Abstract
Surgery 2000;127:491–2
Obesity in the industrialized world is becoming more prevalent.
1
Its effects are undesirable and the cost is prohibitive.2
, 3
, 4
The NIH has concluded that for the morbidly obese, bariatric surgery is the most successful manner of losing weight and keeping it off.5
Surgical options include gastric restrictive, malabsorptive, or a combination of these 2 procedures.6
, 7
, 8
Adjustable gastric banding is being increasingly utilized as a gastric restrictive operation.9
, 10
Gastric restrictive operations have been my procedure of choice to date. They result in less weight loss, but in fewer of the metabolic and nutritional deficiencies associated with bypass procedures.In this issue of Surgery, Hauri and colleagues analyze their data in 207 morbidly obese people implanted with the Swedish adjustable gastric band (SAGB) and followed for 1 year or more. They present the complications, weight loss, and number of adjustments performed. Their complication rate and weight loss are acceptable; however, longer follow-up is necessary.
The authors position the reservoirs subcutaneously on the lower third of the sternum. As a consequence, they are able to perform band adjustments in their office. They evaluate the effect of the adjustment by the subjective response of the patient to drinking 100 mL of water and to eating a meal. In the USA Lapband study, the reservoir is positioned in the musculature of the anterior abdominal wall. Fluoroscopic control is necessary to access it. Simply by getting the patient to drink contrast, immediate radiologic information is easily obtained. Evaluable data include the size of the esophageal lumen, the rate of esophageal emptying, whether there is any tertiary esophageal contraction, the position of the band, the size of the pouch, the degree of restriction achieved, and the presence or absence of reflux. In my opinion, radiologic control, although more demanding of time and equipment, provides a more rational means of assessing the consequences of a band adjustment. At least intermittently, I advocate utilizing radiologic evaluation to optimally perform band adjustments.
The authors calculate that an individual surgeon, who performs both the operation and the subsequent adjustments, will have to stop accruing patients when 500 implantations have been performed. Although the actual number of patients may be negotiable, there will in fact be a finite number of band implantations that a solo practitioner will be able to perform. I agree with the conclusion of the authors that a multidisciplinary team is desirable when managing patients who have received an adjustable gastric band.
It seems appropriate, in this forum, to raise a specific concern which I have about gastric restrictive operations in general and adjustable banding in particular. Of the 300 subjects recruited for the 8-center USA Lapband study, I implanted 75. Analysis of my first 50 patients identified 2 factors which predisposed to band slippage: a dysfunctional esophagus or hiatus hernia or both.
11
Accordingly, concern about esophageal function led me to obtain preoperative esophageal manometry. The data were disquieting. Manometric abnormalities were documented in 61% of potential patients.12
This is all the more troubling as the esophagus is the stress organ for gastric banding. I concluded that preoperative evaluation of the esophagus may be desirable when considering adjustable gastric banding. Manometry may identify individuals at greatest risk of postoperative technical complications. It may also help define sub-populations who will, or will not, benefit from implantation of an adjustable gastric band.In summary, gastric restrictive operations offer less radical surgery and fewer nutritional and metabolic deficiencies. An option increasingly being performed is adjustable gastric banding. Such procedures merit cautious consideration, thorough preparation, appropriate instrumentation, meticulous operative technique, cautious postoperative adjustments, and long-term follow-up.
References
Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults, The National Health and Nutrition Surveys 1960 to 1991. JAMA 194;272:205–11.
- Medical hazards of obesity.Ann Intern Med. 1993; 119: 655-660
- Body-mass index and mortality in a prospective cohort of US adults.N Engl J Med. 1999; 341: 1097-1105
- The cost of obesity: a US perspective.Pharmacoeconomics. 1994; 5: 34-37
- Am J Clin Nutr. 1992; 55: 615S-619S
- Vertical banded gastroplasty for obesity.Arch Surg. 1982; 117: 701-706
- Bilio-pancreatic bypass for obesity II: initial experience in man.Br J Surg. 1979; 66: 618-620
- Gastric bypass.Ann Surg. 1969; 170: 329-336
- Laparoscopic placement of adjustable silicone gastric band in the treatment of morbid obesity: How to do it.Obes Surg. 1995; 5: 66-70
- Validation of pouch-size measurement following the Swedish Adjustable Gastric Banding using endoscopy, MRI and barium swallow.Obes Surg. 1996; 6: 463-467
- Esophageal anatomy and function in laparoscopic gastric restrictive bariatric surgery: implications for patient selection.Obes Surg. 1998; 8: 199-206
- High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients.Obes Surg. 1999; 9: 390-395
Article info
Publication history
Accepted:
January 26,
2000
Footnotes
*Reprint requests: Reprints are not available from the author.
Identification
Copyright
© 2000 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
