Minimally Invasive Surgery of Obesity Top

  ...... Introduction - Surgical Technique - Postoperative Course - Own Results - Discussion - References

Summary

Of the currently available minimally invasive surgical techniques to treat morbid obesity (defined in terms of a body mass index > 40 kg/m²), laparoscopic adjustable gastric banding is an effective surgical procedure. It not only leads to satisfactory weight reduction but is also associated with a low rate of complications. Compared to other therapeutic modalities this procedure helps the patient with morbid obesity to achieve a reasonable long-term quality of life within a relatively short period. A body mass index (BMI) of 40 kg/m² or more represents clinically severe obesity, and warrants operative treatment. These patients are commonly referred to bariatric surgery. Two recently introduced laparoscopic gastric restrictive procedures are adjustable silicone gastric banding (ASGB - Kuzmak, 2) and the Swedish adjustable band (Hallberg, 3). These operations are safe and effective bariatric procedures, effecting a weight loss that is comparable to that produced by more extensive operations. Moreover, adjustable gastric banding is fully reversible and may be adjusted to the patient's needs.

Introduction

Extreme forms of overweight cannot be influenced by diet, behavioural therapy or medication (1). In the last 40 years more than 50 different surgical methods have been proposed in the management of morbid adiposity (body mass index more than 40 kg/m2). So-called adjustable gastric banding has become popular since 1985 as a means of achieving gastric restriction and treating morbid adiposity. Adjustable silicone gastric banding (ASGB) as described by Kuzmak (2) and the Swedish adjustable gastric band proposed by Hallberg (3) permit regulation of gastric restriction.

The adjustable gastric band is 12 mm wide, made of soft silicone and equipped with an elastic balloon that can be inflated to the desired volume by means of injection. The band is placed around the upper part of the stomach and causes the stomach to be divided into two sections. The small part lies above the band and has a pouch with a capacity of 15 to 20 ml while the remaining part of the stomach lies below the band. This constriction is known as a stoma. Adjustable gastric banding permits the surgeon to alter the diameter of the stoma. A small tube attached to the band leads to an injection reservoir (known as the port). The port is fixed below the fascia of the rectus muscle and is visible on x-ray fluoroscopy. Injection of fluid into the port causes the elastic part of the band to be enlarged. Conversely, removal of fluid from the port causes the elastic part to be reduced in size. Thus, the stoma may be enlarged or made smaller.

The first laparoscopic implantation of an adjustable gastric band was published in 1994 by Belachew (4), who used the band in an animal model. Besides conventional gastroplasty with a reinforced band, laparoscopic gastric banding is routinely used in our department since July 1994.

Surgical technique

Five trocars are introduced with the patient in half-sedentary position. By means of a calibration balloon positioned in the stomach, the site of incision is determined at the small curvature. At this site, a 0.5 to 1-cm window is placed closed to the cardia. The fenestration is continued along the posterior wall of the gastroesophageal junction up to the angle of His.

 
Thereafter, the endodissector (Inamed Company) is introduced and attached to the end of the catheter. The catheter end of the gastric band is placed around the cardia. For final positioning of the band the calibration balloon in the cardia is filled up to 10-15 ml. Below this so-called pouch the band is closed with a special sealing device. In the Swedish adjustable gastric band of Hallberg an interrupted suture is used for closure. Three to four seromuscular sutures are made in the large curvature to prevent the band from slipping. The catheter end of the band is brought outward via an 18-mm trocar and is connected here to the port, which is fixed below the anterior rectus sheath with four interrupted sutures.

Postoperative course

Using gastrografin, a contrast medium-enhanced roentgenogram was made on the first postoperative day. If the findings were negative, the patient was permitted to take fluids, followed by a structured diet. If the patient had undergone an endoscopic operation, the last series followed by a postoperative hospital stay of 2-4 days. The stoma was finally adjusted above the port after 4-6 weeks, in the out-patient department. Control examinations at close intervals (also in the out-patient department) were mandatory.

Own Results

In bariatric operations performed from July 1994 to July 1997, laparoscopic gastric banding was used in 71 patients and conventional vertical banded gastroplasty in 147. The small number of endoscopic adjustable gastric bands was related to the high cost of the material.

The results in terms of loss of weight were identical with both methodsmorbidity, however, was minimal when the laparoscopic technique was used. ASGB is more easily reversible, since no anastomosis or clip suture is required in the stomach. Especially highly overweight patients are liable to profit from the laparascopic method. The patient may be mobilized much earlier and a much lower rate of morbidity has been registered. Wound healing disorders are also minimized. By way of early postoperative complications we observed a transitory cholestasis in only one patient (2%) who had simultaneously undergone cholecystectomy. The rate of conversion to the open method is currently very low (5%). By way of late complications we encountered 2 pouch dilatations (3%) which required re-operation. No early or late postoperative lethality was registered.

All (100%) of the laparoscopically operated patients (n=71) could be followed up (duration of follow-up, 5 to 23 months). The overall complication rate (conversion to open surgery, pouch dilatation, band leakage, insufficient loss of weight, etc.) is currently about 17%. In open gastroplasty the overall complication rate is as high as 35% even in centers with extensive experience in this field (5,6). In Table 1 the complication rates associated with the laparoscopic surgical techniques used in various centers are summarized.

Discussion

Vertical banded gastroplasty is currently the standard method for surgical treatment of morbid adiposity. Worldwide, about 20.000 interventions are performed every year. In the studies performed so far, laparoscopic vertical banded gastroplasty proved in no way superior to open surgery.

Nevertheless, laparoscopic adjustable gastric banding appears to be the surgical method of choice in the future. The results reported in the literature as well as our own experience showed that the method is difficult to learn but is associated with a markedly lower postoperative morbidity for the patient. Adjustable gastric banding is a surgical method that provides the patient a very early feeling of satiety without markedly influencing the quality of life. It should be kept in mind that the operation marks the beginning of treatment. Control examinations at close intervals, performed in cooperation with psychologists and dieticians, are essential to ensure the long-term success of this therapy.

Without the patient's cooperation, no adiposity operation will be successful on a long-term basis. Notwithstanding its advantages, minimally invasive operative treatment of morbid obesity is associated with a certain degree of surgical risk, which is reported to be less than 1% in the literature.

References

1 Council on Scientific Affairs. Treatment of obesity in adults. JAMA 1988; 260: 2547-2551

2 Kuzmak L. Silicone gastric banding: a simple and effective operation for morbid obesity. Contemp Surg 1986; 28: 13-18

3 Hallberg D, Forsell P. Ballongband vid behandling av massiv övervikt. Svensk Kirurgi 1985; 43 (2): 106.

4 Belachew M, Legrand M, Jaquet N. Laparoscopic placement of adjustable silicone gastric banding in the treatment of morbid obesity: an animal model experimental study. Obes Surg 1993; 3: 140

5 Hell E, Lang B. Postoperative Komplikationen nach vertikaler bandverstärkter Gastroplastik in 235 Fällen. In: Standards in der Chirurgie. Boeckl o. Waclawiczek HW (Hrsg.). W.Zuckerschwendt Verlag 1995, München Bern Wien New York.

6 Berns KE, Smith DC , Kelly KA, Sarr MG. Reoperative bariatric surgery. Lessons learned to improve patient selection and results. Ann Surg 1993; 218: 646-653

Correspondence:

Karl Miller, M.D.

Second Surgical Department, Landeskrankenanstalten Salzburg

Müllner Hauptstr. 48, A-5020 Salzburg, Austria

Tel. ++43-662-4482-2401

Fax. ++43-662-45 49 75

E-Mail: k.miller@lkasbg.gv.at