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Results and complications of the laparoscopic adjustable gastric band in Bolivia

Tito Grgeda FACS, Jos Paredes FACS,Christian Ferrrufino FACS,Marcela Zabalaga,Laura Grgeda,Luis Quiroga,Maya Sanchez-Baya,Luis Parada,Marcelo Prraga

 Servicio de Ciruga del Hospital Elizabeth Seton, Caja Petrolera de Salud y Clnica San Pedro. Cochabamba,Bolivia.


Abstract:Objective:Evaluate the results and complications of the laparoscopy adjustable gastric banding (LAGB) to patients with excess corporal weight and/or comorbidity associated with obesity. Patients and Methods:Prospective longitudinal quasi-experimental study of 125 patients with Body Mass Index (BMI) > or equal to 40, or > o equal to 35 with co morbidities. The procedure was done by the Pars flaccid technic. The post-operative follow up was 24 months, with a minimum of 12 and maximum of 36. The statistics analysis was done with SPSS.Results:65.1 % were woman and 34.9% male. The pre-operative weight was 13.9 Kg and the BMI was 38.56. The percentage of excess weight loss(%EWL) in the first year was 59%, and at the third year the conversion rate for bleeding was 0.8%, the post-operative complications were pouch dilatation 25%; anterior sliding 3.7%, erosions 2.7% and reflux 3.7%.Conclusions:The short term results were not ideal, although the LAGB should be consider as an alternative for surgical treatment for the obesity, always accompanied with a follow up of the multidisciplinary team, dietetic measures, exercises and psychological orientation.

Key words: Surgery, Bariatric, Obesity, Laparoscopy

 Introduction

La Laparoscopic Adjustable Gastric Band (LAGB) is a restrictive operation to treat morbid obesity if the Body Mass Index (BMI) is >40 o when patients have comorbidities (high blood pressure, myocardium hypertrophy, hyperlipidemia, several types of cancer colelithiasis, sleep apnea, degenerative arthritisand psychologicalproblems) if the BMI is >351.Morbid obesity is a worldwide health problem with an increase incidence and there is more than 300 millions new obese, in the US nearly 6 millions have a BMI >40 and another 10 millions IMC>35 with associated comorbidities 3.

 
Tito Gr
geda Soto MD FACS

Cirujano General-Laparoscopia

JefeDepartamento de Ciruga Hospital Elizabeth Seton

Av. Blanco Galindo Km.5

Cochabamba BOLIVIA. Cachogs29@yahoo.es


In Bolivia the incidence of obesity is 2.1% of the population and increasing continually. The restrictive operations area option to lose weight long-term because medical management is not being successful and does not correct comorbidities6.

LAGB was introduced in 1993 with the advantages of being minimally invasive, adjustable and allows agradual weight loss in the patient7. The short-term results were excellent with a low morbidity, almost no mortality and adequate weight loss (WL) 1,8,9. Buchwald 10in a multicenter study informed that %EWL was 61.%in 61.% of the  patients after 9 years of a interactive team and OBrien reports %EWL of 55% at 5 years, and 51.0% and 59.3% at 7 and 8 years.

Our objective is to determine the results with LAGB in patients with EW and comorbidities associated with obesity in Bolivia

Patients and Methods

The present study is quasi experimental, prospective and longitudinal. The Ethical Committee and the Continuous Medical Education Board of the Elizabeth Seton and San Pedro Clinic, Cochabamba, Bolivia have approved it.

126 patients were included with BMI>40 or if comorbidities (Diabetes, High blood pressure, hyperlipidemia) the BMI>35. A multidisciplinary team evaluated the patients pre-op with labs, radiology, abdominal ultrasound, upper endoscopy, and psychological, metabolic, nutritional, cardiologic and endocrine evaluation

The clinical history,demographic data, associated comorbidities, Pre & post op weight and BMI, intra and post-op complicationswere accounted.

All patients had general anesthesia, three doses of prophylactic antibiotics (cephalosporin) and a daily dose of low-molecularheparin.  Lap-band or VG (Allergan, Santa Brbara,CA) the Swedish(SAGB; Optech Medical), by the  ParsFlacida7,8 we used all by laparoscopy. Adjustments were done under barium control the first time and later at the office depending on the subjective patient’s symptoms as hunger sensation or increase on the intake. 108 patients (85,7 %) were followed, 18 (14,3 %) were lost at 24 months.

Patients were followed with a mean of 24 months, 12 m minimum and y 36maximum.  At 1,2 and 6 weeks they were seeing at consultation during thefirst year and finally 3 times a year for the second and third. Weight, BP, symptoms related to the GB post-op complications and labs (CBC, glucose, BUN, creatinine, cholesterol, triglycerides, total protein and Albumin)

A SPSS -17 program was used for the statistical analysis with the mean, standard deviation and t-Student test.

Results

Of the 126 patients, 65.1% (n=82) were femalesand  34.9% (n= 44) males. Pre-op Weight 103.17 13.9 Kg and Initial BMImean 38.564,5.

Only one case required conversion to open, 0.8%, due to bleeding when doing the retro gastric tunnel and the band was paced at laparotomy. The %EWL was 65% (n-126) on the first year and 59% (n-71) by the 3rd year. WL and BMI are shown in Table 2 comparing males /females and in Table 3 the comparison in between both sexes. The comorbidities are in Table 4 including DM2

Major complications required se operation andminor if they did not. Dilation of the pouch was present in 25% (n-27) of the patients and were treated by medical means and deflation of the band, 3.5% (n=4) had GERD, 2.7% (n=3) erosions, 3,7% (n=4) anterior slippage treated by laparoscopy, re positioning the band in 3 cases and removing it in 1 case. The mean in between the operation and re-operation was 15 months (8 to 21 months) Table 5. Less than 1% patients complicated with dysphagia and 12% had vomiting.

 

Discussion

Obesity has increased worldwide13. Obesity leads to a higher morbidity and less life expectancy. . Medical management with diets, exercise, medications generally works in between 5-10% of the cases and 90% of them regain its original weight within 3 to 5 years 14

Weight loss surgery is effective and obtains adequate weight losses. 15,16,17, reducing morbidity and mortality obesity related19. Ideally bariatric surgery should be low risk, had prolonged weight losses over 50% of %EWL in 80% of the patients for more than 5 years , with  good quality of life, low re operation indexes, reversible and reproducible.20,21. LGB was introduced more than 17 years ago and the early results were excellent20,21

The %EWL of patients with LAGBgoes from 49,4% at 34 months, 55% at 5 years, 51% at 7years, 59,3% at 8 years and up to 61.8% at 9 years. The comparative results of this work is similar to the international numbers22, except at 36 months that is a little bit higher .

It is important to mention that the EWL is low in between 24-36 months, and this should be explain to the patient before surgery to force him/she to be strict in the dietetic  and exercise recommendations form the beginning. WL is similar in males and females (Table 3) but LAGB is favorable to both. The good results in the comorbidities were good at 12 months but decreased at 36 months (Table 4). This is why the multidisciplinary team is so important to use coadjutantmeasures to prevent progression of the comorbidities.

A 33,1 % of the patients had a surgical complication short or median- term as dilation of the pouch 6,33-21%, erosions 9,5%, slippage 20.5% and port-related problems 7.6%25. The frequency and % of the post-op complications in this work are less excepting thedilation of thepouch which is higher. All these complications can be resolved and be under control by laparoscopy, and are related to the technical details of the placement of the LAGB and the experience of the surgical team are determinant on the % and frequency of the complications.

In conclusion, even if the expected final mid-term results on WL and comorbidities are not ideal and the post-op complications occur in a third of the patients LAGB should be consider a good alternative in the surgical management of obesity if is performed by a dedicated multidisciplinary team and complemented with diet, exercise and psychological orientation.


References

 


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