6 things you should know about laparoscopic adjustable gastric banding (LAGB)

Laparoscopic adjustable gastric banding (LAGB) was a popular procedure at the end of the 20th century and the first years of the 21Ist century. In recent decades, there has been a shift in the treatment of morbid obesity from LAGB to Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG). This surgical technique was mainly used on young patients. When asked, patients cite the ability of the band to be reversed, adjusted and controlled as one of the main reasons to choose this procedure over others. Surgical technique Surgical technique has changed from perigastric technique as originally described to the pars flaccida technique. In the perigastric technique the band was placed around the superior portion of the stomach by creating a retrogastric tunnel from the lesser to the greater curvature across the lesser sac. A 25-30 cc gastric pouch remained. A high incidence of slippage (~30%) and erosion (3%) were associated with this technique. The pars flaccida technique places the band higher in the stomach, preserving the lesser sac and the posterior gastric attachments. This technique creates a 1cm virtual gastric pouch and is associated with less slippage, less weight loss failure, and less chronic reflux. Complications – Band Slippage: the gastric wall migrates upward through the band. Its incidence is reported to be up to 22%. Symptoms are nonspecific such as abdominal pain, nausea or vomiting. The more reliable test for diagnosing band slippage is un upper gastrointestinal swallow. If the phi angle (angle between the longitudinal axis of the gastric band and the spine) is less than 4º or more than 58º, band slippage is diagnosed. It may be treated by removing the fluid in the subcutaneous port. If the slippage does not resolve by decompression, surgery is indicated. – Band erosion: reported to be as high as 11%, band erosion usually occurs in the first 2 years after the procedure. Patients can be asymptomatic or present with decreased restriction or epigastric pain, bleeding, port-site infection or intraabdominal abscesses. Diagnosis is usually made by CT scan or upper endoscopy. Emergency surgery is seldom necessary. – Gastric pouch/esophageal dilation: reported to occur in 11% of patients in the long-term. Long-term outcomes: the long-term outcomes of LAGB have been reported by several groups as disappointing. Long-term failure rates have been reported to be as high as 40-50%, with an incidence of revisional surgery ranging from 20% to 40%. Economic analysis also shows the superior cost-effectiveness of RYGB (17.07 QALYs, $ 138,632) compared to LAGD (16.10 QALYs, $ 135,923).