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1.  Laparoscopic Gastric Plication for the Treatment of Morbid Obesity: A Review 
Minimally Invasive Surgery  2012;2012:696348.
Introduction. Laparoscopic greater curvature plication is an operation that is gaining ground in the treatment of morbid obesity, as it appears to replicate the results of laparoscopic sleeve gastrectomy with fewer complications. Aim. Review of current literature, especially results on weight loss and complications. Method. 11 (eleven) published articles on laparoscopic gastric plication, of which 1 preclinical study, 8 prospective studies for a total of 521 patients and 2 case reports of unusual complications. Results. Reported Paracentage of EWL in all studies is comparable to Laparoscopic Sleeve Gastrectomy (around 50% in 6 months, 60–65% in 12 months, 60–65% in 24 months) and total complication rate is at 15,1% with minor complications in 10,7%, major complications in 4,4%. Reoperation rate was 3%, conversion rate was 0,2%, and mortality was zero. Conclusion. Current literature on gastric plication and its modifications is limited and sketchy at times. Low cost, short hospital stay, absence of prosthetic material, and reversibility make it an attractive option. Initial data show that LGCP is effective for short- and medium-term weight loss, complication and reoperation rates are low, and GERD symptoms are unaffected. More data is required, and randomized control trials must be completed in order to reach safe conclusions.
PMCID: PMC3397205  PMID: 22811900
2.  Gastric Plication Can Reduce Slippage Rate After Laparoscopic Gastric Banding 
Laparoscopic gastric plication appears to add security to gastric band application and reduce the incidence of slippage after this procedure.
Laparoscopic insertion of a gastric band for weight reduction is increasingly performed in obese and morbidly obese patients. Complication rates after gastric band insertion are reduced by using certain techniques.
Patients and Methods:
This was a prospective study of all patients who underwent laparoscopic adjustable gastric band (LAGB) insertion at our unit. This procedure is performed through the classical 4-port technique and the use of a liver retractor. The pars flaccida method is performed in all patients, and the gold finger, a malleable instrument, is used to guide the band through the retroesophageal window in patients with difficult anatomy. Band slippage is avoided by using 2 types of gastric plication, depending on the anatomical characteristics of the stomach. Outcomes and morbidity are recorded, and patients are followed up in outpatient clinics.
Laparoscopic adjustable gastric band (LAGB) insertion was performed in 464 patients. A single consultant surgeon performed all procedures over a 2-year period. From August 2005 through August 2007, 380 (81.89%) women and 84 (18.10%) men were included in this study. The mean age was 41 years (range, 21 to 62). The mean body mass index was 43 (range, 35 to 62). Morbidity included dysphagia, epigastric pain, port displacement, port infection, erosion, and acute respiratory distress. Only one (0.21%) case of band slippage was reported. The mean follow-up was 26 months (range, 18 to 42).
Laparoscopic gastric plication adds greater security and provides optimum gastric band placement. It is an effective method to reduce slippage after gastric band insertion.
PMCID: PMC3043572  PMID: 20932373
Laparoscopic gastric band; Plication technique; Anterior slippage; Posterior slippage; Longitudinal plication; Transverse plication; Oblique plication; Gastro-gastric stitches
3.  Laparoscopic sleeve gastrectomy in management of weight regain after failed laparoscopic plication☆ 
Weight regain after bariatric surgery remains a challenging problem with regard to its surgical management.
A 30 year-old-female patient with weight regain after failed laparoscopic gastric plication and previous gastric banding was evaluated in a tertiary-care university setting. Her last body mass index was calculated as 40.4 kg/m2. Preoperative ultrasonography revealed cholelithiasis. Laparoscopic sleeve gastrectomy with cholecystectomy was planned as a redo surgery. A floopy and plicated stomach with increased wall thickness of the greater curvature was seen. After adhesiolysis between the plicated part of stomach and the surrounding omental tissues, concomitant laparoscopic sleeve gastrectomy and cholecystectomy were performed. She was discharged on the 4th post-operative day without any complaint. At the postoperative 3rd month, her body mass index was recorded as 24 kg/m2.
Redo surgery of morbid obesity after failed bariatric surgery is a technically demanding issue. Type of the surgical treatment should be decided by the attending surgeon based on the morphology of the remnant stomach caused by previous operations.
As a redo surgery after failed laparoscopic gastric plication and gastric banding procedures, laparoscopic sleeve gastrectomy may be regarded as a safe and feasible approach in experienced hands.
PMCID: PMC3785862  PMID: 23973898
Bariatric surgery; Sleeve gastrectomy; Gastric plication; Weight regain
4.  AB 64. Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis 
Journal of Thoracic Disease  2012;4(Suppl 1):AB64.
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the age, and the co-morbidity (respiratory/cardiac disease, morbid obesity, etc.) Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment is indicated in non-resolving respiratory failure. We present early hemi-diaphragmatic plication, in a high risk patient with postcardiotomy phrenic nerve paresis.
Patient and methods
A 72 year old woman, with bioprosthetic mitral valve endocarditis, native aortic valve endocarditis, and acute renal failure, underwent urgent redo mitral valve replacement and aortic valve replacement (predicted mortality Euroscore II: 23.86%). Despite good valve and cardiac function, infection control, and weaning from mechanical ventilation she had respiratory failure (dyspnoea, tachypnoea, orthopnoea, hypoxaemia, need continuous oxygen supplementation). Chest radiography revealed a new right hemi-diaphragm elevation, with severe progressing lung atelectasis. Right hemi-diaphragm postero-anterior plication was performed through a video assisted right mini-thoracotomy on the 25th postoperative day.
Early extubation was achieved, adequate respiratory function was established, chest radiography was normalized (normal right hemi-diaphragm position, right lung expansion). After mobilization and rehabilitation the patient was discharged home on the 8th day after plication.
Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The early plication through a video assisted mini-thoracotomy was safe and effective, offering minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, leading to fast rehabilitation and avoidance of prolonged hospitalization complications.
PMCID: PMC3537436
5.  Laparoscopic Adjustable Gastric Band: How to Reduce the Early Morbidity 
Laparoscopic adjustable gastric band insertion is a safe weight reduction procedure, but serious complications can develop. The aim of this study was to evaluate our technique in preventing early band complications.
Patients were given the choice of procedure according to body mass index, the presence of diabetes, and preference. Weight loss data were not considered, as our aim was to evaluate the morbidity of band surgery using a specific technique. A pars flaccida approach and plication technique were used for all patients. Postoperative follow-up was provided at 1 month, 2 months, and every 3 months for the first year and then yearly for a further 2 years. Thereafter, general practitioners referred patients if late complications arose.
From January 2007 to August 2011, 1149 patients (245 men [21.32%], 904 women [78.67%]) underwent laparoscopic adjustable gastric band insertion under the care of a single bariatric surgeon. Patients were hospitalized for 1 night only unless they developed early complications. The primary and secondary outcomes were major and minor band complications, respectively. Patients' age range was 18 to 64 years (mean, 44 years). Body mass index ranged from 33 to 62 kg/m2 (mean, 42 kg/m2). There were 2 band erosions (0.17%), 6 cases of band prolapse (0.52%), 4 port problems (0.34%), 1 band leak (0.08%), 3 tight bands (0.26%), 2 port infections (0.17%), and no deaths. Five procedures (0.43%) were abandoned and excluded from this study, and 1 (0.17%) was converted to minilaparotomy to control abdominal wall bleeding. The duration of follow-up ranged from 16 to 60 months.
A combined pars flaccida and plication technique is associated with a low early complication rate.
PMCID: PMC4154413  PMID: 25392623
Laparoscopic adjustable gastric band; Body mass index; pars flaccida
6.  Early Results of Trans-Oral Endoscopic Plication and Revision of the Gastric Pouch and Stoma following Roux-en-Y Gastric Bypass Surgery 
In patients with severe gastroesophageal reflux disease post gastric bypass surgery, endoscopic plication with revision of the gastric pouch may be beneficial.
A new technique for endoscopic plication and revision of the gastric pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was evaluated in patients with severe GERD, dumping syndrome, failure of weight loss, or all of these.
Patients and Methods:
Patients underwent EPRGP over a 12-month period. The StomaphyX device (Endogastric Solutions, Redmond, WA) was utilized over a standard flexible gastroscope. Patients were kept on a liquid diet for 1 week.
The study included 64 patients with a mean age of 48 years who underwent 67 procedures. EPRGP was performed an average of 5 years after RGB. The mean preoperative BMI was 39.5 kg/m2. The primary indications for the procedure were inadequate weight loss, dumping syndrome (42), and GERD (15). The mean follow-up period was 5.8 months (range, 3 to 12). The average operative time was 50 minutes, with a significant reduction with increased operator experience. There were only 2 (3%) intraoperative complications during the early period (equipment failure), which did not result in any morbidity. All symptoms from dumping syndrome or reflux improved, with no further operative-related complications. The mean weight loss was 7.3kg.
This study demonstrates the technical feasibility, safety, and efficacy of EPRGP.
PMCID: PMC3043571  PMID: 20932372
Gastric bypass; Bariatric; Natural orifice; Revision; Endoscopic; Plication
7.  Three-Year Experience of Pouch Dilatation and Slippage Management after Laparoscopic Adjustable Gastric Banding 
Yonsei Medical Journal  2013;55(1):149-156.
Pouch dilatation and band slippage are the most common long-term complications after laparoscopic adjustable gastric banding (LAGB). The aim of the study is to present our experience of diagnosis and management of these complications.
Materials and Methods
The pars flaccida technique with anterior fixation of the fundus was routinely used. All band adjustments were performed under fluoroscopy. We analyzed the incidence, clinico-radiologic features, management, and revisional surgeries for treatment of these complications. We further presented the outcome of gastric plication techniques as a measure for prevention of these complications.
From March 2009 to March 2012, we performed LAGB on 126 morbidly obese patients. Among them, 14 patients (11.1%) were diagnosed as having these complications. Four patients (3.2%) had concentric pouch dilatations, which were corrected by band adjustment. Ten (7.9%) had eccentric pouch with band slippage. Among the ten patients, there were three cases of posterior slippage, which were corrected by reoperation, and seven cases of eccentric pouch dilatation with anterior slippage. Three were early anterior slippage, which was managed conservatively. Two were acute anterior slippage, one of whom underwent a revision. There were two cases of chronic anterior slippage, one of whom underwent a revision. The 27 patients who underwent gastric plication did not present with eccentric pouch with band slippage during the follow-up period.
The incidence of pouch dilatation with/without band slippage was 11.1%. Management should be individualized according to clinico-radiologic patterns. Gastric plication below the band might prevent these complications.
PMCID: PMC3874894  PMID: 24339300
Pouch dilatation; band slippage; laparoscopic adjustable gastric band
8.  Using the StomaphyXTM Endoplicator to Treat a Gastric Bypass Complication 
Rapid advances in endoluminal technology such as tissue placating devices offer an alternative for repair of some postbariatric surgical complications.
Background and Objectives:
As the number of bariatric operations performed increases, the number of patients requiring reoperation for failed weight loss is expected to proportionately increase. Natural orifice surgery is an alternative approach to revisional gastric bypass surgery when postoperative complications, such as dilatation of the gastrojejunostomy, gastrogastric fistula, and gastric pouch, dilation occur.
The present article reports on the safe and successful use of an endoscopic tissue plicating device in a patient found to have a dilated gastric pouch and a gastrogastric fistula 12 years after an open, nondivided RYGB.
The procedure was performed without complications and resulted in a reduced pouch size to approximately 30cc to 50cc and redirection of the flow of gastric contents through her gastrojejunostomy. The patient's early satiety returned and, 1 year postoperatively, she had incurred a 45-pound weight loss.
The morbidity and mortality of revision gastric bypass was avoided while the patient's goal of moderate weight loss was achieved. Tissue plicating devices offer an alternative for repair of some postbariatric complications. With the rapid advances in endoluminal technology and increasing experience with natural orifice surgery, the ability to successfully address surgical problems through less invasive means will continue to improve.
PMCID: PMC3134684  PMID: 21902955
Bariatric surgery; Complications; Fistula; Endoscopy
9.  Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis 
Journal of Thoracic Disease  2012;4(Suppl 1):56-68.
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25th day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.
PMCID: PMC3537434  PMID: 23304442
Respiratory paralysis/surgery; respiratory paralysis/etiology; dyspnea/etiology; diaphragm/surgery; phrenic nerve/injuries
10.  Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m2) 
BMC Surgery  2010;10:33.
Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m2). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.
In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.
Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.
To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.
PMCID: PMC2992483  PMID: 21073750
11.  Neoumbilicoplasty is a useful adjuvant procedure in abdominoplasty 
Neoumbilicoplasties are indicated in congenital conditions associated with umbilical agenesis, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump and in surgical procedures for herniorrhaphy, as well as in the rare condition of umbilical endometriosis.
Neoumbilicoplasty is an adjuvant procedure that may be necessary during abdominoplasty with wide myofascial plication, or repair of concomitant hernias of the abdominal wall. The present article justifies sacrificing the umbilicus followed by neoumbilicoplasty in patients with significant wide myofascial plication or concomitant hernias of the abdominal wall.
Seventeen patients underwent a combination of abdominoplasty and wide (greater than 10 cm) vertical plication of the myofascial complex and required neoumbilicoplasty. The male to female ratio was 1:16; mean age was 44 years, mean weight 94.1 kg and mean height 160.2 cm. Characteristic body morphology included gross trunk obesity with a prominent anterior abdominal wall.The female patients were multiparous. Sacrificing the umbilici followed by neoumbilicoplasty was required in patients with umbilical hernias and patients who had divarication of the rectus abdominis muscles with short umbilical stumps.
Nine patients had concomitant ventral hernias (52.94%) and eight patients had divarication of the rectus abdominis muscles with short umbilical stumps (47.05%). The mean perioperative myofascial plication distance was 15.41 cm and the gap closure required three to five rows of sutures.
Neoumbilicoplasty is a useful adjuvant procedure during abdominoplasty with wide myofascial plication or repair of concomitant hernias of the abdominal wall.
PMCID: PMC2827282  PMID: 21119826
Abdominal hernias; Abdominoplasty; Myofascial plication; Musculoaponeurotic plication; Neoumbilicoplasty
12.  Early Results of Recently Introduced Laparoscopic Adjustable Gastric Banding Procedure for Morbid Obesity in Croatia 
Morbid obesity is a growing medical problem that has become of epidemic proportions. Various dietary and pharmaceutical approaches do not obtain acceptable long-term results. Surgery, however, especially gastric restriction, represents a viable therapeutic solution. Individuals with a body mass index (BMI) >40 kg/m2 or >35 kg/m2 with at least one severe comorbidity are considered morbidly obese and generally qualify for weight-loss surgery. Laparoscopic adjustable gastric banding (LAGB) is currently the most commonly performed procedure, because it is minimally invasive, does not cause metabolic complications, is completely reversible, and is adjustable. In Croatia, the first LAGB was performed in May 2004 at Clinical Hospital “Sestre Milosrdnice.” The aim of this report is to illustrate a newly performed surgical treatment and its results for morbid obesity in Croatia.
Within a 12-month period, the adjustable gastric band was implanted in 15 morbidly obese patients (female, 8; male, 7; mean age, 46.67 years; range, 26 –59 years). The so-called “pars flaccida” technique was used.
One operation required conversion to laparotomy due to a gastric lesion, and 1 laparoscopy operation was terminated due to massive postoperative adhesions. The average duration of surgery was 90±30 minutes. Mean length of stay was 4.9 days (range, 3–9). An average BMI at the time of surgery was 52.21 kg/m2 (range, 45.29 to 61.59; mean body weight was 155.58 kg (range, 127 to 204). Throughout 1-, 3-, 6-, 9-, and 12-month follow-ups, an average of 18.71%, 25.06%, 34.37%, 41.23%, and 47.32% of excessive weight loss (EWL) was observed. Good tolerance and a low complication rate were noted.
LAGB resulted in good early results and a low complication rate. LAGB appears to be a quality surgical procedure for the management of morbid obesity.
PMCID: PMC3015744  PMID: 17575750
Morbid obesity; Laparoscopy; Gastric banding; Weight loss
13.  Laparoscopic adjustable gastric banding: a report of 228 cases 
Gastroenterology Report  2013;1(2):144-148.
Objective: To evaluate the surgical outcomes and complications after laparoscopic adjustable gastric banding (LAGB) in obese patients.
Methods: This retrospective study included 228 patients (73 males and 155 females, mean age, 32.5 ± 10.3 years) who underwent LAGB at the Changhai Hospital of the Second Military Medical University from June 2003 to June 2011. The body weight and postoperative complications were followed up.
Results: The pre-operative mean body mass index (BMI) was 39.5 ± 6.3 kg/m2. Except in one case of inadequate exposure of the stomach, all laparoscopic procedures were successfully accomplished, with no conversion to open surgery. The mean operation time was 65.0 ± 20.3 min. The mean hospital stay was 2.7 ± 0.9 days. Early postoperative complications (<30 days) occurred in five cases (2.2%) and late complications (>30 days) occurred in 75 cases (32.9%), including 56 cases (24.6%) with band-associated complications. The percentage of excess weight loss (EWL%) at 1, 3 and 5 years was 40.5 ± 30.5%, 59.5 ± 41.5% and 58.9 ± 46.4%, respectively. The percentages of patients with EWL% >25%, >50% and >75% were, respectively, 60%, 33% and 0% at 1 year follow-up, 43%, 39%, and 16% at 3 years follow-up and 40%, 34% and 16% at 5 years follow-up.
Conclusion Although LAGB has low peri-operative mortality and morbidity rates, it is associated with a high late complication rate and unsatisfactory weight loss. It may be optional, but not the first choice, for the treatment of obesity.
PMCID: PMC3938002  PMID: 24759820
obesity; gastric banding; laparoscopy; complications; percentage of excess weight loss
14.  Longitudinal plication - a surgical strategy for complete rectal prolapse management 
BMC Surgery  2014;14:17.
Rectal prolapse is a known problem since antiquity and the cause is not fully understood. Despite the presence of more than 100 lines of treatment, none of them is ideal.
Between the years of (2005–2011), thirty patients with full-thickness rectal prolapse were operated upon. Age ranged between (2–65 years) with a mean of 21.5 year. Male to female ratio was (2:1). Each prolapsed rectum was repaired with longitudinal plication (LP) at two or three points accordingly using braded polyglycolic acid – absorbable 1.0 suture material. Plications started by inserting a stitch at the most proximal part of the prolapse, followed by successive similar transverse stiches continuing in a spiral fashion till the mucocutaneous junction. We used three LP in adults and two in children. All of the patients where operated upon as a day-case procedure and discharged 6 hours after the operation.
In this series of patients, twenty-nine of them had complete recovery from the prolapse. Only one patient had recurrence 2 years after the operation, and the same procedure was applied successfully with uneventful post-operative period. Although twenty-three patients had fecal Incontinence, twenty-one of them regained continence after operation.
This method is an easy perineal procedure, with fewer complications. It can be performed for all age groups, in an ordinary surgical unit, by an expert anorectal surgeon. We found that our procedure is simple, safe and less invasive.
PMCID: PMC3994363  PMID: 24655367
Fecal incontinence; Procidentia; Circumferential protrusion; Rectal wall; Anal sphincter complex
15.  Bariatric Surgery 
Executive Summary
To conduct an evidence-based analysis of the effectiveness and cost-effectiveness of bariatric surgery.
Obesity is defined as a body mass index (BMI) of at last 30 kg/m2.1 Morbid obesity is defined as a BMI of at least 40 kg/m2 or at least 35 kg/m2 with comorbid conditions. Comorbid conditions associated with obesity include diabetes, hypertension, dyslipidemias, obstructive sleep apnea, weight-related arthropathies, and stress urinary incontinence. It is also associated with depression, and cancers of the breast, uterus, prostate, and colon, and is an independent risk factor for cardiovascular disease.
Obesity is also associated with higher all-cause mortality at any age, even after adjusting for potential confounding factors like smoking. A person with a BMI of 30 kg/m2 has about a 50% higher risk of dying than does someone with a healthy BMI. The risk more than doubles at a BMI of 35 kg/m2. An expert estimated that about 160,000 people are morbidly obese in Ontario. In the United States, the prevalence of morbid obesity is 4.7% (1999–2000).
In Ontario, the 2004 Chief Medical Officer of Health Report said that in 2003, almost one-half of Ontario adults were overweight (BMI 25–29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). About 57% of Ontario men and 42% of Ontario women were overweight or obese. The proportion of the population that was overweight or obese increased gradually from 44% in 1990 to 49% in 2000, and it appears to have stabilized at 49% in 2003. The report also noted that the tendency to be overweight and obese increases with age up to 64 years. BMI should be used cautiously for people aged 65 years and older, because the “normal” range may begin at slightly above 18.5 kg/m2 and extend into the “overweight” range.
The Chief Medical Officer of Health cautioned that these data may underestimate the true extent of the problem, because they were based on self reports, and people tend to over-report their height and under-report their weight. The actual number of Ontario adults who are overweight or obese may be higher.
Diet, exercise, and behavioural therapy are used to help people lose weight. The goals of behavioural therapy are to identify, monitor, and alter behaviour that does not help weight loss. Techniques include self-monitoring of eating habits and physical activity, stress management, stimulus control, problem solving, cognitive restructuring, contingency management, and identifying and using social support. Relapse, when people resume old, unhealthy behaviour and then regain the weight, can be problematic.
Drugs (including gastrointestinal lipase inhibitors, serotonin norepinephrine reuptake inhibitors, and appetite suppressants) may be used if behavioural interventions fail. However, estimates of efficacy may be confounded by high rates of noncompliance, in part owing to the side effects of the drugs. In addition, the drugs have not been approved for indefinite use, despite the chronic nature of obesity.
The Technology
Morbidly obese people may be eligible for bariatric surgery. Bariatric surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs.
There are various bariatric surgical procedures and several different variations for each of these procedures. The surgical interventions can be divided into 2 general types: malabsorptive (bypassing parts of the gastrointestinal tract to limit the absorption of food), and restrictive (decreasing the size of the stomach so that the patient is satiated with less food). All of these may be performed as either open surgery or laparoscopically. An example of a malabsorptive technique is Roux-en-Y gastric bypass (RYGB). Examples of restrictive techniques are vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB).
The Ontario Health Insurance Plan (OHIP) Schedule of Benefits for Physician Services includes fee code “S120 gastric bypass or partition, for morbid obesity” as an insured service. The term gastric bypass is a general term that encompasses a variety of surgical methods, all of which involve reconfiguring the digestive system. The term gastric bypass does not include AGB. The number of gastric bypass procedures funded and done in Ontario, and funded as actual out-of-country approvals,2 is shown below.
Number of Gastric Bypass Procedures by Fiscal Year: Ontario and Actual Out-of-Country (OOC) Approvals
Data from Provider Services, MOHLTC
Courtesy of Provider Services, Ministry of Health and Long Term Care
Review Strategy
The Medical Advisory Secretariat reviewed the literature to assess the effectiveness, safety, and cost-effectiveness of bariatric surgery to treat morbid obesity. It used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. The interventions of interest were bariatric surgery and, for the controls, either optimal conventional management or another type of bariatric procedure. The outcomes of interest were improvement in comorbid conditions (e.g., diabetes, hypertension); short- and long-term weight loss; quality of life; adverse effects; and economic analysis data. The databases yielded 15 international health technology assessments or systematic reviews on bariatric surgery.
Subsequently, the Medical Advisory Secretariat searched MEDLINE and EMBASE from April 2004 to December 2004, after the search cut-off date of April, 2004, for the most recent systematic reviews on bariatric surgery. Ten studies met the inclusion criteria. One of those 10 was the Swedish Obese Subjects study, which started as a registry and intervention study, and then published findings on people who had been enrolled for at least 2 years or at least 10 years. In addition to the literature review of economic analysis data, the Medical Advisory Secretariat also did an Ontario-based economic analysis.
Summary of Findings
Bariatric surgery generally is effective for sustained weight loss of about 16% for people with BMIs of at least 40 kg/m2 or at least 35 kg/m2 with comorbid conditions (including diabetes, high lipid levels, and hypertension). It also is effective at resolving the associated comorbid conditions. This conclusion is largely based on level 3a evidence from the prospectively designed Swedish Obese Subjects study, which recently published 10-year outcomes for patients who had bariatric surgery compared with patients who received nonsurgical treatment. (1)
Regarding specific procedures, there is evidence that malabsorptive techniques are better than other banding techniques for weight loss and resolution of comorbid illnesses. However, there are no published prospective, long-term, direct comparisons of these techniques available.
Surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs. In the absence of direct comparisons of active nonsurgical intervention via caloric restriction with bariatric techniques, the following observations are made:
A recent systematic review examining the efficacy of major commercial and organized self-help weight loss programs in the United States concluded that the evidence to support the use of such programs was suboptimal, except for one trial on Weight Watchers. Furthermore, the programs were associated with high costs, attrition rates, and probability of regaining at least 50% of the lost weight in 1 to 2 years. (2)
A recent randomized controlled trial reported 1-year outcomes comparing weight loss and metabolic changes in severely obese patients assigned to either a low-carbohydrate diet or a conventional weight loss diet. At 1 year, weight loss was similar for patients in each group (mean, 2–5 kg). There was a favourable effect on triglyceride levels and glycemic control in the low-carbohydrate diet group. (3)
A decision-analysis model showed bariatric surgery results in increased life expectancy in morbidly obese patients when compared to diet and exercise. (4)
A cost-effectiveness model showed bariatric surgery is cost-effective relative to nonsurgical management. (5)
Extrapolating from 2003 data from the United States, Ontario would likely need to do 3,500 bariatric surgeries per year. It currently does 508 per year, including out-of-country surgeries.
PMCID: PMC3382415  PMID: 23074460
16.  Off-pump anteroapical aneurysm plication following left ventricular postinfarction aneurysm: effect on cardiac function, clinical status and survival 
Canadian Journal of Surgery  2013;56(2):119-127.
In patients with coronary disease and aneurysm, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. We report our results with off-pump aneurysm plication after ventricular aneurysm with relative wall thinning.
We retrospectively reviewed the records of 248 patients who had an operation for postinfarction left ventricular aneurysm. Reconstruction was accomplished by off-pump anteroapical aneurysm plication. The following variables were recorded: preoperative clinical, angiographic and echocardiographic findings and operative procedures. Outcomes were early mortality, long-term survival and poor 5-year result, defined as the need for transplantation or repeated hospitalization for congestive heart failure. Risk factors were pinpointed using the t test and survival curves. Independent risk factors were identified using Cox regression methods.
Hospital mortality was low (2.0%). Mean follow-up was 5.8 (standard deviation [SD] 3.8) years. Actuarial survival at 1 and 5 years was 94% and 84%. Among the 232 survivors, 200 were in functional class I or II, and the average increase in ejection fraction was 14.0% (SD 3.1%). As determined by multivariable analysis, factors predicting poor outcome were advanced age, ejection fraction less than 0.35, conicity index less than 1, end-systolic volume index greater than 80 mL/m2, advanced New York Heart Association functional class and congestive heart failure.
Using wall thinning as a criterion for patient selection, the technique of off-pump anteroapical aneurysm plication can be performed with low operative mortality and provides good symptomatic relief and long-term survival.
PMCID: PMC3617117  PMID: 23351499
17.  Banded gastric bypass - four years follow up in a prospective multicenter analysis 
BMC Surgery  2014;14(1):88.
The gastric bypass is the gold standard of bariatric surgery. Nevertheless some patients show insufficient weight loss or weight regain. Dilation of the pouch or the pouch outlet may be the cause. The banded gastric bypass tries to overcome dilation by placing an implant around the pouch or pouch outlet. In this study we describe our results using the GaBP™ ring system in banded gastric bypass operations in 3 bariatric centers.
183 patients in 3 bariatric reference centers received a banded gastric bypass operation using the GaBP™ ring system. Up to 4 years follow up was evaluated including weight loss and complications.
Mean EWL after 6 Months was 60% with a mean BMI of 30.1 kg/m2. After one year mean EWL reached 75.3% with a mean BMI of 27 kg/m2 (110 patients). After two and three years the EWL was 78.8% (n = 49) and 79.9% (n = 35). There was a mean EWL of 85% after 4 years. Thirteen patients finished a 4 year follow up period and mean BMI after 4 years was 25.2 kg/m2. In the perioperative and early postoperative period there was a low complication rate (4.3%). Stenosis or dysphagia was observed in only one patient. There was only one ring related complication.
Banded gastric bypass using the GaBP™ ring system allows good weight loss with no regain of weight in a four year follow up. The complication rate is low. A randomized controlled trial is currently underway to compare banded and conventional gastric bypass.
PMCID: PMC4236457  PMID: 25391401
Gastric bypass; Banded gastric bypass; Restriction; Gastric banding; Bariatric surgery
18.  Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity 
Roux-en-Y gastric bypass (RYGB) is considered the gold standard bariatric procedure with documented safety and effectiveness. Laparoscopic sleeve gastrectomy (LSG) is a newer procedure being done with increasing frequency. Randomized comparisons of LSG and other bariatric procedures are limited. We present the results of the first prospective randomized trial comparing LSG and RYGB in the Polish population.
To assess the efficacy and safety of LSG versus RYGB in the treatment of morbid obesity and obesity-related comorbidities.
Material and methods
Seventy-two morbidly obese patients were randomized to RYGB (36 patients) or LSG (36 patients). Both groups were comparable regarding age, gender, body mass index (BMI) and comorbidities. The follow-up period was at least 12 months. Baseline and 6 and 12 month outcomes were analyzed including assessment of percent excess weight lost (%EWL), reduction in BMI, morbidity (minor, major, early and late complications), mortality, reoperations, comorbidities and nutritional deficiencies.
There was no 30-day mortality and no significant difference in major complication rate (0% after RYGB and 8.3% after LSG, p > 0.05) or minor complication rate (16.6% after RYGB and 10.1% after LSG, p > 0.05). There were no early reoperations after RYGB and 2 after LSG (5.5%) (p > 0.05). Weight loss was significant after RYGB and LSG but there was no difference between both groups at 6 and 12 months of follow-up. At 12 months %EWL in RYGB and LSG groups reached 64.2% and 67.6% respectively (p > 0.05). There was no significant difference in the overall prevalence of comorbidities and nutritional deficiencies.
Both LSG and RYGB produce significant weight loss at 6 and 12 months after surgery. The procedures are equally effective with regard to %EWL, reduction in BMI and amelioration of comorbidities at 6 and 12 months of follow-up. Laparoscopic sleeve gastrectomy and RYGB are comparably safe techniques with no significant differences in minor and major complication rates at 6 and 12 months.
PMCID: PMC3557743  PMID: 23362420
bariatric surgery; morbid obesity; gastric bypass; sleeve gastrectomy; randomized trial
19.  Laparoscopic re-sleeve gastrectomy as a treatment of weight regain after sleeve gastrectomy 
AIM: To evaluate laparoscopic re-sleeve gastrectomy as a treatment of weight regain after Sleeve.
METHODS: Laparoscopic sleeve gastrectomy is a common bariatric procedure. Weight regain after long-term follow-up is reported. Patients were considered for laparoscopic re-sleeve gastrectomy when we observed progressive weight regain and persistence of comorbidities associated with evidence of dilated gastric fundus and/or antrum on upper gastro-intestinal series. Follow-up visits were scheduled at 1, 3, 6 and 12 mo after surgery and every 6 mo thereafter. Measures of change from baseline at different times were analyzed with the paired samples t test.
RESULTS: We observed progressive weight regain after sleeve in 11 of the 201 patients (5.4%) who had a mean follow-up of 21.1 ± 9.7 mo (range 6-57 mo). Three patients started to regain weight after 6 mo following Sleeve, 5 patients after 12 mo, 3 patients after 18 m. Re-sleeve gastrectomy was always performed by laparoscopy. The mean time of intervention was 55.8 ± 29.1 min. In all cases, neither intra-operative nor post-operative complications occurred. After 1 year follow-up we observed a significant (P < 0.05) mean body mass index reduction (-6.6 ± 2.7 kg/m2) and mean % excess weight loss (%EWL) increase (+31.0% ± 15.8%). An important reduction of antihypertensive drugs and hypoglycemic agents was observed after re-sleeve in those patients affected by hypertension and diabetes. Joint problems and sleep apnea syndrome improved in all 11 patients.
CONCLUSION: Laparoscopic re-sleeve gastrectomy is a feasible and effective intervention to correct weight regain after sleeve.
PMCID: PMC4073220  PMID: 24976903
Obesity; Bariatric surgery; Laparoscopic surgery; Stomach stapling; Gastrectomy; Surgery; Repeat
20.  Efficacy of endoluminal gastroplication in Japanese patients with proton pump inhibitor-resistant, non-erosive esophagitis 
AIM: To evaluate the efficacy, safety, and long-term outcomes of endoluminal gastroplication (ELGP) in patients with proton pump inhibitor (PPI)-resistant, non-erosive reflux disease (NERD).
METHODS: The subjects were NERD patients, diagnosed by upper endoscopy before PPI use, who had symptoms such as heartburn or reflux sensations two or more times a week even after 8 wk of full-dose PPI treatment. Prior to ELGP, while continuing full-dose PPI medication, patients’ symptoms and quality of life (QOL) were assessed using the questionnaire for the diagnosis of reflux disease, the frequency scale for symptoms of gastro-esophageal reflux disease (FSSG), gastrointestinal symptoms rating scale, a 36-item short-form. In addition, 24-h esophageal pH monitoring or 24-h intraesophageal pH/impedance (MII-pH) monitoring was performed. The Bard EndoCinchTM was used for ELGP, and 2 or 3 plications were made. After ELGP, all acid reducers were temporarily discontinued, and medication was resumed depending on the development and severity of symptoms. Three mo after ELGP, symptoms, QOL, pH or MII-pH monitoring, number of plications, and PPI medication were evaluated. Further, symptoms, number of plications, and PPI medication were evaluated 12 mo after ELGP to investigate long-term effects.
RESULTS: The mean FSSG score decreased significantly from before ELGP to 3 and 12 mo after ELGP (19.1 ± 10.5 to 10.3 ± 7.4 and 9.3 ± 9.9, P < 0.05, respectively). The total number of plications decreased gradually at 3 and 12 mo after ELGP (2.4 ± 0.8 to 1.2 ± 0.8 and 0.8 ± 1.0, P < 0.05, respectively). The FSSG scores in cases with no remaining plications and in cases with one or more remaining plications were 4.4 and 2.7, respectively, after 3 mo, and 2.0 and 2.8, respectively, after 12 mo, showing no correlation to plication loss. On pH monitoring, there was no difference in the percent time pH < 4 from before ELGP to 3 mo after. Impedance monitoring revealed no changes in the number of reflux episodes or the symptom index for reflux events from before ELGP to 3 mo after, but the symptom sensitivity index decreased significantly 3 mo after ELGP (16.1 ± 12.9 to 3.9 ± 8.3, P < 0.01). At 3 mo after ELGP, 6 patients (31.6%) had reduced their PPI medication by 50% or more, and 11 patients (57.9%) were able to discontinue PPI medication altogether. After 12 mo, 3 patients (16.7%) were able to reduce the amount of PPI medication by 50% or more, and 12 patients (66.7%) were able to discontinue PPI medication altogether. A high percentage of cases with remaining plications had discontinued PPIs medication after 3 mo, but there was no difference after 12 mo. No serious complications were observed in this study.
CONCLUSION: ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term in patients with PPI-refractory NERD.
PMCID: PMC3491602  PMID: 23139611
Endoluminal gastroplication; Esophageal pH; Gastro-esophageal reflux disease; Non-erosive reflux disease; Proton pump inhibitor-resistant
21.  An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome 
The genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.
A retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps: Complete proximal to distal surgical decompression of the peroneal nerveRadical release and mobilization of the severe quadriceps contracture and iliotibial band contractureDistal lateral hamstring lengthening/tenotomy and lateral collateral ligament releaseProximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocationProximal tibial varus osteotomy with partial fibulectomy and anterior compartment releaseOccasionally, distal femoral osteotomy
In all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.
The operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.
Level of evidence
PMCID: PMC3935021  PMID: 24488845
Chondroectodermal dysplasia; Ellis-van Creveld syndrome; Genu valgum deformity surgery
22.  A Mid-term Experience with the Cousin Bioring—Adjustable Gastric Band 
Obesity Surgery  2011;22(1):152-157.
Since March 2003, we have used the Cousin Bioring in our laparoscopic gastroplasty procedures for morbid obesity. The Bioring belongs to the new generation of adjustable gastric bands. The aim of this study is to review our experience with this particular type of band.
Between March 2003 and March 2010, 316 patients had a laparoscopic implantation of the Cousin Bioring in our department. As many as 169 patients had the operation at least 5 years ago, of which 161 had a complete follow-up. Short- and long-term results were prospectively collected and analysed.
There were no intra-operative and only two mild early post-operative complications. Mortality was zero. The mean percent of excess weight loss (%EWL) was 56% at 5 years, 55% at 6 years and 56% at 7 years. Of the 169 patients, four had a band removal for intolerance and/or insufficient weight loss and 11 (6.5%) developed late complications requiring surgery. We managed to solve all complications by minimally invasive procedures without loss of the device. Fifteen of the 169 patients suffered preoperatively from diabetes mellitus type 2. Ten of these had a remission after 5 years. The quality-of-life was assessed 3 years post-operatively for 164 patients and showed an improvement in 83.5% of them.
Laparoscopic implantation of the Cousin Bioring is a straightforward and safe operation. Complications occur, but they are rather benign and easy to remediate. The mean weight loss is considered successful (%EWL > 50) and persists 5 to 7 years after the operation.
PMCID: PMC3257430  PMID: 21544698
Morbid obesity; Bariatric surgery; Laparoscopy; Laparoscopic adjustable gastric banding
23.  Long-Term Results of Bariatric Restrictive Procedures: A Prospective Study 
Obesity Surgery  2010;20(12):1617-1626.
Laparoscopic adjustable gastric banding (LAGB) and vertical-banded gastroplasty (VBG) are surgical treatment modalities for morbid obesity. This prospective study describes the long-term results of LAGB and VBG. One hundred patients were included in the study. Fifty patients underwent LAGB and 50 patients, open VBG. Study parameters were weight loss, changes in obesity-related comorbidities, long-term complications, re-operations including conversions to other bariatric procedures and laboratory parameters including vitamin status. From 91 patients (91%), data were obtained with a mean follow-up duration of 84 months (7 years). Weight loss [percent excess weight loss (EWL)] was significantly more after VBG compared with LAGB, 66% versus 54%, respectively. All comorbidities significantly decreased in both groups. Long-term complications after VBG were mainly staple line disruption (54%) and incisional hernia (27%). After LAGB, the most frequent complications were pouch dilatation (21%) and anterior slippage (17%). Major re-operations after VBG were performed in 60% of patients. All re-operations following were conversions to Roux-en-Y gastric bypass (RYGB). In the LAGB group, 33% of patients had a refixation or replacement of the band, and 11% underwent conversion to another bariatric procedure. There were no significant differences in weight loss between patients with or without re-interventions. No vitamin deficiencies were present after 7 years, although supplement usage was inconsistent. This long-term follow-up study confirms the high occurrence of late complications after restrictive bariatric surgery. The failure rate of 65% after VBG is too high, and this procedure is not performed anymore in our institution. The re-operation rate after LAGB is decreasing as a result of new techniques and materials. Results of the re-operations are good with sustained weight loss and reduction in comorbidities. However, in order to achieve these results, a durable and complete follow-up after restrictive procedures is imperative.
PMCID: PMC2996534  PMID: 20563663
Restrictive procedures; VBG; LAGB; Long-term results; Re-operations
24.  Laparoscopic Sleeve Gastrectomy as a Primary Operation for Morbid Obesity: Experience with 200 Patients 
Introduction. Laparoscopic sleeve gastrectomy (LSG) represents a valid option for morbid obesity, either as a primary or as a staged procedure. The aim of this paper is to report the experience of a single surgeon with LSG as a standalone operation for morbid obesity. Methods. From April 2006 to April 2011, 200 patients underwent LSG for morbid obesity. Each patient record was registered and prospectively collected. In July 2011, a retrospective analysis was conducted. Results. Patients were 128 females and 72 males with a median age of 40.0 years. Median pre-operative BMI was 49.4 kg/m2. Median follow-up was 27.2 months. Median post-operative BMI was 30.4 kg/m2. Median %excess weight loss (%EWL) was 63.6%. Median post-operative hospital stay was 4.0 days in the first 84 cases and 3.0 days in the last 116 cases. Six major post-operative complications occurred (3%): two gastric stump leaks (1%), three major bleedings (1.5%) and 1 (0.5%) bowel obstruction. One case of mortality was registered (0.5%). To date only 4 patients are still in the range of morbid obesity (BMI > 35 kg/m2). Conclusions. Laparoscopic sleeve gastrectomy is a formidable operation in the short-term period. Median %EWL in this series was 63.6% at 27.2 months follow-up.
PMCID: PMC3371683  PMID: 22701478
25.  Five-Year Weight Loss Experience of Outpatients Receiving Laparoscopic Adjustable Gastric Band Surgery 
Obesity Surgery  2013;23(7):903-910.
This study evaluated the efficacy and safety of laparoscopic adjustable gastric banding (LAGB) in a large cohort of morbidly obese patients followed for up to 5 years.
Morbidly obese patients, ≥16 years of age, who underwent LAGB surgery at the Surgical Weight Loss Clinic in Ontario, Canada, between May 2005 and January 2011 were eligible for this retrospective chart review. Electronic files were searched to identify all patients who met the inclusion/exclusion criteria. Demographics, weights at baseline and follow-up visits (up to 60 months following surgery), and post-operative complications were documented. As follow-up visits occurred at unevenly spaced intervals within and across patients, modeling methods were used to more accurately assess mean % weight loss (WL) and % excess weight loss (EWL) over time.
This study included 2,815 patients (82 % female, mean age 43 years, mean baseline BMI 44.6 kg/m2) followed for a mean of 21.8 ± 15.4 months. Complications developed in 238 patients (8.5 %), the most frequent being prolapse/slippage (4.2 %), tubing/access port problems (1.2 %), and explantation (1.2 %). Mean %WL and %EWL progressed continuously over the first 2.5 years post-LAGB, plateauing at 20 and 49 %, respectively, for up to 5 years of follow up. Factors associated with increased weight loss were time since surgery, greater baseline weight (excess weight), older age at time of surgery, and male gender.
Weight loss was maintained for up to 5 years in our population of patients who underwent LAGB for the treatment of morbid obesity.
PMCID: PMC3671103  PMID: 23446665
Laparoscopic adjustable gastric banding (LAGB); Obesity; Lap-Band; Outpatient

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