Faculty Bibliography

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is safe and effective. This less invasive option involving fewer incisions and umbilical approaches is coined as single-incision laparoscopic surgery (SILS). Over the last 3 years, we performed 46 % of our LAGBs as SILS with excellent results. METHODS: This is a retrospective review of 1,644 LAGBs performed between 2008 and 2010. A total of 756 were performed as SILS bands (46 %) and 888 as standard (non-SILS) (54 %). Data points compared include operative time, percent of excess weight loss at 1 and 2 years, complication, and re-operation rates. RESULTS: Groups were matched by age, initial BMI, and gender: 584 non-SILS and 710 SILS patients. The average operating time was 44.3 +/- 19.6 min for SILS and 51.1 +/- 19.4 min for non-SILS (p < 0.001). The 12-month percent excess weight loss (%EWL) for SILS was 45.0 +/- 19.1; it was 40.7 +/- 17.5 for non-SILS (p = 0.003). The 24 month %EWL for SILS was 54.4 +/- 16.3; it was 46.4 +/- 16.1 for non-SILS (p = 0.10). Complication rates were 5.6 % (40 of 710) for SILS and 4.5 % (26 of 584) for non-SILS (p = 0.34). The 30-day readmission/re-operation rates are 1 % (seven of 710) for SILS and 1.5 % (nine of 584) for non-SILS (p = 0.37). There was one death in the SILS group. CONCLUSIONS: We have been performing more SILS bands over time. Our operative times and weight loss figures show that it is an efficient and effective means of weight loss. Furthermore, the data also show that the SILS approach is safe and does not increase operative time. In conclusion, SILS laparoscopic adjustable gastric banding is a safe and effective means of attaining weight loss in selected patients.

Purpose: Bariatric surgery can achieve sustained weight loss compared to medical management. Among bariatric surgeries, laparoscopic adjustable gastric banding (LAGB) is less-invasive and potentially reversible. LAGB may decrease BMI through restriction of food intake, behavior changes, satiety and digestive hormone levels. The dramatic reduction of appetite observed with LAGB can be ameliorated if the band is underfilled. This effect has not been well evaluated in terms of patient behavior and hormonal changes. Our aim was to assess outcomes related to eating behavior, insulinotropic hormones, and weight change before and after temporary gastric band release. Methods: Adults >= 18 yeaars of age who previously underwent LAGB and achieved successful weight loss were enrolled. All patients underwent standardized evaluation including anthropometric measurements and completion of the Three-Factor Eating Questionnaire (TEFQ-R18) before and after a period of 14 days during which the band was completely loosened. At baseline and follow-up, blood was collected after an overnight fast and 1h after a standard high protein meal, and levels of insulinotropic hormones determined. Results: The mean age of the study cohort (9 women and 6 men) was 42 +/-14 years with mean pre-band adjustment BMI of 32.9 +/- 5.6 and mean waist circumference of 40 +/- 7 inches. All patients had >30% percent reduction in weight within 12-months of the LAGB and demonstrated a lower degree but continued weight loss in the 6-months before study enrollment. Compared to baseline values for the TEFQ-R18, within 2-weeks of loosening the band, cognitive restraint was reduced (11.2 +/- 3 vs. 10.4 +/- 4), while there was a significant increase in both disinhibition (6.4 +/- 3 vs. 9.4 +/- 3, p=0.004) and hunger scores (4.1 +/- 3 vs. 8.0 +/- 3, p=0.004). Compared to baseline, at follow-up insulin output in response to a meal showed a downward trend [Median (IQR) 1,110 (728-1,332) vs. 621 (375-1,325) pg/ml; p=0.21] while leptin was significantly elevated [10,400 (6,030-11,350) vs. 13,700 (10,500-43,900) pg/ml; p=0.001]. Consistent with these findings BMI significantly increased (32.9 +/- 5.6 vs. 34.5 +/- 5.6, p=0.001) along with waist size (40 +/- 7 vs 42 +/- 6, p=0.003). The amount of weight regained within two weeks, returned the cohort to the weight loss level noted at the 12-month post LAGB time point. Conclusion: LAGB adjustment continues to impact eating behavior, satiety hormones, and body weight beyond the initial 12-months following placement. Complete loosening of the LAGB can result in rapid changes in eating behavior, insulinotropic hormones, and significant changes in BMI. Careful adjustment of the band is necessary for continued maintenance of weight loss

BACKGROUND: The need for revision after laparoscopic adjustable gastric band (LAGB) surgery has been reduced over the past 10 years with the introduction of the pars flaccida technique, delicate band tightening, and concurrent hiatal hernia repairs. However, band revision still occurs for as many as 5% of patients. Placement of a lesser-curvature gastrogastric suture distal to the band is one newer technique suggested to lower band slippage. To evaluate the worth of this technique, the authors have investigated two groups of patients in their practice: one group with the plication stitch and one group without it. METHODS: This retrospective review examined data for 1,365 LAGB patients collected prospectively by an institutional review board-approved database between July 2007 and May 2010. One surgeon did not perform the plication stitch (n = 776) and one did (n = 589). The surgical techniques were very similar. The majority of the patients had crural repair at the primary operation. Band revision rates were assessed. RESULTS: For 1,365 patients, LAGB was performed safely. The mean follow-up period was 22 months. The two groups were similar. The no-stitch group consisted of 776 patients (496 women, 64%) with a mean age of 42 years, a mean weight of 278 lb, and a mean body mass index (BMI) of 44.6 kg/m(2). The stitch group consisted of 589 patients (426 woman, 72%) with a mean age of 40 years, a mean weight of 278 lb, and a mean BMI of 44.8 kg/m(2). The no-stitch group had an estimated weight loss (EWL) of 44% at 12 months and 50% EWL at 2 years. The stitch group had 37% EWL at 12 months and 45% EWL at 2 years. Both groups had very low revision rates. The no-stitch group had 4 revisions in 776 patients (0.26%), and the stitch group had 9 revisions in 589 patients (1.5%). CONCLUSION: Adding gastrogastric plication sutures offers no benefit of reducing the rate of revision after LAGB surgery

BACKGROUND: Although esophageal dilation after laparoscopic adjustable gastric banding (LAGB) has been reported, the effect of banding on esophageal peristalsis, including the development of aperistalsis and its potential reversibility, have received only little attention. GOALS: Our aim was to report our experience with 6 patients who developed manometric evidence of esophageal aperistalsis after LAGB. STUDY: We retrospectively reviewed the clinical, manometric, and radiologic data of 6 patients referred between September 2005 and June 2007 to our Center for Esophageal Disease for evaluation of dysphagia or heartburn that developed after LAGB, and in whom manometric studies showed aperistalsis. Patients had the fluid in the band completely removed (N=5) or had the band removed (N=1). Reversibility of esophageal aperistalsis was then assessed. Clinical follow-up was obtained from 2009 to early 2010. RESULTS: Six patients (all female, age range, 37 to 55 y old) were evaluated because of dysphagia or heartburn after LAGB and had complete aperistalsis on manometry. Five of the 6 patients had manometry after removal of all the fluid from the band (N=4) or after surgical removal of the band (N=1). Two patients had partial return of peristalsis, 1 had normal peristalsis, and 2 others had continued aperistalsis but did show clinical improvement. Another patient had improvement of radiologic esophageal dilation but declined repeat manometry. CONCLUSIONS: LAGB can cause an achalasia-like esophageal aperistalsis that may be reversible. Gastroenterologists caring for bariatric patients need be aware of this pseudoachalasia, as the treatment of such patients differs from those with primary achalasia

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a proven method for weight reduction. Less is known about pregnancies in patients after LAGB. METHODS: Information was gathered, through database and survey, on women who underwent LAGB at NYU Medical Center between 2001 and 2008 then became pregnant. RESULTS: Pregnancy occurred in 133 women, resulting in 112 babies, including six sets of twins. The average pre-pregnancy body mass index (BMI) was 32.7. Average weight gain was 11.5 kg, but was higher for those with pre-pregnancy BMI <30.0 compared to BMI >30.0 (16.4 vs 8.6 kg). Of singleton pregnancies, 89% were carried to full term, with cesarean section in 45%. Those with pre-pregnancy BMI <30.0 had a lower rate of cesarean section (35.71%), but it was not statistically significant (p = 0.55). Average birth weight was 3,268.6 g. Eight percent of babies from singleton pregnancies were low birth weight (<2,500 g), and seven percent were high birth weight (>4,000 g). Average Apgar scores at 1 and 5 min were 8.89 and 9.17. Four percent of patients developed gestational diabetes, and 5% developed pre-eclampsia. Band adjustments were performed in 71% of patients. Weight gain was higher in those who had their bands loosened in the first trimester (p = 0.063). Three patients had intrapartum band slips; one required surgery during pregnancy. CONCLUSIONS: LAGB is tolerable in pregnancy with rare intrapartum band slips. Weight gain is less in those with higher pre-pregnancy BMI and those who had their bands filled or not adjusted. Babies born to these mothers are as healthy as the general population

AIM: To determine if natural killer T cell (NKT) populations are affected in nonalcoholic fatty liver disease (NAFLD). METHODS: Patients undergoing bariatric surgery underwent liver biopsy and blood sampling during surgery. The biopsy was assessed for steatosis and immunocyte infiltration. Intrahepatic lymphocytes (IHLs) were isolated from the remainder of the liver biopsy, and peripheral blood mononuclear cells (PBMCs) were isolated from the blood. Expression of surface proteins on both IHLs and PBMCs were quantified using flow cytometry. RESULTS: Twenty-seven subjects participated in this study. Subjects with moderate or severe steatosis had a higher percentage of intrahepatic CD3+/CD56+ NKT cells (38.6%) than did patients with mild steatosis (24.1%, P = 0.05) or those without steatosis (21.5%, P = 0.03). Patients with moderate to severe steatosis also had a higher percentage of NKT cells in the blood (12.3%) as compared to patients with mild steatosis (2.5% P = 0.02) and those without steatosis (5.1%, P = 0.05). CONCLUSION: NKT cells are significantly increased in the liver and blood of patients with moderate to severe steatosis and support the role of NKT cells in NAFLD.

BACKGROUND: Studies reporting the revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been complex, underpowered, and lacking long-term data. We have previously shown that short-term (12-month) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. To report the midterm outcomes of LAGB after RYGB failure. METHODS: A retrospective review of prospectively collected data before and after RYGB, when available, and before and after LAGB was performed at the New York Langone University Hospital (New York, NY). The data collected included weight, height, body mass index (BMI), gender, race, age, operative time, length of stay, postoperative complications, and the percentage of excess weight loss. RESULTS: A total of 43 patients (9 men and 34 women) underwent LAGB after weight loss failure with RYGB. Of the 43 patients, 27 patients had undergone RYGB at other institutions, and preoperative RYGB data were available for 23 total patients. The average interval to LAGB was 6.6 years. The mean BMI before RYGB was 50.4 kg/m(2) and before LAGB was 43.3 kg/m(2) (%EWL was 17% after RYGB). At follow-up after LAGB, the average BMI was 35.2 kg/m(2), with a %EWL of 38% (calculated from LAGB only) at 26 months (range 6-66). At the 1- and 2-year follow-up visit, the BMI had decreased by 8.7 kg/m(2). The reoperation rate for complications related to LAGB was 10% and included 2 band erosions, 1 band slip, and 1 port flip. CONCLUSION: The results of our study have shown that LAGB had good midterm data as a revisionary procedure for weight loss failure after RYGB

BACKGROUND: This study aimed to assess the efficacy of laparoscopic adjustable gastric banding (LAGB) during a 6-year follow-up period. METHODS: A retrospective database analysis of patients who underwent LAGB at New York University Medical Center between 1 January 2000 and 29 February 2008 was conducted. Patients were included for the efficacy analysis if they were 18 years old or older at the surgery date and had one or more visits with a recorded weight after surgery. Efficacy was assessed using percentage of excess weight loss (%EWL) at 1-year intervals after surgery. Missing weight values were interpolated using a cubic spline function. Linear regression models were used to assess the characteristics that affected the last available %EWL. All patients had implantation of the LAP-BAND system. RESULTS: The inclusion criteria for the efficacy analysis were met by 2,909 patients. The majority of the patients were white (83.3%) and female (68.4%). The mean patient age was 44.6 years, and the mean baseline body mass index (BMI) was 45.3 kg/m2. The %EWL 3 years after surgery was 52.9%, which was sustained thereafter. In multivariate models, increased number of office visits, younger age, female gender, and Caucasian race were significantly associated with a higher maximum %EWL. CONCLUSIONS: The LAP-BAND patients achieved a substantial and sustainable weight loss of approximately 50% at 6 years after surgery

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss procedures performed in the United States. The authors' high-volume academic medical center has gathered a database of almost 3,000 patients who have undergone LAGB since January 2001. The goal of this series, the largest to date on LAGB outcomes at a single institution, was to assess complications associated with LAGB. METHODS: A retrospective analysis was performed using longitudinal data from adult patients who underwent LAGB between 1 January 2001, and 29 February 2008. General and band-related complications were reported for all patients. Death and reoperation for weight gain (LAGB followed by either a second band insertion or a gastric bypass) also were reported. RESULTS: Of the 2,965 patients who received LAGB during the study period, 2,909 met the criteria for inclusion in this analysis, and 363 (12.2%) experienced one or more complications. The most common complications were band slip (4.5%) and port-related problems (3.3%). Other complications were rare. Only seven patients (0.2%) had band erosion. Eleven patients (0.4%) underwent reoperation for weight gain. A total of 10 deaths (0.34%) occurred during the study period. Three patients died within 30 days of surgery. Two of these deaths (0.06%) were related to surgery, and one resulted from a motor vehicle accident. Seven patients died of causes unrelated to surgery during the course of the study. CONCLUSIONS: The LAGB technique is a relatively safe procedure with few early or late complications. Few LAGB patients undergo reoperation for weight gain, and mortality is very rare