The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on adjustable gastric banding.

BACKGROUND: Bariatric surgery is one of the clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, and laparoscopic adjustable gastric banding (LAGB) is one of the three anchoring bariatric procedures. To improve surgeon lifelong learning, the Masters Program seeks to identify sentinel articles of each of the 3 bariatric anchoring procedures. In this article, we present the top 10 articles on LAGB. METHODS: A systematic literature search of papers on LAGB was completed, and publications with the most citations and citation index were selected and shared with SAGES Metabolic and Bariatric Surgery Committee members for review. The individual committee members then ranked these papers, and the top 10 papers were chosen based on the composite ranking. RESULTS: The top 10 sentinel publications on LAGB contributed substantially to the body of literature related to the procedure, whether for surgical technique, novel information, or outcome analysis. A summary of each paper including expert appraisal and commentary is presented here. CONCLUSION: These seminal articles have had significant contribution to our understanding and appreciation of the LAGB procedure. Bariatric surgeons should use this resource to enhance their continual education and acquisition of specialized skills.

Late-Onset Gastric Band Erosion Following Heavy Nonsteroidal Anti-inflammatory Drug Use.

Laparoscopic adjustable gastric band (LAGB) surgery is now an uncommon bariatric procedure; however, complications may still be encountered. A 64-year-old man with a history of LAGB placement 13 years prior presented with 2 months of epigastric pain. He endorsed chronic heavy nonsteroidal anti-inflammatory drug use. Computed tomography showed inflammation around the LAGB tubing with near-complete, circumferential erosion of the LAGB into the fundus. Upper endoscopy confirmed erosion of the LAGB along with port tubing into the gastroesophageal junction and fundus. The patient was referred to a foregut surgeon who performed robotic band removal.

Changes in Cognitive Function Following Bariatric Surgery: An Updated Systematic Review.

Since a previous systematic review published in 2016, there have been further studies investigating the association of changes in cognitive function following bariatric surgery. All studies since the original review that reported at least one element of cognitive function before and after bariatric surgery were eligible. A total of 137 additional studies were identified; 13 were included in addition to the 18 studies previously. Almost all studies reported improvements in at least one domain. Most revealed improvements were limited to a few domains and were not universal. Further findings investigated cognitive function improvement in relation to procedure choice, and mental health or quality of life post-surgery. Further high-powered studies are still necessary, but these findings support the impact of bariatric surgery on cognitive function in obesity.

Improvement in Pulmonary Hypertension Following Metabolic and Bariatric Surgery: a Brief Review and Meta-analysis.

We reviewed the available evidence on the outcome of metabolic and bariatric surgery (MBS) in patients with pulmonary hypertension (PH). Five studies examining 174 patients were included; the mean age was 54.5 ± 9.27 years; the mean BMI before surgery and at the end of follow-up were 47.2 ± 5.95 kg/m2 and 37.4 ± 2.51 kg/m2, respectively. Furthermore, the results showed a significant decrease in the right ventricle systolic pressure (RVSP) after MBS with a mean difference of 10.11% (CI 95%: 3.52, 16.70, I2 = 85.37%, p = < 0.001), at 16.5  ±  3.8 month follow-up with a morbidity rate of 26% and 0 mortality. Thirty-day postoperative complications included respiratory failure, pulmonary embolism, pulmonary edema, and anastomotic leak. There appears to be a significant improvement in PH with a decrease in medication requirements after MBS.

Reports of Gastric Banding and Bowel Obstruction: A Narrative Review of the Literature.

The utilization rates of laparoscopic gastric banding (LAGB) declined worldwide from 42.3% in 2008 to 1.8% in 2018. Rates of complications requiring removal may reach 40-50% in the medium to long term. Bowel obstruction is a rare but severe complication that occurs after LAGB. A comprehensive literature search in PubMed was carried out to identify all available case reports of intestinal obstruction after gastric banding. The search terms were as follows: "intestinal obstruction", "small bowel obstruction", "gastric band", "gastric banding", "gastric band complications", and "laparoscopic gastric band obstruction". The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flowchart was used. Forty-three case reports were included in our review. Laparotomy was necessary in 18/43 (41%) of patients. Vomit was not always reported, while abdominal pain was constantly present. A CT scan was the preferred diagnostic tool. The main causes of occlusion were found to be the erosion of the gastrointestinal tract or internal hernia due to a loose tube loop. Forty-six percent of cases occurred within 5 years from insertion. Even if rare, small bowel obstruction after LAGB requires surgical intervention often with an open approach. The absence of vomit masks symptoms, but an obstruction must be always suspected in the case of severe colicky abdominal pain. A CT scan is recommended for making diagnoses.

Retrieval of Gastric Band Eroding Into the Stomach: A Gastrointestinal Fistula Case Managed Through a Combined Laparoscopic and Colonoscopic Approach.

Obesity is an important public health concern worldwide. In Saudi Arabia, the overall prevalence of obesity has increased in both men and women in recent decades. The laparoscopic approach to bariatric surgery was first reported in the 1990s, with laparoscopic adjustable gastric banding (LAGB) developed soon after. The performance of bariatric procedures has increased rapidly in recent years, with safety and efficacy data available for the surgical treatment of obesity and related metabolic disorders. Herein, we report a challenging condition of a female patient who underwent LAGB insertion in 2013. The patient presented with a complaint of a foreign body passing through her rectum during defecation that was manually pushed back by the patient. Radiological imaging and upper/lower endoscopy confirmed the diagnosis of complete gastric band erosion into the stomach, and the reservoir with the remaining tube was observed inside the colon near the splenic flexure. This case was complicated by complete band erosion and gastrointestinal (GI) fistula formation following the delivery of her second child in January 2022. Colonic band erosion is a rare complication of LAGB. Most patients with gastric band erosion are asymptomatic or exhibit nonspecific symptoms. The definitive management of gastric band erosion involves band removal. Several approaches are commonly used in clinical practice. In our case, the band was removed using a combined laparoscopic and endoscopic retrieval approach, which is the first such report in the literature.

Revisional One-Step Bariatric Surgical Techniques After Unsuccessful Laparoscopic Gastric Band: A Retrospective Cohort Study with 2-Year Follow-up.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has high reported rates of revision due to poor weight loss (WL) and high complication rates. Yet, there is yet to be a consensus on the best revisional procedure after unsuccessful LAGB, and studies comparing different revisional procedures after LAGB are still needed. METHODS: This was a retrospective cohort study that compared the outcomes of one-step revisional Roux-en-Y gastric bypass (rRYGB), one-anastomosis gastric bypass (rOAGB), or laparoscopic sleeve gastrectomy (rLSG) after LAGB. WL, complications, resolution of associated medical conditions, and food tolerance were assessed with a post hoc pairwise comparison one-way analysis of variance (ANOVA) throughout a 2-year follow-up. RESULTS: The final analysis included 102 (rRYGB), 80 (rOAGB), and 70 (rLSG) patients. After 2 years, an equal percentage of excess weight loss was observed in rOAGB and rRYGB (both >90%; p=0.998), significantly higher than that in rLSG (83.6%; p<0.001). In our study, no leaks were observed. rRYGB had higher complication rates according to the Clavien-Dindo classification (10.8% vs. 3.75% and 5.7% in rOAGB and rLSG, respectively, p=0.754), and re-operations were not statistically significant. Food tolerance was comparable between rOAGB and rRYGB (p = 0.987), and both had significantly better food tolerance than rLSG (p<0.001). The study cohorts had comparable resolution rates for associated medical problems (p>0.60). CONCLUSION: rOAGB and rRYGB had better outcomes after LAGB than rLSG regarding WL, feasibility, food tolerance, and safety. rOAGB had significantly higher rates of nutritional deficiencies.

The Prevalence of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass (RYGB): a Systematic Review and Meta-analysis.

We reviewed the literature on the prevalence of small intestinal bacterial overgrowth (SIBO) after Roux-en-Y gastric bypass (RYGB). Eight studies examining 893 patients were included. The mean age of the patients was 48.11 ± 4.89 years. The mean BMI before surgery and at the time of SIBO diagnosis was 44.57 ± 2.89 kg/m2 and 31.53 ± 2.29 kg/m2, respectively. Moreover, the results showed a 29% and 53% prevalence of SIBO at < 3-year and > 3-year follow-up after RYGB, respectively. Symptoms included abdominal pain, diarrhea, bloating, nausea, vomiting, constipation, soft stool, frequent defecation, flatulence, rumpling, dumping syndrome, and irritable bowel syndrome. SIBO is prevalent after RYGB; digestive symptoms should prompt the consideration of SIBO as a potential etiology. Antibiotic therapy has proven to be therapeutic.

Laparoscopic Adjustable Gastric Band Colonization May Indicate Re-classification of Surgical Wounds.

BACKGROUND: Surgical wounds are classified as either clean, clean-contaminated, contaminated, or dirty wounds. Historically laparoscopic adjustable gastric band (LAGB) removals have been classified as clean wounds since there is thought to be no existing infection and no transection of the gastrointestinal tract. Surgical site infection (SSI) remains a publicly reported source of morbidity after laparoscopic bariatric surgery and is considered a CMS hospital-acquired condition. We present a retrospective chart review to reveal the rate of bacterial colonization of gastric bands. METHODS: This retrospective chart review included 15 patients who underwent removal of LAGB. The entire LAGB and port were removed and then sent for aerobic and anaerobic cultures. Patients were followed up to 1 month, and the incidence of surgical site infection development was recorded. RESULTS: Of the fifteen LAGBs cultured, eight cases (53%) returned positive for bacterial growth. Five of the cultures (33%) were positive for coagulase-negative Staphylococcus. One culture was positive for micrococcus species (6.7%), one culture was positive for Bacteroides fragilis (6.7%) and another was positive for Propionibacterium (6.7%). None of the 15 patients followed in the study developed an SSI by the end of 1 month. CONCLUSIONS: Given the consideration of LAGB removals as clean wounds, the incidence of LAGB colonization is high. Classification of the surgical wounds in LAGB removals should be changed from clean to contaminated. Further studies need to be pursued to determine the correlation between colonized LAGBs and the rate of SSIs. KEY POINTS: • Gastric band removals are a common bariatric procedure. • Surgical site infection remains an outcome of interest to patient, surgeon and payor. • Fifty-three percent of recovered bands were positive for bacterial growth.

Asymptomatic gastric band migration.

Gastric band migration, for which abscess of the subcutaneous port is an alarm signal, can in some cases be asymptomatic. Therapeutic options for withdrawal of the migrated band include colonoscopy (if the band is located at the level of the ileo-caecal valve), laparoscopy and mini-laparotomy.

Significance of Hormone Alteration Following Bariatric Surgery.

The prevalence of obesity has increased significantly over the last several decades, and with its increase comes a wide variety of comorbidities, such as diabetes and cardiovascular disease. Traditionally, diet and exercise have been prescribed for individuals to try and regain control of their weight and health status. Despite this successful method, the compliance rate is significantly below the desired amount. Over the last few decades, a new treatment has been offered to significantly decrease an individual's weight to an optimal BMI between 18 and 25 kg/m2. Bariatric surgery has been proposed to be the most appropriate treatment for obesity, and there are several different types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), adjustable gastric band (AGB), and sleeve gastrectomy (SG). Hormones may be significantly involved in losing and maintaining weight loss. This paper aims to evaluate hormone changes in appetite suppression, appetite activation, glycemic control, and lipid metabolism and how these impact overall weight loss concerning the most prominent surgeries. The hormones assessed were ghrelin, insulin, leptin, GLP-1, PYY, and adiponectin, and their levels before and after each surgery were compared. RYGB is one of the most successful types of bariatric surgeries, and this correlates with it having the most suppressed levels of ghrelin, insulin, and leptin following surgery with a slow return to normal. RYGB has also led to the most significant increased levels of PYY, pre- and post-prandial GLP-1, and adiponectin. Hormones following SG followed the hormone trend after RYGB but were not as prominent. BDP-DS has the highest success rate. However, numerous adverse effects have limited the amount of studies assessing the surgery. What was present was not as significant as RYGB, possibly due to manipulation.

Management of Laparoscopic Adjustable Gastric Band Erosion: A Case Report.

Gastric banding was one of the first operations to gain popularity within the field of bariatric surgery. This case details one patient's presentation and subsequent management of gastric band erosion with the hope of guiding other physicians and supporting the decreased use of gastric banding. The patient, a 61-year-old Caucasian female, presented to the bariatric clinic complaining of a multiyear history of epigastric pain and acid reflux, which was refractory to treatment with proton pump inhibitors. She had a history of laparoscopic adjustable gastric band (LAGB) placement in 2007. She was initially successful in achieving weight loss and maintained regular band adjustments but was lost to follow-up and regained a body mass index (BMI) of 41.59 kg/m2. Evaluation with upper gastrointestinal (GI) endoscopy was recommended and performed. This revealed a LAGB in its entirety with tubing within the gastric fundus. Removal with dual endoscopy and abdominal laparoscopy was recommended and scheduled. During attempts to remove the band using an endoscopic snare, significant difficulty was encountered. Ultimately, an endoscopic rat-tooth grasper was used to lyse the band and tubing into four sections for complete removal. The subcutaneous port of the band was successfully removed laparoscopically, and the patient was discharged from the operating room. She reported limited pain in the postoperative suite but was lost to follow-up regarding long-term symptom relief. This report describes the presentation and management of one patient's experience with a known complication of LAGB-band erosion. This complication necessitated two additional procedures with anesthesia and placed the patient at increased risk for esophageal perforation, complications related to sedation, and the development of abdominal adhesions. Her case aims to support the decreasing prevalence of LAGBs within bariatric surgery and hopes to guide other physicians challenged with the management of similar cases.

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report.

In the context of adjustable gastric band (AGB) placements and the prevalent issue of weight regain with associated complications, revision surgery for gastric bands becomes imperative. Such revisions may encompass band removal or conversion to bariatric procedures, often accompanied by an escalated risk profile, potentially contributing to a 20% morbidity rate. Laparoscopic sleeve gastrectomy (LSG) has gained prominence due to its technical simplicity, effectiveness in weight loss, and lower complication rates. Specific cases involving LSG post-AGB complications are associated with staple line disruptions and leaks. This case report describes a rare complication in a 59-year-old patient following AGB removal and subsequent laparoscopic sleeve gastrectomy. The complication emerged six hours after the surgery, with approximately 400 cc of bile material reported in the drainage. A laparoscopic reintervention was conducted, revealing bile leakage from the second Couinaud hepatic segment. Successful management of the leakage was achieved through simple hepatic suturing using non-absorbable monofilament. Within 24 hours, no further leakage occurred, and the patient was discharged without additional complications. Our case also demonstrates how complex it can be to switch between different medical procedures, and it emphasizes the need for careful planning and precise surgery in the evolving world of bariatric medicine. It is worth noting that there is a dearth of literature addressing this specific complication. Consequently, this study has the potential to provide valuable insights for surgeons who may encounter a similar scenario in their clinical practice.

Roux-en-Y gastric bypass and sleeve gastrectomy as revisional bariatric procedures after adjustable gastric banding: a retrospective cohort study.

INTRODUCTION: The frequency of revisional bariatric surgery is increasing, but its effectiveness and safety are not yet fully established. The aim of our study was to compare short-term outcomes of primary (pRYGB and pSG) and revisional bariatric surgeries (rRYGB and rSG). METHODS: We performed a retrospective cohort study assessing all patients submitted to primary and revisional (after a failed AGB) RYGB and SG in 2019. Each patient was followed-up at 6 months and 12 months after surgery. We compared pRYGB vs. rRYGB, pSG vs. rSG and rRYGB vs. rSG on weight loss, surgical complications, and resolution of comorbidities. RESULTS: We assessed 494 patients, of which 18.8% had undergone a revisional procedure. Higher weight loss at 6 and 12 months was observed in patients undergoing primary vs. revisional procedures. Patients submitted to rRYGB lost more weight than those with rSG (%EWL 12 months = 82.6% vs. 69.0%, p < 0.001). Regarding the resolution of obesity-related comorbidities, diabetes resolution was more frequent in pRYGB than rRYGB (54.2% vs. 25.0%; p = 0.038). Also, 41.7% of the patients who underwent rRYGB had dyslipidemia resolution vs. 0% from the rSG group (p = 0.035). Dyslipidemia resolution was also more common in pSG vs. rSG (68.6% vs. 0.0%; p = 0.001). No significant differences in surgical complications were found. CONCLUSION: Revisional bariatric surgery is effective and safe treating obesity and related comorbidities after AGB. Primary procedures appear to be associated with better weight loss outcomes. Further prospective studies are needed to better understand the role of revisional bariatric surgery.

Experience of Robotic Complex Revisional Bariatric Surgery in a High-Volume Center.

PURPOSE: A revisional bariatric surgery (RBS) is necessary in about 28% of the patients. The role of robotic surgery in RBS is still a subject of debate. We aim to report the outcomes of robotic-assisted RBS at our institution. MATERIALS AND METHODS: We identified patients who underwent robotic-assisted RBSs between January 1, 2016, and May 31, 2022. We analyzed patient demographics and indications for surgery. Measured outcomes included peri- and postoperative morbidity, comorbidity management, and weight loss outcomes. RESULTS: A total of 106 patients were included. Primary procedures were adjustable gastric band 44 (41.5%), sleeve gastrectomy 42 (39.6%), Roux-en-Y gastric bypass (RYGB) 18 (17%), duodenal switch (DS) 1 (0.9%), and vertical banded gastroplasty 1 (0.9%). RBSs performed included 85 (78.7%) RYGB, 16 (14.8%) redo-gastrojejunostomy, and 5 (4.6%) DS. The median time to revision was 8 (range 1-36) years, and the main indication was insufficient weight loss (49%). Median length of hospital stay was 2 (range 1-16) days, and 9 (8.5%) patients were readmitted during the first 30 days. Only 4 (3.7%) patients had early Clavien-Dindo grade III or higher adverse events. No anastomotic leaks were documented. Median excess weight loss was 35.1%, 42.23%, and 45.82% at the 6-, 12-, and 24-month follow-up. Of 57 patients with hypertension, 29 (50.9%) reduced their medication dosage, and 20/27 (74.1%) reduced their diabetes mellitus medication dosage. Finally, of the 75 patients with symptoms, 64 (85.3%) reported an improvement after the RBS. CONCLUSION: Robotic-assisted RBS is feasible, significantly improves patients' comorbidities and symptoms, and leads to considerable weight loss.

Bariatric Surgery Emergencies in Acute Care Surgery.

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Intra-jejunal migration with intestinal obstruction and perforation after gastric banding: A case report.

Laparoscopic adjustable gastric banding (LAGB) is an approved procedure in bariatric surgery. However, serious complications due to band erosion have been reported. There have been few reports of intestinal obstruction and perforation caused by gastric banding invading the gastric wall and migrating to the jejunum. Case introduction: A 56-year-old man was admitted to our hospital with right lower abdominal pain ten years after LAGB surgery. An intraoperative gastric band showed erosion of the gastric wall and movement down to the jejunum, resulting in intestinal obstruction and jejunal perforation. Conclusion: Patients should undergo regular outpatient gastroscopic follow-up after gastric band surgery to prevent serious complications.

Discitis and Osteomyelitis Caused by a Migrated Laparoscopic Adjustable Gastric Banding (LAGB) Catheter.

Laparoscopic adjustable gastric banding (LAGB) is a popular bariatric surgical procedure used to aid in weight loss. Although significant complications may occur after LAGB, they are rare. LAGB causing discitis and osteomyelitis are incredibly rare, with only one other reported case. In this case report, we describe the case of a middle-aged woman who experienced discitis and osteomyelitis due to a disengaged LAGB catheter, which had eroded through her stomach and a part of her cecum. Overall, this case highlights the rare but potential complication of LAGB causing discitis and osteomyelitis. Patients with a history of LAGB placement should be monitored for this possibility and further investigation is needed to identify and mitigate risk factors.

Laparoscopic Banded Gastric Bypass: A Case Report of a Successful Weight Loss Despite Gastro-Gastric Fistula.

Obesity is a global health issue, Roux-en-Y gastric bypass (RYGB), is an effective treatment for weight loss. However, some patients experience insufficient weight loss after RYGB, leading to alternative strategies such as adding an adjustable gastric band to the bypass. This case reports a 43-year-old female with morbid obesity who underwent open RYGB in 2004, achieving significant weight loss. However, she experienced weight regain, indicating RYGB failure. A laparoscopic band was placed around her bypass with no post-operative complications and successful steady weight reduction. During follow-up, an upper gastrointestinal series revealed a gastro-gastric fistula. Despite the fistula, the patient maintained a steady weight, with a significant excess weight loss of 40.2% since the banded gastric bypass surgery. The development of a gastro-gastric fistula, which typically affects weight loss outcomes, was managed conservatively without impacting the patient's steady weight maintenance. This highlights an unexpected weight loss outcome in a patient who underwent laparoscopic banding following RYGB failure and later developed a gastro-gastric fistula. Despite the initial RYGB failure, the patient achieved significant weight loss, surpassing the average reported in previous studies.