Laparoscopic Adjustable Gastric Banding Patients Research Articles

Weight Loss and Changes in Salivary Ghrelin and Adiponectin: Comparison Between Sleeve Gastrectomy and Roux-en-Y Gastric Bypass and Gastric Banding

Weight loss is associated with increased levels of adiponectin with a greater increase observed following Roux-en-Y gastric bypass (RYGB) compared to restrictive procedures. However, currently there are no data on changes in adiponectin following laparoscopic sleeve gastrectomy (LSG). Ghrelin was reported to be also produced by the salivary glands. There are also no data available regarding its changes following bariatric surgery. The present study examined weight loss, and salivary ghrelin and HMW adiponectin levels in 43 morbidly obese subjects undergoing three different types of bariatric surgery. We found that weight loss following LSG is superior to laparoscopic adjustable gastric banding (LAGB) and comparable to RYGB at 12 months after surgery. Although blood glucose decreased similarly following all three procedures, fasting insulin continuously declined only in LSG and RYGB patients. Changes in both fasting and postprandial salivary ghrelin greatly varied between all three procedures with no similarities to changes in serum ghrelin reported in the literature. HMW adiponectin significantly increased following LSG, and this increase was more marked than in LAGB patients and almost identical compared to RYGB. Weight loss following LSG is comparable to RYGB in the short term. Changes in HMW adiponectin are comparable following LSG and RYGB which may further contribute to the successful results after LSG. Furthermore, the results of the present study support the hypothesis that there is an autonomous production of ghrelin in salivary glands irrespective of nutritional status and weight loss.

Influence of Reoperations on Long-Term Quality of Life After Restrictive Procedures: A Prospective Study

Quality of life improves after bariatric surgery. However, long-term results and the influence of reoperations are not well known. A prospective quality of life assessment before, 1 and 7 years after laparoscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG) was performed in order to determine the influence of reoperations during follow-up. One hundred patients were included in the study. Fifty patients underwent VBG and 50 LAGB. Patients completed the quality of life questionnaires prior to surgery and two times during follow-up. Health-related quality of life (HRQoL) questionnaires included the Nottingham Health Profile I and II and the Sickness Impact Profile 68. Follow-up was 84% with a mean duration of 84 months (7 years). During follow-up, 65% of VBG patients underwent conversion to Roux-en-Y gastric bypass while 44% of LAGB patients underwent a reoperation or conversion. One year after the procedure, nearly all quality-of-life parameters significantly improved. After 7 years, the Nottingham Health Profile (NHP)-I domain “physical ability”, the NHP-II and the SIP-68 domains “mobility control”, “social behavior”, and “mobility range” were still significantly improved in both groups. The domains “emotional reaction”, “social isolation” (NHP-I), and “emotional stability” (SIP-68) remained significantly improved in the VBG group while this was true for the domain “energy level” (NHP-I) in the LAGB group. Both the type of procedure and reoperations during follow-up were not of significant influence on the HRQoL results. Weight loss and decrease in comorbidities were the only significant factors influencing quality of life. Restrictive bariatric surgery improves quality of life. Although results are most impressive 1 year after surgery, the improvement remains significant after long-term follow-up. Postoperative quality of life is mainly dependent on weight loss and decrease in comorbidities and not on the type of procedure or surgical complications.

Changes in Satiety, Supra- and Infraband Transit, and Gastric Emptying Following Laparoscopic Adjustable Gastric Banding: A Prospective Follow-up Study

Laparoscopic adjustable gastric banding (LAGB) induces and sustains weight loss, likely by activating the peripheral satiety mechanism. Recent data suggests that food is not retained above the optimally adjusted LAGB, suggesting that an alternate mechanism is inducing satiety. How transit and gastric emptying change following LAGB and correlate with satiety and weight loss have not been adequately defined. LAGB patients underwent preoperative and 12-month follow-up nuclear scintigraphic assessments of esophageal transit and gastric emptying. A new technique that allowed the calculation of emptying times and transit through the supra- and infraband compartments was used to assess emptying and transit patterns postoperatively. Postoperatively, patients reported increased satiety both after a standard fast (3.7 ± 2.3 vs. 4.8 ± 2.1, p = 0.04) and following a standard semisolid meal (5.9 vs. 7.8 ± 1.7, p = 0.003). The mean percent excess weight loss was 48.5 ± 23.2%. The gastric emptying half-time (minutes) did not change significantly (63.5 ± 41.1 vs. 73.3 ± 26.8, p = 0.64). Semisolid transit into the infraband stomach was delayed briefly postoperatively in more patients (11 vs. 2, p = 0.001). There was minimal retention of the meal above the LAGB 2 min after commencing the gastric emptying study (median, 3%; interquartile range, 1.75-10); therefore, an emptying half-time of the supraband region could not be defined. Weight loss, satiety, and early satiation following LAGB were associated with briefly delayed bolus transit into the infraband stomach. Retention of the semisolid meal above the LAGB was not observed. This is further evidence that suggests satiety develops following LAGB without physical restriction of meal size.

Revisional bariatric surgery at a single institution

BackgroundBariatric surgery, although safe, can have long-term complications that require revision. Our series illustrates the spectrum of primary procedures, indications for surgery, and strategies for revision. MethodsThe study was a retrospective chart review. Sixty-three patients were identified. Of specific interest were complications and percentage of excess weight loss (EWL) during the follow-up period. ResultsEighteen patients had a previous vertical banded gastroplasty (VBG), 26 had a Roux-en-Y gastric bypass (RYGB), 18 had a laparoscopic adjustable gastric banding (LAGB), and 1 had a jejunal-ileal bypass. All VBG patients were revised to RYGB. Seventeen RYGB patients were revised with RYGB. Eight LAGB patients were revised with RYGB. Eight RYGB patients had placement of LAGB. Two LAGB patients were revised with LAGB because of a slipped band. Eight LAGB patients had the band removed. The morbidity rate was 30% with a major morbidity rate of 11%. There were 2 leaks, neither required reoperation. Other major complications included 3 pneumonias, 2 reoperations, and 2 intra-abdominal abscesses. There were no mortalities. In the 15 patients who had conversion of VBG to RYGB, the mean EWL was 50%, with 60% of patients achieving more than 50% EWL. In the 10 patients who had revision of their RYGB, the mean EWL was 51%, with 60% of patients achieving more than 50%. In the 6 patients who had revision of LAGB to RYGB, the mean EWL was 39%, with 33% of patients achieving more than 50% EWL. In the 8 patients who had LAGB after RYGB the mean EWL was −2%, with 0% of patients achieving more than 50%. ConclusionsRevisional surgery is effective, although complication rates are higher than primary bariatric surgery. The type of initial and revisional procedure affects EWL.

Financial implications of coverage for laparoscopic adjustable gastric banding

Background Employers and insurers have become increasingly concerned about the cost implications of providing coverage for bariatric procedures. We sought to quantify the costs and potential cost savings resulting from coverage for laparoscopic adjustable gastric banding (LAGB) using a claims analysis. Methods U.S. healthcare claims data of >7000 LAGB patients and a propensity score-matched control group were used to quantify the costs and potential cost savings resulting from LAGB for the overall surgery-eligible population and for the subset of the surgery-eligible population with diabetes mellitus. The matched control group consisted of those with a morbid obesity diagnosis code and/or a body mass index >35 kg/m 2 as reported in the Health Risk Assessment data. Results Including the related medical payments in the 90 days before and after the procedure, the mean cost of LAGB was approximately $20,000. After placement, a modest reduction occurred in the health expenditures relative to the preoperative payments. In the postoperative period, these decreases were maintained for the LAGB sample. In contrast, the payments for the comparison sample continued to increase. As a result, the net cost of coverage for LAGB was reduced to 0 by approximately 4 years after band placement. For those with diabetes, the net costs resulting from LAGB were reduced to 0 in just >2 years. Conclusion These results suggest that the LAGB procedure pays for itself within a relatively short period, especially for those with diabetes.

Insurance-mandated medical programs before bariatric surgery: do good things come to those who wait?

Background Insurance companies often require a mandated medical program (MMP) before bariatric surgery. It is unknown whether MMPs improve weight loss before and after surgery. The purpose of our study was to determine whether MMPs improve pre- and postoperative weight loss at a tertiary care, U.S. academic teaching hospital. Methods After institutional review board approval, data were collected prospectively from consecutive patients undergoing nonrevisional laparoscopic gastric bypass or adjustable gastric banding from August 2006 to 2010 by a single surgeon (T.S.K.). The patients were divided into 2 groups: those undergoing a MMP and those who did not. The MMP patients underwent a standardized program of ≥6 months' duration under the direction of our medical bariatricians and nutritionists. The data from the laparoscopic gastric bypass and laparoscopic adjustable gastric banding patients were analyzed separately. The primary outcome data included the interval to surgery and the percentage of excess weight loss before surgery and at 6 and 12 months after surgery. Results A total of 440 patients (327 laparoscopic gastric bypass and 113 laparoscopic adjustable gastric banding) were included in the present study. No significant difference was found in the preoperative percentage of excess weight loss or the percentage of excess weight loss at 6 and 12 months after surgery between the MMP and non-MMP patients. The MMP patients had a significantly longer wait time to surgery. Conclusion Patients who underwent a standardized MMP had a significant delay in their time to surgery and did not experience significant benefit in their preoperative or postoperative weight loss. Insurance companies should abandon the policy of mandating preoperative medical weight loss programs.

Travel distance as factor in follow-up visit compliance in postlaparoscopic adjustable gastric banding population

Background Despite the 2008 “American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient,” consensus does not exist for postoperative care in laparoscopic adjustable gastric banding (LAGB) patients (grade D evidence). It has been suggested that regular follow-up is related to better outcomes, specifically greater weight loss. The aim of the present study was to investigate the effects of travel distance to the clinic on the adherence to follow-up visits and weight loss in a cohort of LAGB patients in the setting of a rural, university-affiliated teaching hospital in the United States. Methods A retrospective chart review was performed of all consecutive LAGB patients for a 1-year period. Linear regression analysis was used to identify the relationships between appointment compliance and the distance traveled and between the amount of weight loss and the distance traveled. Results Linear regression analysis was performed to investigate the effect of the travel distance to the clinic on the percentage of follow-up visits postoperatively. This effect was not significant ( P = .4). Linear regression analysis was also performed to elucidate the effect of the travel distance to the clinic on the amount of weight loss. This effect was significant ( P = .04). Conclusion The travel distance to the clinic did not seem to be a significant predictor of compliance in a cohort of LAGB patients with ≤1 year of follow-up in a rural setting. However, a weak relationship was found between the travel distance to the clinic and weight loss, with patients who traveled further seeming to lose slightly more weight.

Effects of Adjustable Gastric Bands on Gastric Emptying, Supra- and Infraband Transit and Satiety: A Randomized Double-Blind Crossover Trial Using a New Technique of Band Visualization

The laparoscopic adjustable gastric band (LAGB) has previously been classified as a restrictive procedure; physically limiting meal size. Recently, the key mechanism has been hypothesized to be the induction of satiety without restriction. Effects can be controlled by modifying LAGB volume, possibly as a result of effects on gastric emptying or transit through the LAGB. Successful LAGB patients underwent paired, double blinded, esophageal transit and gastric emptying scintigraphic studies; with the LAGB at optimal volume and near empty. A new technique allowed assessment of emptying and transit through the infra- and supraband compartments. Fourteen of 17 patients completed both scans (six males; mean age, 48.9 ± 11.3 years, % excess weight loss 69.0 ± 15.2). At optimal volume a delay in transit of semi-solids into the infraband compartment was observed in ten patients vs. three when the LAGB was empty, (p = 0.01). The median retention of a meal in the supraband compartment immediately after cessation of intake was: empty 2.8% (2.3-7.9) vs. optimal 3.6% (1.7-4.5), (p = 0.57). Overall gastric emptying half time (minutes) was normal at both volumes: optimal 64.2 ± 29.8 vs. empty 95.2 ± 64.1, (p = 0.14). LAGB volume did not affect satiety before the scan: optimal 4.3 ± 1.9 vs. empty 4.0 ± 2.2, (p = 0.49), or 90 min later: optimal 6.1 ± 1.9 vs. empty 5.9 ± 1.4, (p = 0.68). The optimally adjusted LAGB briefly delays semi-solid transit into the infraband stomach without physically restricting meal size. The supraband compartment is usually empty of an ingested meal 1-2 min after intake ceases and overall gastric emptying is not affected.

Does Pregnancy Increase the Need for Revisional Surgery After Laparoscopic Adjustable Gastric Banding?

Over 80% of laparoscopic adjustable gastric banding (LAGB) patients are women, and approximately half of these are of reproductive age; therefore, pregnancy post-LAGB is common. It is not known if pregnancy increases the need for revisional procedures. We compare the incidence of revisions in two matched cohorts of LAGB patients, with or without subsequent pregnancy. From September 1994 to May 2009, 5,467 patients underwent LAGB at the Centre for Bariatric Surgery, Australia. Women with births post-LAGB were matched to controls, with a "matched follow-up date" calculated equivalent to pregnancy. Rates of primary and overall revisions for band-related (erosions and proximal pouch dilatations) and port/tubing complications were compared for cases and controls at 2 and 3 years post-pregnancy. One hundred eighty-nine women had ≥1 pregnancies post-LAGB, including 137 with follow-up at 2 years and 104 at 3 years post-pregnancy. There was no significant difference in band or port/tubing revisions between groups at either time point: 16.8% vs 10.5% (p = 0.13) and 23.9% vs 14.6% (p = 0.09) for primary band revisions, and 5.8% vs 5.3% (p = 0.84) and 10.5% vs 6.6% (p = 0.35) for primary port/tubing revisions at 2 and 3 years, respectively. Percentage excess weight loss (%EWL) 3 years post-pregnancy was similar (47.9% vs 47.7%). Pregnancy LAGB management was not found to affect revisions; however, less time between LAGB and pregnancy was associated with a higher rate of primary band revisions (p = 0.03). These data suggest that pregnancy post-LAGB does not affect revision rate or %EWL; however, a shorter time between LAGB operation and pregnancy may predispose to band revisions.

Prosthesis related sepsis following laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding (LAGB) is well-recognized as a superior method to achieving durable weight loss in the medium term when compared with non-surgical methods of weight loss. In this paper, we described the clinical presentation and outcomes of patients presenting with band or band-adjustment reservoir sepsis from our series from a single institution. We conducted a retrospective review of prospectively collected clinical, anthropometric and biochemical data from patients who underwent LAGB placement over a five-year period at a metropolitan teaching hospital. Those patients requiring surgical intervention for prosthesis-related sepsis were included in the review. Of the 445 patients in this series, 10 (2.2%) developed prosthesis sepsis and required operative intervention. Three (0.7%) presented with reservoir sepsis requiring removal of the reservoir. One had band erosion identified and the entire prosthesis removed. In seven (1.5%) of the patients, infections occurred at the gastric band. Two patients presented with purulent peritonitis and underwent immediate band removal. The remainder presented with band abscesses and either had their band removed (three patients) or left in position and the sepsis treated with drainage and antibiotics (two patients). In our current series, a small proportion of LAGB patients developed prosthesis-related infection that typically required port or band removal and usually occurred early in the post-operative course. We have modified our prophylactic antibiotic regime and surgical technique as a result of this review. In selected cases of band infection, bands were salvaged with subsequent acceptable weight loss, suggesting that LAGB salvage in the presence of sepsis may be achievable in some patients.

Do Patients Seeking Laparoscopic Adjustable Gastric Banding Surgery Differ from Those Seeking Gastric Bypass Surgery? A Comparison of Psychological Profiles Across Ethnic Groups

Understanding presurgical psychological functioning is important in determining whether patients may benefit from psychological support before or after undergoing bariatric surgery. However, few studies have directly explored whether presurgical psychosocial profiles differ for patients presenting for different bariatric surgeries and what, if any, impact ethnic background might have. The present study compared presurgical depressive symptomatology, binge eating symptoms, and psychopathology in Caucasian and African American laparoscopic adjustable gastric banding (LAGB) and gastric bypass (RYGB) patients. Patients (n=272) presenting for either LAGB or RYGB surgery completed self-report measures of depressive symptomatology (BDI), binge eating symptoms (BES), and psychopathology/personality (PAI) as part of the presurgical psychological evaluation. RYGB patients endorsed more depressive symptomatology, binge eating symptoms, somatic complaints, and antisocial features than LAGB patients, though higher BMI in the RYGB patients accounted for differences in binge eating symptoms. When the sample was examined by ethnic group, LAGB-RYGB differences were found only in African American, and not Caucasian, patients. Psychosocial profiles appear to differ for African American patients presenting for LAGB and RYGB surgeries; however, some of these differences are accounted for by differences in presurgical BMI. Gaining a better understanding of the initial psychological characteristics of bariatric surgery candidates may improve clinicians' abilities to identify and address specific areas of concern for these patients.

A five year Canadian laparoscopic adjustable gastric band experience

Background The aim of this study was to review 5 years of laparoscopic adjustable gastric band (LAGB) procedures in which low-pressure bands were used. Methods All LAGB cases at the authors' center were retrospectively analyzed. A survey of these patients was conducted in 2008 and 2009. Results Of 90 LAGB patients, 86 were surveyed. Follow-up averaged 17.5 months. Weight loss averaged 24.8 ± 19.4 kg. Weight loss averaged 2.7 kg/mo and did not significantly drop over the last 10.7 months (2.7 vs 1.5 kg/mo, P = .16). Excess body weight loss was 27.5%, 39.1%, and 67.2% in the first, second, and following years, respectively. Patients averaged 4.14 adjustments of their bands and vomited 2.13 times per week. The mortality rate was 0%. No band slippages or band erosion occurred. Resolution or improvement occurred in most obesity-related illness. Gastroesophageal reflux disease symptoms worsened in 25% of patients. Conclusions These results replicate world LAGB literature. Low complication rates result either from the authors' band or their techniques.

Access-Port Fixation on the Left Pectoral Fascia in Laparoscopic Adjustable Gastric Banding

Access-port (AP) complications after laparoscopic adjustable gastric banding (LAGB) are often seen but seldom reported in literature. AP complications requiring additional surgery is reported in 3.6% to 24% of LAGB patients (Susmallian et al. Obes. Surg, 4:128–131, 2003; Peterli et al. Obes. Surg., 12(6):851–856, 2002; Busetto et al. Obes. Surg., 12:83–92, 2002; Mittermair et al. Obes. Surg., 19:446–450, 2009; Holeczy et al. Obes. Surg., 9:453–455, 1999; Bueter et al. Arch. Surg., 393:199–205, 2008; Launay-Savary et al. Obes Surg, 18:1406–1410, 2008; Balsiger et al. J. Gastrointest. Surg., 11:1470–1477, 2007; Szold and Abu-Abeid Surg. Endosc., 16:230–233, 2002). We evaluated the effect of fixing the AP on the pectoral fascia using the Velocity™ Injection Port on complication and re-operation rate. From January 2005 till October 2007, 619 LAGB procedures were performed using the SAGB QuickClose™. All procedures were performed by three dedicated surgeons using the pars flaccida technique. APs were placed on the fascia of the pectoral muscle using an infra-mammary incision. The AP device was fixed on the fascia using the Velocity™ Injection Port and Applier. Data was obtained retrospectively and records of 619 consecutive patients were reviewed for access-port complications. Sixty-eight AP complications were observed. Complications could be divided in four categories. Discomfort was reported in 30 patients, seven needing additional surgery. Infection contributed to 11 patients needing surgical removal of the device. Fourteen Patients with superficial infection were treated conservatively. Nine patients had inaccessible APs. Ultrasound-guided access was required in three patients. The remainder needed surgical relocation of the AP. Leakage of the tube was observed in four patients all of which needed revisional surgery. Our experience shows that fixation of the AP on the left pectoral fascia using the Velocity™ leads to a readily accessible AP with good anaesthetic and aesthetic results. In our series, 68 (11%) complications were recorded, of which 28 (4.5%) needed additional surgery.

Comparison of comorbidity resolution and improvement between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding

This study aimed to compare the rates for resolution and improvement of common comorbidities between laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding. The comorbid conditions included were type 2 diabetes mellitus (DM), hypertension (HTN), hyperlipidemias (LPD), degenerative joint disease (DJD), gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and asthma. A retrospective chart review of the patients who underwent LSG or laparoscopic adjustable gastric banding at our institution from July 2004 to July 2007 was performed. The resolution of comorbidities was determined via patient-completed questionnaires and objective data. Of the 123 patients (29 men and 94 women) reviewed, 49 had undergone LSG, and 74 had undergone laparoscopic adjustable gastric banding. The mean preoperative body mass index (BMI) was 52 kg/m(2) for the LSG patients and 44 kg/m(2) for the laparoscopic adjustable gastric banding patients. The overall percentages of excess weight loss (%EWL) were respectively 50.6 and 40.3% (P = 0.03) during mean follow-up periods of 15 and 17 months. There was a greater resolution or improvement of DM after LSG (100% vs 46%), HTN (78% vs 48%), and LPD (87% vs. 50%) than after laparoscopic adjustable gastric banding. Other comorbidities resolved or improved at a similar rate. Although both LSG and laparoscopic adjustable gastric banding resulted in postoperative improvement or resolution of comorbidities associated with obesity, LSG statistically showed a significantly higher rate of resolution or improvement of DM, HTN, and LPD. There was no significant difference between the groups for DJD, GERD, OSA, or asthma.

Laparoscopic Roux-en- Y gastric bypass versus laparoscopic adjustable gastric banding: five years of follow-up

Background Bariatric surgery is an effective treatment for morbid obesity. Laparoscopic Roux-en- Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are commonly performed procedures. The aim of the present study was to evaluate and compare the long-term outcomes after LRYGB and LAGB. Methods We studied the data from a prospective database of all patients undergoing LRYGB or LAGB with 5 years of follow-up. Results From July 2001 to September 2003, 91 and 62 patients underwent LRYGB and LAGB, respectively. Of these patients, 73.6% of the LRYGB and 91.9% of the LAGB patients had 5 years of follow-up. Of the 91 and 62 patients, 89% and 82% were women, respectively. The mean age and body mass index was 34.5 ± 11.0 years and 39.6 ± 4.9 kg/m 2 for the LRYGB group and 38.4 ± 13.1 years and 35.8 ± 4.0 kg/m 2 for the LAGB group, respectively. The mean operative time was 150 ± 58 minutes for LYRGB and 73 ± 23 minutes for LAGB ( P <.05). The conversion and reoperation rate was 8% and 4.3%, respectively, for the LRYGB group versus 0% for the LAGB group. Early postoperative complications were observed in 12 and 1 patient ( P = .014) after LRYGB and LAGB, respectively. Late complications developed in 33 and 17 patients after LYRGB and LAGB, respectively ( P = NS). The percentage of excess weight loss at 5 years postoperatively was 92.9% ± 25.6% and 59.1% ± 46.8% ( P <.001) for LRYGB and LAGB, respectively. Surgical failure (percentage of excess weight loss <50%) at 5 years was 6% for LRYGB and 45.6% for LAGB. A late reoperation was needed in 24.1% of the LAGB patients. Conclusion A greater percentage of excess weight loss at 1 and 5 years was observed after LRYGB than LAGB. The LAGB group had a >40% rate of surgical failure and a 24.1% reoperation rate at 5 years of follow-up.

One Year Improvements in Cardiovascular Risk Factors: a Comparative Trial of Laparoscopic Roux-en-Y Gastric Bypass vs. Adjustable Gastric Banding

Coronary artery disease (CAD) is the leading cause of death in the industrialized world with obesity as a leading preventable risk factor. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to improve certain biochemical cardiovascular risk factors (BCRFs) at 1 year post-op, however no study has directly compared the 12-month BCRF improvements of RYGB vs. LAGB. At a single academic institution (2004-2009), we measured BCRF in 838 consecutive bariatric patients (765 RYGB, 73 LAGB) pre-operatively and at 12 months post-operatively. BCRF included total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides (Trig), Trig/HDL ratio, lipoprotein(a) (Lp(a)), homocysteine (HmC), high sensitivity C-reactive protein (hs-CRP), fasting insulin (FI), and hemoglobin A1C (Hgb A1C). Pre-op and 12-month post-op values were compared by a paired t test of equal variance. At 12 months post-op, RYGB patients had lost 77% of their excess weight and had significant improvements in TC, LDL, HDL, Trig, Trig/HDL, HmC, hs-CRP, FI, and Hgb A1C. LAGB patients lost 47.6% of their excess weight and had significant improvements in Trig, Trig/HDL, HmC, hs-CRP, and Hgb A1C. Having RYGB instead of LAGB was predictive of significantly greater improvements in TC at 12 months post-operatively. In this study, both RYGB and LAGB demonstrated significant weight loss and improvements in BCRF at 12 months post-op. RYGB produced significant improvements in a greater number of BCRFs and in some instances the 12-month post-op BCRF values were significantly lower risk in RYGB vs. LAGB patients.

Band erosion after laparoscopic gastric banding: a retrospective analysis of 865 patients over 5 years

Gastric band erosion is a well-reported complication after laparoscopic adjustable gastric banding (LAGB). The published literature is limited and inconclusive with regard to its management. The authors therefore reviewed all band erosions detected during a 5-year period in a high-volume bariatric practice. Because a significant proportion of the band insertions (65%) were undertaken by an operator beyond his learning curve, the authors hoped to gain a mature, comprehensive understanding of this significant complication. The authors retrospectively reviewed the operative log of the operating theaters in their obesity surgery unit to find all the operations performed on LAGB patients for erosion from January 2003 to December 2007. The clinical notes and electronic records for each patient were reviewed. These data were cross-referenced against the authors' obesity surgery database, and denominator data such as the total number operations performed and demographics were found. Finally, postoperative outcomes were collated from the outpatient follow-up data and telephonic interviews, and the results were analyzed. From January 2003 to December 2007, a single surgeon performed 865 LAGBs in the authors' unit. The authors identified 18 operations performed for LAGB erosions. The 18 patients (one referred from elsewhere, 14 women) formed the final study cohort (median preoperative body mass index [BMI], 46 kg/m(2)). Of the 17 erosions, 15 occurred relatively early in the series. The patients with the 213 Swedish adjustable gastric bands experienced 12 erosions (incidence, 5.6%) compared with 6 erosions with the 652 LAP-BANDs (incidence, 0.9%). The median time to presentation was 7 months (range, 1-60 months). However, 55% of the erosions (n = 10) occurred within the first year, and only 10% occurred after the second year. The most common presenting symptom was pain followed by weight regain. None of the patients experienced peritonitis. After surgical management of the erosion, three patients had a second LAGB and at this writing are well. Of the remaining patients, 11 are well, but 6 of these patients have returned to their previous weight (4 patients were lost to follow-up evaluation). The overall incidence of LAGB erosions in our series was 1.96%. This incidence fell with increasing experience to 0.5% after the initial 300 bands were excluded from the analysis (3 band erosions in the last 565 band insertions). However, further increases in incidence are likely with a longer follow-up period. The most common presentation was abdominal pain followed by weight regain and port-site sepsis. In the authors' hands, laparoscopic omental plugging and band removal through a separate anterior gastrotomy appear to be effective methods for dealing with band erosions. Band erosion is a significant source of morbidity, with at least one-third of the erosion patients in our series not achieving their final goal of weight loss despite appropriate treatment. This study highlights the need for a future prospective randomized study to clarify the apparent strong influence of band design and construction on the etiopathogenesis of band erosion.

Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence

Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss procedures performed in the United States. The authors' high-volume academic medical center has gathered a database of almost 3,000 patients who have undergone LAGB since January 2001. The goal of this series, the largest to date on LAGB outcomes at a single institution, was to assess complications associated with LAGB. A retrospective analysis was performed using longitudinal data from adult patients who underwent LAGB between 1 January 2001, and 29 February 2008. General and band-related complications were reported for all patients. Death and reoperation for weight gain (LAGB followed by either a second band insertion or a gastric bypass) also were reported. Of the 2,965 patients who received LAGB during the study period, 2,909 met the criteria for inclusion in this analysis, and 363 (12.2%) experienced one or more complications. The most common complications were band slip (4.5%) and port-related problems (3.3%). Other complications were rare. Only seven patients (0.2%) had band erosion. Eleven patients (0.4%) underwent reoperation for weight gain. A total of 10 deaths (0.34%) occurred during the study period. Three patients died within 30 days of surgery. Two of these deaths (0.06%) were related to surgery, and one resulted from a motor vehicle accident. Seven patients died of causes unrelated to surgery during the course of the study. The LAGB technique is a relatively safe procedure with few early or late complications. Few LAGB patients undergo reoperation for weight gain, and mortality is very rare.

Mechanisms of Bolus Clearance in Patients with Laparoscopic Adjustable Gastric Bands

The components of esophageal function important to success with laparoscopic adjustable gastric banding (LAGB) are not well understood. A pattern of delayed, however, successful bolus transit across the LAGB is observed. Successful LAGB patients underwent a high-resolution video manometry study in which bolus clearance, flow, and intraluminal pressures were recorded. Liquid and semi-solid swallows and stress barium (a combination of semi-solid swallows and liquid barium) were performed. A new measurement, the lower esophageal contractile segment (LECS), was defined and evaluated. Twenty patients participated (mean age 48.3 +/- 12.0 years, four men, %excess weight loss 65.6 +/- 18.0). During semi-solid swallows, two patterns of esophageal clearance were observed: firstly, a native pattern (n = 10) similar to that which is expected in non-LAGB patients; secondly, a lower esophageal sphincter-dependent pattern (n = 7), where flow only occurred when the intrabolus pressure increased during the lower esophageal sphincter (LES) aftercontraction. In both patterns, if there was incomplete bolus clearance, reflux was observed and was usually followed by another swallow. A mean of 4.5 +/- 2.9 contractions were required to clear the semi-solid bolus. Contractions with an intact LECS demonstrated longer flow duration: 7.1 +/- 3.8 vs.1.6 +/- 3.2 s, p < 0.005. During the stress barium, an intrabolus pressure of 44.5 +/- 16.0 mm Hg leads to cessation of intake. In LAGB patients, normal esophageal peristaltic contractions transition to a LES aftercontraction, producing trans-LAGB flow. Repeated contractions are required to clear a semi-solid bolus. Incorporating measurements of the LECS into assessments of esophageal motility in LAGB patients may improve the usefulness of this investigation.

Criteria for Assessing Esophageal Motility in Laparoscopic Adjustable Gastric Band Patients: The Importance of the Lower Esophageal Contractile Segment

Esophageal function appears critical in laparoscopic adjustable gastric band (LAGB) patients; however, conventional motility assessments have not proven to be clinically useful. Recent combined video fluoroscopic and high-resolution manometric studies have identified important components of esophageal function in LAGB patients. Successful and symptomatic LAGB patients, with normal or mildly impaired esophageal peristalsis, underwent a standardized, water swallow, high-resolution manometry protocol designed specifically to assess the lower esophageal contractile segment (LECS), in combination with conventional measures of esophageal motility. Differences in response to changes in LAGB volume were assessed. There were 101 symptomatic and 29 successful patients. More symptomatic patients had a mild impairment in esophageal motility (39.6% vs. 3.4%, p < 0.005). Successful patients demonstrated an intact LECS during normal swallows more frequently than symptomatic patients (95% vs. 43%, p < 0.005). Absolute intraluminal pressures were not different between the groups. Removing all fluid from the LAGB revealed more hypotensive swallows in the symptomatic patients (30% vs. 17%, p = 0.002), an effect not observed when the LAGB volume was increased (8% vs. 5%, p = 0.21). Receiver operator characteristic analysis determined that an intact LECS in 70% of normal swallows defined normal motility in LAGB patients. The LECS is a valuable measure of esophageal function in LAGB patients and complements conventional manometric criteria. Symptomatic patients have less normal swallows; however, these also frequently demonstrate a deficient LECS. Further information can be elucidated by performing swallows at differing LAGB volumes. High-resolution manometry, using these adapted criteria, is now a useful in the investigation in symptomatic LAGB patients.