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Laparoscopic Lap-Band® Antiobesity Surgery - The laparoscopic Lap-Band Antiobesity procedure is proving to be safe and effective and should be considered the optimal initial approach for the long-term control of morbid obesity and its co-morbid conditions.
Background
Laparoscopic adjustable gastric banding (LAGB) was introduced in the early 1990's. This section addresses the importance of this technique in the management of morbid obesity and its co-morbid conditions. The technique has been in use world-wide for more than 10 years, with more than 100,000 patients treated and with more than 100 peer-reviewed papers published.1 Almost all the published data and reports relate to the Bioenterics Lap-Band® system (Inamed -Mantis Surgical, U.K.) which is the device used by Mr Rogers and the only LAGB system that is FDA approved.
Safety
The mortality rates for laparoscopic Lap-Band surgery are 10 times less than Roux-en-Y gastric by-pass (RYGB) and 6 time less than vertical banded gastroplasty (VBG). Morbidity rates were also lower at 10.7% for LAGB vs. 27.4% after RYGB and 23.6% after VBG.2
Efficacy
When considering efficacy one should consider not only the effects on weight-loss but also the effects on the co-morbid conditions and quality of life of the patients.
Weight-loss
A review of the results of a number of series indicate that the median percentage of excess weight loss (EWL) at 3, 4, and 5 years for Lap-Band surgery were 55%, 53% and 56% respectively. For the same time intervals the EWL for RYGB were 69%, 58% and 59%. Of importance there was no statistical difference between the EWL for Lap-Band surgery when compared to RYGB at 5 years. The report suggest that the weight loss profile for Lap-Band surgery is advantageous in that it generates a slower but continuous weight loss in the first 2 to 3 years followed by stable weight in the following 3 years. Whereas the maximal weight loss occurs between 1 and 1½ years after RYGB there is a steady decrease in the effectiveness of the operation with time.2
In our own prospective study published in the American Journal of Surgery 2002 median excess weight loss was 53% and 62% at 1 and 2 years respectively.3 (See Results and Graph)
Effect on co-morbid conditions of obesity
Type II diabetes mellitus: In a study of 50 patients followed for 1 year after Lap-Band surgery complete remission of diabetes was seen in 32 (64%), improved control in 13 (26%) and little change in 5 (10%).4
Insulin resistance: the effect on insulin resistance is of importance and it's associated conditions of hypertension, dyslipidaemia, polycystic ovary syndrome and steatohepatitis. During the first year after Lap-Band surgery insulin sensitivity improved from 37.5% to 62% in 254 patients, in addition pancreatic ß-cell function also significantly improved. The latter indicating a brake on the mechanism for the progression of Type II diabetes.5
Gastro-oesophageal reflux: In 87 patients with moderate to severe GORD who were followed for more that one year after Lap-Band surgery the problem resolved totally in 73 (89%) defined as absence of symptoms without treatment for 1 month.6
Obstructive sleep apnoea: the rate of sleep apnoea decreased from 33% to 2%, habitual snoring from 82% to 14%, abnormal daytime sleepiness from 39% to 4% and poor sleep quality from 39% to 2%.7
Depression: when assessed by Beck Depression Inventory (BDI) the weight-loss was associated with a significant and sustained fall in BDI scores from 17.7 ± 9.5, n=487) to 7.8 ± 6.5, n=373 at 1 year and 9.6 ± 7.7, n=134 at 4 years. This suggests that depression associated with obesity is reactive rather than causative.8
Changes in quality in life: a study of 459 severely obese patients using the Medical Outcomes Trust Short Form (SF-36) showed lower than normal community values before surgery. Lap-Band surgery resulted in a dramatic and sustained improvement in all measures of the SF-36. After Lap Band surgery the mean scores of the group returned to normal community values by 1 year and remained within the normal range for the 4 years of the study.1
Conclusion
The laparoscopic Lap-Band Antiobesity procedure is proving to be safe and effective and should be considered the optimal initial approach for the long-term control of morbid obesity and its co-morbid conditions.
(Continued on page 6)
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