Laparoscopic gastric banding and individual bariatric surgery.

Different factors (strategic, anatomical, instrumental, etc.) can cause difficult surgical situations, especially in bariatric surgery. In a difficult surgical situation, the surgeon faces a dilemma as to whether to continue the intended operation "at all costs" or to deviate from the initially planned surgical procedure to some alternative technique or procedure. The dilemmatic nature of the difficult surgical situation in bariatric surgery has motivated us to discuss the following aspects because they all contribute to the problem: standards in bariatric surgery, deviation from standards, the role of experts, and the focus of research. We also propose to classify bariatric patients according to intraoperative difficulty (I to IV) as: (I) ideal cases (i.e., easy to operate, no problems), (II) not quite ideal cases (some minor difficulties may occur), (III) problematic cases (difficult to operate, some operative techniques are considerably more difficult than others), and (IV) very difficult cases (every operative step is difficult). We discuss the establishment of a registry of difficult surgical situations including the possibilities of deviating from the standard. Scientific analyses of such registries should focus on patients with apparent modifications in treatment (process deviations), but might also look at those with surprisingly good or bad results (outcome deviations). The technical steps of laparoscopic adjustable gastric banding (LAGB) have been chosen to illustrate this concept.

Initial clinical experience with telemetrically adjustable gastric banding.

BACKGROUND: The feasibility and safety of laparoscopic adjustable gastric banding for treatment of morbid obesity has been demonstrated in a large number of studies. Access port-related complications constitute a significant part of all complications related to gastric banding. Further, adjustment of hydraulic gastric bands can be fairly lengthy, uncomfortable, and is not a precise procedure. A study was performed to assess the usefulness and efficacy of a new type of band adjusted telemetrically without the need for an access port. The initial worldwide results of the first telemetrically adjustable gastric band for morbid obesity (EASYBAND EndoArt Medical Technologies, Switzerland) in two German academic centers are described herein. METHODS: EASYBAND is a purely mechanical gastric band, in which adjustment is achieved by means of an embedded micromotor, controlled by an external control unit using telemetry. The exact band diameter is displayed continuously during adjustment on the external control unit screen. Thirty-seven patients, means 36 +/- 8 (range: 22-60) years, 7 (19%) men and 30 (81%) women, with a mean body mass index (BMI) of 44.1 +/- 4.5 (range: 35.6-59.6), were implanted using the standard laparoscopic technique during the period from June 2005 to October 2005. Prospective data were collected on all morbidly obese patients who underwent laparoscopic telemetrically adjustable gastric banding (LTAGB). RESULTS: No serious adverse events occurred during the operative period or immediately postoperatively in relation to the device. A mean of 3.0 +/- 0.6 adjustments per patients were performed during the follow-up schedule at one, three and six months. The band diameter was set to 29 mm (fully open) at implantation, 24.5 mm +/- 0.5 mm at one month, 23.3 mm +/- 0.7 mm at three months, and 23.0 mm +/- 1.0 mm at six months. The mean percent excess weight loss was 10.2% +/- 4.5% at one month, 23.8% +/- 8.8% at three months, and 30.2% +/- 10.5% at six months. CONCLUSION: This initial study shows that the new telemetrically adjustable gastric banding device is implanted and operated safely, allows for atruamatic band adjustments with superior patient comfort, and leads to early excess weight loss comparable to that achieved by other gastric bands. Longer-term follows and larger population studies are needed to establish the final safety and performance profile of the telemetric gastric band.