| Bariatric Surgery.info Research Into Adjustable Gastric Band Surgery to Reduce Obesity |
Study of stomach lap banding, laparoscopy,
weight loss results |
Research Into Adjustable Gastric Band SurgeryEarly experience gained in Europe with the LAP-BAND system made by Bioenterics (Inamed Corporation, USA) led to repeated modification of the technique and resulted in great improvements in outcome. As with the adjustable band, the so-called Swedish band (SAGB, Obtech AG, ETHICON), which makes a smaller pouch, significantly reduced the post-operative complication rate. Adjustable Gastric Band ProcedureThe AGB is a 12-mm-wide soft silicone band with an elastic balloon that can be inflated by injection according to individual need. The band is fitted around the upper part of the stomach, dividing it into two sections, the smaller of which is above the band and has a capacity of approximately 15–20 ml (pouch); the larger remaining part is below the band. The constriction is called a stoma. The following are the main differences in technique for gastric banding: by means of a calibration balloon positioned in the stomach, the site of incision is determined at the small curvature. At this site, a 0.5 to 1-cm window is placed close to the cardia. The fenestration is continued along the posterior wall of the gastro-oesophageal junction up to the angle of His. Another so-called pars flaccida technique starts at the medial edge of the right crus of the diaphragm after incision of the pars flaccida of the lesser omentum dissecting to the angle of HIS. Tunnelled suturing is obligatory to prevent band slippage and to ensure that the fundus does not slide under the band. We also recommend gastropexy in addition to the stomach wall suture (fundus sutured to the left side of the diaphragm). The AGB makes it possible for the surgeon to alter the stoma diameter. Laparoscope-Assisted Gastric BandingLaparoscopic implantation of an AGB requires approximately the same level of skill as laparoscopic Nissen fundoplication. As with all laparoscopic procedures, there is a learning curve for banding that can vary quite substantially. Good surgical training, careful patient selection and inter-disciplinary follow-up management are some key factors. Trouble-free banding requires experience and practice. De Jong and van Ramshorst report a re-operation rate of 30% in their first 50 patients and a significant reduction of 13% for the next 47. Elmore et al. report that the largest number of complications occurred in the first 25 patients. Angrisani and colleagues report disappointing results in the early laparoscopic operations. Adjustable Gastric Band Weight Loss ResultsWeight loss is given in the literature as BMI 43–46 pre-operatively to BMI 28–32 post-operatively. The target of a 50–60% reduction of excess weight is achievable. Belachew et al. have demonstrated that 80% of their patients reduced their excess weight by 60%. OBrian et al. reported excess weight loss of 51% in the first year, 58% in the second, 61% in the third and 68% in the fourth year post-operatively. Studies with a follow-up of over 5 years confirm that the weight loss is long-term. Adjustable Gastric Band Complications and RisksA prospective study in our department, comparing the two bands, found no difference in weight loss and complication rate between LAP banding and SAGB after a 4-year follow-up. Complications break down into peri-operative and late complications. Top priority is given to the prevention of complications, however. Thorough training and an inter-disciplinary approach to therapy are essential. We believe that the laparoscopically implanted AGB, both the LAP-BAND system and SAGB, is an efficient treatment method for patients with morbid obesity. It dispenses with the need for open surgery on the stomach or small intestine, which remain intact in terms of anatomy and digestive physiology. Long-term metabolic complications are not anticipated. Weight loss and food intake can be adapted to individual patient needs. Of the patients, 80–90% can expect to lose 60–70% of their excess weight. It is much easier with this method than with other procedures for the surgeon to remove the band and restore the original situation. The surgical technique is difficult in the learning phase, but it becomes easy with practice and is fairly low risk provided that the safety recommendations are observed. All these reasons make gastric banding a relatively safe and efficient treatment for morbid obesity, and it is likely to be an important surgical addition to the treatments available for most of these patients. Biliopancreatic
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