Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass
Earlier this week, I blogged about the rather frequent occurence (upto 30%) of band and port complications seen with laparoscopic adjustable gastric banding (LABG). I also mentioned that other complications of this surgically simple procedure, like band migration, pouch-enlargement, esophageal dilation, or port-site infections, can require reoperation or conversion to roux-en-Y gastric bypass (RYGB). Fortunately, this conversion can be done laparoscopically with a high rate of success. That, at least, is the gist of a report by Langer and colleagues from the Medical University of Vienna, Austria, in this month’s issue of Obesity Surgery, who addressed the poor long-term outcome in a growing number of LABG patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to prospectively assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in 25 patients, who failed LABG due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15). All procedures were completed laparoscopically within a mean duration of 219 +/- 52 (135-375) min with no significant complications. This shows that revisional surgery, while possible, takes significantly longer than a primary RYGBP (which generally takes around 90 mins). Following conversion to RYGBP, mean body weight was reduced by 14%, 18% and 24% at 3, 6, and 12 months, respectively. No statistically significant differences were found comparing weight loss within these two groups. Thus, while this study shows that it is technically possible to convert failed LABG to RYGBP with good results, it also reemphasizes the fact that a significant number of LABG patients will fail in the long-term and will need reoperation. Although, LABG remains a simple and relatively successful bariatric option in the short term, all patients planning to undergo LABG should be warned of the relatively high long-term failure rates of this procedure and should be given the option of undergoing RYGBP as a primary intervention. All bariatric surgical centres should offer both procedures to their patients and be prepared to convert failed LABGs to RYGBPs. AMS Edmonton, Alberta
Obesity and Chewing Ability
Yesterday, I had my remaining wisdom teeth extracted. As anyone, who has had this done to them knows, chewing with a swollen cheek and a gaping wound is no fun. Interestingly, chewing also appears to be impaired in folks with severe obesity (even without the trauma of wisdom tooth extraction). This, at least, was the finding from a study by Jean-Luc Veyrune and colleagues (faculté d’Odontologie, Clermont-Ferrand, France) published in the latest issue of Obesity Surgery. Veyrune compared the chewing parameters in a group of 44 obese adult patients (BMI = 49.1 +/- 7.2) scheduled for gastric bypass surgery with those of a control group (BMI=20.9 +/- 2.1). In both groups, the subjects’ dental status was characterized by the number of functional dental units. Kinematic parameters, namely chewing time (CT), number of chewing cycles (CC), and chewing frequency (CF), were video recorded during the mastication of five natural standardized foods (banana, apple, sweet jelly, peanut, and carrot). The particle size distribution of the expectorated bolus from carrot and peanuts was characterized by the 50th percentile (D (50)) (sounds kind of yucky to me). Even in fully dentate obese patients, chewing time and chewing cycles were higher with lower values for D (50). This was particularly true for carrot and peanut (that obviously require more chewing than banana, apple or jelly). As restrictive bariatric surgeries (like adjustable gastric banding), require fine mastication of foods, this study is again a reminder to evaluate both dental status and chewing ability in patients scheduled for bariatric surgery. Obviously, the ability to properly chew healthy foods (which generally require a lot of chewing – try biting into an apple with lose teeth) is a prerequisite for health eating. Dental assessments can be an important barrier to healthy eating and should be part of the general assessment in bariatric patients. AMS Edmonton, Alberta
Band and Port Complications after Adjustable Gastric Banding
Laparoscopic adjustable gastric banding (LAGB) is now one of the most popular forms of bariatric surgery. Its two main advantages are surgical ease of band placement and the possibility of subsequent adjustment of band volume (and thus restriction). Drawbacks include introduction of a foreign body, high-dependence on patients compliance and adherence, and the continuing need for band adjustments. But there are also technical issues that can arise, often requiring reoperation. Based on a recent study by Marie-Veronique Launay-Savary and colleagues, Hôtel-Dieu, Clermont-Ferrand, France, the frequency of technical complications of adjustable gastric banding may in fact be higher than most experts think (Obesity Surgery). Based on an evaluation of 286 consecutive patients, who underwent laparoscopic adjustable gastric banding (LAGB) between January 1997 and December 2004 at their centre, the researchers found that port or band complications (e.g. port displacements, port rupture, band rupture, etc.) occurred in around 20-30% of all patients over the mean follow-up period of 3.3 years. The mean time for complications was around 2 years post-surgery). While there were some variations in the frequency of complications depending on which version of the LapBand was used in the study, with the exception of rupture rates, which decreased after changing the junction between port and catheter after March 2002, complication rates remained rather high. Importantly, the study did not look at other reasons for failure such as patient non-compliance or food intolerance, that sometime also require revisional surgery – so the overall complication and failure rate is even higher than reported in this study. Since enrollment of patients in this study, band technology and surgical experience has improved world-wide, however, there is little question that technical issues related to adjustable banding remain a significant challenge – the fact that as many as 30% of patients may require revisional surgery within 3-5 years is alarming. This is particularly important information for patients seeking LABG surgery at private centres or out-of-country, as it is often not clear exactly who will bear the additional costs of revisional surgery (that in some cases may not only involve complete replacement of the band or conversion to bypass surgery) when necessary . While there is no question that for many patients, LABG is a valuable and often life-changing tool with high rates of remission of obesity complications, when things go wrong (as they always will for a certain percentage of patients undergoing any kind of surgery),… Read More »
Pfizer Also Halts its CB-1 Program for Obesity
Really no surprise here. After first Merck stopped the development of its CB-1 antagonist taranabant and earlier this week, Sanofi-Aventis abandoned further development of rimonabant , Pfizer yesterday announced, that they too had now discontinued the development of their CB-1 antagonist CP-945,598. Not that these drugs were not effective for obesity treatment. In fact all three compounds were as, if not more, effective for weight loss as the prescription drugs currently on the market. Not only had they been tested in some of the largest randomized controlled trials ever to be conducted in the field of obesity, but they had clearly demonstrated positive effects on lipids, glucose homeostasis, and even blood pressure. Alas, these positive effects were clouded by a significantly higher rate of anxiety, depression and dysphoria – in the worst cases, even suicidal ideation. Not that these drugs were actually killing people, but clearly, if widely used (as any obesity drug is bound to be), it would have only been a matter of time before someone somewhere on one of these drugs may have put a gun to his head or jumped off a bridge. Unfortunately, I do not ever foresee an effective drug for obesity that will be completely without risk. In fact, most drugs (even aspirin or paracetamol) have risks and, in rare cases, can kill you. It is not about having drugs that are absolutely safe – it is about having effective drugs that are safer than the condition that you are trying to treat: we call that risk/benefit ratio. In fact, everyday in clinical practice we decide (often simply using our best clinical judgement) whether the risk of treating exceeds the risk of not treating a condition. We happily use lethal poisons to treat cancer, because the risk of using these poisons is statistically lower than letting the cancer run its course. Obesity is also a condition that kills – that is why, for patients with severe obesity we increasingly recommend surgery, which, even under the best circumstances, on average kills 1 in every 500 to 1000 patients who get it. Despite this risk – most people with severe obesity would opt for (and all guidelines recommend) surgery, because the risk of dying without surgery is statistically greater than the risk of dying from surgery. With the withdrawal of CB-1 antagonist, patients battling obesity have lost an important option. Given our lack of effective… Read More »
Bariatric Lunch Forum II
Yesterday, I hosted my second Bariatric Lunch Forum – available to viewers through the Alberta teleHealth system. This time the topic was obesity surgery. Although my guest, Dr. Shahzeer Karmali was stuck in the OR and only managed to join me during the last 10 mins of the forum, we did cover a lot of ground. As I’ve blogged before, while the technical advances in surgery are certainly responsible for improving the perioperative outcomes, long-term success is highly dependent on patient selection, patient preparation and long-term follow-up. Even if the results of obesity surgery are often nothing short of spectacular, it is never an easy way out. Being successful, requires daily diligent hard work – obesity surgery is a tool, not a cure! Incidentally, yesterday, Sanofi-Aventis announced that after the recent decision of EMEA to suspend the authorisation of the obesity drug rimonabant (CB-1 antagonist), they have decided to discontinue the further development of this compound for all indications and have called off all ongoing clinical trials. In their press release, they base their decision on the fact that “certain national authorities” have made demands that make further development of this drug unfeasible. No doubt, overall, a major setback for the pharmacotherapy of obesity. The two-horse derby rolls on… AMS Edmonton, Alberta
Non-Invasive Diagnosis of Fibrosis in NAFLD
Non-Alcoholic Fatty Liver Disease (NAFLD), a common and widespread metabolic complication of obesity, is now the most common form of liver disease in the Western world. It is also an increasingly common cause of liver fibrosis, that can ultimately progress to cirrhosis and liver failure. Currently, the accurate diagnosis of fibrosis requires a liver biopsy. Now researchers at the Mayo Clinic have reported that a new non-invasive technology called magnetic resonance elastography (MRE) can diagnose fibrosis with 97% accuracy in patients with NAFLD. According to the Mayo Clinic press release: “The technology, called magnetic resonance elastography (MRE), produces color-coded images known as elastograms that indicate how internal organs, muscles and tissues would feel to the touch. Red is the stiffest; purple, the softest. Other imaging techniques do not provide this information.” For the full press release, including access to a video demonstrating this novel technology click here. AMS, Edmonton, Alberta
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