Hermann Nehoda

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility.

BACKGROUND Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.

Pregnancies after adjustable gastric banding.

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.

Gastroscopic Band Removal after Intragastric Migration of Adjustable Gastric Band: A New Minimal Invasive Technique

Background: Laparoscopic adjustable gastric banding (LAGB) is the most used procedure for bariatric surgery in Europe. Although a low complication rate is reported, band migration within the first 2 years after LAGB is still observed in nearly 5% of cases, requiring operative band removal.To avoid increased risk of complications due to laparotomy, we propose a minimally invasive technique for this purpose. Methods: We performed this operation in five patients who suffered from band migration after LAGB (1.9% in our series of 211 patients, one patient was operated elsewhere). The described method consists of gastroscopic band and tube removal, combined with removal of the port under local anesthesia. Results: The described procedure was developed in the endoscopy unit without additional equipment. The mean operating-time ranged from 65 to 180 minutes (mean 135 minutes). No perioperative complication were observed. In-patient treatment was necessary for 4 days. Conclusions: A novel technique for minimally invasive band removal after adjustable gastric band migration is described, offering the patient a low-risk procedure and a better chance for further laparoscopic approaches.

Adjustable Gastric and Esophagogastric Banding: A Randomized Clinical Trial

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands® were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.

Results and complications after adjustable gastric banding in a series of 250 patients

BACKGROUND Morbid obesity contributes to many health risks including physical, emotional, and social problems. The increasing prevalence of obesity is a major public health concern since obesity is associated with several chronic diseases. Morbid obesity is the biggest independent risk factor for early mortality. Various options for the surgical treatment of morbid obesity have been developed with varying results. METHODS Between January 1996 and December 1999, we operated on a series of 250 patients (200 women and 50 men) at the General Surgical Department of the University Hospital in Innsbruck. The parameters that were evaluated included age, preoperative and postoperative body mass index (BMI), type of surgery, and intraoperative and postoperative complications. RESULTS The mean follow-up period was 12 months (range 3 to 18). The average preoperative weight was 135.5 kg (BMI 46.69 kg/m(2)). The average total weight-loss was 5.5 kg per month, reaching an average total of 35 kg after one year. The excess weight loss (EWL) after 12 months was 72%. Complications requiring reoperation occurred in 8.8%. CONCLUSIONS In the first year after laparoscopic adjustable gastric banding, weight reduction of the study population was excellent. Additionally, the complication rate was reasonable with no mortalities.

DaVinci® Robotic-Assisted Laparoscopic Bariatric Surgery: Is it Justified in a Routine Setting?

Background: Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS®) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome. Methods: Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci® robot system (4 SAGB, 4 IGS®, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS®, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated. Results: The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group. Conclusion: Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.

Injection port complications after gastric banding: incidence, management and prevention.

Background: Laparoscopic adjustable gastric banding is advocated as a minimal invasive procedure with a low risk profile and high efficacy in the treatment of morbid obesity. Nevertheless, injection port complications are occasionally reported. The aim of this study was to assess port disconnections and port dislodgement with respect to two different implantation techniques. Methods: Between January 1996 and October 1999 230 patients underwent laparoscopic gastric banding with the Swedish Adjustable Gastric Band (SAGB). In group 1 (118 patients), the injection port was implanted onto the sterno-xiphoid union. In group 2 (112 patients), an additional incision was made to suture the port onto the fascia of the lower third of the sternum. Results: There is a significant reduction in port disconnection between group 1 (9.3 %) and group 2 (0 %). Port dislodgment was observed in one patient in each group. Reoperation was performed under local anesthesia in 11 patients, and general anesthesia was used for laparoscopic tube salvage in two patients. After reconnection, two patients experienced port infection. Conclusion: Correct implantation technique of the injection port of the SAGB onto the fascia of the lower third of the sternum reduces the risk for port complications.Technical notes are discussed.

Uncommon Intragastric Migration of the Swedish Adjustable Gastric Band

Background:The aim of this study was to assess the incidence of intragastric migration of the Swedish adjustable gastric band (SAGB) and to evaluate the safety and effectiveness of gastroscopic band removal. Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent a laparoscopic SAGB operation. All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status, endoscopic diagnosis of migration, total weight reduction) were prospectively collected in a computerized data bank. Results: Out of the 454 SAGB operations,14 (3.1%) intragastric band migrations were observed. The average preoperative weight was 122.2 kg and the average postoperative minimum weight was 80.4 kg. All 14 patients had unexplained weight gain on an average of 20 months after the operation. The average band filling status was 8.2 ml. In 12 patients, the band was removed endoscopically, avoiding laparotomy.The remaining 2 patients are under endoscopic surveillance.The mean operating time was 120 minutes. No peri- or postoperative complication was observed. Conclusion: Intragastric band migration is a rare complication and should be considered if a patient starts to regain weight. Migration does not require immediate therapy and therefore this complication could be safely treated endoscopically.

Plasma amine oxidase: a postulated cardiovascular risk factor in nondiabetic obese patients

Increased activity of semicarbazide-sensitive plasma amine oxidase (SSAO), an enzyme converting various amines, has been implicated in the generation of endothelial damage through formation of cytotoxic reaction products. We investigated if SSAO activity is elevated in morbidly obese patients, which might contribute to the increased cardiovascular risk associated with obesity. SSAO activity was determined in 74 nondiabetic, obese patients (median body mass index [BMI]: 42.9 kg/m(2)) and in 32 healthy, non-obese controls (median BMI: 23.3 kg/m(2)) using a radiometric assay based on the conversion of [(14)C]benzylamine. SSAO and parameters of glucose and lipid metabolism were compared for subgroups of obese patients with normal (n = 49) and impaired (n = 25) glucose tolerance using nonparametric statistical tests. Median SSAO activity was 434 microU/mL in obese patients, which was significantly higher than in healthy, non-obese controls (median SSAO activity: 361 microU/mL). Median SSAO activity in patients with normal and impaired glucose tolerance was 423 and 464 microU/mL, respectively. SSAO activity was not correlated with any other clinical or laboratory parameters characteristic of the metabolic alterations associated with obesity. Elevated SSAO activity is found in nondiabetic, morbidly obese patients and might be an interesting independent risk factor for obesity-related cardiovascular morbidity. Long-term follow-up of SSAO and its possible role in pathogenic events is warranted since intervention with specific SSAO inhibitors is available.

Organ Transplantation and Obesity: Evaluation, Risks and Benefits of Therapeutic Strategies

Obesity is a prevalent health problem that has discernible impact on all fields of surgery. However, little attention is paid in the literature to the underlying relation of surgical, immunological and metabolic links between transplantation and morbid obesity. Pre-operative obesity has been reported to worsen the outcome of organ transplantation. Impairment of graft function as well as decreased patient and graft survival can contribute to this effect. Post-transplant weight gain is common and may be attributed to an imbalance of the adipostatic and appetite stimulating hormones. Reduction of obesity before transplantation has to cope with limited time, increased risk of therapeutic side-effects in patients with end-stage organ failure, and psychosocial stress. Overweight reduction following organ transplantation interferes with diverse effects associated with immunosuppressive therapy. A case of adjustable gastric banding following renal transplantation is presented.