bowel obstructions. The first occurred 2 months after laparoscopic surgery and required laparotomy; the second occurred 2 years after surgery and had laparoscopic division of an adhesive band to a pelvic staple. There was one infected lymphocoele treated percutaneously.

Blunt arterial injury.

A 5 year retrospective review of blunt arterial injuries at the Royal Brisbane Hospital revealed that delay in diagnosis had catastrophic effects on limb survival. Only 17 of 23 patients with arterial injury were diagnosed at the time of admission. No record of symptoms of limb ischaemia was made in 13 patients and no signs recorded in five. Eight limbs required amputation. Improved results should follow more accurate diagnosis at the time of admission.

Two cases of pseudo-aneurysm of the gastroduodenal artery.

Pseudo-aneurysm of the gastroduodenal artery is a rare cause of bleeding-complicated pancreatitis. The use of computerized tomography and angiography lead to early diagnosis. The key to surgical treatment is arterial inflow occlusion prior to opening the aneurysm.

Skin necrosis secondary to meningococcal septicaemia in an adult.

A case of skin loss after meningococcal septicaemia is presented. This is a rare condition in adults and occurs after very severe infections. The skin loss is due to vasculitis, resulting from a combination of direct infection of the skin by Neisseria meningitidis, and an immunological reaction. Secondary infection frequently occurs under the eschar. Skin loss is treated by debridement and delayed split skin grafting.

Homograft skin banking--current practices and future trends.

Homograft skin remains a very successful technique for covering major burns. This paper reviews current techniques of harvesting, microbiological testing, freezing and thawing of the skin, that lead to its optimal use. Recent advances, especially the use of homograft skin in combination with split skin and skin cultures, will add to the effectiveness of homograft skin application.

Spontaneous neonatal renal vein thrombosis.

A case of spontaneous neonatal renal vein thrombosis is presented. A 1 week old, 36 week gestation, male child presented with gross haematuria and a large right flank mass. Investigations including intravenous pyelogram, ultrasound and venacavogram indicated the diagnosis. The child was clinically well, with normal renal and clotting function. No predisposing cause could be found. A conservative approach to treatment was undertaken in view of the normal renal function, and no evidence of consumptive coagulopathy or pulmonary emboli. The child remains well, but may require nephrectomy in the future.

Laparoscopic cholecystectomy for acute cholecystitis.

Sixty-eight cases of acute cholecystitis managed by laparoscopic cholecystectomy (LC) are reviewed. Thirty-two patients were admitted up to 10 days after onset of symptoms and 31 were completed by LC. One patient was referred from intensive care with gangrenous acalculus cholecystitis and was completed by LC but required subsequent laparotomy to control a bleeding omental vessel. Five patients were admitted with recurrent attacks of pain and histology confirmed resolving acute cholecystitis. Thirty patients had LC on routine operating lists, having recently had pain within 10 days of admission. Histology confirmed acute cholecystitis or resolving acute cholecystitis in these patients. All were completed by LC. Laparoscopic cholecystectomy is a very effective treatment for acute cholecystitis if complete dissection of anatomy can be performed.

Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases.

BACKGROUND: Morbid obesity occurs in 2-5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients. MATERIALS AND METHODS: A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications. RESULTS: All patients have needed band adjustments of 1-4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss. CONCLUSIONS: Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience.

Laparoscopic common bile duct exploration.

Twenty-one patients underwent laparoscopic common bile duct exploration during a 9 month period. Ten had stones flushed after ampullary dilatation. Seven had stones removed with a Dormier basket and one had direct common duct incision with T-tube insertion. Three failed attempted stone flushing and had stones removed by endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. Operating time ranged from 1.5 to 3.5 h. Nineteen patients were discharged by the second postoperative day. This early experience with laparoscopic stone removal is encouraging, reducing the need for pre-operative or postoperative ERCP.

Laparoscopic mesh repair of recurrent inguinal hernia.

BACKGROUND: Pre-peritoneal mesh repair has been a long-standing technique for recurrent hernias. Laparoscopic technique has been applied to this operation with the aim of assessing its results at early follow up of 1 year. METHODS: The outcome in 56 patients was reviewed and all patients contacted 12 months after surgery. RESULTS: There was one immediate failure at 1 week, needing a further operation. There were no other recurrences at 1 year. Ten patients had minor postoperative complications. CONCLUSIONS: At early follow up, this is a satisfactory technique for recurrent hernias.

Stapled marlex mesh abdominal closure for repeat laparotomy in pancreatic disease.

A series of seven cases of severe pancreatic disease have been managed by repeat laparotomy for debridement of necrotizing pancreatitis, drainage of abscesses or control of haemorrhage with stapled marlex mesh closure of the abdominal wall. The use of a stapled marlex mesh at first laparotomy provides for safe, expedient relaparotomy until sepsis or haemorrhage is controlled.

Management of gallstone pancreatitis.

The clinical course of 143 patients with gallstone pancreatitis is reviewed. Thirty-one patients (22%) had three or more positive prognostic factors on admission and 24 (77%) of these had a complicated course. Thirteen patients died, giving an overall mortality rate of 9%. Patients were divided into three groups on the basis of performance and timing of surgery. In group 1 (n = 56), surgery was undertaken during the first admission with acute pancreatitis; eight of these patients had a complicated course and three died. In group 2 (n = 40), biliary surgery was deferred to a subsequent admission; none of these patients died but 10 experienced further attacks of pancreatitis while awaiting reoperation. Group 3 patients (n = 47) did not undergo surgery; nine patients were diagnosed as having gallstone pancreatitis for the first time at autopsy, five refused operation, seven were lost to follow-up, six were dealt with by endoscopic sphincterotomy, and in 20 cases surgery was not considered appropriate because of general debility or advanced age. Despite the zero mortality rate in group 2, it is advocated that biliary surgery be carried out during the index hospital admission. Endoscopic sphincterotomy can now be considered as an alternative to cholecystectomy and duct clearance in the elderly and unfit, and may be used as a preliminary manoeuvre when severe acute pancreatitis fails to settle promptly on conservative management.

Acute pancreatitis and pancreatic fistula formation.

The cause, management and outcome of 23 patients with a pancreatic fistula following acute pancreatitis are reviewed. Nineteen patients developed an external fistula following necrosectomy or drainage of a pancreatic abscess or pseudocyst; four of these patients died. In the 15 survivors spontaneous closure occurred in 11 cases with low output fistulae; operative intervention was needed in the four cases with high output fistulae. Four patients with internal fistulae had not undergone previous surgery; two of them had a pancreaticopleural fistula with associated pancreaticogastric fistulae, while two had pancreatic ascites. All four of these patients required surgical intervention and one died.