Brief History and Summary of Bariatric Surgery

Chapter 6.

GASTRIC BANDING

Another example of a purely restrictive bariatric procedure is nonadjustable gastric banding. It was first introduced in 1978 by Wilkinson, who applied a 2 cm Marlex mesh round the upper part of the stomach and separated the stomach into a small upper pouch and the rest of the stomach. Eventual pouch dilatation resulted in unsatisfactory weight loss.

In 1980, Molina described the gastric segmentation procedure, in which a Dacron vascular graft was placed around the upper stomach. The gastric pouch was smaller than Wilkinson’s procedure. Because the Dacron graft produced adherence of the liver to the band, it was replaced ultimately by PTFE (Gortex®).

In 1983, Kuzmak began using a 1 cm Silicone® band to encircle the stomach, creating a 13 mm stoma and a 30-50 mL proximal gastric pouch. This band was later modified to provide adjustability of the band diameter using an inflatable balloon (see below: “Laparoscopic adjustable gastric banding”).

Advantages of gastric banding

Absence of anemia
Absence of dumping
Lack of malabsorption
Short hospital stay
Very low mortality rate

Complications of gastric banding

Gastric perforation
Incisional hernia
Stomal stenosis
Band slippage
Band erosion into stomach
Need for reversal or revision

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

The adjustable band was developed by Kuzmak who devised a Silicone® band lined with an inflatable balloon in 1986. This balloon was connected to a small reservoir that is placed under the skin of the abdomen through which the diameter of the band can be adjusted. Inflation of the balloon functionally tightens the band and thereby increases weight loss, while deflation of the balloon loosens the band and reduces weight loss. These bands can be inserted laparoscopically, thereby reducing the complications and discomfort of an open procedure.

Currently several brands of adjustable bands are available – the LAP-BAND ® System, the Swedish Adjustable Band and the Mid-Band. None have yet been shown clearly to be superior to the other. The LAP-BAND ® system (Inamed, Santa Barbara, CA) received US FDA approval in 2001.

Since these procedures do not involve an intestinal bypass, laparoscopic adjustable gastric banding (LAGB) is a procedure which induces weight loss solely through the restriction of food intake. For optimal results, strict patient compliance and frequent follow-up for band adjustments are required. The LAP-BAND ® is a reversible procedure that does not carry the risks of nutritional and mineral deficiencies of other bariatric procedures. The mortality risk with the LAGB is about 0.1% , which is less than that with the RYGBP.

The LAGB is safe and has a low rate of life-threatening complications. Excess weight loss with the laparoscopic adjustable gastric band is lower than that with the gastric bypass or malabsorptive procedures, varying between 28% and 65% at 2 years and 54% at 5 years. An improvement in weight-related comorbidities has been observed, including Type II diabetes mellitus, dyslipidemia, sleep apnea, gastroesophageal reflux, hypertension, and asthma. However, compared to the gastric bypass, the impact on co-morbidities appears to be somewhat less favorable. Remission of diabetes with LAGB is seen in 64-66% at one year and 80% at 2 yrs versus 93% at 9 years with RYGBP. Long-term results comparing LAGB with gastric bypass or BPD are not yet available.

While some studies have documented weight loss equal to RYGBP with fewer complications, other groups have had disappointing outcomes. Some studies document a substantial number of patients who have required re-operation for long-term complications of the adjustable band (such as for port problems, erosions and slippage, or inadequate weight loss). Conversion of a failed LAGB to another bariatric procedure may be technically more difficult and associated with more complications than with a first time RYGBP or DS operation.

Advantages of LAGB

Same as gastric banding
Adjustability of the band
Reversibility (by band removal)
Laparoscopic placement

Complications after LAGB

Intraoperative :
Hemorrhage
Injury to the spleen, stomach, or esophagus
Conversion to open procedure

Postoperative :
Band slippage (stomach prolapse)
Leakage of the balloon or tubing
Port Infection
Band infection
Obstruction
Nausea and vomiting

Late complications

Band erosion into the stomach
Esophageal dilatation
Failure to lose weight

REFERENCES

Gastric banding

Oria, HE. Gastric banding for morbid obesity. Eur J Gastroenterol Hepatol 1999;11:105-114.

Kuzmak, LI, Yap, IS, McGuire L, et al. Surgery for morbid obesity. Using an inflatable gastric band. AORN J 1990;51:1307-24.

Laparoscopic adjustable gastric banding

Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-568.

O’Brien PE, Dixon JB, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band): a prospective study of medium-term effects on weight, health and quality of life. Obes Surg 2002;12:652-60.

Dixon JB, O’Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care 2002;25:358-63.

Ponce J, Haynes B, Paynter S, et al. Effect of Lap-Band-induced weight loss on type 2 diabetes mellitus and hypertension. Obes Surg 2004;14:1335-42.

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TABLE OF CONTENTS

• Chapter 1. INTRODUCTION

• Chapter 2. JEJUNOILEAL BYPASS

• Chapter 3. GASTRIC BYPASS & LAPAROSCOPIC GASTRIC BYPASS

• Chapter 4. BILIOPANCREATIC DIVERSION DUODENAL SWITCH

• Chapter 5. GASTROPLASTY

• Chapter 6. GASTRIC BANDING & LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

• Chapter 7. ON THE HORIZON & SUMMARY

• References

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