Laparoscopic Adjustable Gastric Banding: An Attractive Option

Obesity is a public health problem, for which the prevalence has increased worldwide at an alarming rate, affecting 1.7 billion people in the world.

To describe the technique employed in incomplete penetration of gastric band where endoscopic management and/or primary closure is not feasible.

Laparoscopic removal of gastric band was performed in five patients with incomplete penetrance using Foley catheterization in the perforation site that could lead to the development of a gastro-cutaneous fistula.

The cases presented include a leak that required surgical lavage with satisfactory outcome, and one patient developed stenosis 3 years after surgical management, which was resolved endoscopically. In all cases, the penetration site closed spontaneously.

Gastric band erosion has been reported in 3.4% of cases. The reason for inserting a catheter is to create a controlled gastro-cutaneous fistula, allowing spontaneous closure.

Various techniques have been described: the totally endoscopic, hybrid techniques (endoscopic/laparoscopic) and completely laparoscopic. A technique is described here that is useful and successful in cases where the above-described treatments are not viable.

La obesidad es un problema de salud pública cuya prevalencia se ha incrementado a nivel mundial de forma alarmante, afectando a 1.7 billones de personas en el mundo.

Describir la técnica empleada en penetración incompleta de banda gástrica cuyo manejo endoscópico o cierre primario no es viable.

Se realizó retiro laparoscópico de banda gástrica en 5 pacientes con penetración incompleta y colocación de sonda Foley en el sitio de perforación, favoreciendo el desarrollo de una fístula gastrocutánea.

Se presentó una fuga que requirió lavado quirúrgico con evolución satisfactoria; un paciente desarrolló estenosis 3 años después del manejo quirúrgico, que se resolvió con dilatación endoscópica. En todos los casos se logró el cierre espontáneo del sitio de penetración.

La erosión por banda gástrica se ha reportado en un 3.4%. El razonamiento de poner una sonda consiste en crear una fístula gastrocutánea controlada que permita el cierre espontáneo.

Se han descrito diversas técnicas: las totalmente endoscópicas, técnicas híbridas (endoscópicas/laparoscópicas) y totalmente laparoscópicas. Se describe una técnica que resulta útil y exitosa en casos en los que los tratamientos antes descritos no son viables.

Laparoscopic sleeve gastrectomy (SG) is gaining popularity as a revision option after failed laparoscopic adjustable gastric banding (LAGB). Data have shown that single stage revisions may be associated with a higher complication rate. A histologic basis for this observation has not been studied. The objective of this study was to document the histologic properties of the LAGB capsule across the gastric staple line after SG at various time points after LAGB removal.

Gastric sleeve specimens of all LAGB to SG revisions were identified from January to May 2013 and underwent histologic evaluation of the LAGB capsule. Single blinded pathologist interpretation was performed, with inflammation, fibrosis, neovascularization, foreign body (FB) reaction, and wall thickness assessed semi-quantitatively and scored from 0–3. Based on combined features, an attempt was made to predict the timing of revision surgery.

The study identified 19 revisions performed for inadequate excess weight loss or weight regain. The mean age for revision was 44 (19–65). The minimum time to revision was 42 days, the longest 1,188 days. There were no surgical complications. Varying degrees of inflammation and fibrosis were common features at all times. Angiogenesis, neovascularization and FB reaction were prominent in revisions performed before 80 days. The gastric wall was thicker during early revision. The optimal time to perform revision was difficult to determine.

LAGB caused varying degrees of inflammatory and FB reaction that time did not fully resolve. The lower leak rates observed with delayed revisions do not appear to be attributable to gastric histology.

We present a series of 22 patients who underwent laparoendoscopic single-site (LESS) surgery for placement of an adjustable gastric band at a U.S. university hospital.

From December 2007 to December 2008, LESS surgery, through a transumbilical incision, to place an adjustable gastric band was performed on 22 patients under institutional review board approval. Multiple ports were placed through a single incision in the umbilicus to allow for liver retraction, visualization, and the working instruments. None of the critical steps of the standard pars flaccida technique were altered.

A total of 22 patients were carefully selected and included 20 women and 2 men, with an age range of 18–67 years (mean 42). The mean body mass index was 42 kg/m² (range 35–45). The exclusion criteria included hepatomegaly, central obesity, previous abdominal surgery, and super-obesity. The mean operative time was 84 minutes (range 53–111). All patients were discharged home within the 23-hour admission, and no perioperative complications were noted. In addition, no wound-related complications developed. One patient required conversion to conventional laparoscopy. No intraoperative or postoperative complications occurred.

In our experience, LESS surgery for adjustable gastric band placement shows this technique to be both feasible and safe in selected patients to date. Although technical limitations exist that will be improved on, additional studies are needed to compare LESS surgery for placement of an adjustable gastric band with traditional laparoscopic techniques.

Gastric banding has emerged in the development of bariatric surgery as an important therapeutic option for morbidly obese patients. Following the major pioneering milestones of Wilkinson and Peloso, who placed a nonadjustable band around the upper part of a patient's stomach in 1978, and Hallberg and Forsell, as well as Kuzmak, who worked on separate continents to develop the clinical application of adjustable gastric bands in the early 1980s, banding entered into widespread use in the mid 1990s, when the innovation of the laparoscopic technique made it possible to insert adjustable bands without open surgery. Today, several institutions have reported long-term (≥5-year) results with laparoscopic adjustable gastric banding (LAGB). With a small number of exceptions, LAGB efficacy data range from satisfactory to excellent, with some institutions noting annual reoperation rates in the vicinity of 5%, and quality of life scores using the Bariatric Analysis and Reporting Outcome System in the good-to-excellent range in up to 70% of patients. These outcomes, coupled with the fact that LAGB has the best record of safety among the bariatric operations, is reversible, and can be performed at a relatively low cost, have established LAGB as an important tool in the long-term management of morbid obesity.