Obesity Surgery, 12, 391-394
Laparoscopic Adjustable Esophagogastric Banding: Preliminary Results Francesco Domenico Capizzi, MD; Sergio Boschi, MD; Mauro Brulatti, MD; Andrea Cuppini, MD1; Marco Di Domenico, MD; Luciano Fogli, MD; Vito Papa, MD; Patrizio Patrizi, MD Departments of General Surgery and 1Endocrinology, Bellaria Hospital, Bologna, Italy Background: Laparoscopic gastric banding is effective in surgical treatment of morbid obesity, but has had the drawback of specific complications, like slippage and gastric erosion. To prevent such complications, modifications have been used, including high retrogastric positioning above the bursa omentalis, complete anterior fixation by gastro-gastric stitches over the band, and reduction of the pouch volume to £15 ml. These technical variants may induce dysphagia. Methods: We adopted a different technique, consisting of placement of the band (9.75 cm BioEnterics Lap-Band ® ) around the esophagus just above the cardia, to induce an amplification of the dysphagic mechanism. No fixation stitches were used. Results: From January 1999 to March 2001, 80 consecutive patients (16 males, 64 females, mean age 41 years, average BMI 45) were operated this way. All operations were completed laparoscopically. However, in 1 patient the procedure had to be interrupted for bleeding from a large fatty liver injury by the retractor. Complications included 2 cases of slippage: an early one after 24 h, requiring surgical removal, and a late one after 9 months, treated by laparoscopic repositioning. The third complication, a reactive esophageal stenosis, occurred in a transsexual male on estrogen treatment, that needed replacement with a wider Swedish band. Band adjustment was required in 28 patients, one time in 22 cases and twice in the other 6. Mean BMI decreased from 45 to 38 after 6 months, remaining at 37 after 24 months, while excess weight was reduced by 50% at 24 months. Conclusions: The technique has a re-educational function, in that patients are induced to chew thoroughly, to introduce small morsels of food and to prolong the mastication time, in order to avoid dysReprint requests to: Luciano Fogli, MD, Divisione di Chirurgia Generale, Ospedale Bellaria, Via Altura, 3, 40139, Bologna, Italy. Fax: 0039 51 622 5706; e-mail:
[email protected] © FD-Communications Inc.
phagia. Laparoscopic adjustable esophagogastric banding gave no problem if well positioned, and promoted new alimentary habits through a dysphagic mechanism, inducing significant excess weight loss.
Key words: Morbid obesity, bariatric laparoscopy, esophagogastric banding
surgery,
Introduction Laparoscopic adjustable gastric banding (LAGB) combines the advantages of mini-invasivity, adjustment and reversibility, with effective weight loss. Like all bariatric surgery, this operation is fraught with specific complications related to the band, in particular slippage (2.5-12%), gastric erosions (0.6-1.9%), and band infection (0.6-3%). 1-10 Although decreasing with experience, they still represent the main drawback of the procedure. In order to avoid the above mentioned complications, we modified the original gastric banding technique, shifting to laparoscopic esophagogastric banding (LEGB). There are two reasons for this choice: 1) The mechanism of action of the band. We hypothesized that reduction in food intake was not related so much to the gastric pouch stretching by food, but to the resulting dysphagia, forcing the patient to introduce small morsels of food, and to masticate thoroughly. Indeed, obese people frequently toss down food without chewing it. 2) Preventing the two main complications of the band impinging on the gastric wall. Obesity Surgery, 12, 2002
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Patients and Methods Patients were screened on the basis of BMI, and binge eaters, sweet eaters and individuals with severe psychiatric and endocrine dysfunctions were excluded. Screening included blood analysis including metabolic and hormonal basic studies, barium meal and liver ultrasonography; esophagogastroduodenoscopy and esophageal manometry were done only in selected cases on clinical and radiological grounds. Patients underwent LEGB with antithrombotic prophylaxis with calcic heparin and elastic lower limb compression, using antibiotic short-term perioperative prophylaxis. The 9.75 cm LapBand® (BioEnterics, Carpinteria, CA, USA) was used, placed around the esophagus approximately 2 cm above the cardia (Figure 1). Surgical technique entails partial dissection of the phreno-gastric ligament on the left and opening of the pars flaccida of the lesser omentum on the lesser curvature. After identification of the diaphragmatic pillars, retroesophageal dissection is completed bluntly using an articulated dissector, to provide lodging for the LapBand®. No fixation stitches on the gastric wall are used. In all cases, an intraoperative methylene blue test was carried out. All patients were kept fasting until Gastrografin® swallow 24 h after the operation. Patients were maintained on a semi-liquid diet for 3-4 weeks, followed by a solid diet, and were
Figure 1. Postoperative Gastrografin® swallow demonstrating esophagogastric positioning of the LapBand ® .
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instructed to eat slowly, to introduce small morsels of food, and to chew thoroughly. Follow-up involved office evaluation after 1 month and after 3 months, and 6-monthly thereafter. Body weight, body mass index (BMI), and complete blood analyses were done each time, while barium meal was repeated after 6 months. In 4 cases, postoperative esophageal manometry has been also performed. Patients underwent band adjustment in the case of cessation or strong reduction of weight loss, beginning with injection of 1 ml saline the first time, followed by 0.5 ml the other times.
Results From January 1999 to March 2001, LEGB has been performed on 80 patients, 16 males, 64 females; mean age was 41 ± 11.5 SD years (range 23-69); BMI was 45 ± 5.5, range 33-59; percent excess weight (%EW) was 78.14 ± 25.29. Co-morbidities included hypertension in 32 patients, diabetes in 9, sleep apnea syndrome in 12, and degenerative arthropathies in 21. Preoperative barium meal was performed routinely on all patients, gastroscopy in 9 patients, and esophageal manometry in two random cases for investigational purposes. No associated gastroesophageal problems were found. All patients were operated on laparoscopically: the conversion rate has been zero. However, in one female patient the LapBand® could not be placed, because of intraoperative bleeding due to hepatic injury by a retractor inappropriate for a huge hypertrophic liver. This patient is not considered in the following analyses. Average operating time was 110 minutes (range 60-240); in 21 patients, an associated operation was also performed, consisting of adhesiolysis, cholecystectomy or prosthetic hernia repair. There have been three postoperative complications. In two cases it consisted of slippage, which occurred respectively after 24 hours and after 9 months following LEGB. In both patients, a small part of the gastric wall had been accidentally included within the LapBand®. Both patients underwent laparoscopic reoperation: in the first patient, the band was removed, while in the second
Laparoscopic Esophagogastric Banding
one the slippage was reduced and the stomach was sutured to the diaphragmatic pillars. The third complication was a case of immediate esophageal stenosis by the LapBand®, which necessitated removal and replacement by a Swedish Adjustable Gastric Band® (Obtech Medical AG, Baar, Switzerland) of greater calibre. This patient was a male transsexual on estrogen therapy. No further immediate or late complications have been registered. Radiological examinations performed at 6 months after the operation have shown no abnormalities nor indirect signs of intra-gastroesophageal migration. Postoperative esophageal manometry revealed aboral lengthening of the lower esophageal sphincter high-pressure zone, and wider peristaltic waves. Long-term compliance of patients has been good. Patients are compelled by the LapBand® to chew accurately, to avoid disturbing dysphagia. No clinically relevant gastroesophageal reflux has been registered. Band adjustment was required in 28 patients, one time in 22 patients and twice in the other six. The change in BMI is shown in Figure 2. Mean BMI decreased from 45 to 38 after 6 months, and is 37 after 24 months, while %EW has reduced by 50% of the original at 24 months. Accompanying weight loss, there has been clinical improvement of co-morbidities; in particular, 4 of 9 diabetic patients, and 10 of 33 hypertensive patients could be withdrawn from pharmacological therapy. 55
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Figure 2. BMI (kg/m2) in the first 79 patients after laparoscopic adjustable esophagogastric banding. Bars = SD. No. of patients at each point is in brackets.
Discussion Multiple improvements in technique have been introduced to gastric banding, to lower the postoperative complication rate: high retrogastric positioning above the bursa omentalis, full anterior fixation via gastro-gastric stitches over the band, and reduction of the gastric pouch volume to £15 ml.1,4,11-13 The technique adopted by us amplifies the dysphagic mechanism, and avoids the most common complications – slippage and gastric pouch dilatation, if the band is placed above the cardia. Actually, LEGB educates obese patients to regular mastication, and consequently to lower food intake. The at least 3-4 fold prolongation of the mastication time and the need to introduce food in small morsels leads to restriction of food intake, allowing prolonged tolerance of 600 to 1200 calorie diets. This new eating habit has a further gratifying effect on patients: increased or renewed perception of previously unknown tastes. The ensuing weight reduction favors new life-styles, increasing the band effectiveness. In fact, patient compliance for this operation has been excellent. This technique has given few complications so far, and in particular no gastric erosions nor problems related to the band around the esophagus. No clinical or radiological signs of pseudo-achalasia have been registered so far. Long-term follow-up and meticulous study of esophageal function in symptomatic cases will search for late dysmotility problems associated with high positioning of the band. In conclusion, esophagogastric banding: increases the dysphagic mechanism, automatically avoided by the patient by changing eating habits; is well accepted by patients; has few drawbacks and avoids classical gastric banding complications; promotes new eating habits and favors a new lifestyle.
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