Gianni Segato

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.

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.

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.

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.

Bariatric Analysis and Reporting Outcome System (BAROS) Applied to Laparoscopic Gastric Banding Patients

Background: The definition of success and failure of a bariatric procedure should include weight loss as well as improvement in comorbidity and quality of life assessment. The Bariatric Analysis and Reporting Outcome System (BAROS), introduced by Oria and Moorhead in 1997, seems to provide a standard for comparison in the surgical treatment of morbid obesity. Methods: 180 morbidly obese and super-obese patients, who underwent laparoscopic gastric banding (lap-band) at our institutions and had a follow-up > 18 months (19-55 months) were evaluated with BAROS. Results: The patients were divided into four outcome groups (failure, fair, good, and excellent) based on a scoring table that adds or subtracts points while evaluating three main areas: percentage of excess weight loss, changes in medical conditions, and assessment of quality of life. Points were deducted for complications and reoperative surgery. Conclusions: The BAROS outcome system has proved to be a useful instrument in evaluating midterm results in our series of lap-band patients.

Treatment of Morbid Obesity with the Transcend® Implantable Gastric Stimulator (IGS®): A Prospective Survey

Background: The implantable gastric stimulator (IGS), a pacemaker-like device, has been found to be safe and effective to induce and maintain weight loss. We present our experience with 20 morbidly obese patients. Methods: Between September 20 and November 22, 2002, 20 patients (F/M 12/8), mean age 40.3 years (23-62) underwent IGS implantation. Mean BMI was 40.9 (33.9-48.2), mean weight 115.0 kg (87.0-137.0) and mean excess weight (EW) 51.3 kg (35.6-70.1).Co-morbitidies were: 3 cases of hypertension, 1 diabetes, 1 dislipidemia and 1 depression. Mean operative time was 58.5 min (37-85). The IGS was actived 30 days after implantation. Patients were advised to follow a low calorie diet and behavior modification (to avoid fat and to ingest more liquids during meals, to chew slowly, to eat vegetables before main meals, and to perform exercise daily). Results: Mean ± standard error percent excess weight loss (%EWL) was: 10.6±1.8 at 1 month; 15.0±2.3 at 2 months; 16.6±2.6 at 3 months; 18.1±3.5 at 4 months; 15.5±3.5 at 6 months; 18.9±3.5 at 8 months; and 23.8±5.0 at 10 months. There were no intra-operative surgical or long-term complications. There were 3 intra-operative gastric penetrations, observed by gastroscopy, without sequelae. One patient with hypertension ceased his medical therapy at the 4th month. Conclusion: IGS can be implanted laparoscopically with minimal perioperative complications. The observed weight loss is comparable to other noninvasive procedures. If weight loss is maintained, IGS could be considered as a first choice therapy in the treatment of morbid obesity in selected patients.

Variation in Lipid Levels in Morbidly Obese Patients Operated with the LAP-BAND® Adjustable Gastric Banding System: Effects of Different Levels of Weight Loss

Background: A moderate weight loss is known to improve the lipid levels in simple obesity.The extent of weight loss needed to achieve a clinically meaningful effect on lipid abnormalities in morbid obesity is little understood.We analyzed the effects of different levels of body weight loss on the lipid levels of morbidly obese patients operated with the LAPBAND® System. Methods: 225 morbidly obese patients (172 F and 53 M) in which a complete lipid profile has been collected both before and 12-18 months after surgery were studied. The changes of the lipid profile were analyzed according to different levels of percent weight loss (%WL: <10%, 10-20%, 20-30%, >30%). Results: Mean weight loss was 30.7±15.2 kg, corresponding to a 23.1±9.7% reduction of body weight. A large variability in the weight loss was observed. A significant difference in the change of the lipid parameters between the group with <10%WL and the group with 10-20%WL was observed for total-cholesterol (+10.0±17.2% vs-0.7±14.7%; p<0.05), for the LDL (+18.7±26.3% vs +3.1±22.9%; p<0.05), and for the triglycerides (+7.7±26.3% vs -21.9±25.4%; p<0.05). No further significant differences were found between the two groups with greater weight loss (20-30%WL and >30%WL) and the group with 10-20%WL, the only exception being the percent change in triglycerides levels, i.e. higher in the group with %WL >30 (-33.6±31.5% vs -21.9±25.4%; p<0.05). Conclusion: A moderate weight loss of 10-20% of initial body weight produced the maximal effects on the lipid levels in morbid obesity.

Laparoscopic Adjustable Silicone Gastric Banding: Technique and Results

Background: Kuzmaks Adjustable Silicone Gastric Banding (ASGB) is the least invasive operation available for morbid obesity, and it is one of the more effective. Based on the know-how gained from performing more than 250 ‘open’ procedures, we have developed an original laparoscopic technique, whose main steps are pouch measurement, limited dissection along the lesser and the greater curvature and the application of the retention sutures. Methods: From September 1993 through October 1994, 30 morbidly obese patients underwent laparoscopic ASGB. Results: Mean operative time was 2 h and the post-operative stay 2-3 days. Only one major perioperative complication (stomach slippage) was observed. The weight loss achieved, reported as a variation of Body Weight, Body Mass Index, per cent Ideal Body Weight and per cent Excess Weight Loss was similar to that obtained with the open procedure. Conclusion: This new approach is a major achievement in bariatric surgery, because it combines the minimal invasiveness of laparoscopy with the reversibility and adjustability of ASGB.

Postoperative Management of Laparoscopic Gastric Banding

Background:The authors investigated the postoperative management of morbidly obese patients treated by laparoscopic adjustable gastric banding (LAGB) with the Lap-Band® System. Methods: The 3-year postoperative band management is presented in 379 morbidly obese patients, divided according to intra-operative band filling and quartiles of maximum postoperative band filling. Results: LAGB resulted in a 40.8±24.5 percent excess weight loss (%EWL). Stoma stenosis occurred in 87 patients (23.0%), pouch dilatation in 52 (13.7%) and esophageal dilatation in 22 (5.8%). Most bandrelated complications were controlled by simple band deflation. The mean number of postoperative band adjustments was 2.3±1.7, and mean maximum band filling after surgery was 2.8±1.2 ml. Weight loss at 3 years was identical in 205 patients who had the band completely unfilled at surgery and in 174 patients who had the band filled with 1 to 3 ml of sterile saline.The rate of band-related complications was significantly lower in the first group. No differences in %EWL were observed between quartiles of maximum band filling after surgery.The rate of band-related complications increased with increasing levels of postoperative maximum band filling. In patients with the band filled with <3.0 ml of sterile saline at 6 months, the inflation of further saline produced a dose-related increase in the rate of weight loss. In patients with the band filled with ≥ 3.0 ml of sterile saline at 6 months, the inflation of further saline was associated with a reduced %EWL. Conclusion: Postoperative adjustability of the LapBand® was useful in the treatment of band-related complications and was able to significantly influence the rate of weight loss. On the other hand, aggressive postoperative band filling was associated with an increased rate of complications.

The Influence of a New Timing Strategy of Band Adjustment on the Vomiting Frequency and the Food Consumption of Obese Women Operated with Laparoscopic Adjustable Silicone Gastric Banding (LAP-BAND)

Objective: To evaluate the effects of a new timing strategy of band adjustment on the short-term outcome of obese women operated with adjustable silicone gastric banding. Subjects: The outcome of 30 women without binge-eating disorder operated with laparoscopic adjustable silicone gastric banding with a wider intraoperatory band calibration (LAP-BAND) was compared to that of 30 body mass index-matched women without binge-eating disorder previously operated with adjustable silicone gastric banding (ASGB) applied by laparotomy with the usual intraoperatory band calibration. The patients were evaluated 3, 6 and 12 months after surgery. Measurements: (1) weight loss; (2) total daily energy intake; (3) percent as liquid, soft or solid food; (4) vomiting frequency; (5) rate of postoperative percutaneous band adjustments; (6) rate of band-related complications. Results: Both the weight loss and the daily energy intake did not differ between patients with LAP-BAND and patients with ASGB. After surgery, the patients with LAP-BAND ate more solid food and less liquid food than the patients with ASGB. Vomiting frequency was higher in patients with ASGB than in patients with LAP-BAND. The total number of percutaneous band adjustments was higher in women with LAP-BAND than in women with ASGB. Band inflation because of weight stabilization was performed in six (20.0%) women with ASGB and in 19 (63.3%) women with LAP-BAND. Neostoma stenosis occurred in one women with ASGB, but in none of the women with LAP-BAND. One patient with LAP-BAND presented band slippage. Conclusions: The wider intraoperatory band calibration performed in patients with LAP-BAND did not reduce the short-term efficacy of adjustable silicone gastric banding. This new timing strategy of band adjustment required more postoperative percutaneous band inflations, but it improved the eating pattern of the patients (low vomiting frequency and high intake of solid food).