Faculty Bibliography

BACKGROUND: This study reviews outcomes after laparoscopic adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGBP). METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-operative age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percentage excess weight loss (EWL), and postoperative complications. RESULTS: 11 patients (seven females, four males) were referred to our program for weight loss failure after RYGBP (six open, five laparoscopic). Mean age and BMI pre-RYGBP were 39.5 years (24-58 years) and 53.2 kg/m(2) (41.2-71 kg/m(2)), respectively. Mean EWL after RYGBP was 38% (19-49%). All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain. The average time between RYGBP and LAGB was 5.5 years (1.8-20 years). Mean age and BMI pre-LAGB were 46.1 years (29-61 years) and 43.4 kg/m(2) (36-57 kg/m(2)), respectively. Vanguard (VG) bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 76 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosions; however, one patient required reoperation for a flipped port. The average follow-up after LAGB was 13 months (2-32 months) with a mean BMI of 37.1 kg/m(2 )(22.7-54.5 kg/m(2)) and an overall mean EWL of 59% (7-96%). Patients undergoing LAGB after failed RYGBP lost an additional 20.8% EWL (6-58%). CONCLUSION: Our experience shows that LAGB is a safe and effective solution to failed RYGBP

BACKGROUND: Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study compare the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR. METHODS: A retrospective review of a prospective database of all patients undergoing LAGB was performed to determine the incidence of reoperation in the two groups. RESULTS: Between July 2001 and August of 2006, 1298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range, 71.1-245.7 kg) and 45.4 kg/m(2) (range, 28-75 kg/m(2)). Average follow-up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months, respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.6% and 1.7% respectively (p < 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.9% and 3.5%, respectively (p < 0.001). There was no significant difference in rate of slip repair alone between the two groups: 2.3% and 1.7%, respectively (p < 0.44). CONCLUSIONS: Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation

Background: This is the first systematic review and meta-analysis of the large body of data describing the Swedish adjustable gastric band (SAGB) and Lap-Band (LB). Methods: A systematic review was performed that included screening of studies published in any language (January, 1 1998 through April 30, 2006) identified through MEDLINE Current Contents, or the Cochrane Library. Studies with >= 10 SAGB or I-B patients reporting >= 30-day efficacy or safety outcomes were eligible for review; the data were extracted from the accepted studies. A weighted means analysis and random-effects meta-analysis of efficacy outcomes of interest were conducted. Results: A total of 4592 bariatric surgery Studies met the initial criteria. Of these studies, 129 (28,980 patients) were accepted (33 SAGB and 104 LB studies): most had a retrospective single-center design. For 4273 patients (36 treatment groups) in 33 SAGB Studies and 24,707 patients (111 groups) in 104 LB studies. the mean baseline age (39.1-40.2 yr), body mass index (43.8-45.3 kg/m(2))and gender (women 79.2-92.5%) were similar. A laparoscopic technique Was used in >= 88% and a pars flaccida technique in >= 41% of both groups. Early mortality was equivalent for SAGB/LB (<=.1%). The 3-year mean SAGB and LB excess weight loss (56.36% and 50.20%, respectively) and body mass index reduction (-11.99 and -11.81 kg/m(2), respectively) from baseline were statistically significant (P <.05), as was the resolution of diabetes (61.45% and 60.29%, respectively) and hypertension (62.95% and 43.58%, respectively). Although scant and inconsistently reported data precluded direct statistical comparisons, the complication rates for the 2 devices appeared comparable. In 8 directly comparative studies. meta-analysis found a significantly greater absolute weight loss (P <.05) with the SAGB at 2 years (48.4 versus 41.9 kg, mean difference -4.84, 95% confidence interval -9.47 to -0.22), although no difference was found in the percentage of excess weight loss or change in body mass index. Conclusion: In a systematic review of the published world SAGB and LB data. at 1, 2, and 3 years. the weight loss, resolution of diabetes and hypertension. and complications appeared comparable. (Surg Obes Relat Dis 2008 4:1 74-185.) (C) 2008 American Society for Metabolic and Bariatric surgery. All rights reserved

BACKGROUND: Adolescent obesity continues to present one of the most difficult and important challenges for both the pediatric and adult medical communities. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for both adolescents and adults. Although most US adult bariatric surgeons prefer the gastric bypass, our institution has demonstrated equivalent weight loss with significantly less morbidity using laparoscopic adjustable gastric banding (LAGB) in both adults and adolescents. This analysis is an update of our results in our first 73 patients, including resolution of comorbid conditions and compliance data. METHODS: All adolescents aged 13 to 17 years who have undergone LAGB at our institution have been entered into our prospectively collected database since September 2001 and were reviewed. Data collected preoperatively included age, sex, race, body mass index (BMI), and presence of comorbid conditions. Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, percentage of excess weight loss (%EWL), and BMI at 3-month intervals; status of any comorbid conditions, and number of postoperative visits and band adjustments. RESULTS: Seventy-three adolescents aged 13 to 17 years (mean, 15.8 +/- 1.2 years) have undergone LAGB at our institution since September, 2001. Of these, 54 were female and 19 were male. The mean preoperative weight was 298 lb, with a BMI of 48 kg/m(2). The %EWL at 6 months, 1 year, and 2 years postoperatively was 35% +/- 16%, 57% +/- 23%, and 61% +/- 27%, respectively. One patient experienced a gastric perforation after a reoperation for band replacement because of a slip. One additional patient requested band removal because of restriction intolerance after a slip. A total of 6 patients developed band slippage, and 3 patients developed symptomatic hiatal hernias. Nutritional complications included asymptomatic iron deficiency in 13 patients, asymptomatic vitamin D deficiency in 4 patients, and mild subjective hair loss in 14 patients. In 21 patients who entered our Food and Drug Administration-approved study and had reached 1-year follow-up, there were 51 identified comorbid conditions. Of these, 35 (68.5%) were completely resolved, 9 (17.5%) were improved, 5 (10%) were unchanged, and 2 (4%) were aggravated after 1 year. Of 50 initial patients who underwent surgery more than 1 year ago, 2 patients lived a large distance from our institution, where band maintenance is being performed locally, and thus, the patients were excluded from the analysis. Two patients were lost to follow-up in the first year, and 3 patients were lost to follow-up in the second year, for an overall compliance rate of at least 89.5%. The mean number of office visits was 10 +/- 3 in the first year, and the mean number of adjustments was 6 +/- 2. CONCLUSIONS: Laparoscopic adjustable gastric banding continues to represent an attractive treatment strategy for morbidly obese pediatric patients with a %EWL of more than 55% at both 1- and 2-year follow-up, with minimal morbidity compared with the gastric bypass. Furthermore, the weight loss associated with LAGB provides excellent resolution or improvement of comorbid conditions. Although there is a necessary commitment by the patient that involves frequent office visits and band adjustments, adolescents are entirely capable of this commitment, and noncompliance should not be a reason to dissuade adolescents from having LAGB. It remains, in our opinion, the optimal surgical option for pediatric patients with morbid obesity

Obesity is about to surpass cigarette smoking as the number one preventable cause of death in the United States. In the year 2000, data showed that 435,000 Americans died from cigarette smoke and 400,000 from obesity. This represents 18,1% and 16.6%, respectively, of all deaths in the US. Greater than 33% of US adults (>72 million people) were obese in 2005-2006. Obesity in children and adolescents is also on the rise and is associated with increased morbidity and mortality in adult life.

BACKGROUND: Bariatric operation is the most effective treatment for diabetes mellitus in the morbidly obese. The purpose of this study is to compare the rate of resolution of diabetes mellitus after three common laparoscopic bariatric procedures: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD/DS). STUDY DESIGN: All data were prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included preoperative age, body mass index, duration of diabetes, race, gender, operative time, length of stay, percent excess weight loss, oral hypoglycemic requirements, and insulin requirements. RESULTS: A total of 282 bariatric patients with diabetes mellitus were analyzed (218 LAGB, 53 RYGB, and 11 BPD/DS). Preoperative age (46 to 50 years), body mass index (46 to 50; calculated as kg/m(2)), race and gender breakdown, and baseline oral hypoglycemic (82% to 87%) and insulin requirements (18% to 28%) were comparable among the three groups (p = NS). Percent excess weight loss at 1, 2, and 3 years was: 43%, 50%, and 45% for LAGB; 66%, 68%, and 66% for RYGB; and 68%, 77%, and 82% for BPD/DS (p < 0.01 LAGB versus RYGB and LAGB versus BPD/DS at all time intervals). At 1 and 2 years, the proportion of patients requiring oral hypoglycemics postoperatively was 39% and 34% for LAGB; 22% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). At 1 and 2 years, the proportion of patients requiring insulin postoperatively was 14% and 18% for LAGB; 7% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). CONCLUSIONS: Despite the disparity in percent excess weight loss between LAGB, RYGB, and BPD/DS, the rate of resolution of diabetes mellitus is equivalent

BACKGROUND: Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. METHODS: A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. RESULTS: The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. CONCLUSIONS: Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of respiratory complications, delayed gastric emptying, length of hospital stay, or whether this therapy is applicable to other operations