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      Clinical Management of Patients Presenting with Non-Adjustable Gastric Band (NAGB) Complications

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          Abstract

          Background: A number of bariatric surgical procedures have been developed to manage morbid obesity and related co-morbidities. The non-adjustable gastric band (NAGB) was one such procedure that created restriction to food intake by gastric segmentation. Benefits of the procedure included a low risk of perioperative complications and substantial early weight loss. Unfortunately, the long term results of NAGB include a high incidence of complications and failure to maintain weight loss. The purpose of this study was to examine the presentation, workup, and treatment of patients presenting with complications following NAGB placement.

          Methods: A retrospective review of the diagnosis and management of 11 patients who presented with complications related to NAGB placement.

          Results: All patients presented with some degree of proximal gastric outlet obstruction. The majority of patients (8/11) presented with vomiting as the main complaint. Other complaints included intolerance to solids, liquids, and reflux. Only 2/11 patients presented with weight loss since undergoing NAGB placement, while the remainder had weight regain to their pre-NAGB level and above. Depending on clinical presentation, desire for additional weight loss and co-morbid conditions, patients underwent a variety of treatments. This included NAGB removal (endoscopic, laparo-endoscopic, and laparoscopic) as well as conversion to another bariatric procedure (sleeve gastrectomy, Roux-en-Y gastric bypass).

          Conclusion: Patients with NAGB complications present with symptoms related to a proximal gastric outlet obstruction, related to constriction imposed by the band. This may result in severe food and liquid intolerance and subsequent weight loss, but more likely results in maladaptive eating and subsequent weight gain. Optimal therapy involves removal of the NAGB. Laparoscopic conversion to another bariatric procedure, optimally a Roux-en-Y gastric bypass, is warranted to treat morbid obesity and associated co-morbidities.

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          Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature.

          Jennifer O’Brien, Madolyn L MacDonald, Leah Brennan … (2012)
          To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery. Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures. We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years. A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL. The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.
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            Evolution of operative procedures for the management of morbid obesity 1950-2000.

            Henry Buchwald, J. N. Buchwald (2002)
            At the turn of the 21st century, obesity is the epidemic with the greatest prevalence in the United States. Fifteen million people, 1 out of 20, in this country have a body mass index (BMI) > or = 35 kgm2. Obesity is not only a medical problem, but also a social, psychological, and economic problem. At present, the morbidly obese are refractory to diet and drug therapy, but have a substantial, sustained weight loss after bariatric surgery. This chronology of the landmark operations in bariatric surgery is based on a review of the medical literature. Bariatric surgery can be classified into 4 categories: malabsorptive procedures, malabsorptive/restrictive procedures, restrictive procedures, and other, experimental procedures. The prototype of malabsorptive procedures and the first operation performed specifically to induce weight loss was the jejunoileal bypass. The problems associated with this operation caused its demise. Today's popular malabsorptive procedures are the biliopancreatic diversion and the duodenal switch. Malabsorptive/restrictive surgery currently is predicated on the Roux-en-Y gastric bypass, both the traditional short-limb, and the long-limb for the super obese. Restrictive procedures are represented by the banded and ringed vertical gastroplasty, as well as gastric banding. Experimental procedures include gastric pacing. All of these operations can be performed by open surgery and laparoscopically. Since bariatric surgery is the only broadly successful treatment for morbid obesity, it is incumbent on all physicians to be familiar with current bariatric operations, and to understand the evolution of bariatric surgery.
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              The surgical technique of the Fobi-Pouch operation for obesity (the transected silastic vertical gastric bypass).

              Benjamin Lee, Mathias A L Fobi (1998)
              The Fobi-Pouch operation (FPO) for obesity is the product of clinical trials, more than 15 years of personal clinical experience and information gathered from publications, scientific meetings, and personal communications with other bariatric surgeons. The essence of the operation is the small vertical pouch (< 25 ml), an externally supported stoma, the interposed Roux-en-Y limb, the gastrostomy and the bypassed stomach marker to facilitate percutaneous transabdominal access to the bypassed segment. Patients undergoing this operation are usually given bowel prep the day before the operation, admitted the morning of the operation and started on subcutaneous heparin, prophylactic antibiotic and hydration. Antithrombotic sequential compression devices are regularly used. The hospital stay is usually 4 days. Our results and those of other surgeons who have used this modification substantiate the rationale for the modifications entailed in the FPO. Our longer-term experience and results are being compiled for publication.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Yale J Biol Med
                Journal ID (iso-abbrev): Yale J Biol Med
                Journal ID (pmc): yjbm
                Journal ID (publisher-id): YJBM
                Title: The Yale Journal of Biology and Medicine
                Publisher: YJBM
                ISSN (Print): 0044-0086
                ISSN (Electronic): 1551-4056
                Publication date (Electronic): 6 June 2014
                Publication date Collection: June 2014
                Volume: 87
                Issue: 2
                Pages: 159-166
                Affiliations
                [a ]Houston Methodist Hospital, Houston, Texas
                [b ]University of Alberta, Edmonton, Alberta
                [c ]Bariatric and Metabolic Surgery Center, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
                Author notes
                [* ]To whom all correspondence should be addressed: Vadim Sherman, MD, FRCSC, FACS, Medical Director, Bariatric and Metabolic Surgery Center, Houston Methodist Hospital, Assistant Professor, Weill Cornell Medical College, 6550 Fannin St., SM 1661, Houston, TX 77030; Email: vsherman@ 123456houstonmethodist.org .
                Article
                Publisher ID: yjbm872159
                PMC ID: 4031789
                SO-VID: b39aa92a-4321-4d44-9945-4cbd1c8f0f57
                Copyright © Copyright ©2014, Yale Journal of Biology and Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License, which permits for noncommercial use, distribution, and reproduction in any digital medium, provided the original work is properly cited and is not altered in any way.

                History
                Categories
                Subject: Focus: Obesity
                Series title: Focus: Obesity

                ScienceOpen disciplines: Medicine
                Keywords: bariatric,complications,revision,laparoscopic,non-adjustable gastric band
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: bariatric, complications, revision, laparoscopic, non-adjustable gastric band

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