The ideal way to perform gastric band

Perché ancora il Bendaggio
Gastrico?
All over the world more than 800.000 Gastric Bands have been placed!
Why such a success…?
According to the World Health Organization: “worldwide
obesity has more than doubled since 1980 to over 500 million
people and keeps increasing and the related costs to public
health and the economy are skyrocketing…..”
"Global obesity is a mega-investment theme for the
next 25 years and beyond."
Gastric Band is still a major bariatric surgical procedure for obesity
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Safe : the lowest % of mortality
Effective :
- ≥ 50 % excess weight loss
- Major co-morbidity benefits
- Improved quality of life
- Durable up to 15 years, so far
“Gentle approach”
- Minimally invasive
- Adjustable
Cost –Effective
No other Bariatric Surgical Approach has these peculiarities
 Can be used in wide variety of patients, including adolescents
 Highly reproducible laparoscopic technique
 Short learning curve
 Few complications with very low mortality rate
 Adjustability
 Total reversibility and all surgical options remain open
 Acceptable results in terms of %EWL
 Is an excellent first step procedure for the super-morbidly obese
Too many complications??
Was the report from pioneer bariatric surgeons!
 Relatively
poor design of bands/ports (rigid,
tiny, no cincunferential pressure ......)
The materials
has changed…
marlex mesh, dacron vascular prosthesis, silicone covered mesh, GoreTex, silicon drains…….
Which technique, for the best results?
Pars Flaccida
Approach
Perigastric
Two steps
“Flopping Band”
Band setting
“Stitched Band”
Technical “guidelines”
1. Minimal dissection of the gastrophrenic ligament
2. The ”two-steps” technique
3. The band fixation
4. Gastro-gastric “Rossetti-like” stitch
5. The new life stile . The scrupulous follow up
1.
Minimal Dissection of the gastro-frenic ligament
2. The “two steps” perigastric technique
OLD TECHNIQUE
“one step”
The peri and retrogastric tunnel was performed in a
single step
with high risk of cauterization and gastric wall injury
Perigastric
approach
NEW TECHNIQUE
“ two steps”
1° step: retrogastric tunnel
2° step: perigastric tunnel
2. The “two steps” technique
The same of the “pars flaccida”
First step
Peculiar
Second step
No risk of damaging the gastric wall.
No complications.
SICOB 2013, Cagliari
2. The “two steps” technique
Why are we still performing
the perigastric technique?
2. The “two steps” technique
Perigastric
5-10%
acute postoperative stenosis
in Pars Flaccida Technique!!
Pars Flaccida
2. The “two steps” technique
Perigastric
- Correct band use
- Homogeneous calibration
Pars Flaccida
- NO homogeneous calibration
- Early risk of acute obstruction
2. The “two steps” technique
The “two step” is less familiar
and not well-known, but can
cover all different anatomical
situation!!
The perigastric technique is considered “abandoned” by
many, but most surgeons have not even tried this approach in
theirs gastric Band experience!
2. The “two steps” perigastric technique
No
openings for
Posterior
Slippage!!!
No
possibilities for
Posterior
Slippage!!!
3. Band Fixation
Two stitches from the gastric fundus to the cardial region
 Very near to the band
 Gastro-gastric stitch
No stitches on the left crus!!!
3. Band Fixation
Vomiting :
the initial and the main cause of the BAND slippage!!
With the stitches we reduce the slippage
although the patient behaviour
Band fixation
>
Band stability
SICOB 2013, Cagliari
3. Band Fixation
 A. Bécaud, 58 non fixed Bands (Allergan) 2 acute slippages
 J.M.Zimmermann, 35 non fixed Bands, (Allergan) 2 acute slippages
Total: 93 cases, 4 acute slippages, 4.3%
2008 a new study A. Bécaud, J.M. Zimmermann
SICOB 2013, Cagliari
4. Gastro-gastric stitch
The “Rosseti-like stitch” avoids slippage of the gastric wall trough the band.
The same as performed in the “Nissen fundoplicatio”
5. The new life stile and scrupulous follow up
Motivation
and
long-term commitment,
are critical for successful weight reduction
following LAGB.
SICOB 2013, Cagliari
5. The new life stile and scrupulous follow up
We must be partners with our patients!
Teaching the “ new eating behaviour “
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Small bite
Good food
Chew well
Swallow
Wait a minute
Best Patient Care: Better Outcomes
Better Outcomes = Lower Exposure to complications
SICOB 2013, Cagliari
Medical
Nutrition
Surgery
Support
Groups
Psychology
Nursing
Education
Exercise
“Bariatric and
Metabolic Unit”
Desenzano
Dr F. Bellini
2002
3236
Heliogast System®
“ Obesity Surgery
Center”
Policlinico Monza
Dr P. Pizzi
2012
Mean BMI
3236 pts
70
42.9
60
41.2
50
40
30
20
10
0
M
F
BMI EVOLUTION
45
43
41
39
37
35
33
31
29
27
25
Pre op
6
12
18
24
3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years
months months months months
m
41.4
38.2
34.8
33
32.9
31
31.2
32
31.6
30.9
30.2
30.4
31
f
42.2
37.9
33
32.8
30.3
31.2
30.2
30.2
30.3
31.6
31
29.7
30
pts
3236
3110
2993
2767
2412
2110
1754
1423
1010
655
354
199
98
% EWL TRAND
100
90
80
70
60
50
40
30
20
10
0
Pre op
6
12
18
2 years
months months months
3 years
4 years
5 years
6 years
7 years
8 years
9 years 10 years
m
0
27
42
50
51
55
55
54
53
52.7
51
51.6
50.6
f
0
29
46
51
53
53
53
55.7
53.9
53.4
52.7
51.9
51.8
3236
3110
2993
2767
2412
2110
1754
1423
1010
655
354
199
98
pts
3236 Patients: 10 Years Results
Major and Minor Complications Requiring SURGERY
Number
Slippage
Rate of
Complications
137
4,23%
(only anterior)
Surgical
approach
• Removal
• Repositioning
Number
Rate of
Reoperation
55
82
1.69%
2.53%
Erosion
14
0.43%
Removal
14
0.43%
Psychological
Intolerance
19
0.58%
Removal
16
0.49%
Incisional hernia
27
0.83%
Repair
25
0.77%
Port change/repositioning
Catheter leak repair
41
1,26
Repair
41
1.26
Total
235
7.26%
Total
233
7,20%
6,6%
• Removal
• RYGBP:
• BPD
1
74
11
2.65%
Unsatisfactory Results
Lack of Compliance
<25%EWL
201
Conclusion
The “two-step” technique
is not
the perigastric technique as commonly
thought!!!
Conclusion
1. The minimal dissection of the gastro-frenic ligament
avoids slippage of the gastric fundus
2. The “two-step” technique is:
technically simple
avoids intimate posterior gastric wall dissection
facilitates tight posterior band support
dramatically reduces posterior slippage
3. The band fixation avoids early slippage and reduction of slippage
4.
5.
percentage although the patient behaviour
The “Rossetti-like stitch avoids stomach slippage trough the band
The new Port with 360° accessibility, avoids problems with
rotation/malposition
Learn from
experience of
others!
Need not repeat
mistakes….. .