Gastric Banding Shown to be Safe and Effective
Please read this in it's entirety! I have highlighted some stats for your review....The complication rate dropped drastically when the Pars Flaccida technique was used as this study notes (this is the technique in use by most bariatric surgeons today)...parts of this study have been posted previously, but I thought it would be good to have the entire study posted.
Journal of Obesity
Volume 2011 (2011), Article ID 128451, 6 pages
doi:10.1155/2011/128451
Clinical Study
Fourteen-Year Long-Term Results after Gastric Banding
Christine Stroh,1 Ulrich Hohmann,1 Harald Schramm,1 Frank Meyer,2 and Thomas Manger1
1Department of General, Abdominal and Pediatric Surgery, Municipal Hospital, Straße des Friedens 122, 07548 Gera, Germany
2Otto-von-Guericke University, 39106 Magdeburg, Germany
Received 13 August 2010; Revised 7 October 2010; Accepted 18 October 2010
Academic Editor: Francesco Saverio Papadia
Copyright © 2011 Christine Stroh et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background. Gastric banding (GB) is a common bariatric procedure that is performed worldwide. Weight loss can be substantial after this procedure, but it is not sufficient in a significant portion of patients. Long-term rates for associated complications increase with every year of follow up, and only a few long-term studies have been published that examine these rates. We present our results after 14 years of postoperative follow up. Methods. Two hundred patients were operated upon form 01.02.1995 to 31.01.2009. Data collection was performed prospectively. In retrospective analysis, we analyzed weight loss, short- and long-term complications, amelioration of comorbidities and long-term outcome.
Results. The mean postoperative follow up time was 94.4 months (range 2–144). The follow up rate was 83.5%. The incidence of postoperative complications for slippage was 2.5%, for pouch dilatation was 9.5%, for band migration was 5.5% and 12.0% for overall band removal. After 14 years, the reoperation rate was 30.5% with a reoperation rate of 2.2% for every year of follow up. Excess weight loss was 40.2% after 1 year, 46.3% after 2 years, 45.9% after 3 years, 41.9% after five years, 33.3% after 8 years, 30.8% after 10 years, 33.3% after 12 years and 15.6% after 14 years of follow up. Conclusion. The complication and reoperation rate after GB is high. Nevertheless, GB is still a therapeutic option in morbid obese patients, but the criteria for patient selection should be carefully evaluated.
1. Introduction
Demographic studies worldwide have shown a recent increase in the incidence of morbid obesity, and this condition has been identified as a major public health problem. Nonoperative treatments for weight loss offer limited success and have a high rate of failure. Currently, a Swedish obese subject study has shown that operative treatment of morbid obesity is the only effective therapy [1]. Besides weight reduction, the amelioration of obesity-associated comorbidities is an important consequence of surgical treatment of morbid obesity. Among the variety of restrictive and malabsorptive bariatric procedures, gastric banding has been performed in most countries worldwide. In Germany, GB (besides RYGBP) is the most performed bariatric procedure according to data from a nationwide survey [2].
Because GB has the advantages of being less invasive and a reversible procedure, it has been the procedure of choice for the treatment of morbid obesity for several years in Europe. In 2009, it was the most performed bariatric procedure in the USA.
The aim of our study was to analyze long-term results after GB from 1995 to 2009 and to assess the efficacy of GB for weight loss, improvement of comorbidities, and the incidence of complications.
2. Materials and Methods
2.1. Patients
Between February 1st 1995 and January 31st 2009, in 200 morbid obese patients, GB was performed at the Municipal Hospital in Gera, Germany. All patients were carefully selected according to IFSO-Guidelines [3].
Data collection was performed prospectively and analyzed retrospectively.
Preoperative characteristics of the patients are listed in Table 1. The operation was performed in 41 (20.5%) men and 159 (79.5%) women with a mean age of 41.5 years. The preoperative BMI was 47.9 kg/m². The mean BMI in men was 52.0 kg/m², which was significantly higher than in women (46.8 kg/m²).
tab1
Table 1: Demographic data.
2.2. Operative Technique and Data
Between February 1st 1995 and June 15th 1997, 39 (19.5%) procedures had been performed by one surgeon using open approach technique.
In June 1997, we started the GB procedure with a laparoscopic technique used in 80.5% of operations (Table 2). From June 1997 to February 2001, all Lap Bands were placed using perigastric approach. This technique was used in 68.5% of patients. Conversion rate of laparoscopic technique was 7.4% during the first 100 laparoscopic operations. After introduction of the pars flaccida technique in March 2001, we performed all GB procedures (31.5%) with the pars flaccida technique by a standardized laparoscopic approach to avoid posterior slippage. The space between the left crus and the band was closed to avoid lateral slippage by a stitch between the greater curvature and the left crus. We formed a small pouch of less than 20 cc. The pouch was secured by 3 to 5 gastrogastric stitches to avoid anterior slippage.
tab2
Table 2: Operation data.
We used 11 SAGB (SAGB; Obtech, Ethicon Endo-Surgery) and 189 Lap-Band bands (INAMED Health, Santa Barbara, CA).
2.3. Postoperative Management
The patients were followed in our hospital. The first consultation and clinical examination was performed six weeks postoperatively and then every three months for the first two years of followup. Followup examinations were performed twice a year or whenever needed after the second postoperative year.
A liquid diet was recommended for the first 5 days postoperatively. A normal diet was introduced thereafter. During each visit, a standardized fup was performed with documentation of weight, eating behavior, and a short clinical examination. Band adjustments were very rare. The band was adjusted only in cases of weight loss less than 2 kg per month or a less than 25% change in the EBWL after 3 months. In the case of discomfort from a normal diet or reflux symptoms, the filling of the band was reduced. The injection volume depended on the weight loss and the patient’s tolerance as well as his or her eating behaviors.
3. Results
3.1. Followup
Followup data were available from 83.5% of patients. The mean followup time was 94.4 (6–144) months.
3.2. Slippage
The slippage rate was 2.5% (
𝑛
=
5
). After an open approach in 3 patients, slippage occurred with a mean followup time of 10.3 (1–24) months. After laparoscopy in 2 patients, slippage occurred with a mean followup time of 18 (12–24) months. The operation was performed in all patients in perigastric approach. After introduction of pars flaccida technique, slippage rate decreased to zero.
3.3. Pouch Dilatation (PD)
During the postoperative course, the great majority of our patients developed PD (9.5%,
𝑛
=
1
9
). A total of 12 patients were operated on by an open technique, and 7 patients underwent a laparoscopic technique. After introduction of the pars flaccida technique, pouch dilatation no longer occurred.
3.4. Band Migration
Band migration occurred in 5.5% (
𝑛
=
1
1
) of cases. In all patients, the operation was performed using a perigastric placement of the band.
3.5. Band Removal
Band removal was performed in 24 (12%) patients. Five patients wished to have the band removed due to discomfort. In one patient, the band was removed due to her excellent excessive weight loss. In 18 patients, the band had to be removed in case of long-term complications such as band migration in 11 cases and slippage in 2 cases. In 2 cases, the band was removed at an out-of-town hospital without any described reason after a cholecystectomy. Epiphrenic esophageal diverticula, gastric wall necrosis, and acute peritonitis were the reasons for band removal among the other patients (Table 3).
tab3
Table 3: Reasons for band removal.
3.6. Reoperation
Among the above-mentioned complications, 61 (30.5%) patients required reoperation. In 5 patients, the band was explanted without any substitution. The total number of patients requiring reoperation was significantly higher in the open approach group (31.3%,
𝑛
=
4
3
) versus the pars flaccida group (3.2%,
𝑛
=
3
). Data for reoperation are shown in Table 4. The reoperation rate was 2.2% per year.
tab4
Table 4: Overall reoperation rate
3.7. Weight Loss after Gastric Banding
Weight loss after gastric banding is summarized in Table 5.
tab5
Table 5: Excess body weight loss in comparison with literature.
3.8. Changes in Comorbidities
During the postoperative period, 85.7% of patients who had previously suffered from diabetes prior to bariatric surgery could significantly reduce their insulin doses. In 14.3% of patients, diabetes was resolved, completely. Amelioration of hypertension was observed in 82.2% of patients.
3.9. Postoperative Mortality
There was no early postoperative mortality.
During the followup period, four patients (3 female and 1 male) died. The mean age of these patients was 64.1 (range 50.5–70) years. Two patients died due to their severe comorbidities 6 months and 96 months after GB. One patient died due to gastric cancer 36 months after GB [4]. Another woman died after repair of an abdominal wall hernia 132 months after band implantation.
4. Discussion
GB is beside RYGBP the most frequently performed bariatric operation worldwide. According to the data of a meta-analysis study, this procedure has been carried out in 95% of countries performing bariatric surgery [5].
When GB was introduced, the results were excellent in comparison with other restrictive bariatric procedures.
In the literature, only a few prospective randomized studies have been reported. These studies compared GB with RYGBP or/and SG. In addition, randomized trials comparing different kinds of bands (low- and high-pressure bands) were also performed. Single center studies report data with low evidence on the complication rates, outcome, and amelioration of comorbidities. In general, patient’s outcome after GB is influenced by the incidence of long-term complications. These include slippage, pouch dilatation, and band migration as well as port-site complications and esophageal dilatation. Nevertheless, there are only a few studies examining long-term results with a time period longer than 10 years available in the literature.
In our clinical experience, the results obtained after 14 years show a high complication rate and a weight regain after the 5th year of followup. These data are comparable with data published by Lanthaler et al. [6]. In their data describing young patients, weight loss was very successful within the first 4 years postoperatively [6]; thereafter, the BMI increased slowly. However, the reason for weight regain after that time was not described in detail. In our experience, most of the patients change their eating behaviors to liquids and sweets leading to a high calorie intake.
Nevertheless, an improvement in obesity-related comorbidities was observed in most patients. However, complete resolution of diabetes was less than reported in a published meta-analysis [4]. Reasons for this difference may have been the high BMI of our patients and the early onset of diabetes prior to surgery.
In our retrospective examination with preoperative data collection, the majority of our patients were female, which is consistent with data from the literature [5, 6]. The BMI (47.5 kg/m²) in our patients was higher than in most published studies due to the reimbursement problems of bariatric surgeries in Germany.
4.1. Slippage and Pouch Dilatation
Over time, the complication rates for incidences of slippage and pouch dilatation decreased. The drop in the complication rate was the result of a switch from the perigastric to a pars flaccida technique as well as the introduction of next generation bands and the development of band devices especially made for the connecting tube and the port system.
In fact, there was a decrease in the slippage rate from 3.6% in the perigastric approach to 0% in the pars flaccida technique [7].
Pouch dilatation is a long-term complication after GB. The incidence of pouch dilatation is influenced by the surgical approach (open versus laparoscopic) and the technique (perigastric versus pars flaccida). Opening the lesser sac during open band placement leads to a higher incidence of pouch dilatation than the laparoscopic approach, which creates a small retrogastric channel. Data in the literature examining the incidence of pouch dilatation are mostly heterogeneous because most studies include different approaches and techniques. Otherwise, there are only a few reports with a followup period of more than 5 years.
4.2. Band Migration
Intragastric band migration is characterized by a “silent" migration of the band into the stomach [8, 9]. Peritonitis symptoms are usually absent, and there are limited retrospective data obtained from long-term studies available [10, 11]. The incidence of band migration ranges from 0.6% to 14.4% according to the literature [10–13]. In a few studies, band migration has been considered as a complication associated with the first 2 postoperative years, which is caused by intraoperative gastric perforation [6, 14–16].
In our data, most patients with band migration had an uncritical uptake of nonsteroidal antirheumatic agents, bronchospasmolytic drugs, and anticoagulant substances. Specifically, 26.6% of patients were treated with nonsteroidal antirheumatic substances, 20.2% with anticoagulant substances, and 0.6% with bronchospasmolytic drugs. Therefore, in our opinion, these medications should be considered as potential causes of band migration. Chronic inflammation at the tissue area covered by the band could be a further reason for developing erosion. In our experience, band migration occurs by 30–86 months postoperatively [17]. In addition, the erosion rate has been shown to increase over the long-term followup period [18].
Band erosion can lead to a life-threatening condition in cases of upper gastrointestinal bleeding and bowel obstruction. Therefore, finding a correct diagnosis is essential. In our study, we did not see any port infection in the first 3 postoperative months and after band filling. In the literature, port infection has been reported to be the first symptom of erosion [19]. However, our own data revealed varying intervals between the onset of port infection and the occurrence of erosion.
Thus, the treatment depends on symptomatology. We favor band removal in cases of complete erosion using gastroscopy and an AMI Band Cutter (CJ Medical, Buckinghamshire, Great Britain) [17].
In the literature, a correlation of erosion rate with the band type (high-pressure versus low-pressure bands) has not been described [20].
At the end of the 1990s, repositioning of the band in cases of slippage and pouch dilatation was widely performed. However, data from our study indicated a higher incidence of gastric band migration, and data in the literature have shown disappointing results [17, 18, 21]. Thus, in cases of slippage and pouch dilatation, most published results and our findings reveal no indication for rebanding [18]. We believe band removal in cases of erosion accompanied by a simultaneous “rebanding" should not be performed because there is a potential risk of infection of the new band. This conclusion is based on the different causes of band erosion, a significantly higher migration rate following intraoperative gastric perforation and the currently available data in the literature. In addition, because of the high failure rate after band revision, a conversion to a Roux-en-Y gastric bypass or biliopancreatic diversion needs to be considered.
4.3. Amelioration of Comorbidities
According to data from a German nationwide survey on bariatric surgery, our reported patients had a significantly higher age and BMI compared with data obtained in the meta-analysis on bariatric surgery patients [5]. In addition, significantly more patients suffered from type-II diabetes mellitus and arterial hypertension in our study. Thus, the consequential higher rate of comorbidities was due to the occurrence of a severe metabolic syndrome. However, the impact of a high preoperative BMI on weight reduction needs to be investigated through a long-term study.
4.4. Reoperation Rate
The reintervention rate per year of followup in our patients was 2.2%. These data correspond to the literature, which reports a reoperation rate between 3 and 4% per year of followup [18].
4.5. Excess Weight Loss
Concerning the EBWL, the literature reports an EBWL of 47.5% from a meta-analysis study. This meta-analysis reported a progression in weight loss for the first 3 years after GB, which was followed by a stable level of weight loss out to 8 years with no detectable regain of weight [22]. Data of long-term studies with a followup time of more than five years are shown in Table 5. Studies comparing weight loss after perigastric technique to pars flaccida approaches have not shown any influence of operation technique on EWL [23]. GB results in a continuous weight loss during the first 3 years and is sustained for up to 5 years. These results are in concordance with data from the Italian Band Group, but not with weight loss patterns observed in Australian data [14, 23]. We believe the patients in our study had a lower weight loss due to the higher preoperative BMI and the higher incidence of diabetes type II. For better long-term results, we suggest interdisciplinary teamwork to reduce long-term complication rates, increase weight loss, and ameliorate comorbidities.
5. Conclusion
GB has been shown to be a safe and efficient bariatric procedure when performed by an experienced surgeon using a standardized operation technique. The importance of a close and standardized followup by an experienced multidisciplinary team and the surgeon can result in a decreased complication rate, increased weight loss, and reduced comorbidities.
Furthermore, there are no data in the literature addressing specific criteria, which allow the selection of patients for either restrictive or malabsorptive procedures so as to improve final outcome. To guarantee long-term success after bariatric surgery and to avoid complications, particularly when following combined procedures, lifelong postoperative care is required, which is a specific concern for obesity surgery. Moreover, there is a limited amount of long-term followup data available in the literature and these are from just a few single center studies. Thus, researchers and clinicians should prospectively enroll all patients as indicated by the German multicenter observational study for quality assurance in obesity surgery. This study annually registered parameters such as weight reduction, amelioration of comorbidities, and long-term complications. Subsequently, these data were used to assess the surgical treatment of morbid obesity in Germany [2].
Abbreviations
EWL: Excess weight loss
Fup: Followup
GB: Gastric banding
PD: Pouch dilatation
RYGBP: Roux-en-Y Gastric Bypass.
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12. J. Zehetner, F. Holzinger, H. Triaca, and CH. Klaiber, “A 6-year experience with the Swedish adjustable gastric band: prospective long-term audit of laparoscopic gastric banding," Surgical Endoscopy and Other Interventional Techniques, vol. 19, no. 1, pp. 21–28, 2005.
13. J.-M. Chevallier, F. Zinzindohoué, R. Douard, J.-P. Blanche, J.-L. Berta, J.-J. Altman, and P.-H. Cugnenc, “Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years," Obesity Surgery, vol. 14, no. 3, pp. 407–414, 2004.
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Copyright © 2011 Hindawi Publishing Corporation. All rights reserved.
Journal of Obesity
Volume 2011 (2011), Article ID 128451, 6 pages
doi:10.1155/2011/128451
Clinical Study
Fourteen-Year Long-Term Results after Gastric Banding
Christine Stroh,1 Ulrich Hohmann,1 Harald Schramm,1 Frank Meyer,2 and Thomas Manger1
1Department of General, Abdominal and Pediatric Surgery, Municipal Hospital, Straße des Friedens 122, 07548 Gera, Germany
2Otto-von-Guericke University, 39106 Magdeburg, Germany
Received 13 August 2010; Revised 7 October 2010; Accepted 18 October 2010
Academic Editor: Francesco Saverio Papadia
Copyright © 2011 Christine Stroh et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background. Gastric banding (GB) is a common bariatric procedure that is performed worldwide. Weight loss can be substantial after this procedure, but it is not sufficient in a significant portion of patients. Long-term rates for associated complications increase with every year of follow up, and only a few long-term studies have been published that examine these rates. We present our results after 14 years of postoperative follow up. Methods. Two hundred patients were operated upon form 01.02.1995 to 31.01.2009. Data collection was performed prospectively. In retrospective analysis, we analyzed weight loss, short- and long-term complications, amelioration of comorbidities and long-term outcome.
Results. The mean postoperative follow up time was 94.4 months (range 2–144). The follow up rate was 83.5%. The incidence of postoperative complications for slippage was 2.5%, for pouch dilatation was 9.5%, for band migration was 5.5% and 12.0% for overall band removal. After 14 years, the reoperation rate was 30.5% with a reoperation rate of 2.2% for every year of follow up. Excess weight loss was 40.2% after 1 year, 46.3% after 2 years, 45.9% after 3 years, 41.9% after five years, 33.3% after 8 years, 30.8% after 10 years, 33.3% after 12 years and 15.6% after 14 years of follow up. Conclusion. The complication and reoperation rate after GB is high. Nevertheless, GB is still a therapeutic option in morbid obese patients, but the criteria for patient selection should be carefully evaluated.
1. Introduction
Demographic studies worldwide have shown a recent increase in the incidence of morbid obesity, and this condition has been identified as a major public health problem. Nonoperative treatments for weight loss offer limited success and have a high rate of failure. Currently, a Swedish obese subject study has shown that operative treatment of morbid obesity is the only effective therapy [1]. Besides weight reduction, the amelioration of obesity-associated comorbidities is an important consequence of surgical treatment of morbid obesity. Among the variety of restrictive and malabsorptive bariatric procedures, gastric banding has been performed in most countries worldwide. In Germany, GB (besides RYGBP) is the most performed bariatric procedure according to data from a nationwide survey [2].
Because GB has the advantages of being less invasive and a reversible procedure, it has been the procedure of choice for the treatment of morbid obesity for several years in Europe. In 2009, it was the most performed bariatric procedure in the USA.
The aim of our study was to analyze long-term results after GB from 1995 to 2009 and to assess the efficacy of GB for weight loss, improvement of comorbidities, and the incidence of complications.
2. Materials and Methods
2.1. Patients
Between February 1st 1995 and January 31st 2009, in 200 morbid obese patients, GB was performed at the Municipal Hospital in Gera, Germany. All patients were carefully selected according to IFSO-Guidelines [3].
Data collection was performed prospectively and analyzed retrospectively.
Preoperative characteristics of the patients are listed in Table 1. The operation was performed in 41 (20.5%) men and 159 (79.5%) women with a mean age of 41.5 years. The preoperative BMI was 47.9 kg/m². The mean BMI in men was 52.0 kg/m², which was significantly higher than in women (46.8 kg/m²).
tab1
Table 1: Demographic data.
2.2. Operative Technique and Data
Between February 1st 1995 and June 15th 1997, 39 (19.5%) procedures had been performed by one surgeon using open approach technique.
In June 1997, we started the GB procedure with a laparoscopic technique used in 80.5% of operations (Table 2). From June 1997 to February 2001, all Lap Bands were placed using perigastric approach. This technique was used in 68.5% of patients. Conversion rate of laparoscopic technique was 7.4% during the first 100 laparoscopic operations. After introduction of the pars flaccida technique in March 2001, we performed all GB procedures (31.5%) with the pars flaccida technique by a standardized laparoscopic approach to avoid posterior slippage. The space between the left crus and the band was closed to avoid lateral slippage by a stitch between the greater curvature and the left crus. We formed a small pouch of less than 20 cc. The pouch was secured by 3 to 5 gastrogastric stitches to avoid anterior slippage.
tab2
Table 2: Operation data.
We used 11 SAGB (SAGB; Obtech, Ethicon Endo-Surgery) and 189 Lap-Band bands (INAMED Health, Santa Barbara, CA).
2.3. Postoperative Management
The patients were followed in our hospital. The first consultation and clinical examination was performed six weeks postoperatively and then every three months for the first two years of followup. Followup examinations were performed twice a year or whenever needed after the second postoperative year.
A liquid diet was recommended for the first 5 days postoperatively. A normal diet was introduced thereafter. During each visit, a standardized fup was performed with documentation of weight, eating behavior, and a short clinical examination. Band adjustments were very rare. The band was adjusted only in cases of weight loss less than 2 kg per month or a less than 25% change in the EBWL after 3 months. In the case of discomfort from a normal diet or reflux symptoms, the filling of the band was reduced. The injection volume depended on the weight loss and the patient’s tolerance as well as his or her eating behaviors.
3. Results
3.1. Followup
Followup data were available from 83.5% of patients. The mean followup time was 94.4 (6–144) months.
3.2. Slippage
The slippage rate was 2.5% (
𝑛
=
5
). After an open approach in 3 patients, slippage occurred with a mean followup time of 10.3 (1–24) months. After laparoscopy in 2 patients, slippage occurred with a mean followup time of 18 (12–24) months. The operation was performed in all patients in perigastric approach. After introduction of pars flaccida technique, slippage rate decreased to zero.
3.3. Pouch Dilatation (PD)
During the postoperative course, the great majority of our patients developed PD (9.5%,
𝑛
=
1
9
). A total of 12 patients were operated on by an open technique, and 7 patients underwent a laparoscopic technique. After introduction of the pars flaccida technique, pouch dilatation no longer occurred.
3.4. Band Migration
Band migration occurred in 5.5% (
𝑛
=
1
1
) of cases. In all patients, the operation was performed using a perigastric placement of the band.
3.5. Band Removal
Band removal was performed in 24 (12%) patients. Five patients wished to have the band removed due to discomfort. In one patient, the band was removed due to her excellent excessive weight loss. In 18 patients, the band had to be removed in case of long-term complications such as band migration in 11 cases and slippage in 2 cases. In 2 cases, the band was removed at an out-of-town hospital without any described reason after a cholecystectomy. Epiphrenic esophageal diverticula, gastric wall necrosis, and acute peritonitis were the reasons for band removal among the other patients (Table 3).
tab3
Table 3: Reasons for band removal.
3.6. Reoperation
Among the above-mentioned complications, 61 (30.5%) patients required reoperation. In 5 patients, the band was explanted without any substitution. The total number of patients requiring reoperation was significantly higher in the open approach group (31.3%,
𝑛
=
4
3
) versus the pars flaccida group (3.2%,
𝑛
=
3
). Data for reoperation are shown in Table 4. The reoperation rate was 2.2% per year.
tab4
Table 4: Overall reoperation rate
3.7. Weight Loss after Gastric Banding
Weight loss after gastric banding is summarized in Table 5.
tab5
Table 5: Excess body weight loss in comparison with literature.
3.8. Changes in Comorbidities
During the postoperative period, 85.7% of patients who had previously suffered from diabetes prior to bariatric surgery could significantly reduce their insulin doses. In 14.3% of patients, diabetes was resolved, completely. Amelioration of hypertension was observed in 82.2% of patients.
3.9. Postoperative Mortality
There was no early postoperative mortality.
During the followup period, four patients (3 female and 1 male) died. The mean age of these patients was 64.1 (range 50.5–70) years. Two patients died due to their severe comorbidities 6 months and 96 months after GB. One patient died due to gastric cancer 36 months after GB [4]. Another woman died after repair of an abdominal wall hernia 132 months after band implantation.
4. Discussion
GB is beside RYGBP the most frequently performed bariatric operation worldwide. According to the data of a meta-analysis study, this procedure has been carried out in 95% of countries performing bariatric surgery [5].
When GB was introduced, the results were excellent in comparison with other restrictive bariatric procedures.
In the literature, only a few prospective randomized studies have been reported. These studies compared GB with RYGBP or/and SG. In addition, randomized trials comparing different kinds of bands (low- and high-pressure bands) were also performed. Single center studies report data with low evidence on the complication rates, outcome, and amelioration of comorbidities. In general, patient’s outcome after GB is influenced by the incidence of long-term complications. These include slippage, pouch dilatation, and band migration as well as port-site complications and esophageal dilatation. Nevertheless, there are only a few studies examining long-term results with a time period longer than 10 years available in the literature.
In our clinical experience, the results obtained after 14 years show a high complication rate and a weight regain after the 5th year of followup. These data are comparable with data published by Lanthaler et al. [6]. In their data describing young patients, weight loss was very successful within the first 4 years postoperatively [6]; thereafter, the BMI increased slowly. However, the reason for weight regain after that time was not described in detail. In our experience, most of the patients change their eating behaviors to liquids and sweets leading to a high calorie intake.
Nevertheless, an improvement in obesity-related comorbidities was observed in most patients. However, complete resolution of diabetes was less than reported in a published meta-analysis [4]. Reasons for this difference may have been the high BMI of our patients and the early onset of diabetes prior to surgery.
In our retrospective examination with preoperative data collection, the majority of our patients were female, which is consistent with data from the literature [5, 6]. The BMI (47.5 kg/m²) in our patients was higher than in most published studies due to the reimbursement problems of bariatric surgeries in Germany.
4.1. Slippage and Pouch Dilatation
Over time, the complication rates for incidences of slippage and pouch dilatation decreased. The drop in the complication rate was the result of a switch from the perigastric to a pars flaccida technique as well as the introduction of next generation bands and the development of band devices especially made for the connecting tube and the port system.
In fact, there was a decrease in the slippage rate from 3.6% in the perigastric approach to 0% in the pars flaccida technique [7].
Pouch dilatation is a long-term complication after GB. The incidence of pouch dilatation is influenced by the surgical approach (open versus laparoscopic) and the technique (perigastric versus pars flaccida). Opening the lesser sac during open band placement leads to a higher incidence of pouch dilatation than the laparoscopic approach, which creates a small retrogastric channel. Data in the literature examining the incidence of pouch dilatation are mostly heterogeneous because most studies include different approaches and techniques. Otherwise, there are only a few reports with a followup period of more than 5 years.
4.2. Band Migration
Intragastric band migration is characterized by a “silent" migration of the band into the stomach [8, 9]. Peritonitis symptoms are usually absent, and there are limited retrospective data obtained from long-term studies available [10, 11]. The incidence of band migration ranges from 0.6% to 14.4% according to the literature [10–13]. In a few studies, band migration has been considered as a complication associated with the first 2 postoperative years, which is caused by intraoperative gastric perforation [6, 14–16].
In our data, most patients with band migration had an uncritical uptake of nonsteroidal antirheumatic agents, bronchospasmolytic drugs, and anticoagulant substances. Specifically, 26.6% of patients were treated with nonsteroidal antirheumatic substances, 20.2% with anticoagulant substances, and 0.6% with bronchospasmolytic drugs. Therefore, in our opinion, these medications should be considered as potential causes of band migration. Chronic inflammation at the tissue area covered by the band could be a further reason for developing erosion. In our experience, band migration occurs by 30–86 months postoperatively [17]. In addition, the erosion rate has been shown to increase over the long-term followup period [18].
Band erosion can lead to a life-threatening condition in cases of upper gastrointestinal bleeding and bowel obstruction. Therefore, finding a correct diagnosis is essential. In our study, we did not see any port infection in the first 3 postoperative months and after band filling. In the literature, port infection has been reported to be the first symptom of erosion [19]. However, our own data revealed varying intervals between the onset of port infection and the occurrence of erosion.
Thus, the treatment depends on symptomatology. We favor band removal in cases of complete erosion using gastroscopy and an AMI Band Cutter (CJ Medical, Buckinghamshire, Great Britain) [17].
In the literature, a correlation of erosion rate with the band type (high-pressure versus low-pressure bands) has not been described [20].
At the end of the 1990s, repositioning of the band in cases of slippage and pouch dilatation was widely performed. However, data from our study indicated a higher incidence of gastric band migration, and data in the literature have shown disappointing results [17, 18, 21]. Thus, in cases of slippage and pouch dilatation, most published results and our findings reveal no indication for rebanding [18]. We believe band removal in cases of erosion accompanied by a simultaneous “rebanding" should not be performed because there is a potential risk of infection of the new band. This conclusion is based on the different causes of band erosion, a significantly higher migration rate following intraoperative gastric perforation and the currently available data in the literature. In addition, because of the high failure rate after band revision, a conversion to a Roux-en-Y gastric bypass or biliopancreatic diversion needs to be considered.
4.3. Amelioration of Comorbidities
According to data from a German nationwide survey on bariatric surgery, our reported patients had a significantly higher age and BMI compared with data obtained in the meta-analysis on bariatric surgery patients [5]. In addition, significantly more patients suffered from type-II diabetes mellitus and arterial hypertension in our study. Thus, the consequential higher rate of comorbidities was due to the occurrence of a severe metabolic syndrome. However, the impact of a high preoperative BMI on weight reduction needs to be investigated through a long-term study.
4.4. Reoperation Rate
The reintervention rate per year of followup in our patients was 2.2%. These data correspond to the literature, which reports a reoperation rate between 3 and 4% per year of followup [18].
4.5. Excess Weight Loss
Concerning the EBWL, the literature reports an EBWL of 47.5% from a meta-analysis study. This meta-analysis reported a progression in weight loss for the first 3 years after GB, which was followed by a stable level of weight loss out to 8 years with no detectable regain of weight [22]. Data of long-term studies with a followup time of more than five years are shown in Table 5. Studies comparing weight loss after perigastric technique to pars flaccida approaches have not shown any influence of operation technique on EWL [23]. GB results in a continuous weight loss during the first 3 years and is sustained for up to 5 years. These results are in concordance with data from the Italian Band Group, but not with weight loss patterns observed in Australian data [14, 23]. We believe the patients in our study had a lower weight loss due to the higher preoperative BMI and the higher incidence of diabetes type II. For better long-term results, we suggest interdisciplinary teamwork to reduce long-term complication rates, increase weight loss, and ameliorate comorbidities.
5. Conclusion
GB has been shown to be a safe and efficient bariatric procedure when performed by an experienced surgeon using a standardized operation technique. The importance of a close and standardized followup by an experienced multidisciplinary team and the surgeon can result in a decreased complication rate, increased weight loss, and reduced comorbidities.
Furthermore, there are no data in the literature addressing specific criteria, which allow the selection of patients for either restrictive or malabsorptive procedures so as to improve final outcome. To guarantee long-term success after bariatric surgery and to avoid complications, particularly when following combined procedures, lifelong postoperative care is required, which is a specific concern for obesity surgery. Moreover, there is a limited amount of long-term followup data available in the literature and these are from just a few single center studies. Thus, researchers and clinicians should prospectively enroll all patients as indicated by the German multicenter observational study for quality assurance in obesity surgery. This study annually registered parameters such as weight reduction, amelioration of comorbidities, and long-term complications. Subsequently, these data were used to assess the surgical treatment of morbid obesity in Germany [2].
Abbreviations
EWL: Excess weight loss
Fup: Followup
GB: Gastric banding
PD: Pouch dilatation
RYGBP: Roux-en-Y Gastric Bypass.
References
1. L. Sjöström, K. Narbro, and K. Narbro, “Effects of bariatric surgery on mortality in Swedish obese subjects," The New England Journal of Medicine, vol. 357, no. 8, pp. 741–752, 2007.
2. C. Stroh, D. Birk, and D. Birk, “A nationwide survey on bariatric surgery in Germany—results 2005-2007," Obesity Surgery, vol. 19, no. 1, pp. 105–112, 2009.
3. S. Sauerland, L. Angrisani, and L. Angrisani, “Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (E.A.E.S.)," Surgical Endoscopy and Other Interventional Techniques, vol. 19, no. 2, pp. 200–221, 2005.
4. C. Stroh, U. Hohmann, H. Urban, and TH. Manger, “Gastric cancer after laparoscopic adjustable gastric banding," Obesity Surgery, vol. 18, no. 9, pp. 1200–1202, 2008.
5. H. Buchwald, Y. Avidor, E. Braunwald, M. D. Jensen, W. Pories, K. Fahrbach, and K. Schoelles, “Bariatric surgery: a systematic review and meta-analysis," JAMA, vol. 292, no. 14, pp. 1724–1737, 2004.
6. M. Lanthaler, M. Sieb, S. Strasser, H. Weiss, F. Aigner, and H. Nehoda, “Disappointing mid-term results after laparoscopic gastric banding in young patients," Surgery for Obesity and Related Diseases, vol. 5, no. 2, pp. 218–223, 2009.
7. R. Weiner, D. Wagner, R. Blanco-Engert, and H. Bockhorn, “A new technique for laparoscopic placement of the adjustable gastric banding (LAP band) to prevent slippage," Chirurg, vol. 71, no. 10, pp. 1243–1250, 2000.
8. H. Weiss, H. Nehoda, B. Labeck, R. Peer, and F. Aigner, “Gastroscopic band removal after intragastric migration of adjustable gastric band: a new minimal invasive technique," Obesity Surgery, vol. 10, no. 2, pp. 167–170, 2000.
9. A. Westling, K. Bjurling, M. Öhrvall, and S. Gustavsson, “Silicone-adjustable gastric banding: disappointing results," Obesity Surgery, vol. 8, no. 4, pp. 467–474, 1998.
10. A. E. Chapman, G. Kiroff, P. Game, B. Foster, P. O'Brien, J. Ham, and G. J. Maddern, “Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review," Surgery, vol. 135, no. 3, pp. 326–351, 2004.
11. S. Gustavsson and A. Westling, “Laparoscopic adjustable gastric banding: complications and side effects responsible for the poor long-term outcome," Seminars in Laparoscopic Surgery, vol. 9, no. 2, pp. 115–124, 2002.
12. J. Zehetner, F. Holzinger, H. Triaca, and CH. Klaiber, “A 6-year experience with the Swedish adjustable gastric band: prospective long-term audit of laparoscopic gastric banding," Surgical Endoscopy and Other Interventional Techniques, vol. 19, no. 1, pp. 21–28, 2005.
13. J.-M. Chevallier, F. Zinzindohoué, R. Douard, J.-P. Blanche, J.-L. Berta, J.-J. Altman, and P.-H. Cugnenc, “Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years," Obesity Surgery, vol. 14, no. 3, pp. 407–414, 2004.
14. F. Favretti, G. Segato, and G. Segato, “Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results," Obesity Surgery, vol. 17, no. 2, pp. 168–175, 2007.
15. E. Chousleb, S. Szomstein, and S. Szomstein, “Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature," Surgical Laparoscopy, Endoscopy and Percutaneous Techniques, vol. 15, no. 1, pp. 24–27, 2005.
16. W. Ceelen, J. Walder, A. Cardon, K. Van Renterghem, U. Hesse, M. El Malt, and P. Pattyn, “Surgical treatment of severe obesity with a low-pressure adjustable gastric band: experimental data and clinical results in 625 patients," Annals of Surgery, vol. 237, no. 1, pp. 10–16, 2003.
17. C. Stroh, U. Hohmann, and U. Hohmann, “Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding—the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006," International Journal of Colorectal Disease, vol. 23, no. 9, pp. 901–908, 2008.
18. M. Suter, J. M. Calmes, A. Paroz, and V. Giusti, “A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates," Obesity Surgery, vol. 16, no. 7, pp. 829–835, 2006.
19. A. Keidar, E. Carmon, A. Szold, and S. Abu-Abeid, “Port complications following laparoscopic adjustable gastric banding for morbid obesity," Obesity Surgery, vol. 15, no. 3, pp. 361–365, 2005.
20. M. Fried, K. Miller, and K. Kormanova, “Literature review of comparative studies of complications with Swedish Band and Lap-Band®," Obesity Surgery, vol. 14, no. 2, pp. 256–260, 2004.
21. C. Stroh, U. Hohmann, H. Schramm, and T. Manger, “Long-term results after gastric banding," Zentralblatt fur Chirurgie, vol. 130, no. 5, pp. 410–418, 2005.
22. P. E. O'Brien, T. McPhail, T. B. Chaston, and J. B. Dixon, “Systematic review of medium-term weight loss after bariatric operations," Obesity Surgery, vol. 16, no. 8, pp. 1032–1040, 2006.
23. M. Bueter, J. Maroske, and J. Maroske, “Short- and long-term results of laparoscopic gastric banding for morbid obesity," Langenbeck's Archives of Surgery, vol. 393, no. 2, pp. 199–205, 2008.
24. M. Belachew, P. H. Belva, and C. Desaive, “Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity," Obesity Surgery, vol. 12, no. 4, pp. 564–568, 2002.
25. P. E. O'Brien and J. B. Dixon, “Weight loss and early and late complications—the international experience," American Journal of Surgery, vol. 184, no. 6, supplement 2, pp. S42–S45, 2002.
26. R. Weiner, R. Blanco-Engert, S. Weiner, R. Matkowitz, L. Schaefer, and I. Pomhoff, “Outcome after laparoscopic adjustable gastric banding—8 years experience," Obesity Surgery, vol. 13, no. 3, pp. 427–434, 2003.
27. T. Martikainen, E. Pirinen, E. Alhava, E. Poikolainen, M. Pääkkönen, M. Uusitupa, and H. Gylling, “Long-term results, late complications and quality of life in a series of adjustable gastric banding," Obesity Surgery, vol. 14, no. 5, pp. 648–654, 2004.
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Copyright © 2011 Hindawi Publishing Corporation. All rights reserved.
6-7-13 band removed. No revision. Facebook Failed Lapbands and Realize Bands group and WLS-Support for Regain and Revision Group
thank you Steph. I hate it when people post articles they only post what they want people to see and not the WHOLE article !!!!
If you are going to post a article then post the whole thing not just copy and paste out of it to prove your point .
If you are going to post a article then post the whole thing not just copy and paste out of it to prove your point .
Quit Smoking 10/8/10
Starting BMI 52.9 BMI now 44.4 updated 6/6/11
I work in a surgical intensive care unit. Yesterday a man had a Roux N Y, He had bleeding problems immediately after surgery, came to the ICU, continued to bleed, went back to surgery, came back to the ICU and still had bleeding problems. He looked about 40. All I kept thinking 2% of bypass patients die, and prayed that would not be him. Give me a band any day of the week.
On March 11, 2011 at 3:55 PM Pacific Time, sesmith wrote:
I work in a surgical intensive care unit. Yesterday a man had a Roux N Y, He had bleeding problems immediately after surgery, came to the ICU, continued to bleed, went back to surgery, came back to the ICU and still had bleeding problems. He looked about 40. All I kept thinking 2% of bypass patients die, and prayed that would not be him. Give me a band any day of the week.Don't be so quick to say that. Banded folks have just as many issues as bypass. Just different issues. Sometimes it is surgeon skill like the 4 people that died through 800 GET SLIM. Sometimes it is the band, most times it is the band. It's no easy task removing those buggars when they go bad. Plenty of people have been in ICU due to the band.
You don't stand any fewer complications because of the band, you just stand different complications. Ever seen the mess an erosion causes? I stand a risk of a leak months after surgery, you guys stand a leak for the duration of your band.
Previously Midwesterngirl
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
I'll never believe banding is safe or effective. Having gone through what I did and having witnessed myriad others suffer with complications, I have come to my own conclusions over the past 9 years.
Statistics are fine for research, but talking to people who have gone through it and come out the other side, in spite of the complications they had, would be more realistically beneficial.
I do think that it's important to read statistics, of course, but let it be only part of what helps make your decision in this process.
Statistics are fine for research, but talking to people who have gone through it and come out the other side, in spite of the complications they had, would be more realistically beneficial.
I do think that it's important to read statistics, of course, but let it be only part of what helps make your decision in this process.
Avoid kemmerling, Green Bay, WI
Good article! I am glad that it mentioned the fact that complications in general have went down considerably after improvements in the technique and application of the band. I do not think that gets stressed when the whole lapband complications stuff comes up. Newer band models and application techniques have cut down considerably on issues. Thanks for posting:)
Mari 
WAY TO GO STEPH i love my band People have just been posting bits and pieces of this? Not the entire study? That's wrong.
Anytime you see a study be sure and ask for the link. There is actually a woman that used to post here, on the band board, and she would alter the studies to defend her bizarro claims. Well, you probably know her.. Sandy?
Anytime you see a study be sure and ask for the link. There is actually a woman that used to post here, on the band board, and she would alter the studies to defend her bizarro claims. Well, you probably know her.. Sandy?
Previously Midwesterngirl
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
People have just been posting bits and pieces of this? Not the entire study? That's wrong.
Here is the link Bubbles so yes people when giving facts are NOT posting the whole article just what they want to post.
http://www.obesityhelp.com/forums/LapBand/4353637/Repost-Why -I-Chose-the-Band/action,replies/topic_id,4353637/page,2/
go look at Maria's post she only posted half of this article and Steph went and looked it up and then posted the rest of it in the same thread so no Maria did not post this whole article Steph had to find the rest of it so we could read the whole thing .
Then that is why Steph went and posted it again in this one because it was the whole thing together
That is why I made the comment if you cant post the entire article without paste and copy of what you want to show then dont post at all. '
give us all the facts not what you want to show .
Here is the link Bubbles so yes people when giving facts are NOT posting the whole article just what they want to post.
http://www.obesityhelp.com/forums/LapBand/4353637/Repost-Why -I-Chose-the-Band/action,replies/topic_id,4353637/page,2/
go look at Maria's post she only posted half of this article and Steph went and looked it up and then posted the rest of it in the same thread so no Maria did not post this whole article Steph had to find the rest of it so we could read the whole thing .
Then that is why Steph went and posted it again in this one because it was the whole thing together
That is why I made the comment if you cant post the entire article without paste and copy of what you want to show then dont post at all. '
give us all the facts not what you want to show .
Quit Smoking 10/8/10
Starting BMI 52.9 BMI now 44.4 updated 6/6/11
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