Abstract
Surgery 2000;127:489–490
In recent years, laparoscopic adjustable gastric banding (LAGB) has become increasingly popular throughout Europe and elsewhere. Two explanations appear to explain this rapid spread of new technology. First, a number of laparoscopic specialists without previous experience in obesity surgery have found a big market with obese people who eagerly desire to have something done about their weight. The principle of LAGB is easily understood by patients, and the operation looks simple and reversible. Second, LAGB manufacturers apply a lot of pressure on the laparoscopic community to adopt this operation. However, there are at present no long-term data proving the efficacy and safety of this method.
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Therefore, the large clinical series of LAGB patients presented by Hauri and colleagues in this issue of Surgery is very important. The authors have followed up all of their patients for 12 months. Among more than 200 patients, there were only single postoperative complications. All patients were evaluated radiographically after one year and, interestingly, there were no slippages and no proximal pouch dilations. Thus the authors have been very skillful (and lucky?) to avoid these bothersome complications reported by others.
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The authors admit that LAGB required multiple clinic visits postoperatively. During the first postoperative year, each patient was seen a mean of 8 times for inflating or deflating of the band. It is no longer possible for a surgeon to see and handle all his own cases. In fact, it was calculated that after 500 operations the surgeon would have a full-time job only by inflating and deflating bands.
Even if further follow-up studies by Hauri and his colleagues provide important information in the future, their study at present cannot be taken as evidence for long-term efficacy and safety. There are reports on development of erosive esophagitis, Barrett's esophagus, late pouch dilatations, weight loss failures, and patient dissatisfaction in the long run after LAGB.
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After a spell of enthusiasm for LAGB in Sweden between 1994 and 1997, more and more bariatric surgeons became disappointed with the side effects. Today, the “Swedish” band is hardly ever used in Sweden. Even with the short observation period of one year in the paper by Hauri and colleagues, a serious and very significant problem is revealed, namely band penetration or band erosion.Silicone is foreign material, and when in contact with the constantly moving gastric wall, in an unknown percentage of patients the band will erode and penetrate the gastric wall. With gastroscopy, the band becomes visible from the inside. With time, the entire band is expelled into the lumen. Peristalsis will try to propel the band in an aboral direction, but its movement will be hampered by the anchoring of the tube to the injection port.
Clinically, band erosion can go undetected for a long time, only to be discovered by gastroscopy. But band erosion can also result in dramatic clinical events. DeJonge and colleagues
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reported a patient in whom the eroded band gave rise to multiple intestinal perforations. We have seen one patient with peritonitis and another with severe gastrointestinal bleeding.4
Often the patients with band erosion report that they suddenly can eat without resistance and that their weight increases. Pain between the shoulder blades and infection along the tube have also been reported. The incidence of erosion varies between 1% and 10%. Of course, when gastroscopy is part of the follow-up, incidence figures are higher.4 Estimates of the incidence of band erosion in clinical series without gastroscopy must be considered as minimum figures and should probably be multiplied by an unknown factor possibly as great as 2 or 3 to reflect true incidence.Hauri and colleagues report 2 penetrations and 1 band erosion already during the first year, giving an annual incidence of 1.5%. In all 3 patients, the band was removed endoscopically and a new band was placed laparoscopically after a few months. It is likely that Hauri and colleagues have more patients with band erosion who have gone undetected without or with only minor symptoms. Let us assume that the true incidence is only 1.5% per year but that the incidence is linear over time. Thus, also with this conservative assumption, the authors will have 3 new band erosions to redo every year out of their original 200 patients. In 10 years, 30 patients will have to be redone. This may be a worse-case scenario, but we do not know the long-term incidence of band erosion. Some patients will encounter serious problems from their band erosion, such as peritonitis, intra-abdominal abscess, or gastrointestinal bleeding.
We must remember that we are treating a young patient group who will have a long life expectancy with their weight reduction. The mean age among Hauri's patients was 43 years. Therefore, when calculating the number of band erosions with the above assumptions, it will take about 33 years until half of the patients will have experienced at least one band erosion.
Ironically, these problems with band erosion could have been and probably were anticipated from the surgical literature. The Angelchik prosthesis is a silicone sausage to be tied around the distal esophagus to treat gastroesophageal reflux. This imaginative therapeutic principle worked but the method had to be abandoned because of side-effects, namely erosion and migration.
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LAGB may follow the same route. The approach in the United States has been to start with a limited trial and investigate the patients carefully postoperatively. Hopefully, the FDA will not prematurely approve LAGB before follow-up studies, including gastroscopy after 3 to 5 years, have proven the predictions I have offered to be totally wrong about LAGB.References
- Prospective investigation of complications, reoperations, and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity.J Gastrointest Surg. 1998; 2: 102-108
- Disappointing long-term results of laparoscopic adjustable silicone gastric banding.Br J Surg. 1997; 84: 868-869
- Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases.Surg Endosc. 1997; 212: 268-271
- Silicone-adjustable gastric banding: disappointing results.Obes Surg. 1998; 8: 467-474
- Adjustable silicone gastric banding, first results of laparoscopic approach.Obes Surg. 1998; 8 ([abstract]): 385
- Intraluminal erosion and migration of the Angelchik antireflux prosthesis.Arch Surg. 1984; 119: 849-853
Article info
Publication history
Accepted:
December 18,
1999
Footnotes
*Reprint requests: Reprints not available from the author.
Identification
Copyright
© 2000 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
