Brad M. Watkins

Laparoscopic Adjustable Gastric Banding: Weight Loss, Co-morbidities, Medication Usage and Quality of Life at One Year

Background: The objective of this study was to determine the weight loss, changes in co-morbidities, medication usage and general health status at 1 year after laparoscopic adjustable gastric banding (LAGB). Methods: Prospective data were obtained from all subjects undergoing LAGB. These measurements included a medical history and review of systems, medications, height and weight and the SF-36 general health survey. Patients were seen for band adjustments as needed throughout the year. At the 1-year follow-up visit, patients were weighed and interviewed about the status of their health conditions and their current medications, and the SF-36 was repeated. Results: Between November 2002 and November 2003, 195 patients had LAGB. The majority of subjects were female (82.8%), married (65.1%), and white (94.9%). Complications occurred in 18 subjects (9.2%). These included 3 slipped bands (1.5%), 4 port problems (2.1%), 8 patients with temporary stoma occlusion (4.1%), 1 explantation (0.5%), and 1 mortality (0.5%). Mean BMI decreased from 45.8 kg/m2 (± 7.7) to 32.3 kg/m2 (± 7.0). Mean percent excess body weight lost was 45.7% (± 17.1) during the first year. Major improvements occurred in arthritis, asthma, depression, diabetes, gastro-esophageal reflux disease, hyperlipidemia, hypertension, joint and back pain, sleep apnea and stress incontinence. Medication usage declined remarkably. Quality of life (QoL) by the SF-36 showed highly significant improvements. Conclusions: At 1 year after LAGB, patients had experienced significant weight loss, resolution of comorbidities, decreases in medication usage, and improvements in QoL.

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUNDnSurgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset.nnnMETHODSnThe patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up.nnnRESULTSnA total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds.nnnCONCLUSIONSnIncisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Laparoscopic Adjustable Gastric Banding: Early Experience in 400 Consecutive Patients in the USA

Background: Early experience with 400 consecutive patients who underwent laparoscopic adjustable gastric banding (LAGB) is reported. Methods: From Nov 2002 to Aug 2004, prospective data were collected on 400 consecutive LAGB patients and evaluated retrospectively. Results: There were 354 (88.5%) females and 46 males (11.5%), with mean age 43.6 years and mean BMI 46.2 kg/m 2 . For outpatients (freestanding ambulatory surgery center), mean OR time was 55.4 min in 208 patients (52%), compared to mean inpatient OR time of 70.5 min in 192 patients. Inpatients had a higher BMI (48.2 ± 9.3 SD) than outpatients (43.9 ± 5.7 SD) (P<0.0001). Complications occurred in 35 patients (8.8%). These consisted of 9 slipped bands (2.3%) that were surgically repositioned, 6 port problems (1.5%) that were successfully repaired, 17 patients with temporary stoma occlusion (4.3%) that spontaneously resolved, and 2 bowel perforations (0.5%) that required surgical repair and band removal. One patient died of pneumonia 2 weeks after an uneventful procedure. Average 1-year percent excess weight loss (%EWL) in 138 patients was 48.2%. Patients who had ≤50 kg initial excess weight (n=37, 27%) had a significantly higher %EWL (55.2%) at 1 year than patients who had >50 kg initial excess weight (P=0.0011). Conclusions: LAGB has been safe and effective thus far for the surgical treatment of morbid obesity, and can be performed as an outpatient in select patients.

Adjustable Gastric Banding in an Ambulatory Surgery Center

Background: We report our early experience with 343 consecutive patients who underwent laparoscopic adjustable gastric banding (LAGB) as an outpatient procedure in a self-standing ambulatory surgery center. Methods: Between Apr 2003 and Feb 2005, data was collected prospectively on 343 consecutive patients who underwent LAGB as an outpatient. Results: There were 305 females (88.9%) and 38 males (11.1%), with mean age 43.5 years (±SD 9.9, range 19-67) and mean BMI 44.5 kg/m 2 (±SD 6.1, range 32.7-62.7). Mean operating-room time was 52.9 (±16.3) minutes. 10 complications occurred in 9 patients (2.8%): 5 stoma occlusion, 3 port problems requiring port replacement, 1 superficial wound infection, and 1 colon perforation associated with adhesiolysis requiring band removal. 3 patients required admission to the hospital: 1 for nausea, 1 for observation after bloody nasogastric tube drainage, and 1 for dysphagia due to esophageal spasm. All 9 patients with complications recovered fully. 1-year weight loss data was available in 91 patients; mean percent excess weight lost (%EWL) at 1 year was 45.4% (±17.6). Conclusions: LAGB has become an appropriate outpatient procedure in select patients.

Laparoscopic adjustable gastric banding in an ambulatory surgery center

BACKGROUNDnIn the management of morbid obesity by laparoscopic adjustable gastric banding (LAGB), careful patient preparation and attentive follow-up have been shown to produce the best long-term results.nnnMETHODSnBetween November 2002 and August 2007, prospective data were collected on 2,411 consecutive patients, 84% of whom underwent LAGB at our freestanding outpatient surgery center, staffed by our dedicated multidisciplinary bariatric team. Outcomes reported include changes in mean body mass index (BMI), percentage excess body weight loss (%EBWL), and incidence of complications at 1 year, as well as the slippage rate up to 3 years.nnnRESULTSnA total of 2,003 (83%) female and 409 (17%) male patients with a mean age of 44.1 years (range 15-76 yrs) and a BMI (mean +/- SD) of 45.7 +/- 7.9 kg/m2 (range 29.1-83.1 kg/m2) underwent LAGB. In 2,027 patients (84%), LAGB was performed as an outpatient procedure, with 1 (0.04%), conversion from a laparoscopic to an open procedure. The majority of operations were completed in less than 1 hour, using the pars flaccida technique. One-year weight loss data were available in 1,144 patients (47%). BMI decreased to 36.9 +/- 7.4 kg/m2 (-8.8). Mean %EBWL at 1 year (+/- 60 days) was 41.0% +/- 18.1% (range 0.7%-113.9%). Complications occurred in 241 of 2,411 (10%) patients. There was 1 death (0.04%). Cumulative slippage at 1, 2, and 3 years, respectively, was 0.4%, 2.4%, and 10%. There were 56 (2.3%) port-related problems, and 13 band explantations (0.54%).nnnCONCLUSIONSnWith extensive staff experience and patient preparation, LAGB can be performed safely as an outpatient procedure for select patients. Close follow-up is crucial in order to optimize LAGB outcomes for the long term.

Nonsteroidal-induced benign strictures of the colon: a case report and review of the literature

Colonic strictures are a rare complication reported to result from chronic use of sustained release formulations of indomethacin and diclofenac. Such strictures often present with associated mucosal ulceration and are thought to result from nonsteroidal antiinflammatory drug-induced alterations in enterocyte homeostasis. Strictures generally occur in the cecum, ascending, and proximal transverse colon with symptoms of occult blood loss, obstruction, changes in bowel habits, and rarely, perforation. The first reported case of a 69-year-old woman who developed recurrent colonic strictures with inflammatory changes and mucosal ulceration while taking Lodine (etodolac) is presented. A brief review of the relevant literature and suggested preventative therapies are discussed.

Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors

BackgroundLeak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3xa0%. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures.MethodsRisk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence.ResultsPathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage.ConclusionsThis review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40xa0Fr, EL:1, (2) begin the gastric transection 5–6xa0cm from the pylorus, EL:2–3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1xa0cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.

Gastric compartment syndrome: an unusual complication of gastric plication surgery.

f p a T b t f t T l g p I o s i a p a f t a a c c s t g a w t w Despite being an investigational gastric restrictive procedure, gastric plication surgery (GPS) is gaining in popularity. The attributes attractive to patients include no stapling, no rearranging, and no need for a port or adjustments. The concept of gastric plication as a weight loss procedure has previously been published in animal models [1–3]. The largest clinical experience stems from Ramos et al [4] in Brazil, Talebpour nd Amoli [5] in Iran, and Brethauer et al [6] at the Cleveland linic. Reports are now appearing with gastric plication as an djunct to laparoscopic adjustable gastric banding [7]. The resent case report describes an unusual complication after PS performed as a primary operation for weight loss.

Safety and effectiveness of bariatric surgery: Roux-en-y gastric bypass is superior to gastric banding in the management of morbidly obese patients: a response

Background nThe recent article by Guller, Klein, Hagen was reviewed and discussed by the authors of this response to critically analyze the validity of the conclusions, at a time when patients and providers depend on peer reviewed data to guide their health care choices. The authors of this response all have high volume bariatric surgery practices encompassing experience with both gastric bypass and gastric banding, and have made significant contributions to the peer reviewed literature. We examined the assumptions of the paper, reviewed the main articles cited, provided more evidence from articles that were included in the materials and methods of the paper, but not cited, and challenge the conclusion that Roux-en-Y gastric bypass is superior to gastric banding.BackgroundThe recent article by Guller, Klein, Hagen was reviewed and discussed by the authors of this response to critically analyze the validity of the conclusions, at a time when patients and providers depend on peer reviewed data to guide their health care choices. The authors of this response all have high volume bariatric surgery practices encompassing experience with both gastric bypass and gastric banding, and have made significant contributions to the peer reviewed literature. We examined the assumptions of the paper, reviewed the main articles cited, provided more evidence from articles that were included in the materials and methods of the paper, but not cited, and challenge the conclusion that Roux-en-Y gastric bypass is superior to gastric banding.Results and discussionThe paper by Guller et al was subject to significant bias. The authors did not demonstrate an understanding of gastric banding, selectively included data with unfavorable results towards gastric banding, did not provide equal critique to the literature on gastric bypass, and deliberately excluded much of the favorable data on gastric banding.ConclusionThe papers conclusion that gastric bypass is the procedure of choice is biased, unsubstantiated, not supported by the current literature and represents a disservice to the scientific and health care community.

What matters after sleeve gastrectomy: patient characteristics or surgical technique?

Background. The impact of operative technique on outcomes in laparoscopic sleeve gastrectomy has been explored previously; however, the relative importance of patient characteristics remains unknown. Our aim was to characterize national variability in operative technique for laparoscopic sleeve gastrectomy and determine whether patient‐specific factors are more critical to predicting outcomes. Methods. We queried the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for laparoscopic sleeve gastrostomies performed in 2015 (n = 88,845). Logistic regression models were used to determine predictors of postoperative outcomes. Results. In 2015, >460 variations of laparoscopic sleeve gastrectomy were performed based on combinations of bougie size, distance from the pylorus, use of staple line reinforcement, and oversewing of the staple line. Despite such substantial variability, technique variants were not predictive of outcomes, including perioperative morbidity, leak, or bleeding (all P ≥ .05). Instead, preoperative patient characteristics were found to be more predictive of these outcomes after laparoscopic sleeve gastrectomy. Only history of gastroesophageal disease (odds ratio 1.44, 95% confidence interval 1.08–1.91, P < .01) was associated with leak. Conclusion. Considerable variability exists in technique among surgeons nationally, but patient characteristics are more predictive of adverse outcomes after laparoscopic sleeve gastrectomy. Bundled payments and reimbursement policies should account for patient‐specific factors in addition to current accreditation and volume thresholds when deciding risk‐adjustment strategies.