laparoscopic adjustable gastric band in super morbidly obese patients (bmi > 50)

LaparoscopicAdjustable Gastric Bandin Super Morbidly Obese Patients (BMI >50):A Prospective,Comparative Analysis

GreeceMay 2005

Wilbur B. Bowne MD, Kell Julliard MS, Armando E. Castro MD, Palak Shah MD, Craig B. Morgenthal MD, Emad Kandil MD,Abel Gonzalez MD, Anthony J. Acinapura MD, George S. Ferzli MD, FACS

Disclosure of Interest Declaration

None

Laparoscopic Adjustable Gastric Band inSuper Morbidly Obese Patients (BMI >50):

A Prospective, Comparative Analysis

GreeceMay 2005

Background:

1 Hedley AA. JAMA 2002; 2847-2850.2 Mason, EE. Gastroent Clin of North Am 1987;16:495-502.

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Super- morbid obesity– increasing prevalence in United States1

– body mass index (BMI ≥ 50 kg/m2) 1,2

– ≥ 225 % ideal body weight1,2

Background:

1 Hedley AA. JAMA 2002; 2847-2850.2 Mason, EE. Gastroent Clin of North Am 1987;16:495-502.

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Surgeon’s perspective – substantial co-morbidity 1,2

– technically challenging 1,2

– associated with worse outcome 1,2

Background:

1 Ren, CJ. J. Gastrointest Surg 2004; 396-340.2 Fielding, GA, Ren, CJ Surg Endosc 2003;17:1541-1545.

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Laparoscopic adjustable gastric band (LAGB)

– most common in Europe and

Australia (1993)1,2

– approved by FDA in 20011,2

– alternative treatment

strategy

Background:

Incidence of complications and failure following LAGB

YEAR # PATIENTSAUTHOR

Suter et al. 2001 272 20 7

Biertho et al. 2003 805 74 9

Suter et al. 2000 150 24 16 Chevallier et al. 2004 378 91 24

Holéczy et al. 2001 36 11 31

Gustavson et al. 2002 90 52 58

# FAILURES %

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Background:

Lack of outcome data comparing to laparoscopic

Roux- en-Y gastric bypass (LRYGB)

Role of LAGB in super-morbidly obese patients

not well defined

Clarification of safety, feasiblity, and effectiveness

of LAGB

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Purpose:

To determine and compare weight loss, change in BMI, incidence of complications, and patient satisfaction after LAGB and LRYGB

To establish the effectiveness of LAGB and LRYGB on concomitant medical co-morbidity

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Retrospective review Super-morbidly obese patients

(BMI ≥ 50 mg/kg2) treated between

2001 and 2004

Outcomes analysis— Patient (Age, gender, BMI and weight loss)— Perioperative (Complications and reoperations)— Co-morbidity (Hypertension, diabetes, dyslipidemia,

respiratory, and degenerative arthritis)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Methods:

Methods:

Laparoscopic adjustable gastric bandOperative conduct (Pars flaccida technique)1,2

1 Belachew M. Surg Endosc 1994;8:1354-1356.2 Shapiro K. Surg Endosc 2004;18:48-50.

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Background:

1 Bowne, W. J Am Coll Surg (submitted) 2005.2 Feng, JJ. Surg Endosc 2003;17:1055-1060.3 Himpens, J. Sem Laparosc Surg 2004;11:171-177.

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Laparoscopic

Roux-en-Y gastric bypass: – creation of a 30-cc gastric pouch 1

– extended Roux limb (150 cm) 1,2

– intracorporeal-sutured

gastrojejunostomy 1-3

Morbid ObesityN = 315 patients

Super-Morbid ObesityN = 106 Patients (34%)

LAGBN = 60 Patients (57%)

LRYGBN = 46 Patients (43%)

Results: Surgical Pathway

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Results: Preoperative characteristics of patients

LRYGB (N=46) P-value 1 Characteristic

Age 43 (21-65) 42 (18-63) 0.45

Gender (female/male) 35/11 50/10 0.35

BMI (Kg/ m2) 57 (50-70) 55 (50-68) 0.18

Weight (Kg) 157 (120-195) 150 (124-209) 0.07

Excess weight (Kg) 92 (62 -124) 86 (66 -130) 0.08

1 Independent t-test

LAGB (N=60)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Results: Preoperative co-morbidity of patients

LRYGB (N=46) P-value 1

Co-morbidity

Hypertension 26 (57%) 24 (40%) 0.07

Diabetes mellitus II 8 (18%) 11 (18%) 0.55

Respiratory (asthma) 15 (33%) 17 (28%) 0.75

Sleep Apnea 25 (54%) 28 (47%) 0.27

Degenerative arthritis 21 (46 %) 14 (23%) 0.13

Dyslipidemia 17 (37%) 17 (18%) 0.03

1 Pearson

LAGB (N=60)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

2

Results: Perioperative data

Operation time (min) 75 ± 22 (50-180) 121 ± 45 (70-210) < 0.001

Hospital stay (days) 1.8 ± 1.9 (1-11) 3.5 ± 3.4 (1-18) < 0.002

Conversion to open 1 0

LAGB (N=60) LRYGB (N=46) P1

1 Independent t-test

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Adequate follow-up available for 106 patients identified

Results:

LAGBmedian = 17 months

LRYGBmedian = 13 months

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Results: Early complications ( < 30 days)

N (%) P= 0.33 1

LAGB (N=60)

Emesis/Dehydration 7 (12) Emesis/Dehydration 4 (9)

Food impaction 1 (2) Pneumonia 1 (2)

*Port displacement 1 (2) Anastomotic bleed 1 (2)

Wound infection 1 (2) * Anastomotic leak 1 (2)

Myocardial infarction 1 (2) * Abscess 1 (2)

1 Pearson

LRYGB (N=46)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

2

N (%)

*Reoperation

Results: Late complications ( ≥ 30 days)

N (%) (%) P < 0.05 1

LAGB (N=55)

Emesis/Dehydration 24 (44) Emesis/Dehydration 5 (13)

*Port displacement 11 (20) *Bowel Obstruction 3 (8)

Food impaction 1 (2) Anastomotic stenosis 2 (5)

Reflux 1 (2) Gastritis 1 (2)

*Bland slippage 1 (2)

*Abscess 1 (2)

Wound infection 1 (2)

†Aspiration Pneumonia 1 (2)1 Pearson

LRYGB (N=39)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

2

*Reoperation

†Postoperative death

Results:

LAGB N= 15 (83%)

LRYGB N=3 (17%)

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

*P < 0.04 N = 18

* Pearson 2

Reoperations

0

10

20

30

40

50

60

70

Preop Postop

BMI

LAGB

LRYGB

p < 0.001

Results:

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

(N = 60)

(N = 46)

Change in BMI

1 Independent t-test

Results:

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

N = 55

Number of band adjustments

0

5

10

15

20

24 18 5 4 1 1 1 1

No. of Patients

No.

of A

djus

tmen

ts

Percent excess weight loss

Results:

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

N = 106

0

10

20

30

40

50

60

LAGB LRYGB

Pe

rce

nt

p < 0.001

1 Independent t-test

Preoperative co-morbidity

Results:

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

(N = 60)(N = 46)

0

10

20

30

40

50

60

Perc

ent

LAGB

LRYGB

* P < 0.05* Pearson 2

Postoperative co-morbidity at last follow-up

Results:

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

(N = 55)(N = 39)

*

* P < 0.05

0

5

10

15

20

25

30

35

Perc

ent

LAGB

LRYGB

*

* Pearson 2

0102030405060708090

Verysatisfied

Satisfied Notsatisfied

Regret

Pe

rce

nt LAGB

LRYGB

p = 0.006

Patient satisfaction

Results: Quality of Life

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

(N = 55)(N = 39)

Summary:

LAGB is associated with shorter operative time and hospital stay

LAGB patients experience greater incidence of

late complicatons resulting in more reoperations

LAGB patients have less weight loss and reduction of comorbidities

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese

Conclusion: LRYGB is associated with greater weight loss,

reduction of co-morbidity, less complications, and fewer reoperations compared to LAGB

Quality of life of LRYGB patients is significantly

better compared to LAGB patients

Further evaluation of LAGB in super-morbidly obese patient population appears warranted

Laparoscopic Adjustable Gastric Band in Super- Morbidly Obese