Success Factors and Controversies of Laparoscopic Adjustable Gastric Banding
There are specific requirements for the successful application of Lap-Band.
Although these requirements are not difficult or commonplace, they are necessary.
Surgeons need good laparoscopic surgical skills and experience in bariatric surgery.
Surgical skills and experience can be acquired through training and guidance.
Patient safety must be ensured, patients must be educated and supported, and long-term treatment and timely problem-solving must be provided.
This can be ensured through a multidisciplinary support team (nutritionists, psychologists, internists, and surgeons).
Because of the progressive adjustment of the straps, the patient's weight loss process is also gradual.
Ideally, weight loss should be slow and sustained over two years or longer, without significant restriction or vomiting, and preferably with a feeling of hunger before eating and a feeling of fullness after eating small amounts of food.
Laparoscopic adjustable gastric banding is the only completely reversible weight loss surgery.
It does not cause permanent changes to the patient's anatomy, which is beneficial to both doctors and patients. If necessary, the bandage can be easily removed, and the stomach can return to normal.
Most complications following lap-band surgery are not life-threatening, and even if they do occur, they can usually be repaired laparoscopically.
Advances in surgical methods, including improvements in instruments and techniques, have significantly reduced the incidence of complications.
Of course, avoiding complications as much as possible is always the best strategy to reduce them.
If complications occur after the Lap-Band procedure, or if weight loss is not achieved, a corrective surgery may need to be considered.
There are several options for corrective surgery, including adding a nutrient restriction procedure to the banding procedure (our method), or modifying it to laparoscopic gastric bypass, cholecystopancreatic diversion, or cholecystopancreatic diversion plus duodenal transposition. These corrective surgeries are not only safe for the vast majority of patients, but also achieve good results.
Laparoscopic Adjustable Gastric Bandaging: Controversy
background
Laparoscopic adjustable gastric banding (LAGB) is used by many surgeons around the world as a treatment for morbid obesity.
Since 1990, it has been the most commonly used weight loss surgery method in Australia and Europe.
Following the FDA's approval of gastric banding in 2001, the use of lap-bands increased rapidly, providing patients with an alternative to Y-shaped gastric bypass (RYGB).
Like vertical gastric banding (VBG), LAGB is a procedure that purely restricts gastric capacity, without any complications from intestinal anastomosis and cutting lines, or the risk of gastrointestinal fistula.
Long-term follow-up data from VBG and other gastric capacity-restricting surgeries show that, compared with other surgeries such as RYGB or procedures that combine gastric capacity restriction and nutrient absorption restriction, the effects of excess weight loss and treatment of comorbid obesity are moderate.
In addition, the poor long-term weight loss effect after VBG suggests that the treatment effect of LAGB may not be well sustained.
In the United States, initial LAGB trial results were disappointing.
As part of a Class A clinical trial approved by the U.S. FDA under the "Investigational Medical Device Exemption" program, Virginia Medical School Hospital performed 36 LAGB procedures from March 1996 to May 1998.
Patients eligible for LAGB include those with a preoperative BMI of less than 50, no or minimal history of abdominal surgery, and whose diet does not involve consuming large amounts of calories from sweets.
The straps were placed using standard laparoscopic techniques.
To date, the bandages have been removed in 18 out of 36 cases (50%).
Reasons for removing the bandage and undergoing other surgeries include weight loss failure (defined as excess weight loss of less than 50% or BMI greater than 35), weight loss failure with esophageal dilatation, weight loss failure with bandage leakage, and esophageal dilatation with frequent vomiting.
Of the 18 patients who required removal of the bandages, 14 underwent a modified gastric bypass procedure, either laparoscopic (n=8) or open surgery (n=5).
The overall average excess weight reduction rate was 62% (range 29%–106%), of which 43% of the %EWL was achieved after modified gastric bypass surgery, while the Lap-Band reduced %EWL by only 19%.
Improvement in obesity-related comorbidities also occurred after modified gastric bypass surgery.
African Americans experience less effective weight loss with the LAGB program compared to white people.
There were no significant differences between the two groups in preoperative weight, percentage of ideal weight (%IBW), and body mass index.
However, African Americans had lower rates of additional weight loss during follow-up at 12, 24, and 36 months post-surgery.
Among the other 18 patients whose bandages were not removed, the average %EWL was only 32%.
In another study, Angrissani et al. reported the findings of an Italian collaborative research group on LAGB.
A total of 1,863 patients with LAGB were included, with a preoperative mean BMI of 43.7.
At 6, 12, 24, 36, 48, 60 and 72 months post-surgery, the BMIs were 37.9, 33.7, 34.8, 34.1, 32.7, 34.8 and 32, respectively.
The overall mortality rate was 0.53%, the conversion rate to open surgery was 3.1%, and severely obese patients with a BMI ≥ 50 were more likely to require open surgery than morbidly obese patients with a BMI < 50.
The most common postoperative complications are problems with the connection tube of the bandage, gastric sac dilatation, and gastric erosion.
This study did not provide data on improvements in obesity-related comorbidities.
Several studies have shown that body mass index (BMI) decreases only slightly after LAGB surgery.
Recent clinical results show that only 41% EWL is achieved 1 year after LAGB surgery in the United States, while in Europe it can reach 53% to 64%.
Improvement in obesity-related comorbidities was also moderate, with 64% of type 2 diabetes cases showing improvement, including mild improvement in insulin resistance and pancreatic β-cell function.