Restrictive  Procedures in  BMI > 50 Craig B. Morgenthal, MD George S. Ferzli, MD SUNY Health Science Center  at Brooklyn
Definitions <ul><li>Overweight: BMI > 25 kg/m 2 </li></ul><ul><li>Obesity: BMI > 30 kg/m 2 </li></ul><ul><li>Severe obesit...
Options in Bariatric Surgery <ul><li>Restrictive procedures </li></ul><ul><li>Vertical-banded gastroplasty </li></ul><ul><...
Trends in Bariatric Surgery <ul><li>The U.S. rate of bariatric surgery increased from 2.7 to 6.3 per 100,000 adults from 1...
<ul><li>Comparative overview of weight loss in 54 </li></ul><ul><li>studies, performed in 14,964 patients </li></ul><ul><l...
<ul><li>Selected Laparoscopic VBG Series </li></ul><ul><li>Source N BMI FU (mo.) Weight  </li></ul><ul><li>loss </li></ul>...
<ul><li>Selected Lap Adjustable  </li></ul><ul><li>Silastic Banding Series </li></ul><ul><li>Source N BMI FU (mo.) Weight ...
Is superobesity a distinct entity?   <ul><li>Term superobesity first used when it became apparent </li></ul><ul><li>that m...
<ul><li>Buchwald H. A bariatric surgery algorithm. </li></ul><ul><li>Obesity Surg  2002; 12: 733. </li></ul><ul><li>OC = 1...
<ul><li>Selected Malabsorptive  </li></ul><ul><li>Series for Superobesity </li></ul><ul><li>Source N BMI Procedure EWL </l...
<ul><li>Capella J, Capella R.  The weight reduction operation of  </li></ul><ul><li>choice: VBG or gastric bypass?  Amer J...
<ul><li>Biertho L, Gagner M, et al. Lap gastric bypass vs. </li></ul><ul><li>LAGB: a comparative study.  JACS  2003; 197: ...
Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study.  JACS  2003; 197:536
Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study. JACS 2003; 197:536
<ul><li>Biertho L, Gagner M, et al. Lap gastric bypass vs. </li></ul><ul><li>LAGB: a comparative study.  JACS  2003; 197: ...
<ul><li>Dolan K, Fielding G, et al.  Comparison of LAGB </li></ul><ul><li>and biliopancreatic diversion in superobesity. <...
Dolan K, Fielding G, et al.  Comparison of LAGB and biliopancreatic diversion in superobesity.  Obesity Surg  2004; 13: 16...
Dolan K, Fielding G, et al.  Comparison of LAGB and biliopancreatic diversion in superobesity.  Obesity Surg  2004; 13: 16...
<ul><li>Dolan K, Fielding G, et al.  Comparison of LAGB and </li></ul><ul><li>biliopancreatic diversion in superobesity. O...
Results of Vertical Banded Gastroplasty
<ul><li>Mason E, Doherty C, et al. Super obesity and </li></ul><ul><li>gastric reduction procedures.  Gastroent Clin NA </...
<ul><li>Mason E, Doherty C, et al.  Gastroent Clin NA  1987; </li></ul><ul><li>16: 495. </li></ul><ul><li>Marlex Collar Si...
<ul><li>Mason E, Doherty C, et al.  Gastroent Clin NA  1987; </li></ul><ul><li>16: 495. </li></ul><ul><li>Conclusions: </l...
<ul><li>MacLean L, et al. Late results of vertical banded </li></ul><ul><li>gastroplasty for morbid and super obesity.  Su...
MacLean L, et al. Late results of vertical banded gastroplasty for morbid and super obesity.  Surgery  1990; 107: 20 <ul><...
<ul><li>Bloomston M, Rosemurgy A, et al. Outcome following </li></ul><ul><li>bariatric surgery in super vs. morbidly obese...
Bloomston M, Rosemurgy A, et al. Outcome following bariatric surgery in super vs. morbidly obese patients.  Obesity Surg  ...
<ul><li>Bloomston M, Rosemurgy A, et al. Outcome following </li></ul><ul><li>Bariatric surgery in super vs. morbidly obese...
<ul><li>Mason E, et al. Vertical Gastroplasty: Evolution of Vertical </li></ul><ul><li>Banded Gastroplasty.  World J Surg ...
Mason E, et al. Vertical Gastroplasty: Evolution of Vertical Banded Gastroplasty.  World J Surg  1998; 22: 919. <ul><li>VB...
Results of Laparoscopic  Adjustable Gastric Band
<ul><li>Silva AS, et al. Treatment of morbid obesity with adjustable </li></ul><ul><li>gastric band: preliminary report.  ...
<ul><li>Silva AS, et al. Treatment of morbid obesity with adjustable </li></ul><ul><li>gastric band: preliminary report . ...
<ul><li>Taskin M, et al.  Laparoscopy in Turkish bariatric surgery: </li></ul><ul><li>initial experience.  Obesity Surgery...
<ul><li>Favretti F, et al. Laparoscopic banding: selection and technique in 830 patients.  Obesity Surg  2002; 12: 385. </...
<ul><li>Chevallier JM, et al. Adjustable gastric banding in a public university hospital.  Obesity Surg  2002; 12: 93. </l...
<ul><li>Fielding G. Laparoscopic adjustable gastric banding for </li></ul><ul><li>massive superobesity (BMI> 60).  Surg En...
<ul><li>Fielding G.  Surg Endosc  2003; 17: 1541. </li></ul><ul><li>Weight loss </li></ul><ul><li>Time (mos)  No. pts  BMI...
Conclusion <ul><li>Best to design each operation individually based on BMI, associated morbidities, eating habits, and eso...
Conclusion <ul><li>Restrictive procedures are not as reliable for weight loss but have lower associated risks  </li></ul><...
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  • Brolin, et al. The dilemma of outcome assessment after operations for morbid obesity. Surgery 1989; 105: 337 (Long-limb study- Kral)
  • Restrictive Procedures in BMI > 50

    1. 1. Restrictive Procedures in BMI > 50 Craig B. Morgenthal, MD George S. Ferzli, MD SUNY Health Science Center at Brooklyn
    2. 2. Definitions <ul><li>Overweight: BMI > 25 kg/m 2 </li></ul><ul><li>Obesity: BMI > 30 kg/m 2 </li></ul><ul><li>Severe obesity: BMI >35 kg/m 2 </li></ul><ul><li>Morbid obesity: BMI > 40 kg/m 2 or BMI > 35 kg/m 2 with concomitant obesity related morbidity </li></ul><ul><li>Superobesity: BMI > 50 kg/m 2 , >225% IBW </li></ul>
    3. 3. Options in Bariatric Surgery <ul><li>Restrictive procedures </li></ul><ul><li>Vertical-banded gastroplasty </li></ul><ul><li>Laparoscopic gastric band placement </li></ul><ul><li>Combined restrictive/malabsorptive </li></ul><ul><li>Roux-en-Y bypass </li></ul><ul><li>Malabsorptive procedures </li></ul><ul><li>Biliopancreatic bypass +/- duodenal switch </li></ul><ul><li>Jejunoileal bypass </li></ul>
    4. 4. Trends in Bariatric Surgery <ul><li>The U.S. rate of bariatric surgery increased from 2.7 to 6.3 per 100,000 adults from 1990 to 1997 </li></ul><ul><li>VBG was formerly the most commonly performed bariatric procedure in the U.S in the 1980s, only 14% of bariatric procedures in 1997 </li></ul><ul><li>Lap band is now the most commonly performed bariatric operation outside the U.S., especially in Europe and Australia </li></ul><ul><li>RYGB-the percent of bariatric procedures done by gastric bypass increased from 52% to 84% between 1990 to 1997, making it the most popular procedure in the U.S. </li></ul><ul><li>Pope G, et al. J Gastroint Surg 2002;6:855. </li></ul>
    5. 5. <ul><li>Comparative overview of weight loss in 54 </li></ul><ul><li>studies, performed in 14,964 patients </li></ul><ul><li>according to bariatric operation performed. </li></ul><ul><li>Operation Total %EWL %BMI </li></ul><ul><li>(# studies) patients (n) loss </li></ul><ul><li>Gastric banding (16) 4429 48.6 22.2 </li></ul><ul><li>BPD (9) 3903 68.8 35.5 </li></ul><ul><li>VBG (15) 3382 58.3 29.0 </li></ul><ul><li>Roux-en-Y GB (11) 2949 68.6 34.7 </li></ul><ul><li>Long-limb RYGB (3) 301 71.6 33.9 </li></ul><ul><li>Buchwald H. Obesity Surg 2002; 12: 733 </li></ul>
    6. 6. <ul><li>Selected Laparoscopic VBG Series </li></ul><ul><li>Source N BMI FU (mo.) Weight </li></ul><ul><li>loss </li></ul><ul><li>Goergen et al 1999 203 43.0 Not stated Not stated </li></ul><ul><li>Naslund et al 1999 60 44.4 23 (mean) BMI ↓ 10.9 </li></ul><ul><li>Salval et al 1999 87 43.4 6-18 (range) 76%EWL </li></ul><ul><li>Toppino et al 1999 170 43.9 1-36 (range) 61% EWL </li></ul><ul><li>Morino et al 2002 250 45.0 48 62% EWL </li></ul>
    7. 7. <ul><li>Selected Lap Adjustable </li></ul><ul><li>Silastic Banding Series </li></ul><ul><li>Source N BMI FU (mo.) Weight </li></ul><ul><li>loss </li></ul><ul><li>Fielding et al 1999 335 47 18 62% EWL </li></ul><ul><li>Zimmerman et al 1998 894 42 12 40% EWL </li></ul><ul><li>Dargent 1999 500 43 28 65% EWL </li></ul><ul><li>Blanco et al 2001 407 49 24 58 kg loss </li></ul><ul><li>Angrisani 2001 1265 44 48 BMI 32 </li></ul><ul><li>Szold, Abu-Abeid 2001 715 43 17 BMI 32 </li></ul><ul><li>Nehoda et al 2001 320 47 24 71% EWL </li></ul><ul><li>Chevallier et al 2002 400 44 24 53% EWL </li></ul><ul><li>Belachew et al 2002 763 42 48 BMI 30 </li></ul><ul><li>Favretti et al 2002 830 46 72 BMI 29 </li></ul><ul><li>O’Brien et al 2002 655 45 72 57% EWL </li></ul>
    8. 8. Is superobesity a distinct entity? <ul><li>Term superobesity first used when it became apparent </li></ul><ul><li>that morbid obesity operations were less effective in </li></ul><ul><li>bringing the extremely obese to normal weight. </li></ul><ul><li>Incidence of coexisting medical problems and overall </li></ul><ul><li>health risk greater in superobese </li></ul><ul><li>Heaviest patients must lose more weight to achieve a </li></ul><ul><li>level that represents a valid reduction in their </li></ul><ul><li>actuarial risk </li></ul><ul><li>Mason E, Doherty C, et al. Gastro Clin NA 1987; 16: 495. </li></ul><ul><li>Brolin, et al. Surgery 1989; 105: 337 </li></ul>
    9. 9. <ul><li>Buchwald H. A bariatric surgery algorithm. </li></ul><ul><li>Obesity Surg 2002; 12: 733. </li></ul><ul><li>OC = 1.0 + BMI # ± 0.5(age) ± 0.5 (GRH) ± 1(CoM) </li></ul><ul><li>OC = Operative category decided based on score </li></ul><ul><li>GB = 0-3, VBG= 2-5, RYGBP=3-6, BPD/DS=4-7, </li></ul><ul><li>Long-limb RYGBP= 6-9 </li></ul><ul><li>Overlap of numbers allows for surgeon and patient preference </li></ul><ul><li>Age = <40yrs add 0.5, >40yrs subtract 0.5 </li></ul><ul><li>GRH = body habitus; favorable +0.5, unfavorable -0.5 </li></ul><ul><li>CoM = CoMorbidities; high + 1, low – 1 </li></ul><ul><li>BMI# = 1 to 6 points given depending on BMI </li></ul><ul><li>BMI strongly influences decision: </li></ul><ul><li>• 35 – 40 (LASGB) </li></ul><ul><li>• 40 – 50 (BPD or RYGBP ) </li></ul><ul><li>• > 50 (long-limb RYGBP) </li></ul>
    10. 10. <ul><li>Selected Malabsorptive </li></ul><ul><li>Series for Superobesity </li></ul><ul><li>Source N BMI Procedure EWL </li></ul><ul><li>Hess & Hess 1998 987 51 BPD-DS >50% in 99% </li></ul><ul><li>Marceau et al 1998 181 >50 BPD-DS >60% in 97% </li></ul><ul><li>Kalfarentzos 132 57 BPD-RYGB >50% in 81% 1yr </li></ul><ul><li>et al 2004 >50% in 40% 5yr </li></ul><ul><li>DeMaria 2004 27 >60 RYGB 58% EWL </li></ul>
    11. 11. <ul><li>Capella J, Capella R. The weight reduction operation of </li></ul><ul><li>choice: VBG or gastric bypass? Amer J Surg 1996; 171: 74. </li></ul><ul><li>329 patients had open VBG and 560 had open VBG combined with Roux-en-Y GB (VBG-RGB), mean preop BMI 52 in both groups </li></ul><ul><li>Complications- early 1VBG (0.3%), 6 VBG-RGB (1%); late 29 VBG (9%), 73 VBG-RGB (12%) </li></ul><ul><li>Conclusions: </li></ul><ul><li>VBG-RGB superior to VBG as weight loss operation BMI 52 to 34 at 5 years vs. 52 to 40. </li></ul><ul><li>For superobese, % EWL at 5 years in VBG-RGB was 60% vs. 45% in VBG. </li></ul>
    12. 12. <ul><li>Biertho L, Gagner M, et al. Lap gastric bypass vs. </li></ul><ul><li>LAGB: a comparative study. JACS 2003; 197: 536. </li></ul><ul><li>Series of 805 lap Swedish adjustable gastric bands at the OBEX Institute (Zurich and Bern, Switzerland) compared with 456 lap gastric bypass at Mt. Sinai Hospital, NY </li></ul>
    13. 13. Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study. JACS 2003; 197:536
    14. 14. Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study. JACS 2003; 197:536
    15. 15. <ul><li>Biertho L, Gagner M, et al. Lap gastric bypass vs. </li></ul><ul><li>LAGB: a comparative study. JACS 2003; 197: 536 </li></ul><ul><li>Conclusions: </li></ul><ul><li>LGB gives higher EWL at 18 months for all ranges of </li></ul><ul><li>preoperative BMI. LGB associated with greater </li></ul><ul><li>intraoperative complication rates (2% vs. 1.3%), early major </li></ul><ul><li>complication rates (4.2% vs. 1.7%), and postoperative death </li></ul><ul><li>rates (0.44% vs. 0%). </li></ul><ul><li>Best indication for the two procedures still unclear. </li></ul><ul><li>LGB could be preferred for heavier patients and those with </li></ul><ul><li>associated morbidities. </li></ul>
    16. 16. <ul><li>Dolan K, Fielding G, et al. Comparison of LAGB </li></ul><ul><li>and biliopancreatic diversion in superobesity. </li></ul><ul><li>Obesity Surg 2004; 13: 165. </li></ul><ul><li>134 morbidly obese patients had bilio-pancreatic diversion over 7 year period, 23 were superobese </li></ul><ul><li>1319 patients had LAGB, 23 sex- matched and BMI-matched controls compared to BPD </li></ul><ul><li>BPD done on patients if LAGB failure, prior gastric surgery, or at patient request </li></ul><ul><li>-1 st 11 BPD done via laparotomy, last 12 lap BPD (all completed) </li></ul>
    17. 17. Dolan K, Fielding G, et al. Comparison of LAGB and biliopancreatic diversion in superobesity. Obesity Surg 2004; 13: 165. <ul><li>BPD LAGB </li></ul><ul><li># patients 23 23 </li></ul><ul><li>Females 16 16 </li></ul><ul><li>Age 41 39 </li></ul><ul><li>Complications 13 2 </li></ul><ul><li>Reoperations 7 2 </li></ul><ul><li>Hospital stay 8 1 </li></ul><ul><li>Follow up (mo) 57 56 </li></ul><ul><li>BPD LAGB </li></ul><ul><li>Preop BMI 56.9 55.9 </li></ul><ul><li>BMI 6 mo 42.7 46.8 </li></ul><ul><li>BMI 12 mo 39.1 43.6 </li></ul><ul><li>BMI 24 mo 34.6 38.9 </li></ul><ul><li>%EWL 6 mo 39.8 29.5 </li></ul><ul><li>%EWL12 mo 57.5 37.0 </li></ul><ul><li>%EWL24 mo 64.4 48.4 </li></ul><ul><li>Resolved HTN 4/6 4/6 </li></ul><ul><li>Resolved DM 2/2 2/3 </li></ul>
    18. 18. Dolan K, Fielding G, et al. Comparison of LAGB and biliopancreatic diversion in superobesity. Obesity Surg 2004; 13: 165. <ul><li>lapBPD LAGB </li></ul><ul><li># patients 12 12 </li></ul><ul><li>Females 9 9 </li></ul><ul><li>Age 35 35 </li></ul><ul><li>Complications 4 1 </li></ul><ul><li>Reoperations 2 1 </li></ul><ul><li>Hospital stay 8 1 </li></ul><ul><li>Follow up (mo) 58 58 </li></ul><ul><li>lapBPD LAGB </li></ul><ul><li>Preop BMI 58.4 57.5 </li></ul><ul><li>BMI 6 mo 42.7 48.3 </li></ul><ul><li>BMI 12 mo 38.6 45.1 </li></ul><ul><li>BMI 24 mo 34.0 39.2 </li></ul><ul><li>%EWL 6 mo 39.8 27.6 </li></ul><ul><li>%EWL12 mo 59.1 37.0 </li></ul><ul><li>%EWL24 mo 68.1 46.7 </li></ul><ul><li>Resolved HTN 1/2 2/3 </li></ul><ul><li>Resolved DM 1/2 1/1 </li></ul>
    19. 19. <ul><li>Dolan K, Fielding G, et al. Comparison of LAGB and </li></ul><ul><li>biliopancreatic diversion in superobesity. Obesity Surg </li></ul><ul><li>2004; 13: 165. </li></ul><ul><li>Complications: </li></ul><ul><li>LAGB 1 band slippage, 1 port-site leak </li></ul><ul><li>open/lap BPD 9/4: wound infection 3/2, wound </li></ul><ul><li>dehiscence 3/0, anastomotic leak 1/1, postop bleed 0/1, </li></ul><ul><li>incisional hernia 2/0 </li></ul><ul><li>Conclusions: </li></ul><ul><li>No obvious difference in resolution of obesity related co-morbidities, but small population size </li></ul><ul><li>Extra weight loss with BPD, but longer hospital stay and more complications </li></ul>
    20. 20. Results of Vertical Banded Gastroplasty
    21. 21. <ul><li>Mason E, Doherty C, et al. Super obesity and </li></ul><ul><li>gastric reduction procedures. Gastroent Clin NA </li></ul><ul><li>1987; 16: 495. </li></ul><ul><li>Retrospective study of 1000 patients undergoing open VBG between 11/80 and 5/87 </li></ul><ul><li>711 morbidly obese, 289 super obese (29%) </li></ul><ul><li>M:F ratio: MO 1: 5.3, SO 1: 2.2 </li></ul><ul><li>Operation length: MO 103 min, SO 117 min </li></ul>
    22. 22. <ul><li>Mason E, Doherty C, et al. Gastroent Clin NA 1987; </li></ul><ul><li>16: 495. </li></ul><ul><li>Marlex Collar Size </li></ul><ul><li>5.5 5.0 4.5 </li></ul><ul><li>Super 2 yrs Pts (n) 48 79 17 </li></ul><ul><li>EWL (%) 41 54 58 </li></ul><ul><li>Super 5 yrs Pts (n) 17 22 </li></ul><ul><li>EWL (%) 38 49 ִ </li></ul><ul><li>Morbid 2 yrs Pts (n) 90 220 69 </li></ul><ul><li>EWL (%) 52 62 60 </li></ul><ul><li>Morbid 5 yrs Pts (n) 18 58 </li></ul><ul><li>EWL (%) 45 61 </li></ul>
    23. 23. <ul><li>Mason E, Doherty C, et al. Gastroent Clin NA 1987; </li></ul><ul><li>16: 495. </li></ul><ul><li>Conclusions: </li></ul><ul><li>Marlex collar size 5 cm is optimum </li></ul><ul><li>Greater percentage of superobese are men, as opposed to morbidly obese (women may be motivated earlier by appearance, while men wait until can not function) </li></ul><ul><li>Restrictive procedures in superobese produce more absolute weight loss than morbidly obese, but does not return patients to “normal” weight (50% EWL in superobese with VBG in this study) </li></ul><ul><li>To achieve close to ideal body weight in super obese, something additional needs to be done </li></ul>
    24. 24. <ul><li>MacLean L, et al. Late results of vertical banded </li></ul><ul><li>gastroplasty for morbid and super obesity. Surgery </li></ul><ul><li>1990; 107: 20. </li></ul><ul><li>201 pts underwent VBG at McGill U. and were followed from 2 to 5 years </li></ul><ul><li>reoperation offered if weight loss stabilized without good result; 201 pts, 283 operations </li></ul><ul><li>48% pts had staple line disruption during 5 years </li></ul><ul><li>54/80 pts with staple line disruption had reoperation </li></ul><ul><li>21 pts reoperation for gastroplasty outlet stenosis </li></ul><ul><li>Final results in all patients: at 2 yrs 65% EWL, at 5 yrs 60% EWL </li></ul><ul><li>subgroup analysis of 59 super obese patients </li></ul>
    25. 25. MacLean L, et al. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990; 107: 20 <ul><li>Subgroup analysis </li></ul><ul><li>of morbid obese </li></ul><ul><li>vs. super obese. </li></ul><ul><li>Conclusion: </li></ul><ul><li>Large weight </li></ul><ul><li>losses occurred in </li></ul><ul><li>super obese but </li></ul><ul><li>remained </li></ul><ul><li>significantly obese. </li></ul>
    26. 26. <ul><li>Bloomston M, Rosemurgy A, et al. Outcome following </li></ul><ul><li>bariatric surgery in super vs. morbidly obese patients. </li></ul><ul><li>Obesity Surg 1997; 7: 414. </li></ul><ul><li>Between 11/84-3/94 157 nonrandomized pts had gastric bypass or VBG at Univ. of South Florida </li></ul><ul><li>78 pts super obese, BMI 60.9 vs. 79 MO, BMI 43.6 </li></ul><ul><li>#VBG/#RYGB: SO 69/9, MO 64/15 </li></ul><ul><li>Complications not significantly different b/w groups </li></ul><ul><li>BMI and % EWL values displayed graphically only </li></ul>
    27. 27. Bloomston M, Rosemurgy A, et al. Outcome following bariatric surgery in super vs. morbidly obese patients. Obesity Surg 1997; 7: 414.
    28. 28. <ul><li>Bloomston M, Rosemurgy A, et al. Outcome following </li></ul><ul><li>Bariatric surgery in super vs. morbidly obese patients. Obesity </li></ul><ul><li>Surg 1997; 7: 414. </li></ul><ul><li>Conclusions: </li></ul><ul><li>males responsible for greater percentage of super obese than MO </li></ul><ul><li>MO lost excess body weight at faster rate </li></ul><ul><li>MO weight loss plateaus at 1yr, SO continue to lose weight until 3 years postop </li></ul><ul><li>both groups regain weight after reaching plateaus </li></ul><ul><li>at 6 yrs MO 48% EWL, SO 39% EWL </li></ul><ul><li>SO lose > weight, but not to lower BMI or greater %EWL </li></ul>
    29. 29. <ul><li>Mason E, et al. Vertical Gastroplasty: Evolution of Vertical </li></ul><ul><li>Banded Gastroplasty. World J Surg 1998; 22: 919. </li></ul><ul><li>30 years of experience in gastroplasty at U of Iowa </li></ul><ul><li>multiple refinements in technique over that time with 10 year results available using current VBG technique </li></ul><ul><li>42 morbidly obese had 5.0 cm collar (VBG5) placed </li></ul><ul><li>26 superobese patients had 4.5 cm collar (VBG4.5) </li></ul>
    30. 30. Mason E, et al. Vertical Gastroplasty: Evolution of Vertical Banded Gastroplasty. World J Surg 1998; 22: 919. <ul><li>VBG 5 = MO </li></ul><ul><li>VBG 4.5= SO </li></ul><ul><li>Conclusion: </li></ul><ul><li>VBG is an </li></ul><ul><li>effective </li></ul><ul><li>operation </li></ul><ul><li>that provides </li></ul><ul><li>weight control </li></ul><ul><li>extending at </li></ul><ul><li>least 10 years. </li></ul>
    31. 31. Results of Laparoscopic Adjustable Gastric Band
    32. 32. <ul><li>Silva AS, et al. Treatment of morbid obesity with adjustable </li></ul><ul><li>gastric band: preliminary report. Obesity Surgery 1999; 9: 194. </li></ul><ul><li>18 patients had lap Swedish adjustable gastric band between 11/95 – 4/98 at Hospital Geral Santo Antonio, Portugal </li></ul><ul><li>17 women, 1 man, mean age 35, preop BMI 50.4 </li></ul><ul><li>Mean OR time 160 min </li></ul><ul><li>2 conversions- 1 gastric perforation, 1 exposure </li></ul><ul><li>Mean hospital stay 5 days </li></ul><ul><li>Complications- early: 1 pneumonia late: 1 intragastric band migration, 1 pouch dilation </li></ul>
    33. 33. <ul><li>Silva AS, et al. Treatment of morbid obesity with adjustable </li></ul><ul><li>gastric band: preliminary report . Obesity Surgery 1999; 9: 194. </li></ul><ul><li>Weight loss (BMI) </li></ul><ul><li>Preop 6 mo 12 mo 18 mo </li></ul><ul><li>50.4 39 32 30.4 </li></ul><ul><li>Comorbidity resolution (# off medications/# preop): </li></ul><ul><li>Hypertension 2/3 (66%), Arthropathy 3/4 (75%) </li></ul><ul><li>Sleep apnea 3/3 (100%), Dyslipidemia 2/3 (66%) </li></ul>
    34. 34. <ul><li>Taskin M, et al. Laparoscopy in Turkish bariatric surgery: </li></ul><ul><li>initial experience. Obesity Surgery 2000; 10: 263. </li></ul><ul><li>50 patients had Swedish adjustable gastric band placed from 4/98-4/99 at Istanbul Univ, Turkey </li></ul><ul><li>Mean preop age 35, mean preop BMI 50.4 </li></ul><ul><li>2 Conversions: 1 bleeding, 1 respiratory difficulty </li></ul><ul><li>Postop stay average 4 days </li></ul><ul><li>Weight loss: </li></ul><ul><li>BMI 50.4 to 29.0 at 12 months, EWL 48% </li></ul>
    35. 35. <ul><li>Favretti F, et al. Laparoscopic banding: selection and technique in 830 patients. Obesity Surg 2002; 12: 385. </li></ul><ul><li>LAGB placed in 830 patients between 9/93- 11/00 at 2 institutions in Belgium and Italy </li></ul><ul><li>565 patients morbidly obese with mean BMI 42.7, 235 patients superobese, mean BMI 55.7 </li></ul><ul><li>Years 0 1 2 3 4 5 6 7 </li></ul><ul><li>BMI (series) 46 37 36 37 37 36 40 29 </li></ul><ul><li>BMI (MO) 43 35 34 34 35 35 38 30 </li></ul><ul><li>BMI (SO) 56 44 43 43 43 42 56 – </li></ul>
    36. 36. <ul><li>Chevallier JM, et al. Adjustable gastric banding in a public university hospital. Obesity Surg 2002; 12: 93. </li></ul><ul><li>400 patients underwent LAGB from 4/97 to 1/01 at Hopital Europeen, Paris, France </li></ul><ul><li>352 women, 48 men, mean age 40, mean BMI 43.8 </li></ul><ul><li>55 superobese patients </li></ul><ul><li>Weight loss: </li></ul><ul><li>ALL PATIENTS SUPEROBESE </li></ul><ul><li>Mo postop n BMI %EWL Mo postop n BMI %EWL </li></ul><ul><li>0 400 43.8 0 0 55 none stated 0 </li></ul><ul><li>6 257 36.2 31.8 6 34 45.8 38 </li></ul><ul><li>12 168 34.3 42.1 12 23 42.3 54 </li></ul><ul><li>24 33 32.7 52.7 24 6 37.2 73 </li></ul>
    37. 37. <ul><li>Fielding G. Laparoscopic adjustable gastric banding for </li></ul><ul><li>massive superobesity (BMI> 60). Surg Endosc 2003; 17: 1541. </li></ul><ul><li>Lap adjustable bands placed in 76 pts with BMI >60, median BMI 69, 5 patients BMI > 100 </li></ul><ul><li>Done between 2/96 to 1/02 in Brisbane, Australia </li></ul><ul><li>49 females, 27 males; median age 39 years </li></ul><ul><li>Average hospital stay 3 days; no mortality </li></ul><ul><li>Complications: no PE, 5 wound infections, 6 bands removed for dysphagia (5/6 of these were in pts with previous open VBG; all 6 removed after 2yrs) </li></ul>
    38. 38. <ul><li>Fielding G. Surg Endosc 2003; 17: 1541. </li></ul><ul><li>Weight loss </li></ul><ul><li>Time (mos) No. pts BMI (kg/m 2 ) % EWL </li></ul><ul><li>0 76 69 - </li></ul><ul><li>12 58 49 47 </li></ul><ul><li>24 49 39 57 </li></ul><ul><li>36 33 37 59 </li></ul><ul><li>48 17 37 60 </li></ul><ul><li>60 13 35 61 </li></ul><ul><li>Conclusions : this series demonstrated excellent weight loss </li></ul><ul><li>that matches more complex surgeries, with low morbidity </li></ul><ul><li>and no mortality, supporting lap band in superobese </li></ul>
    39. 39. Conclusion <ul><li>Best to design each operation individually based on BMI, associated morbidities, eating habits, and esophageal motility </li></ul><ul><li>Successful loss of body weight may be best with malabsorptive procedures, but these have higher operative risks and complications </li></ul>
    40. 40. Conclusion <ul><li>Restrictive procedures are not as reliable for weight loss but have lower associated risks </li></ul><ul><li>Superobesity may be a relative contra-indication to undergoing restrictive procedures and risk-benefit ratio may be shifted toward gastric bypass or malabsorptive operations </li></ul>
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