Franco Favretti

Obesity surgery: Evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BackgroundThe increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectivness and surrounding circumstances of the various types of obesity surgery.MethodsA consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.RecommendationsAfter the patient’s multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Laparoscopic Adjustable Silicone Gastric Banding (Lap-Band®): How To Avoid Comlications

Background: The laparoscopic application of LAPBAND is gaining widespread acceptance as a gastric restrictive procedure. At the same time the reported morbidities (i.e., gastric perforation, stomach and/or band slippage) are cause for some concern. Methods: From September 1993 until May 1997, 260 patients underwent LAP-BAND at the Department of Surgery at the University of Padova, Italy. Results: The mortality rate was zero and the morbidity rate requiring reoperation was 3.4% (stomach slippage, gastric perforation, erosion). In order to avoid complications the key points of the technique are reviewed: (1) reference points for dissection (equator of the balloon, left crus); (2) retrogastric tunnel within the layers of the phrenogastric ligament; (3) embedment of the band; (4) proper outlet calibration; and (5) retention sutures. Conclusions: Attention to technical details is of paramount importance for a safe, standardized and effective operation.

The World's First Obesity Surgery Performed by a Surgeon at a Distance

Background: In recent years, laparoscopic procedures have gained popularity. The laparoscopic technique is, however, more difficult than the conventional approach, especially in obese patients. The purpose of this article is to demonstrate a solution to these difficulties. Method: On September 16, 1998, a laparoscopic gastric banding procedure was performed by a surgeon while he was actually sitting at a distance from his patient. The surgeons assistant was scrubbed and gowned and stood at the patients side. The surgeon manipulated handles that were connected to a computer in command of robotic arms mounted on the operating table near the patient. The robotic arms contained surgical tools with articulated tips, well inside the abdominal cavity. The system constituted a master-slave construction called Mona (Intuitive Surgical, Mountain View, CA). The entire procedure (adjustable silicone gastric banding) was performed solely by this system without any other intervention. Results: The entire procedure lasted 90 minutes. The blood loss was 25 mL. The patient left the hospital on the second postoperative day. Conclusion: This procedure demonstrates that telesurgical procedures are feasible, can be performed safely even in obese patients, and improve the surgeons comfort by restoring ergonomically acceptable conditions, by increasing the number of degrees of freedom, and by recreating the eye-hand connection lost in videoendoscopic procedures.

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 leackage) 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.

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

AbstractBackground: Kuzmaks gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure.

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 patients primary care provider are important. All of the elements above are necessary to provide the comprehensive care that contributes to optimal patient outcomes.

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.

Laparoscopic Italian Experience with the Lap-Band®

Background: An increasing number of surgeons with different levels of experience with laparoscopic surgery and open obesity surgery have started to perform laparoscopic implantation of the Lap-Band®. Methods: An electronic patient data sheet was created and was mailed and e-mailed to all surgeons performing laparoscopic adjustable silicone gastric banding (LASGB) in Italy. Patients were recruited since January 1996. Data on 1,265 Lap-Band System® operated patients (258 M / 1,007 F; mean BMI 44.1, range 27.0-78.1; mean age 38, range 17-74 years) were collected from 23 surgeons performing this operation. Results: Intra-operative mortality was absent. Post-operative mortality was 0.55% (7 patients) for causes not specifically related to LASGB implantation. The laparotomic conversion rate was 1.7% (22 patients). LASGB related complications occured in 143 patients (11.3%). Pouch dilatation was diagnosed in 65 (5.2%), and 28 (2.2%) of these underwent re-operation. Band erosion was observed in 24 patients (1.9%). Port or connecting tube-port complications occurred in 54 patients (4.2%), 12 of whom required revision under general anesthesia. Follow-up was obtained at 6, 12, 18, 24, 36 and 48 months, and mean BMI was respectively 38.4, 35.1, 33.1, 30.2, 32.1 and 31.5. The percentage of patients observed at each follow-up was >60%. There was no intra-operative mortality and no complication-related mortality, with acceptable weight loss. Conclusion: The LASGB operation is safe and effective, and deserves wider use for treatment of morbid obesity.

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.

Progress in Implantable Gastric Stimulation: Summary of Results of the European Multi-Center Study

BackgroundThe Implantable Gastric Stimulator (IGS®), 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.MethodsBetween 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.ResultsThe 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.ConclusionIGS 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.