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Published Online January 2008

Gastric Banding – to Band or Bypass

Publication: The Annals of The Royal College of Surgeons of England
Volume 90, Number 1
Whether to band or bypass is a controversial question and these two articles are timely. Interestingly, a ‘band all’ advocacy rarely comes from a bariatric surgeon who has ascended the difficult learning of laparoscopic gastric bypass surgery. In other words, based on their experience, there is little doubt in their minds that bypass surgery has better long-term results in terms of weight loss and resolution of co-morbidities although at a cost of increased morbidity and, possibly, mortality. Patients need to be fully informed about the pros and cons of the various procedures and make a decision along with their bariatric surgeon as to what they are prepared to risk in order to obtain a particular result – which may vary from patient to patient. Both procedures have their advantages and disadvantages and are here to stay despite emerging disquiet about the increasing long-term revision rates for gastric banding. Furthermore, we are slowly learning about choosing the most suitable operation for a particular patient – a science which is still in its infancy.
John BaxterE: [email protected]

Adjustable Gastric Banding: Blessing or Curse?

Author: Jacques M Himpens
The technique of adjustable gastric banding has become the gold standard in the surgical treatment of morbid obesity in Western Europe and in Australia. It is now rapidly gaining popularity in the US as well. The procedure is rather easy to perform, even in massively obese patients, and the band itself is adjustable. Since the band is placed around the stomach, no changes are made to the existing anatomy, which renders the procedure fully reversible. As the main goal in obesity surgery is not to harm, the adjustable gastric band could appear as an ideal solution, yet some caveats exist. We will not focus here on the numerous material failures of the procedure that have emerged with the different types of bands, such as tubing-port disconnection, tubing decay and band chamber leakage, as these problems have been mostly addressed in recent band development.
Some of the effects of the band are not reversible. Permanent damage to oesophageal motility has been reported.1 Band-induced gastro-oesophageal reflux may facilitate the development of distal oesophageal cancer.2 Gastro-oesophageal reflux is a logical consequence of high gastric stenosis. In fact, since the stomach proximal to the band is highly distensible, some unavoidable dilation of the pouch must be anticipated. If, on the other hand, the band is placed very high on the stomach (i.e. in the so-called oesogastric position) oesophageal dilation will very often ensue.3 Not surprisingly, the average number of vomiting episodes in patients reported as successes in terms of weight loss is more than once a day. The questionable quality of life caused by this frequent emesis condition, however, does not always translate in quality of life studies such as the BAROS score in band patients.4 This phenomenon can only be explained by the psychological reward patients obtain with significant weight loss, which renders all other symptoms negligible in their opinion. Nonetheless, if one keeps in mind the potential risk of oesophageal cancer possibly enhanced by marked reflux and frequent vomiting, one should assume that at least annual oesogastroscopies should be performed in this patient population. Also, in order to avoid vomiting and if not managed properly, a significant number of patients will change their eating habits and switch to an often highly caloric semi-liquid diet.5 Poor food selection, particularly avoidance of protein-rich food, more often than not results in protein malnutrition, anaemia, and vitamin depletion. Lack of compliance with postoperative dietary regulations is the principal cause of failure of any restrictive procedure. Band patients experiencing this turn in eating habits can, and should, be treated by temporary loosening of the band, but this implies patient discipline which, as a rule, is not prevalent amongst the bariatric patients.6
Despite this lack of patient discipline, the need for frequent doctor's visits is very likely the most important key to success or failure with this technique. Most studies performed in Australia (but not elsewhere) report excellent results (i.e. a permanent weight loss of 50% of excess weight) in almost all patient groups, regardless of their initial body mass index (BMI). The Australians have established a very well-organised follow-up system, involving dieticians, physician assistants, nurses, etc. who are willing to help patients, even if treated elsewhere.7 Similar empathy is hard to find elsewhere in the world and European patients appear to have a lower tolerance for frequent follow-up visits. As a result, the clinical results of most Australian groups remain unmatched. The need for thorough follow-up, however, cannot be over-emphasised as detection of dangerous symptoms and their adequate treatment can be life-saving. In the rare, but extremely serious, condition of pouch necrosis,8 for example, symptoms often are deceivably mild.
The most serious challenge to a bariatric operation is time. Indeed, many patients will experience weight regain starting some 2 years after the procedure. Few series report on results beyond 5 years; those that have, report dismal longterm results. Re-operation rates continue to rise after 10 years or more.9 In fact, this high incidence of re-operations has pushed researchers into developing a biodegradable band, with the intention of complete disappearance of the band before dreadful delayed complications can occur. Besides material breakdown, the most frequent causes of re-operation are: insufficient weight loss, intractable gastro-oesophageal reflux, pouch dilation or band slippage, and intragastric migration of the band. Whereas some authors can treat this latter complication by endoscopic means,10 most surgeons still rely on a laparoscopic or even ‘open’ approach for band removal. Replacement of a band after slippage or migration is, in our experience and in most others,11 quite unsatisfactory. Some surgeons, however, do not hesitate to replace a band once, twice, or even three times. The therapeutic attitude of some authors towards adjustable band complications is sometimes quite surprising; achalasia-like malformations of the oesophagus, for example, are now judged acceptable by some.12 This disturbing evolution is hardly compatible with the prime intention of the procedure itself, namely minimal aggression to the body.
Many band patients will need another bariatric operation at some point in the future, be it for obesity recidivism or for adverse effects of the technique. There is substantial evidence that re-do operations are technically more demanding, more prone to complications, and less effective than primary ones. Quite logically, the number of conversions into laparotomy will be markedly higher in the re-do situation. The incidence of complications in re-do bariatric surgery is significantly higher than in first comers.13 The pouch is more difficult to construct and will often end up being too large because excessive scarring obscures the view and renders dissection hazardous. Quite often, surgeons will be forced into adapting their technique to the anatomical changes induced by the band and switch to an operation they are not accustomed to, like biliopancreatic diversion.
Can the band be used as a rescue strategy after other failed bariatric procedures? Some authors have had good results by adding an adjustable band after previous failed procedures.14,15 Whilst in the latter case adding restriction may sound logical, it contradicts Scopinaro's principle. Also, placing an adjustable band proximal to the vertical staple line of the VBG involves placement of the band in the aforementioned oesogastric position, prone to oesophageal dilation. Moreover, it implies replacing a failed restrictive construction with another one, which appears illogical to most of us. Indeed, there is substantial evidence in literature that the best way to treat a failed restrictive procedure is a malabsorptive operation. The adjustable band has also been used in conjunction with gastric bypass, in an effort to render the bypass reversible and allow for endoscopic access to the greater stomach and to the biliary tree. A committee of experts, however, recently determined this technique to be unsuitable due to its grave side effects.16

Conclusion

Adjustable band gastroplasty in the treatment of obesity appears to be extremely operator (or country) dependent. The excellent results obtained by some are in sharp contrast to the experience of most others. A good procedure should be easily replicable, not only considering the technique itself, but also considering the approach to follow-up. As long as this is not the case, the adjustable band will remain a questionable tool for many bariatric surgeons, including ourselves.

References

1.
O'Rourke RW, Seltman AK, Chang EY, Reavis KM, Diggs BSHunter JG, et al. A model for gastric banding in the treatment of morbid obesity: the effect of chronic partial gastric outlet obstruction on oesophageal physiology. Ann Surg 2006; 244: 723–33.
2.
Snook KL, Ritchie JD. Carcinoma of esophagus after adjustable gastric banding. Obes Surg 2003; 13: 800–2.
3.
Weiss HG, Nehoda H, Labeck B, Peer-Kuehbrger R, Oberwalder MAigner F, et al. Adjustable gastric and esophagogastric banding: a randomized clinical trial. Obes Surg 2002; 12: 573–8.
4.
Victorzon M, Tolonen P. Bariatric Analysis and Reporting Outcome System (BAROS) following laparoscopic adjustable gastric banding in Finland. Obes Surg 2001; 11: 740–3.
5.
Favretti F, O'Brien PE, Dixon JB. Patient management after LAP-BAND placement. Am J Surg 2002; 184: 38S–41S.
6.
Scopinaro N. Comments to presidential address: gastric bypass and biliopancreatic diversion operations. Obes Surg 2002; 12: 881–3.
7.
Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases. Surg Endosc 1999; 13: 550–4.
8.
Suter M, Calmes JM, Paroz A, Giusti V. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rats. Obes Surg 2006; 16: 829–35.
9.
Kirchmayr W, Ammann K, Aigner F, Weiss HG, Nehoda H. Pouch dilatation after gastric band causing gastric necrosis. Obes Surg 2001; 11: 770–2.
10.
Weiss H, Nehoda H, Labeck B, Peer R, Aigner F. Gastroscopic band removal after intragastric migration of adjustable gastric band: a new minimal invasive technique. Obes Surg 2000; 10: 167–70.
11.
Suter M. Laparoscopic band repositioning for pouch dilatation/slippage after gastric banding: disappointing results. Obes Surg 2001; 11: 507–12.
12.
Boschi S, Fogli L, Berta RD, Patrizi P, Di Domenico MVeter F, et al. Avoiding complications after esophago-gastric banding: experience with 400 consecutive patients. Obes Surg 2006; 16: 1166–70.
13.
Sweeney JF, Goode SE, Rosemurgy AS. Redo gastric restriction: a higher risk procedure. Obes Surg 1994; 4: 244–7.
14.
Wenger M, Piec G, Branson R, Potoczna N, Horber FF, Steffen R. Salvage of gastric restriction following staple line dehiscence after vertical banded gastroplasty by insertion of an adjustable gastric band. Obes Surg 2005; 15: 216–22.
15.
Slater GH, Fielding GA. Combining laparoscopic adjustable gastric banding and biliopancreatic diversion after failed bariatric surgery. Obes Surg 2004; 14: 1141–2reply 1142.
16.
Greve JW, Furbetta F, Lesti G, Weiner RA, Zimmerman JM, Angrisani L. Combination of laparoscopic adjustable gastric banding and gastric bypass: current situation and future prospects—routine use not advised. Obes Surg 2004; 14: 683–9.

The Case for Laparoscopic Banding

Authors: Rishi Singhal and Paul Super
Morbid obesity is associated with a loss of life expectancy averaging 12 years.1 In 2001, the UK National Institute for Health and Clinical Excellence (NICE)2 estimated that more than 600,000 adults have a body mass index (BMI) of ≥ 40 kg/m2; this number is rising annually.
Bariatric surgery can be broadly classified into two groups – malabsorptive procedures and restrictive procedures. Malabsorptive procedures include jejunoileal bypass and biliopancreatic diversion. The restrictive procedures include gastroplasty, gastric bypass and laparoscopic gastric banding. Despite its name, gastric bypass surgery is mostly restrictive with bypass of the duodenum to produce limited dumping syndrome.

History and surgical technique of laparoscopic gastric banding

Gastric banding was first performed by open surgery in 19833 and was made adjustable in 1986. With the increasing popularity of minimally invasive surgery, laparoscopic insertion of the band was performed for the first time by Belachew and colleagues in 1993.4 To date, more than 300,000 band placements have been performed worldwide.5
The procedure is completely laparoscopic and is normally carried out using a 4- or 5-port technique. A window is first created in the pars flaccida and, subsequently, the angle of His is dissected. This facilitates the passage of band behind the cardia which is fastened approximately 2 cm below the gastro-oesophageal junction to create a small proximal stomach pouch and a feeling of satiety upon ingestion of a low-volume meal. The band is connected to tubing attached to an injection port placed subcutaneously. The tightness can be adjusted by subcutaneous injection of fluid into the band, thus helping to achieve the right amount of restriction required.

The case for laparoscopic banding

The most important feature of lap band insertion is that no viscus is opened or anastomosed in order to create this effect. This is almost exclusively carried out laparoscopically (conversions to open are extremely rare – less than 0.5%).6
Patients are usually admitted on the morning of the procedure. The operative technique requires a surgeon competent in performing laparoscopic hiatal surgery. The instrumentation required is the same as for any of these procedures. The operative time is less than an hour on average.6 This subsequently reduces the complications associated with prolonged anaesthesia (predominantly deep vein thrombosis and cardiorespiratory problems) and correlates with quicker recovery, mobility and subsequent discharge.
Postoperatively, the patient is discharged on the day following the surgery in almost all cases. The diet is built up from fluids, to a purée diet, to normal texture over a period of 4–6 weeks. A radiological assessment of the band is normally carried out at this time and thereafter only if clinically indicated. Further tightening can be carried out either under radiological control or by blind adjustments using well-validated fill protocols which do not require radiological screening.
The surgery is reversible and is not associated with any long-term side effects or nutritional deficiencies compared to other more invasive procedures such as gastric bypass. The follow-up protocol is simple and normally involves reviewing the patient 3-monthly for the first year, 6-monthly for the second year and subsequently only on an as-required basis. This is contrary to the more invasive procedures where regular follow-up and serial blood profiling is required to detect and correct metabolic abnormalities.
The efficacy of laparoscopic gastric banding in producing weight loss is comparable to other operative procedures with the added benefit of low postoperative mortality. A recent systematic review by Buchwald et al.7 of the world literature from 1990–2003 yielded good quality relating to 22,094 procedures. This study compared the results of gastric banding, gastric bypass, gastroplasty and biliopancreatic diversion. This analysis quoted excess weight loss of 47.5% for gastric banding compared to 61.6% for gastric bypass, 68.2% for gastroplasty and 70.1% for biliopancreatic diversion. The operative mortality for gastric banding and gastroplasty were quoted as 0.1%. Mortality for gastric bypass and biliopancreatic diversion were 0.5% and 1.1%, respectively.
Besides weight loss, banding also has comparable results as to resolution of co-morbidities. The systematic review by Buchwald et al.7 demonstrated strong evidence for improvement in type 2 diabetes and impaired glucose tolerance for all the surgery types. The reported results for resolution of diabetes were 47.9% for gastric banding compared to 98.9% for biliopancreatic diversion, 83.7% for gastric bypass and 71.6% for gastroplasty. Improvement in hypertension and sleep apnoea with surgery was consistent across all the procedures demonstrating improvement in at least 70% and 85% of the cases, respectively.
A subsequent systematic review on laparoscopic bands by Chapman et al.8 re-iterates the same conclusions. This article quotes a lower mortality with banding (0.05%) and concludes that it is safer than gastroplasty and Roux-en-Y gastric bypass. It also states that there are no significant differences with respect to weight loss between banding and gastric bypass at 4 years.
Both these systematic reviews included patients with a wide range of BMI and were not designed to assess bariatric surgery in the super obese (i.e. BMI ≥ 50 kg/m2). This was studied by Parikh et al.,9 who compared laparoscopic adjustable gastric banding (LAGB; n = 192), Roux-en-Y gastric bypass (RYGBP; n = 97), and biliopancreatic diversion with/without duodenal switch (BPD; n = 43). They demonstrated the superiority of LAGB in terms of conversion rates (0.5%), total operative time (60 min) and length of stay in hospital (24 h). Similar to previous studies, the morbidity with LAGB was statistically lower than the other procedures. In terms of weight loss there was no statistically significant difference in the excess weight loss between LAGB and RYGBP at 2 and 3 years.
The overall rate of complications after this procedure is low and by far the vast majority are minor. In our own local experience of 1140 cases completed up to June 2007,10 we found minor complication rates of port-site bleeding (0.3%) and band infection requiring band removal (0.5%). There were no thrombo-embolic complications or episodes of band erosion. Major complications included gastric perforation at the time of insertion (0.1%), partial slippage/pouch dilatation (0.7%) or complete band slippage (0.1%). The incidence of these complications is extremely low and nearly all can be dealt with laparoscopically – usually by band removal. Reinsertion can be carried out later so long as technical reasons for band failure have been identified. On the other hand, complications for other bariatric procedures such as anastomotic leak or serious intra-abdominal infection have more likelihood of conversion to open surgery and subsequent critical care requirement. In addition, the complications of nutritional deficiency are seldom seen with laparoscopic gastric band insertion but commonly seen in malabsorptive types of procedures.
The end-point of weight loss surgery is not to achieve the cosmetic goal of normal, lean BMI of 25 kg/m2, but to treat the medical co-morbidities associated with the obese state. From the systematic reviews cited here, the cure of practically all reversible obesity related co-morbidity is achievable by a 40–70% reduction in excess weight to a BMI of about 35 kg/m2 rather than the cosmetic target of a BMI of 25 kg/m2 which would represent 100% excess weight loss if achieved. This target is well within the remit of laparoscopic gastric banding.

Conclusions

Laparoscopic gastric band insertion maintains comparable efficacy for weight loss and resolution of obesity-related comorbidities when compared to gastric bypass. In addition, the procedure is simple, safe and carries a lower mortality and morbidity.

References

1.
Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 2003; 289: 187–93.
2.
National Institute for Health and Clinical Excellence. Technology Appraisal Guidance No 46. Guidance on the use of surgery to aid weight reduction for people with morbid obesity 2002; London: NICE
3.
Kuzmak LI. A review of seven years' experience with silicone gastric banding. Obes Surg 1991; 1: 403–8.
4.
Belachew M, Legrand M, Vincent V, Lismonde M, Le Docte N, Deschamps V. Laparoscopic adjustable gastric banding. World J Surg 1998; 22: 955–63.
5.
Favretti F, Segato G, Ashton D, Buseto L, De Luca MMazza M, et al. Laparoscopic adjustable gastric banding in 1,701 consecutive obese patients: 12-year results. Obes Surg 2007; 172: 168–75.
6.
Singhal R, Guy A, Hunt K, Kuzinkovas V, Super P. Early results of laparoscopic banding in 400 patients from a bariatric centre in UK. Br J Surg 2006; 93(Suppl. 1)5.
7.
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories WFahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724–37.
8.
Chapman AE, Kiroff G, Game P, Foster B, O'Brien PHam J, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery 2004; 135: 326–51.
9.
Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI > 50) is safe and effective: a review of 332 patients. Obes Surg 2005; 15: 858–63.
10.
Singhal R, Kitchen M, Nidrika S, Hunt K, Super P. The ‘Birmingham Stitch’ – Avoiding slippage in laparoscopic gastric banding. Obes Surg 2007; In press.

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cover image The Annals of The Royal College of Surgeons of England
The Annals of The Royal College of Surgeons of England
Volume 90Number 1January 2008
Pages: 2 - 6
PubMed: 18201487

History

Published in print: January 2008
Published online: 11 March 2015

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