Adjustable Gastric Band Safe, Effective in Severe Obesity

Laurie Barclay, MD

January 21, 2003

Jan. 21, 2003 — The laparoscopically placed adjustable gastric band (AGB) is safe and effective in severe obesity, according to the results of two studies reported in the January issue of the Annals of Surgery. However, the editorialist is less enthusiastic and suggests that the more traditional Roux-en-Y procedure is still the best.

"Laparoscopic AGB is considered the least invasive surgical option for morbid obesity," write Franck Zinzindohoue, MD, and colleagues from Hopital Europeen G. Pompidou in Paris, France. "It is effective, with an average loss of 50% of excessive weight after two years of follow-up. It is potentially reversible and safe; major morbidity is low and there is no mortality."

Between April 1997 and June 2001, 500 patients with morbid obesity had laparoscopic placement of an AGB, including 438 women and 62 men. Mean age was 40.4 years, preoperative mean body weight was 120.7 kg, and mean body mass index (BMI) was 44.3 kg/m 2.

Mean operative time was 105 minutes, but this decreased to 84 minutes for the last 300 operations. Mean hospital stay was 4.5 days. Of 12 conversions (2.4%), two were during the last 300 operations. There were no deaths.

Of 52 patients (10.4%) requiring a second abdominal reoperation, 49 were reoperated for minor complications including slippage in 43, incisional hernias in three, and reconnection of the catheter in three. Only three patients needed reoperation for major complications, including gastroesophageal perforation in two and gastric necrosis in one. Seven patients had pulmonary complications, and 36 patients had minor problems related to the access port.

Mean BMI decreased from 44.3 kg/m 2 at baseline to 34.2 kg/m 2 at one year, 32.8 kg/m 2 at two years, and 31.9 kg/m 2 at three years. Mean excess weight loss was 42.8% at one year, 52% at two years, and 54.8% at three years.

"Laparoscopic adjustable gastric banding is a beneficial operation in terms of [excess] weight loss, with an acceptably low complication rate," the authors write. "It can noticeably improve the quality of life in obese patients. Half of the excess body weight can be effortlessly lost within two years."

The second study prospectively evaluated the Swedish AGB in 625 patients with severe obesity treated laparoscopically between January 1998 and October 2001. By using a low-pressure AGB, the investigators hoped to avoid stomach erosion and perforation associated with gastric banding.

"Swedish AGB is a safe and effective new method in the management of severe obesity," write Wim Ceelen, MD, from Ghent University Hospital in Belgium, and colleagues. "Long-term follow-up (>3 years) is necessary to confirm its effectiveness and safety."

Median age was 36 years; 80.4% of patients were female; and median preoperative BMI was 40 kg/m 2. Median follow-up was 19.5 months; median operating time was 80 minutes; and median hospital stay was three days.

Two patients required conversion, and 27 (4.3%) had early morbidity, but none died within 30 days. However, 49 patients (7.8%) required late band reoperation for band slippage or pouch dilation, acute total dysphagia, or band leakage or malfunction. Median excess weight loss was 45.8% at one year, 49.9% at two years, and 47.4% at three years, with improvements in arterial hypertension, sleep apnea syndrome, and diabetes control.

In an accompanying editorial, John M. Kellum, MD, from the Medical College of Virginia in Richmond, warns that the AGB is a purely restrictive operation like the vertical banded gastroplasty, which most American surgeons have abandoned. He recommends a randomized prospective study comparing the AGB with the Roux-en-Y, and he also discourages surgeons who are not dedicated to the long-term care of severely obese patients from performing these operations.

"There is a risk that the heavy commercial marketing of these devices may prevent some patients from getting what this reviewer considers a superior operation," he writes. "We should remember that laparoscopic Roux-en-Y gastric bypass has no corporate sponsor."

Ann Surg. 2003;237:1-9, 10-16, 17-18

Reviewed by Gary D. Vogin, MD

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