Minimally Invasive Surgery of Obesity Top
|...... Introduction - Surgical Technique - Postoperative Course - Own Results - Discussion - References
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.
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 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.
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.
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.
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.
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.
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
Karl Miller, M.D.
Second Surgical Department, Landeskrankenanstalten Salzburg
Müllner Hauptstr. 48, A-5020 Salzburg, Austria
Fax. ++43-662-45 49 75