Use of predictive criteria to guide patient selection led to a 50% decline in complications after laparoscopic adjustable gastric banding (LAGB) and improvement in long-term weight loss, a French investigator reported.
The complication rate declined from 19% in an unselected historical control group of LAGB patients to 9% in a selected group of patients. The mean body mass index (BMI) at 5 years was 3 kg/m2 lower in patients selected on the basis of criteria associated with successful weight loss in previous studies of LAGB, Jean-Marc Chevallier, MD, said here at the American Society for Metabolic and Bariatric Surgery.
Rates of reoperation and band removal also declined in the criteria-selected patients, said Chevallier, of Hopital Européen Georges Pompidou in Paris.
“We can conclude, on this prospective series of patients selected on predictive factors of success, that compared with our historical nonselected patients, gastric banding appeared to have a decreased complication rate, a decreased reoperation rate, and a decreased band-removal rate,” he said. “This means that it is nowadays useless to publish long-term results with gastric banding compared with the older perigastric technique and older high-pressure bands and on nonselected patients.”
LAGB has won favor among bariatric surgeons and their patients because of its overall low morbidity, weight-loss efficacy, and reversibility. However, several studies have demonstrated high rates of late complications, and questions have arisen regarding the long-term durability of weight loss achieved with gastric banding.
Chevallier and colleagues previously examined bariatric surgery outcomes in nationwide data collected by the French National Medical Insurance Service (Ann Surg 2007; 246: 1034-1039). They identified five factors associated with increased likelihood of successful weight loss: age <40, BMI <50, patient willingness to change eating habits, physical activity, and surgery by a team with a volume of two or more bariatric procedures a week.
LAGB surgery involves laparoscopically placing an adjustable band around the upper part of the stomach such that the stomach is partitioned into two sections.
The band is tightened creating an outlet (‘stoma’) between the tiny upper and large lower stomach. The capacity of the upper segment of the stomach ranges between 10 and 15 mL. The adjustability of the band allows the surgeon to alter the diameter of the stoma. The adjustable gastric band has an inflatable tube incorporated in it that is connected to a port anchored to the rectus abdominus muscle. The adjustable band is not inflated until at least 4 weeks after surgery in order to allow it to get anchored in position by fibrous tissue (Deitel, personal communication). Once anchored, if the patient is not losing weight then saline is injected percutaneously through the skin into the port, which in turn decreases the volume of the upper stomach by constricting the band. If the patient is losing weight too quickly the band is loosened by withdrawing saline allowing for a larger outlet. The band itself can be coated with silicone or other types of materials impregnated with silicone.
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Investigators prospectively evaluated the criteria by using them to select 429 patients for LAGB from January 2005 to December 2010. They compared outcomes against those of an unselected cohort of 1,227 patients treated from December 2002 to January 2003.
The criteria-selected patients had a mean age of 39.7, BMI of 41.60, weight of 252 lb., and follow-up of 29.24 months (and for as long as 5 years).
A total of 35 complications (a rate of 9%) occurred among the criteria-selected patients: 11 cases of band slippage, four cases of food intolerance, esophageal dilation in four patients, two intragastric migrations, and 14 port-related problems. Additionally, 20 patients (5.1%) required reoperation, and band removal was required in 12 patients (3%).
The historical cohort had an overall complication rate of 19.2% (P<0.001 versus selected patients), reoperation rate of 21% (P<0.001), and a band-removal rate of 10% (P<0.001).
The selected cohort had a mean BMI at 5 years of 30.84, compared with a mean of 33.9 for the historical controls.
The complication rate in the patients selected by predictive criteria also compared favorably with published rates for other large series, which have averaged about 15%, said Chevallier.
Complications specific to adjustable gastric bands Chelala et al. and Favretti et al. described complications of the LAGB
operative technique and suggested ways to avoid them. Specifically, the
physiopathology of pouch dilation was characterized and reasons why some
LAGB cases had to be converted from laparoscopy to open surgery were
explained.
In both series (n=185, n=260), laparoscopic surgery duration was, on average, 90
minutes and the hospital stay averaged two days. Conversion surgery in the
Chelala et al. study occurred in 11 patients (three due to left liver lobe
hypertrophy, eight due to difficult and risky dissection, short instruments and
incorrect band position). Ten patients had conversion surgery in the Favretti
study due to risky peri-gastric dissection (five patients), gastric perforation (two
patients), too short instruments (two patients) and bleeding from a retro-gastric
vessel (one patient).
Complications that occurred less than 12% of the time included:
· aspiration pneumonia
· band slippage
· rotated access ports
· infection of access port
Re-operation was required in approximately 4% of cases and was due to one or
more of the following reasons:
· gastric perforation
· band slippage
· twisted reservoir
· irreversible food intolerance that resulted in pouch dilation
· band replacement due to leakage of band or psychological reasons
· recurrent heartburn/esophagitis
In response to a question, Chevallier said experienced dietitians consult with patients for several months before surgery to determine which individuals are most likely to change their eating habits and to engage in physical activity.
During follow-up after surgery, patients are asked four questions: Do you vomit? Do you have pain? How many times a day do you eat? Are you hungry? Good answers are no, no, six, and no, respectively.
“I would say that we get the good answers 9 months to 1 year after surgery,” said Chevallier.
Noting that relatively few patients in the selected cohort had been followed for 5 years, a member of the audience asked whether late complications are a concern. Chevallier responded that he and his colleagues have observed few complications beyond 2 or 3 years after surgery.
Chevallier disclosed relationships wth Covidien and Allergan.
Primary source: American Society for Metabolic and Bariatric Surgery
Source reference: Chevallier JM, et al “Better weight loss and less reoperation rate following laparoscopic banding in selected obese patients: A prospective study” ASMBS 2012; Abstract PL-118.
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