Laparoscopic adjustable gastric banding for patients with body mass index of

BACKGROUND: Many mild-to-moderately obese individuals (body mass index [BMI] 30-35 kg/m(2)) have serious diseases related to their obesity. Nonoperative therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 1996 and 2004, 93 patients with a BMI of 30-35 kg/m(2) underwent laparoscopic adjustable gastric banding with the LAP-BAND. All patients were referred by their primary physician, entered into a comprehensive bariatric surgery program at one Australian center, and operated on by one surgeon. Data on all patients were collected prospectively and entered into an electronic registry. The study parameters included preoperative age, gender, BMI, presence of co-morbidities, percentage of excess weight loss, and resolution of co-morbidities. RESULTS: The mean age was 44.6 years (range 16-76), mean weight was 98 kg, and the mean BMI was 32.7 kg/m(2) (range 30-34). Of the 93 patients, 42 (45%) had co-morbidities, including asthma, diabetes, hypertension, and sleep apnea. The proportion of patients in follow-up was 79%, 85%, and 89% at 1, 2, and 3 years, respectively. The mean weight was reduced to 71 kg at 1 year, 72 kg at 2 years, and 72 kg at 3 years. The mean BMI was reduced to 27.2 +/- 2.2, 27.3 +/- 3.1, and 27.6 +/- 3.7 kg/m(2), respectively, and the mean percentage of excess weight loss was 57.9% +/- 24.5%, 57.6 +/- 29.3%, and 53.8% +/- 32.8% at 1, 2, and 3 years, respectively. At 3 years, the BMI was 18-24 kg/m(2) in 34%, 25-29 kg/m(2) in 51%, and 30-35 kg/m(2) in 10%. At 3 years, the percentage of excess weight loss was <25% in 10%, 25-50% in 24%, 50-75% in 51%, and >75% in 10%. The co-morbidities improved or completely resolved in most patients. No mortality occurred. CONCLUSION: We are very encouraged by this series of low BMI patients treated with the LAP-BAND. Their weight loss has been good, the complications have been minimal, and the co-morbidities have partially or wholly resolved. With additional study, it is reasonable to expect the weight guidelines for bariatric surgery to be altered to include patients with a BMI of 30-35 kg/m(2).

U.S. experience with 749 laparoscopic adjustable gastric bands: intermediate outcomes.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) has consistently been shown to be a safe and effective treatment for morbid obesity, especially in Europe and Australia. Data from the U.S. regarding the LAGB has been insufficient. This study reveals our experience with 749 primary LAGB over a 3-year period in a U.S. university teaching hospital. METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study include preoperative age, BMI, gender, race, conversion rate, operative time, hospital stay, percent excess weight loss (%EWL) and postoperative complications. Annual esophagrams were performed RESULTS: From July 2001 through September 2004, 749 patients (531 females, 218 males) underwent LAGB for the treatment of morbid obesity. There were 630 Caucasians, 61 African-Americans, and 49 Latin Americans, with a mean age of 42.3 (range 18, 72 years) and mean BMI of 46.0 +/- 7.0 (range 35, 91.5 kg/m(2)). There was one conversion to open (0.1%). Median operative time and hospital stay were 60 minutes and 23 hours, respectively. The mean %EWL at 1 year, 2 years, and 3 years was 44.4 (+/-17.8), 51.8 (+/-20.9), and 52.0 (+/-19.6), respectively. There were no mortalities. Postoperative complications occurred in 12.8% of patients: 1.5% acute postoperative band obstruction, 0.9% wound infection, 2.9% gastric prolapse ("slip"), 2.0% concentric pouch dilatation (without slip), 0.8% aspiration pneumonia, 2.4% port/tubing problems, 0.3% severe esophageal dilatation/dysmotility (reversible), and 1.5% overall band removal. CONCLUSION: These American results substantiate the data from abroad that LAGB is a safe and effective treatment for morbid obesity.

Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is increasingly recommended to women of reproductive age. For continued use, LAGB needs to be proven to be safe and well-tolerated during pregnancy. Maternal obesity is a well-recognized risk factor for gestational diabetes, maternal hypertension and is more likely to result in instrumental delivery or caesarean section. Weight control with the LAGB may reduce the incidence of these complications. METHODS: An observational study was conducted of the LAGB in pregnancy, including a study comparing outcomes of LAGB pregnancies with previous non-LAGB pregnancies. Women who had had successful LAGB pregnancies were identified from a computerized database. A telephone questionnaire was used to collect the additional outcome data needed and was administered by an independent medical practitioner. RESULTS: 49 LAGB and 31 previous non-LAGB pregnancies were included. 2 LAGBs (4%) required removal during pregnancy. Mean maternal weight gain was significantly reduced in the LAGB group, 3.7 kg vs 15.6 kg (P <0.0001), with no effect on fetal weight, 3.31 vs 3.53 kg, or neonatal complications, 4% and 3%. The incidence of gestational diabetes, 8 and 27% (P =0.048), and hypertension, 8 and 22.5% (P =0.06) was significantly reduced in the LAGB group. The overall complication rate during pregnancy for LAGB was 20.4% and 52% for non-LAGB (P =0.0037) CONCLUSION: LAGB is safe and well-tolerated during pregnancy with a lower incidence of gestational diabetes and maternal hypertension. LAGB can be safely recommended to morbidly obese women of childbearing age.

Laparoscopic adjustable gastric banding for massive superobesity ( > 60 body mass index kg/m2).

Surgery for massive super obesity is a formidable challenge. No existing open or laparoscopic procedure reduces BMI below 30 from a starting point above 55. Laparoscopic adjustable gastric banding has been used to treat 76 massive super obese patients with a BMI > 60 kgs/m2. Median weight was 193 kgs +/-34.7 kgs (154-335 kgs). Five patients had a BMI > 100 kgs/m2. There was neither mortality nor pulmonary emboli. hospital stay was 3 days (1-6 days). Excess weight loss was 46.69 +/-10.5 at 1 year; 59.14 +/- 11.7% at 3 years and 61 +/- 15.1% at 5 years. At 2 years, 84% of the patients had greater than 50% excess weight loss and this was maintained at 3, 4, and 5 years. BMI fell from 69 +/- 6.2 to 49 +/- 7.73 at 1 year to 37 +/- 4.45 at 3 years and this was maintained at 4 and 5 years. BMI in 13 patients with > 5 year follow up was 35.09 +/- 53 kgs/m2 (27-44). Weight loss with laparoscopic adjustable gastric banding in this group of massive super obese patients has been similar to all other surgical techniques with reduction of BMI from 69 to 33 kgs/m2 at 3 years. The relative safety of the Lapband avoids bowel surgery in these very big patients, suggesting that laparoscopic adjustable gastric banding is a valid surgical approach to these difficult patients.

The poor quality of information about laparoscopy on the World Wide Web as indexed by popular search engines.

BACKGROUND: This study was undertaken to determine the quality of information on the Internet regarding laparoscopy. METHODS: Four popular World Wide Web search engines were used with the key word "laparoscopy." Advertisements, patient- or physician-directed information, and controversial material were noted. RESULTS: A total of 14,030 Web pages were found, but only 104 were unique Web sites. The majority of the sites were duplicate pages, subpages within a main Web page, or dead links. Twenty-eight of the 104 pages had a medical product for sale, 26 were patient-directed, 23 were written by a physician or group of physicians, and six represented corporations. The remaining 21 were "miscellaneous." The 46 pages containing educational material were critically reviewed. At least one of the senior authors found that 32 of the pages contained controversial or misleading statements. All of the three senior authors (LKN, NAO, GAF) independently agreed that 17 of the 46 pages contained controversial information. CONCLUSION: The World Wide Web is not a reliable source for patient or physician information about laparoscopy. Authenticating medical information on the World Wide Web is a difficult task, and no government or surgical society has taken the lead in regulating what is presented as fact on the World Wide Web.

Lessons learned from laparoscopic gastric banding for morbid obesity.

BACKGROUND: Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. METHODS: We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. RESULTS: At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. CONCLUSIONS: We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice.

Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases.

BACKGROUND: Morbid obesity occurs in 2-5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients. MATERIALS AND METHODS: A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications. RESULTS: All patients have needed band adjustments of 1-4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss. CONCLUSIONS: Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience.

Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients.

PURPOSE: The objectives of this study were to refine the technique of laparoscopically assisted anterior resection (LAR) for diverticular disease and to analyze the morbidity and mortality rates, and longer term follow-up of the first 100 consecutive patients. METHODS: Data were collected prospectively, and follow-up was performed by an independent assessor using a standardized questionnaire. RESULTS: The median duration of surgery was 180 minutes, the median time for passage of flatus was 2 days after surgery, and the median length of hospital stay was 4 days. Overall, the morbidity rate was 21%, and the wound infection rate was 5%. There were no deaths. Eight patients underwent open laparotomy. The rate of complications was significantly greater in the latter group of patients (75%) than in those who underwent laparoscopy (16%, p = 0.002). The comparison between the first 20 cases and the last 20 patients revealed a significantly shorter duration of surgery (median 225 min. vs. 150 min.; p < 0.0001) and decreased length of stay (6 days vs. 4 days, p < 0.0001). Apart from a nonsignificant increase in the length of surgery, there were no differences in other study parameters when comparisons were made between those patients who underwent LAR for complicated diverticular disease and those patients who underwent uncomplicated diverticular disease. FOLLOW-UP: Ninety patients were available for follow-up at a median time of 37 months. Ninety-three percent of the patients reported that the surgery had improved their symptoms. No patient required hospitalization, and no one was treated with antibiotics for recurrent symptoms. CONCLUSION: Laparoscopically assisted anterior resection for diverticular disease has acceptable morbidity and mortality rates and a median postoperative hospital stay of only 4 days. Follow-up investigations revealed no recurrence of diverticulitis, and patients reported satisfaction regarding cosmetic and functional results.

Laparoscopic colectomy.

BACKGROUND: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. METHODS: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. RESULTS: There were 359 cases (206 females, 153 male) average age 58.8 years (18-94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience-the last 20 cases of anterior resection took 150 min (110-240) and of RHC took 130 min (65-210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5-7 days (2-33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days-sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15-46 months). CONCLUSIONS: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer.

Laparoscopic-assisted colorectal surgery. Lessons learned from 240 consecutive patients.

PURPOSE: To audit the development and outcomes of laparoscopic colorectal surgery at the Royal Brisbane Hospital. METHODS: Since July 1991, laparoscopic-assisted colectomy for benign and malignant colorectal disease has been performed on more than 300 patients at the Royal Brisbane Hospital. This paper summarizes the outcome for the first 240 patients who underwent a laparoscopic colorectal procedure. All laparoscopic data were collected prospectively, and for selected studies, data were compared with open surgical controls. RESULTS: Nineteen patients required open conversion (7.9 percent). There was a significant decrease in wound infection rates in patients having a laparoscopic-assisted colectomy (3.6 percent) compared with historical controls (7.9 percent) (P < 0.05; chi-squared). There were five anastomotic leaks, five laparotomies for postoperative adhesive obstruction, and four perioperative deaths. A total of 103 patients had a procedure for colorectal cancer. Of the 79 potentially curative procedures, there have been 5 (6.3 percent) recurrences to date. CONCLUSION: The overall morbidity and mortality in this series seem to be acceptable compared with that of open procedures.

Laparoscopic mesh repair of recurrent inguinal hernia.

BACKGROUND: Pre-peritoneal mesh repair has been a long-standing technique for recurrent hernias. Laparoscopic technique has been applied to this operation with the aim of assessing its results at early follow up of 1 year. METHODS: The outcome in 56 patients was reviewed and all patients contacted 12 months after surgery. RESULTS: There was one immediate failure at 1 week, needing a further operation. There were no other recurrences at 1 year. Ten patients had minor postoperative complications. CONCLUSIONS: At early follow up, this is a satisfactory technique for recurrent hernias.

Laparoscopic inguinal hernia repair.

Between March 1991 and May 1994, 444 laparoscopic inguinal hernia repairs were undertaken in 375 patients: 386 transperitoneal and 58 extraperitoneal. During a follow-up period of 20.5 months (range 1-38) there have been three recurrences at 6, 7 and 12 months, all direct and all after transperitoneal repair. A total of 52 patients were treated as a day case (< 6 h), 317 patients spent less than 24 h in hospital and four patients were discharged on the second postoperative day. Operating time for transperitoneal hernia repair was 27 min (range 10-68) and extraperitoneal repair, 29 min (range 11-48). Short-term complications occurred in 18 patients: six haematomas, four seromas, one urinary retention and seven suffered persistent groin pain. Six patients have had neuralgia, three have had mesh removed and three further patients had individual clips removed from within the inguinal canal. There have been two adhesive small bowel obstructions. The first occurred 2 months after laparoscopic surgery and required laparotomy; the second occurred 2 years after surgery and had laparoscopic division of an adhesive band to a pelvic staple. There was one infected lymphocoele treated percutaneously.

Necrotizing pancreatitis: operating for life.

Infected necrotizing pancreatitis is the most fulminant variety of this disease. Colonic involvement and retroperitoneal fasciitis are particularly lethal. The reported mortality is up to 50%. The purpose of this study is to review our combined experience at the Princess Alexandra Hospital and the Royal Brisbane Hospital, Brisbane, to determine whether patient survival was related to a particular etiology, treatment, or complication. All patients treated since 1986 with infected pancreatitis who required surgical necrosectomy and then ventilation in the intensive care unit (ICU) were studied. There were 48 patients so managed. The median age of survivors was 52 years, and for those who died it was 64 years (p = 0.001). The etiology was gallstones in 22 and alcoholism in 12. Of the alcoholics, 11 survived and 1 died. Of the patients with gallstones, 13 survived and 9 died. There was an overall mortality of 31%. Survivors were in hospital for a median of 73 days, whereas deaths occurred after a median of 35 days (p = 0.04). Seven patients underwent hemofiltration; five survived, and two died. N-Acetylcysteine has been used in four patients, of whom three survived and one died. The abdomen was left open in 38 patients and kept closed in 10. Although Ranson's criteria at admission to the ICU did not predict survival, it was found that the median APACHE II score in survivors was significantly lower than in those who died (p = 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic common bile duct exploration.

Twenty-one patients underwent laparoscopic common bile duct exploration during a 9 month period. Ten had stones flushed after ampullary dilatation. Seven had stones removed with a Dormier basket and one had direct common duct incision with T-tube insertion. Three failed attempted stone flushing and had stones removed by endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. Operating time ranged from 1.5 to 3.5 h. Nineteen patients were discharged by the second postoperative day. This early experience with laparoscopic stone removal is encouraging, reducing the need for pre-operative or postoperative ERCP.

The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy.

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty-nine patients had ERCP performed pre-operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphincterotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.

Laparoscopic cholecystectomy for acute cholecystitis.

Sixty-eight cases of acute cholecystitis managed by laparoscopic cholecystectomy (LC) are reviewed. Thirty-two patients were admitted up to 10 days after onset of symptoms and 31 were completed by LC. One patient was referred from intensive care with gangrenous acalculus cholecystitis and was completed by LC but required subsequent laparotomy to control a bleeding omental vessel. Five patients were admitted with recurrent attacks of pain and histology confirmed resolving acute cholecystitis. Thirty patients had LC on routine operating lists, having recently had pain within 10 days of admission. Histology confirmed acute cholecystitis or resolving acute cholecystitis in these patients. All were completed by LC. Laparoscopic cholecystectomy is a very effective treatment for acute cholecystitis if complete dissection of anatomy can be performed.

Laparoscopic cholecystectomy.

A consecutive series of 220 laparoscopic cholecystectomies (June 1990 to May 1991) is presented. These were the author's initial experience of the technique. Procedures were elective (205) and acute (15), including 3 gangrenous cholecystitis and 4 empyema. There were 166 females and 34 males, 12-75 years, weighing 44-115 kg. Forty-eight patients had prior abdominal surgery. Two hundred and eleven patients had successful laparoscopic cholecystectomies, 6 open cholecystectomies and 3 mini-laparotomies to remove split stones. None of the last 120 cases were opened. Operating time ranged from 20 min to 3 h 20 min. There were 4 serious complications: 2 bile leaks from the gall-bladder bed and 2 jejunal injuries (Veres needle and 5 mm trocar). Sixty-one patients were discharged the next day, 29 on day 2, 5 on day 3, 4 on day 4, 1 on day 5, 1 on day 22 and 1 on day 27. At two weeks follow-up all but 2 patients had fully recovered.