Laparoscopic Adjustable Banding Research Articles

Simultaneous erosion of gastric band into stomach and transverse colon

Laparoscopic adjustable banding was previously considered to be the safest and least invasive technique in bariatric surgery in the mid-1990s. It has since been performed less frequently as newer bariatric interventions and surgical techniques, and a fuller understanding of gastric banding complications have been elucidated. Nevertheless, there are a significant number of patients with in situ gastric bands, and cases of significant and unusual complications involving multiple visceral organs must be described and documented in order to enhance providers’ awareness and facilitate early recognition.

The timing of energy intake.

The aim of the paper is to review the current evidence on the impact of 'the timing of energy intake' on the risk of developing obesity and obesity-related metabolic diseases. The prevalence of obesity is currently increasing worldwide thus becoming a severe health burden for most countries. Indeed, obesity represents a risk factor for several non-communicable diseases such as cancer, type 2 diabetes, dyslipidaemia, CVD and overall mortality. In order to treat obesity, several pharmacological approaches have been developed and are indicated for subjects with obesity with a BMI ≥ 30 kg/m2 or ≥ 27 kg/m2 and obesity-related comorbidities. For severe obesity (BMI ≥ 40 kg/m2), bariatric surgery represents a promising approach. The most common bariatric surgical procedures are represented by the Roux-en-Y gastric bypass, laparoscopic adjustable band, laparoscopic gastric sleeve and biliopancreatic diversion with duodenal switch. Both anti-obesity pharmacological and surgical treatments require change in lifestyle. When a nutritional plan is established, attention is usually paid to macronutrient composition and energy intake, while 'the time of food' is not taken into account. Chronotype, which is the attitude of a subject to carry out most of their daily activities in the first (morning chronotype) or second half (evening chronotype) of the day, has been reported to have a role in the pathogenesis of obesity and obesity-related cardiometabolic diseases as well as eating speed. Thus, adopting a physiological timing of energy intake could be an additional strategy to potentiate the current anti-obesity approaches.

Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery.

This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients. Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examinedin 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1year and from1 to 5 years after surgery, with interactions between insurance group and surgery type. Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups. Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

Length of stay by uncomplicated diabetes bariatric surgery patients: A laparoscopic adjustable banding versus laparoscopic sleeve gastrectomy.

Bariatric surgery is an effective procedure for morbidly obese patients when all else fails. The purpose of this study was to compare the hospital length of stay (LOS) for two surgical procedures, laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG). This study was a retrospective cross-sectional analysis of the Nationwide Inpatient Sample (NIS) from 2009 to 2014. Patients who received bariatric surgery as indicated by International Classification of Diseases, Ninth Revision (ICD-9) procedure codes were selected (N=4001). Cases were limited to uncomplicated diabetic patients. Differences in the odds of long vs short (2< and ≥2) stay for a patient receiving LSG were compared with LAGB while adjusting for hospital volume, hospital size, patient age, gender, ethnicity, season, and year using logistic regression analysis. The odds for LSG (odds ratio [OR]=0.100, 0.066-0.150, P<0.001) patients for long LOS are lower when compared with LAGB. In the stratified logistic regression model, both male (OR=0.157, 0.074-0.333, P<0.001) and female (OR=0.077, 0.046-0.127, P<0.001) had reduced odds of extended LOS for LSG. Discharged patients in the year 2012 (OR=0.660, 0.536-0.813, P<0.001) had decreased odds of having a longer LOS when compared with the year 2014. Both government, nonfederal (OR=0.452, 0.251-0.816, P=0.008), and private investor-owned (OR=0.421, 0.244-0.726, P<0.001) patients had similar odds for long duration of stay when compared with government or private. Urban non-teaching (OR=1.954, 1.653-2.310, P<0.001) patients had higher odds for long LOS in comparison with urban teaching. New England patients' (OR=0.365, 0.232-0.576, P<0.001) odds for extended LOS were lower when compared with pacific. Both patients who received care in low (OR=1.330, 1.109-1.595, P=0.002) and medium (OR=1.639, 1.130-2.377, P=0.009) volume hospital had increased odds for long duration of stay. Female patients in the stratified logistic regression model with high (OR=1.330, 1.109-1.595, P<0.002) volume had elevated odds of extended LOS when compared with very low volume hospital. Among the uncomplicated diabetic patients, LSG provides a substantially low odds of extended LOS after adjusting for covariates when compared with LAGB. The finding of the relative reduction in LOS for LSG suggests opportunities for improvement both for cost reduction for third party insurance payers and greater efficacy and outcomes for patients.

Insurance status differences in weight loss and regain over 5 years following bariatric surgery.

The effectiveness of bariatric surgery among Medicaid beneficiaries, a population with a disproportionately high burden of obesity, remains unclear. We sought to determine if weight loss and regain following bariatric surgery differed in Medicaid patients compared to commercial insurance. Data from the Longitudinal Assessment of Bariatric Surgery, a ten-site observational cohort of adults undergoing bariatric surgery (2006-2009) were examined for patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG). Using piecewise spline linear mixed-effect models, weight change over 5 years was modeled as a function of insurance type (Medicaid, N = 190; commercially insured, N = 1448), time, procedure type, and sociodemographic characteristics; additionally, interactions between all time, insurance, and procedure type indicators allowed time- and procedure-specific associations with insurance type. For each time-spline, mean (kg) difference in weight change in commercially insured versus Medicaid patients was calculated. Medicaid patients had higher mean weight at baseline (138.3 kg vs. 131.2 kg). From 0 to 1 year post-operatively, Medicaid patients lost similar amounts of weight to commercial patients following all procedure types (mean weight Δ difference [95% CI]: RYGB: -0.9 [-3.2, 1.4]; LAGB: -1.5 [-6.7, 3.8]; SG: 5.1 [-4.0, 14.2]). From 1 to 3 years post-operatively Medicaid and commercial patients continued to experience minimal weight loss or began to slowly regain weight (mean weight Δ difference [95% CI]: RYGB: 0.9 [0.0, 2.0]; LAGB: -2.1 [-4.2, 0.1]; SG: 0.7 [-3.0, 4.3]). From 3 to 5 years post-operatively, the rate of regain tended to be faster among commercial patients compared to Medicaid patients (mean weight Δ difference [95% CI]: RYGB: 1.1 [0.1, 2.0]; LAGB: 1.5 [-0.5, 3.5]; SG: 1.0 [-2.5, 4.5]). Although Medicaid patients had a higher baseline weight, they achieved similar amounts of weight loss and tended to regain weight at a slower rate than commercial patients.

A5270 - Small Bowel Obstruction due to Internal Hernia caused by Laparoscopic Adjustable Band Tubing in a Patient with Band over Previous Gastric Bypass

Roux-en-Y gastric bypass has shown to be very effective in achieving weight loss in patients with obesity; however, weight re-gain does still occur in some patients. Often, these patients undergo a second procedure in order to achieve weight loss once again. Placing a laparoscopic adjustable band over the gastric pouch in a bypass patient is one technique used by many surgeons. By placing the band, the gastric pouch is restricted from expanding to prevent risk of weight regain. This is a rare case of a patient who presented with small bowel obstruction due to an internal hernia caused by band tubing from adjustable gastric banding over previous Roux-en-Y bypass.

Early hospital readmission after bariatric surgery.

With the rise in bariatric procedures being performed nationwide and the growing focus on quality and outcome measures, reducing early hospital readmission (EHR) rates has garnered great clinical interest. The aim of this study was to identify the incidence, reasons, and risk factors for EHR after bariatric surgery. Using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2012-2013), patients with a diagnosis of obesity and body mass index ≥35 who underwent bariatric surgery were identified. EHR was defined as at least one hospitalization within 30days of bariatric procedure. The association between readmission and patient factors was assessed using multivariable logistic regression analysis. In addition, reasons for readmission were sought. A total of 36,042 patients were identified. The overall EHR rate was 4.70% [laparoscopic (lap) adjustable band 1.87%, lap gastric bypass (GBP) 5.94%, open GBP 7.86%, and sleeve gastrectomy 3.73%], and it occurred at the median of 11days postoperatively. The rate of EHR significantly decreased from 2012 to 2013 (5.15 vs. 4.32%, p<0.001). The median age and BMI were 44years and 44.7kg/m(2), respectively, 78.99% were female, and 70.78% were white. The most common reason for readmission was nausea/vomiting (12.95%), followed by abdominal pain (11.75%) and dehydration (10.54%). On multivariable analysis, factors most strongly associated with readmission were procedure type (lap band: reference; open GBP: OR 3.78, 95% CI 2.47-5.80; lap GBP 3.18, 2.39-4.22; sleeve gastrectomy: 2.03, 1.52-2.71; all p<0.001), steroid use (1.82, 1.33-2.48, p<0.001), pre-discharge complication (1.64, 1.20-2.24, p<0.001), and black population (1.51, 1.34-1.71, p<0.001). Bariatric centers should consider implementing standardized protocols for outpatient monitoring of patients identified to be at high risk of experiencing early readmission, which in turn would decrease overall costs and improve quality of care.

A185 - Body Contouring Surgery following Roux-En-Y Gastric Bypass in the Longitudinal Assessment of Bariatric Surgery-2 Cohort

gastric bypass (RYGB) patients become intoxicated remarkably fast and reach peak blood alcohol concentrations that are surprisingly high (Steffen et al., 2013). Additionally, data also suggests that patients are more likely to meet criteria for an alcohol use disorder following RYGB (King et al., 2012). Further, the surgical procedure that patients undergo may have an impact on alcoholrelated outcomes: laparoscopic adjustable band patients appear to be less likely to have problems with alcohol than gastric bypass patients (Ostlund, 2011). Methods: Although we know that patients are at an increased risk for problems with alcohol after surgery, we know very little about the patients who have such problems. The current study aimed to gain a better understanding of patients who report having alcohol problems after surgery. To enter the study participants had to: 1) have received RYGB or Sleeve Gastrectomy surgery in the past 14 years, 2) be 21 years of age or older, and 3) have self-reported problems with alcohol use after surgery. Qualifiers completed a number of paper-and-pencil self-report assessments and interviews, including the Mini International Neuropsychiatric Interview, portions of the Structured Clinical Interview for DSM-IV, and the Alcohol Use Disorder Identification Test. Results: At the time of abstract submission 54 people had been screened and 24 participants qualified and completed the protocol. Participants’ age ranged from 27 to 60 with a mean of 43.9 (SD1⁄410.6 years) and twenty-one (87.5%) of the participants were female.Participants completed the protocol an average of 2.2 years after surgery (SD1⁄41.0). Participants mean score on the AUDIT was 21.9 (SD1⁄46.6) with a range of 12 to 36. Before surgery 18.8% of the sample most frequently drank wine, compared with 37.5% of the sample after surgery.Before surgery 31.3% of the sample reported drinking beer most frequently, compared with 12.5% after surgery. Finally, 37.5% of the sample most often drank liquor before surgery and 43.8% did so after surgery. Based on data from the SCID, in the six months prior to surgery less than ten percent of participants reported abuse of alcohol and none reported dependence. After surgery approximately one-third of the sample reported alcohol abuse and half reported dependence. Conclusion: Based on these findings, it appears that although many of the participants met DSM-IV criteria for alcohol abuse or dependence after surgery, surprisingly few of them reported having significant problems with alcohol in the six months prior to surgery. Also, we found that people report drinking beer as their “drink of choice” less frequently and wine and liquor more frequently after surgery.

Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur?

BackgroundComplications following bariatric surgery are uncommon but potentially life threatening. ObjectivesThe aim of this study was to assess the timing of gastrointestinal leaks (GIL) and pulmonary embolism (PE) in patients undergoing bariatric surgery. SettingRetrospective analysis of the nationwide American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2011. MethodsData on patient demographic characteristics, baseline co-morbidities, procedural events, and postoperative occurrences were analyzed. Thirty-day morbidity was assessed. Median (interquartile range) and frequencies are reported. ResultsWe identified 71,694 bariatric surgery patients; median age was 45 years (range 36–54 yr), and median body mass index was 44.8 kg/m2 (range 40.8–50.3 kg/m2). Laparoscopic Roux-en-Y gastric bypass was performed in 39,480 patients, laparoscopic adjustable band in 21,104, laparoscopic sleeve gastrectomy in 3225, open Roux-en-Y gastric bypass in 4243, duodenal switch in 1064, revisional surgery in 1182, and other procedures in 1396 patients. Of these patients, 95.2% had no complications. GIL was found in 441 (.6%), deep vein thrombosis in 184 (.3%), and PE in 134 (.2%). These complications occurred 10 (5–15), 13 (7–20), and 11 (4–19) days after surgery, respectively. GIL and PE developed after discharge in 275 (62.4%) and 96 (71.6%), respectively. Only 35 (26.1%) of the patients who developed PE had deep vein thrombosis. There were no differences in patient characteristics between the groups of early PE versus postdischarge PE. Patients diagnosed with in-hospital GIL were more obese with more severe systemic disease compared with patients with postdischarge diagnosis. ConclusionsThe majority of GILs and PEs after bariatric surgery occur after discharge. This finding goes against the routine use of contrast studies to rule out GIL. The risk of PE remains after discharge from bariatric surgery.

367 Persistent Functional Deficits and Symptoms Among Long-Term Survivors of Colorectal Cancer Treated With Surgery and Multimodality Therapy: Differences by Age at Initial Diagnosis

S A T A b st ra ct s reoperations per year increased steadily from 3.1% in 2007 to 6.3% in 2012. Among patients undergoing reoperations 10,139 (50%) had previously undergone a laparoscopic adjustable band (LAGB) placement, 6411 (31%) a Roux-en-Y gastric bypass (RYGB), 444 (2%) a sleeve gastrectomy (SG), 1685 (8%) a vertical banded gastroplasty (VBG), and 236 (1.2%) a duodenal switch (DS). The operations were most commonly revised to a RYGB in 6801 (33.3%), LAGB (24.8%), SG 1684 (8.1%), DS 393 (1.9%), distal gastric bypass 259 (1.3%) and a group of other operations 6229 (30.6%). EWL at 1-year to RYGB was 27%, LAGB (15.4%), SG (16.5%) and DS (30.9%). The 30-day and 1-year morbidity and mortality rates of the four most common primary and reoperative bariatric operations are low and are shown in Table 1. Conclusions: Although, the rate of reoperations has steadily increased over the last five years to 6.3% per year, most bariatric surgery patients do not need reoperations. Among those who do, the complication rate is low and with satisfactory weight loss. These findings from a large database are critical to convince all stake-holders that outcomes after reoperative bariatric surgery are better than previously believed and are needed to help increase access of patients who need reoperations. Morbidity and Mortality Rates of Primary Bariatric Operations versus Reoperations

Bariatric surgery for diabetes control in overweight people

Although bariatric surgery is advocated for improving glycaemic control in obese patients with type 2 diabetes, less evidence exists for its use in patients with type 2 diabetes who are overweight but not obese. In The Lancet Diabetes & Endocrinology, John Wentworth and colleagues1 report a randomised controlled trial to identify whether laparoscopic adjustable gastric band surgery would improve glucose control in people with type 2 diabetes who were overweight (BMI 25–30 kg/m2). Their findings showed that multidisciplinary diabetes care in conjunction with laparoscopic adjustable band gastroplasty was better than multidisciplinary care alone for achievement of diabetes remission 2 years after randomisation (12 [52%] of 23 vs two [8%] of 25 participants; difference in proportions 0·44, 95% CI 0·17–0·71; p=0·0012).

The impact of accreditation on safety and cost of bariatric surgery

BackgroundThe objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services’ national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003–2009). MethodsWe performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments. ResultsA total of 30,755 patients (43.9±11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [−3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543±$40,145 to $24,510±$37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (−.8%; P = .02) and complication rates (−2.7%; P = .01) were lower at the COEs after the NCD. ConclusionsThe accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.

Weight Loss Surgery for Mild to Moderate Obesity: A Systematic Review and Economic Evaluation

A systematic review and economic evaluation was commissioned to determine the effectiveness and cost-effectiveness of bariatric surgery for mild [class I, body mass index (BMI) 30 to 34.99] or moderate (class II, BMI 35 to 39.99) obesity. We searched 17 electronic resources (to February 2010) and other sources. Studies meeting predefined criteria were identified, data-extracted and assessed for risk of bias using standard methodology. A model was developed to estimate cost-effectiveness. Two RCTs were included. Evidence from both indicated a statistically significant benefit from laparoscopic adjustable banding (LAGB) compared to a non-surgical comparator for weight loss and in obesity-related comorbidity. Both interventions were associated with adverse events. LAGB costs more than non-surgical management. For people with class I or II obesity and type 2 diabetes (T2D), the incremental cost-effectiveness ratio (ICER) at 2 years is £20,159, reducing to £4,969 at 5 years and £1,634 at 20 years. Resolution of T2D makes the greatest contribution to this reduction. In people with class I obesity, the ICER is £63,156 at 2 years, £17,158 at 5 years, and £13,701 at 20 years. Cost-effectiveness results are particularly sensitive to utility gain from reduction in BMI, factors associated with poorer surgical performance and diabetes health state costs. Bariatric surgery appears to be a clinically effective and cost-effective intervention for people with class I or II obesity who also have T2D but is less likely to be cost-effective for people with class I obesity.

A very challenging leak from a sleeve gastrectomy

Sleeve gastrectomy (SG) is a relatively new bariatric procedure that has been gaining popularity in recent years [1,2]. It is regarded as an alternative to procedures, such as Roux-en-Y gastric bypass and laparoscopic adjustable banding, which are associated with significant risks, including internal hernias, dumping syndrome, and malabsorption. The SG procedure itself is relatively simple and quick, it provides immediate calorie restriction, appetite suppression is achieved by removal of the ghrelin-producing portion of the stomach, and no foreign objects are inserted [2,3].

Functional Imaging in Hyperinsulinemic Hypoglycemia after Gastric Bypass Surgery for Morbid Obesity

Hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass (RYGB) has been increasingly reported. It is induced by β-cell hyperplasia often referred to as nesidioblastosis. Positron emission tomography (PET) with [11C]-5-hydroxytryptophan ((11)C-HTP) and 6-[18F]fluoro-3,4-dihydroxy-l-phenylalanine ((18)F-DOPA) has been successfully applied to image neuroendocrine tumors. No data are available of the usefulness of these functional imaging techniques in post-RYGB in this new endocrine disorder, neither for diagnostic purposes nor for follow-up. We present a patient with post-RYGB hypoglycemia who underwent (11)C-HTP and (18)F-DOPA PET scintigraphy for diagnostic purposes and to evaluate the effect of additional laparoscopic adjustable banding of the pouch as a surgical therapy for this disorder. We describe a woman with biochemically confirmed post-RYGB hypoglycemia who showed diffuse uptake of the (11)C-HTP and (18)F-DOPA tracers in the entire pancreas. After failure of dietary and medical treatment options, she underwent a laparoscopic adjustable banding for pouch dilatation. Subjective improvement was noted, which coincided with decreased uptake of (18)F-DOPA and (11)C-HTP in the head of the pancreas. Functional imaging by (18)F-DOPA- and (11)C-HTP-PET can accurately visualize diffuse endocrine pancreatic activity in post-gastric bypass hyperinsulinemic hypoglycemia. Both (11)C-HTP- and (18)F-DOPA-PET imaging appear to have a similar diagnostic performance in the presented case, and uptake of both tracers potentially relates to disease activity after surgical intervention.

Exploration of esophageal hiatus: does crural repair reduce proximal pouch distension?

BackgroundRepair of a hiatal hernia during laparoscopic adjustable gastric banding is advisable; however, the practice of more active esophageal hiatus exploration and repair has been promoted with an expectation of reducing proximal gastric pouch distension (PPD). Our objective was to explore the relationship between crural exploration and repair (CR) and PPD in a private practice in Canada. MethodsThe data from 3000 consecutive patients who underwent primary laparoscopic adjustable banding procedures at a single center from February 2005 to May 2011 were examined. Several analyses were performed, with the PPD cases carefully matched to historic (time-of-placement) and historic-, age-, and gender-matched controls. ResultsThroughout the series, the PPD rates decreased and the CR rates increased. Revision for PPD was performed in 132 patients (4.4%). The patients with PPD were more likely to have undergone CR during primary surgery (odds ratio 1.5, 95% confidence interval 1.2–2.2, P = .001) compared with historic, and historic-, age-, and gender-matched controls (odds ratio 2.3, 95% confidence interval 1.4–3.8, P < .001). The findings were confirmed using adjusted binary logistic regression analysis controlling for age, gender, body mass index, and time-of-placement. This increased risk was most evident early in the series when incident PPD cases were greater. However, at no stage did CR reduce the risk of symmetric or asymmetric PPD. ConclusionThe results of the present analysis do not support the theory that increased exploration and repair of the esophageal hiatus reduces the incidence of PPD. There might be a role for CR at surgery for specific clinical indications. CR increases the complexity and possibly the risk of the procedure.

Outcomes of bariatric surgery in adolescents

The review summarizes the recent studies of bariatric surgery outcomes in adolescents. Randomized prospective studies demonstrate superior weight loss, resolution of comorbidities, and improvement in quality of life in morbidly obese adolescents undergoing bariatric surgery vs. lifestyle changes alone. The enthusiasm for laparoscopic adjustable banding (LAGB) has been tempered by high reoperation rates. Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for adolescents because it avoids intestinal bypass and implantation of a foreign body; recent data from adult series demonstrate mid-term results comparable with laparoscopic roux-en-y gastric bypass (LRYGB) with an improved safety profile. Bariatric surgery is superior to lifestyle changes alone in treating adolescent morbid obesity. LRYGB remains the gold-standard operation for both adolescents and adults. Although LAGB and LSG are appealing because they avoid intestinal bypass, long-term studies are needed to fully evaluate their efficacy and safety in the adolescent population.

Pulmonary complications following laparoscopic adjustable gastric banding

Laparoscopic adjustable silicone banding (LAP-BAND) has rapidly gained acceptance and is now considered the most common bariatric operation. The accumulated experience with LAP-BAND has established this surgical method as safe and effective. However, no data have been issued concerning pulmonary complications following the procedure. We have recently experienced 3 cases of pulmonary complications following LAP-BAND surgery: 1 patient with pulmonary cavitation and 2 with bronchiectasis. Pulmonary physicians should be aware of the possibility of long-term pulmonary complications in patients who have undergone LAP-BAND surgery.

Band revision versus Roux-en- Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding

Background With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States. Methods We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en- Y gastric bypass. Results Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%. Conclusion Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en- Y gastric bypass.

Primary and revisional laparoscopic adjustable gastric band placement in patients with hiatal hernia

Limited evidence exists regarding the outcomes of patients undergoing laparoscopic adjustable band placement (LAGB) with hiatal hernia (HH) and concomitant hiatal hernia repair (HHR). The present study evaluated the safety, efficacy, and cost-effectiveness of primary LAGB (pLAGB) and revisional LAGB (rLAGB) in patients with HH. The University HealthSystem Consortium is an alliance of >100 academic medical centers and nearly 200 affiliate hospitals. The University Health System Consortium database was queried for patients undergoing LAGB with and without HH from 2006 through 2009. The patients undergoing rLAGB had a significantly greater prevalence of HH than patients undergoing pLAGB (18.9% for pLAGB with HH versus 26.3% for rLAGB with HH; P <.001). The mortality (.04% for pLAGB without HH versus 0% for pLAGB with HHR; P >.05), morbidity (3.39% pLAGB without HH versus 2.63% for pLAGB HHR; P >.05), and length of stay (1.33 ± 2.25 days for pLAGB without HH versus 1.17 ± 0.56 days for pLAGB with HHR; P >.05) were comparable in the patients undergoing pLAGB with or without HHR. A trend was seen toward increased morbidity in patients undergoing rLAGB HHR than in those undergoing pLAGB HHR (2.63% for pLAGB HHR versus 13.33% for rLAGB HHR; P = .08). The length of stay (1.17 ± 0.56 days for pLAGB HHR versus 1.73 ± 1.49 days for rLAGB HHR; P <.01) and hospital costs ($12,178 ± 4451 for pLAGB HHR versus $14,616 ± 3538 for rLAGB HHR; P = .04) were increased for the rLAGB HHR group compared with the pLAGB HHR group. The results of the present study have demonstrated the safety of HHR concomitant with pLAGB. In addition, rLAGB was associated with increased morbidity and cost. These data suggest the safety, efficacy, and cost-effectiveness of crural repair of HH simultaneously with pLAGB.