Is it necessary to deflate the adjustable gastric band for subsequent operations?

Patients and methods 

From January 1996 until June 2001, we operated on a total of 408 consecutive patients, which were all performed laparoscopically. In 398 cases we used the SAGB (Swedish Adjustable Gastric Band; Obtech Medical AG, Baar, Switzerland) and in 10 cases the ASGB. Of the total 408 patients, we identified 68 (16.7%) patients, all of them with a SAGB, who underwent subsequent operations: 14 cholecystectomies, 22 plastic reconstructive operations, 5 phlebectomies of subcutaneous varicose veins, 15 port repositions (the access port is displaced from the sternum to the left upper quadrant), 3 appendectomies, 4 incisional hernias, and 5 joint replacements. Twenty-five patients had at least two procedures combined in the same operation such as abdominoplasty in conjunction with breast reconstruction or port reposition. Demographic data of the study population are given in (Table 1) including gender, age, body mass index (BMI) prior to band placement, and the length of time since SAGB placement. The patients were divided into two groups: deflated adjustable system group (DAS, n = 32; Table 2) and nondeflated adjustable system group (NDAS, n = 36; Table 3). In the DAS group the band was completely deflated 1 day prior to surgery and refilled halfway according to the previous amount on the second or third postoperative day. The bands were completely refilled to preoperative level over a period up to 3 months on regular follow-up visits. In the NDAS group the band was not deflated either before the operation or anytime during the hospital stay. Endpoints studied included any complications that could be attributed to the band, such as nausea, prolonged or severe postoperative vomiting, respiratory complications, weight regain, and problems in establishing preoperative levels of oral food intake. Also evaluated was how much weight the patient gained after band deflation and the time required return to preoperative weight.

Table 1. Preoperative demographics for 68 patients

		Deflated band group (n = 32)	Nondeflated band group (n = 36)	P value
	Gender (female/male)	27/5	32/4	NS
	Age (years)	36.4 (19–58)	38.5 (22–62)	NS
	Preoperative BMI	28.4 (23–35)	28.6 (22–39)	NS
	Band in situ (months)	23.4 (18–48)	22.6 (16–46)	NS

BMI = body mass index; NS = not significant.

Table 2. Baseline characteristics of deflated adjustable system

		Total (n = 32)	Preoperative weight (kg)	Operation time (min)	Complications (n = 4)	Intraoperative complications	Revision (n = 1)
	Cholecystectomy	8	69.4	85	0	0	0
	Abdominoplasty	6	75.8	128	2 infections	0	0
	Phlebectomy	3	72.2	68	0	0	0
	Breast reconstruction	5	78.6	180	0	0	0
	Port reposition	6	82.1	24	0	0	0
	Appendectomy	1	91.2	35	1 infection	0	0
	Incisional hernia	1	85.1	41	0	0	0
	Joint replacement	2	85.3	171	1 postoperative bleeding	0	1

Table 3. Baseline characteristics of nondeflated adjustable system

		Total (n = 36)	Preoperative weight (kg)	Operation time (min)	Complications (n = 4)	Intraoperative complications	Revision (n = 1)
	Cholecystectomy	6	76.8	88	0	0	0
	Abdominoplasty	7	76.2	131	1 infection	0	1
					1 postoperative bleeding
	Phlebectomy	2	71.3	61	0	0	0
	Breast reconstruction	4	77.4	175	0	0	0
	Port reposition	9	80.2	28	1 infection	0	0
	Appendectomy	2	87.6	39	0	0	0
	Incisional hernia	3	85.3	43	0	0	0
	Joint replacement	3	81.3	167	1 pneumonia	0	0

Results 

Patient characteristics differ slightly since the NDAS group is older and has a lower BMI. In both groups, female patients predominate. Gender distribution differences between the groups were not significant (Table 1). There were no anesthesia dependent complications or problems. The amounts of analgesic drugs used during anesthesia were equal relative to body mass index. All patients received proton-pump inhibitors intraoperatively and postoperatively and a one-time dose of preoperative antibiotics. The complication rate was minimally higher for the DAS over the NDAS group, with 3 (9.3%) compared with 2 (5.5%) wound infections, and 1 case of hematoma each (3.1% and 2.7%, respectively). None of the DAS patients and 1 (3.1%) of the NDAS patients developed pneumonia postoperatively. That might be due to aspiration although the event of aspiration is observed with a very low frequency. Neither life-threatening complications nor deaths occurred. The incidence of postoperative nausea and vomiting was similar for both groups, with a slight, although statistically insignificant, advantage for the NDAS patients (P = 0.81). Nausea and vomiting were relieved with antiemetics. The postoperative weight was measured and recorded daily. There was a significant difference in the weight gain between the DAS and NDAS group as well as in the time required to achieve the preoperative weight (P < 0.0001). Additional postoperative office visits were necessary for patients in the DAS group in order to refill the emptied band (Table 4), leading to additional patient discomfort and doctor effort and public health costs. Furthermore, the patients were frustrated by their rapid weight gain despite sticking to their diets.

Table 4. Results in term of weight gain and follow-up

		Deflated band group (n = 32)	Nondeflated band group (n = 36)	P value
	Weight gain	15 kg (8–25)	2 kg (−0.5–5)	<0.0001
	Postoperative follow-up visits	5.3 (3–9)	1.6 (1–5)	<0.0001
	Months to gain previous weight	6 (3–11)	0.6 (0–2)	<0.0001

Comments 

Bariatric surgery is the most effective way to manage and prevent the comorbidities of morbid obesity, defined as a BMI of over 40 kg/m2. Today’s effective and relatively safe bariatric surgical techniques justify the more widespread use of bariatric surgery in the management of morbid obesity. Appropriate patient selection coupled with bariatric surgical team input and patient education is important for the success of this procedure. Therefore, the ideal operation must have minimal risks of short- and long- term morbidity and mortality and result in good levels of permanent weight loss, significant improvement or resolution of preexisting comorbid conditions, and a good quality of life. Laparoscopic adjustable gastric banding is still an evolving procedure with no available long-term results, the longest reported observation period being approximately 9 years [13]. The short-term results, however, are very promising [11], [12]. The laparoscopic approach has been associated with a low frequency of postoperative complications, a rapid patient recovery, and low levels of postoperative pain [17]. The adjustable band offers the benefit of retaining control over the degree of gastric restriction through intermittent adjustments of the band. Subsequent adjustments can be made to achieve a lower target weight or sustain a certain weight, or to relieve the restriction during periods of significant illness or pregnancy.

The gastric bypass is presently the gold standard in the United States [18]. However, the complication rate of these operations performed laparoscopically remains high at the moment [19], [20]. The laparoscopic adjustable gastric banding has one major advantage compared with laparoscopic gastric bypass technique, ie, the adjustability of the band. That helps to limit the problems of pouch dilatation and expansion inherent to the stapling procedures. The band can also be tightened as patients lose weight and become hungry, and probably most important is that the procedure involves no division of the stomach and therefore eliminates the complications of anastomoses.

However, it is a well known phenomenon that in cases where it is necessary to deflate the bands, the patients are not able to hold their achieved weight. Instead they gain weight rapidly, up to 20 kg in a week. None of our patients were able to hold their weight with a deflated band. There is to our knowledge no report about the necessity of deflating the LAGB before subsequent operations. In our series of 68 patients, 36 (52.9%) of the bands were not deflated and 32 (47.1%) were deflated preoperatively. Postoperatively, the bands that had been deflated were inflated slowly over a period of up to 3 months, making multiple follow-up visits with additional costs ($100 US per examination) necessary. The patients in the DAS group gained an average of 15 kg (8 to 25 kg) of additional weight in the first month postoperatively. This is compared with an increased weight of 2 kg (−0.5 to 5 kg) in the same period in the NDAS group. The DAS group required up to 6 months to achieve the preoperative weight again. No patient had anesthestic or perioperative problems related to the band filling. The amount of analgesic drugs used during anesthesia were equal relative to body mass index. The incidence of postoperative nausea and vomiting was similar for both groups, and duration of surgery showed no significant difference between the NDAS and DAS group. Altogether there have been two reoperations, all unrelated to the band.

In the context of the ever increasing frequency of LAGB operations in Europe and the recent FDA approval in the United States, the number of LAGB procedures can be expected to dramatically increase. From this patient population, we can expect a rate of subsequent operations of at least 25% to 30% in the next few years. To our knowledge, this is the first study that demonstrates that surgery after LAGB is safe without deflating the adjustable band system. Furthermore, there are various advantages for the patients, doctors, and health care system in terms of cost saving. Therefore we have changed our policy and stopped emptying the bands before an operation with general anesthesia.