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IFSO 2012

IFSO report: LAGB - results and pitfalls

Jacques Himpens described the LAGB complication rate at his centre as "disappointing".
Jacques Himpens presents 12-year results from his centre
ASMBS President Jaimie Ponce updates members on APEX study
Vincent Frering says LAGB for super-obese is "adequate and safe"
Paul Super: pouch dilatation, erosion and slippage "inevitable"

Avoiding potential complications from laparoscopic adjustable gastric banding (LAGB), was one of the key issues under discussion at the XVII World Congress of IFSO, New Delhi, India.

Presenting 12-years results from his centre's early experience with LAGB, Jacques Himpens (Belgium) said that the results were disappointing but the high complication rates were largely due to technical and device related issues.

Himpens and colleagues followed 82 patients (54.3% of the original patient population) for 12 years. Seventy four women were included in the study and at the time of operation the average age was 50 with an average BMI 42. He reported peri-operative 0% mortality rate, with 3.7% unrelated mortality rate.

Twenty two percent of patients had a minor complications, mostly port, port-tube or incisional issues. However, 39% (32 patients) reported major complications; nine pouch dilatations and 23 band erosions (28%). He said that the majority of these erosions were reported four years following surgery (by gastroscopy).

Forty nine of the 82 patients had a reoperation and after nine years, 41 had their band removed. The primary reason for removal was band erosion, which was present in 19 patients. Despite the poor results, EWL% out to three years was consistent with previous studies.

“These poor results can be partially explained by the operators using the peri-gastric technique for implantation, utilisation of first generation devices, poor follow-up and an operator learning curve,” said Himpens. “The fact that pouch dilation was identified 3.6 years post-procedure indicates that this is not a technical issue. I would recommend gastroscopy for all patients, even if they are not presenting with symptoms.”

APEX study

Dr Jaimie Ponce, ASMBS President, provided an update from the APEX study. The study is an on-going multi-centre trial design to assess the effectiveness of LAGB in severely obese patients. The data presented concentrated on 149 patients (from 517 patients), who have completed three year follow-up and quality of life questionnaires.

The outcomes show that patients have experienced significant weight loss, as well as improvements in their quality of life. The majority of patients have also experienced an improvement in their obesity related co-morbidities.  A small number of re-operations were necessary, mostly due to slippages.

“Overall, LAGB has resulted in significant weight loss and improvements in obesity related comorbidities,” said Ponce. “LAGB should continue to be considered as an effective treatment for obesity and its related conditions.”

Ten year experience

Presenting his ten year experience of LAGB in 395 super obese patients, Dr Vincent Frering (France) said that these high risk patients can be adequately and safely treated with the technique, which allows conversion to other bariatric procedures if necessary.

The mean BMI was 55.5, with 85% of patients in the BMI range 50-59. Ten patients had a BMI>70. The patients were mostly female (76.4%) and the mean age was 40.

The most common preoperative comorbidities included hiatal hernia, hypertension and type 2 diabetes.

The outcomes revealed that there were no mortalities and nine patients were hospitalised for transient digestive intolerance, which was resolved with medical treatment.

The late outcomes showed that 58 bands were removed; 27 due to leakage, 13 due to slippage, 12 intolerance and six for erosion.

Despite these complications, the four year results showed that 33.9% of patients has a BMI<30 and 20% a BMI>30-35. The results based on Reinhold’s criteria revealed 33.3% had excellent results and 20% good results. The ten year results showed that 31.4% of patients have a BMI<30 and 28.6% a BMI>30-35. The results based on Reinhold’s criteria revealed 31.4% had excellent results and 28.6% good results.

“The key to these results is using a good device, the newer softer devices, and utilising a good procedure,” said Frering. “It is also important to emphasise a team ethic and these results are because of a good surgical team, not because of a good surgeon.”

Avoiding complications

According to Paul Super, there is an inevitable rate of pouch dilatation, erosion and slippage in gastric banding, but this rate can be limited by surgical technique and good protocols.

Presenting the results from a study investigating the rates of pouch dilatation, erosion and slippage from 5,012 patients, he revealed that there were 31 partial slippages or pouch dilations, six erosions and three total slippages.

“By following key surgical steps, it is possible to avoid posterior and anterior slippage, and pouch dilatation,” said Super. ”These steps include using the gastropexy suture, creating a micro-pouch and avoiding over tight bands, gastric trauma on insertion and NSAIDS.”

He concluded that future changes to the design of bands are likely to reduce the complication rate further.

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