Dr. Anas Yousif Yakoob, General Surgeon

Abstract

Obesity is acommon health problem in the world and mostly in western countries with increase prevelance, and may associated with comorbidities which form areal problem for the community. It is treated either by surgical or non surgical therapy and these include advices for diet behavioral therapy and pharmacological intervention.The more effective wiegth reduction surgery is performed by either open or laparoscopic approach. We are comparing between laparoscopic gastric bypass (LGBP) and laparoscopic adjustable gastric band (LAGB) surgeries in technique, time of operation, post operative complications theirs effect on wt. loss and in the improvement of associated comorbidities.

Keywords Surgery, laparoscopic gastric bypass, gastric band, laproscopy , comparism Briatric.

Materials and methods A literature search was done by using search engine Google, SpringerLink, HighWire Press and library facility at laparoscopic hospital. The following search terms was used: comparism,laparoscopic gastric banding,laparascopic gastric banding.Criteria for selection of papers were upon statistical way of analysis, the technique of operation ,time of surgery , postoperative complication ,wt. loss, improvement of comorbidities

Introduction Obesity is amajor health problem and defined as increase in the body mass index (BMB) more than 30 kg/m2 .It is either mild obesity (BMI 30-34.9 kg/m2) or moderate obesity (BMI 35-39.9 kg/m2 ) or sever or morbid obesity (BMI 40kg/m2 or more ). Morbidly obese, defined as having a body mass index (BMI) greater than or equal to 40 kg/m2 it may associated with health-affecting comorbidities like diabetes mellitus, hyperlipidemia, osteoarthritis ,obstructive sleep apenia , hypertension and cardiac arrhythmia. Recent studies show that more than 64% of US adults are overweight and 5% are morbidly obese. Many obese patients can get temporary weight reduction by means of diet, exercise programmes, anti-obesity drugs, 5% of severely obese patients will only achieve sustained weight reduction. Surgery for obesity (bariartric surgery) remains the most effective treatment of morbid obesity which leads to sustained wt. loss in 90-95% of patients. The application of laparoscopic technique to bariatric operations has reduced perioperative complications and has contributed to a remarkable increase in interest in the surgical treatment of obesity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are the common procedures for morbid obesity.1

Operation

Surgical treatments of morbid obesity either open or Laparoscopic techniques and the last one are the preferable one due to short hospital stay, less peri- operative complication as well as cosmetic factor. Many Laparoscopic procedures was done either as gastric restrictive procedures (lap. Vertical banded gastroplasty LVBG and lap. Adjustable gastric banding LAGB) or malabsorptive procedures (biliopancreatic divertion with duodenal switch andjejunoilial bypass) or mixed procedure roux-en-y gastroJejuno-plasty LRYGB. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are common surgical procedures for morbid obesity.

Preoperative evaluation

All patients submeted for bariatric surgery must had abody mass index (BMI) 40 kg/m2 or more and 35kg\m2 if obesity related- comorbidities.

Preoperative evaluation and preparation consist of:

• Were evaluated by a clinical psychologist and dietician, and attended support group meetings.
• Additional speciality consultation.
• Patients were undergoing overnight polysomnography before surgery. To diagnose obstructive sleep apnea, institution of nocturnal continuous positive airway pressure (CPAP) therapy was required before surgery.
• Patients were given instructions for a low-fat, low-carbohydrate diet and to encourage losing 5% of their initial weight.
• Prophylaxis against venous thromboembolism consisted of perioperative lower extremity sequential pneumatic compression devices.
• Prophylactic intravenous antibiotic administration was routine for allpatients .
• LRYGB patients underwent preoperative bowel preparation.

Technique

Laparoscopic Adjustable Gastric Banding

The technique carried by the use of blunt dissection and electrocautery to identify and separate the angle of His from the gastrophrenic membrane and left crus. Dissection also done by using the technique pars flaccida and here the gastrohepatic divided to identified the right crus. Incision in the peritoneum anterior to both crura was done gentily. Insersion of blunt atrumatic grasper towards the angle of his. The band device tube brought through retrogastric tunnel, then placed with band system and locked. 3-4 sutuers placed to the wall of the stomach to fix the band to gasric wall .The band tube brought to anterior abdominal wall through upper quadrant trocar and the reservoir secured in fascia.

Laparoscopic Roux-en-Y Gastric Bypass

The technique started by placing omentum superiorly to identified the ligament of Treitz then Roux limbwhich measure 150cm and creation of side to side Enteroenterostomy with single application of linear cutting stapler to restore intestinal continuity. Estimation of 20ml gastric pouch which is vertically oriented. Retrocolic ,retrogastric Roux limb of 100 to 150 cm in length. Ahand sewn 2-layers anastmosis use to create gastrojejenstomy. Mesentry closed and 15ml balloon-tipped nasogastric tubeused to size the gastric pouch ,and alinear cutting stapler applied starting at lesser curvature caudal to the nasogastric tube ,proceeding to nangle of His which creat gastric pouch. Antecolic antegastric Roux limb with an intracorporeal suturing of gastrojejunstomy.

Post operative management

• Early mobilization on the evening after surgery was encouraged.
• Analgesia was used for pain management.
• Water-soluble contrast study done to exclude leakage then starts liquid fluid.
• Routin patient discharge of the patient on second post operative day.
• Follow-up ;

LRYGB patients seen 3wks after surgery then every 3 months in first year,6month in second year then yearly. LAGB patients were seen at3 and 6 weeks, then monthly for the first 6 months then bimonthly for the next 6 months, then every 3months for the second year, and then yearly thereafter.

• At each visit, patients were weighed on the same scale and . All patients were given daily multivitamin after 3 weeks and ursodeoxych- cholic acid if there is risk of gall stones.
• Lifelong dialy vit.B12,calicium and iron for LRYGB patints.
• LAGB patients, not added saline to reservoir until after 6 wks.

Postoperative complication

Major complications associated with LRYGB:

1-Early:

A-Peritonitis: mostly due to stoma leakage from gastrojejenstomy or gastric pouch.

B-Hemorrhage: either from stomal or port site.

C-Obstruction: to stomal site.

D-Small bowel obstruction.

E-Respiratory insfficiency.

F-Upper gastrointestinal bleeding: from anastomotic site.

2-Late:

A-Small bowel obstruction: due to stomal stricture or adhesive band.

B-Ulcer perforation: marginal or duodenal.

C-Thiamine deficiency.

Major complications associated with LAGB

1 -Early:

A-Hemorrhage: from trocar orretractor injury.

B-Gastric: perforation

2-Late:

A-Band infection.

B-Acute gastric prolapse.

Minor complications

LRYGB
Stenosis
Wound infection
Incisional hernia
Symptomatic cholelithiasis
Subphrenic abscess
Marginal ulcer
Urinary tract infection
Iron deficiency anemia
Urinary retention
Thiamine defeciency
Hypoproteinemia
Decubitus ulcer

LAGB
Band slippage/pouch dilitation
Port leak
Symptomatic choleithiasis
Malposition
Port dislodgement
Wound infection
Band erosion
Partial small bowel obstruction
Port irritation

Results

Safety
Data as mortality, overall morbidity, specific morbidity, time of surgery, conversion and reoperation rates were considered.

Mortality
The confedence interval for the short-term risk of death shows that LAGB is usually
associated with a decrease in operative risk at least when compared to RYGB [7].

Morbidity and post operative complications
It is found significantly higher rates of pulmonary embolism, wound infection, and incisional hernia, would seem to suggest that the risk, LAGB is least associated with morbidity, whereas RYGB is associated with a higher risk of morbidity [7 ].
The of major and minor complications incidence did not differ significantly
However, morbidity after LRYGB surgery was greater. The LAGB also avoids the uncomfortable side effect known as dumping syndrome. In LRYGB most significant major complication is anastomotic or staple line leak[1,7,8,16,20] .

Efficacy
The efficacy of each procedure will dealt with it in terms of wt. loss , operative results such as duration of operation, conversion rates and post operative factors like length duration of stay in hospital reoperative rates and psychological effect of surgery

Weight loss
LAGB result in weight loss is less than RYGB within first 2 years; for the later 2 years there is no significant difference between LAGB and RYGB. Early loss of weight is greater with gastric bypass, but this difference will be diminishing over time. Within first 18 month after surgery LRYGB procedure significantly more effective than LAGB at reducing weight .For both of the procedures LAGB and RYGB clearly result in long-term weight loss, although the evidence for at 4 years—the maximum extent of follow-up for LAGB mean BMI was reduce by 24% and 27%whereas those studies that reported weight reduction in terms of excess weight lost found that 44%and 68%of excess weight was lost. These latter data compare across the same 4-year period for excess weight lost with RYGB studies reporting ranges from 50% to 67%. Regarding the weight loss, it is clear that both procedures capable to produce a sustained weight loss, for LAGB at least over 4 years and up to14 years in the case of RYGB [1,7 ,12].

Time of surgery andOperative conversion
The time to performed LAGB surgery usually shorter than that of LRYGB surgery time. In the comparism of the shorter operative time in LAGB with the complexity of the of LRYGB procedure which requires multiple precise steps, including creation of two anastomoses and division of the stomach .The covertion rates in both LRYGB and LAGB procedures are associated usually with lower rate of surgical conversion[1].

Post operative recovery

Reoperation rate:
The reoperation rate was higher in the LAGB group than in LRYGB group .Mostly at the first group usually due to band removal or band revesions. Revesion rates in the operation RYGB on the other hand is clearly very low [1,7].

Discharge:
Patients with LAGB surgery have shorter operative times, shorter hospital stays and less blood loss, compared with LRYGB patients.
2-3 weeks needed for most of the gastric bypass patients to be able to return to normal activities for while LAP-BAND patients often complete their surgical recovery in 1-2 weeks.

Pychological effects:
Evaluation of the patients using a range of indices, including weight loss, improvement in medical conditions, and quality of life. Patients treated with LAGB surgery more likely to report a greater disparity between their current weight and their ideal weight, and scored more poorly on a range of measures also they had a significantly less positive evaluation of the surgery when compared to the RYGB patints [7].

Resolusion of comorbidities:
It found that more improvement in LRYGB for the comorbidities compaired with LAGB patients wher there is improvement in asthma , hypertension, venous-stasis, hyperlibidemia, congestive heart failure, cardiac arrhythmia, osteoarthritis, and sleep-apenia, [20].

Discussion

For both of the two procedures they produce asustained weight loss and they result in improvement in obesity related comorbidities. .In early post operative year’s weight loss is greater with gastric bypass, but the difference appears to diminish after the second year. LRYGB resulted in high rates of improvement in obesity-related comorbidity,
And mostly those associated with diabetes mellitus and sleep apnea cessation. LRYGB effect appears to be more in super morbidly obese patients when compared with LAGB (52% vs 31% EWL) . Interestingly, the disparity between superobese patients and nonsuper- obese patients was not seen in the LAGB group .In American patients Two major factors weigh against the widespread use of this device, The first one is the recent reports of excellent weight loss results and low mortality and morbidity rates for patients with laparoscopic Roux-en-Y gastric bypass surgeries .Both RYGB and LAGB cause weight loss by decrease in caloric intake and induce satiety,but the real mechanism for weight loss has yet well completely known .LAGB is less effective than or equally effective as VBG in its effect for weight loss and VBG is significantly less effective than RYGB at same effect, so LAGB is less effective than RYGB[1,7,12,16].

The LAGB proucedure have shorter operative times with less blood loss, and the staing ofr patiens at hospital after surgery take ashort tim compared with LRYGB patients, the shorter operative time for these pateints is explained when one compares the complexity of the LRYGB technique which requires multiple precise steps, including the two anastomoses as well as division of the stomach. In LAGB surgery main disadvantage is in the follow-up which must be more tense that required for the band ajusment and complications monitoring. One of the most significant LRYGB specific major complication is the leakage from anastmotic or staple line , although the incidence of complications did not differ between the LRYGB and LAGB, it is believed that the surgery morbidity of early major complications after LRYGB surgery is more severe than that after LAGB surgery. SO suggestion that in LAGB is safer than its LRYGB procedure with regard to both mortality and morbidity. It is not surprising to consider the less invasive nature of LAGB and the preservation of normal gastrointestinal continuity [1,7,8].

Types of morbidities with each procedure appear to reflect the idea of that LAGB complications relating to misplacing or inadequately securing the device to the gastric wall, while the RYGB type of complications associated with ‘‘large incision’’ problem as well as breakdowns in the anastomotic line; and patients undergoing RYGB appear to be at higher risk of metabolic changes that are due to malabsorption[7].

Conclusion
Laparoscopic surgery for obesity (bariatric surgery) is usually associated with less perioperative complications and rapid recovery if compaired with open surgery, these procedures include gastric bypass,vertical banded gastroplasty ,adjustable gastric banding and billopancreatic diversion. The common laparoscopic procedures used now are LAGB and LRYGB .Both of these two procedures are safe and effective [1,7].

Most benifiets of LAGB is minimally invasive,short time surgery,less short term mortality and morbidity rates,allowing reduction of weight ,easlly reversible by reconstructive surgery ,as well as preserve normal gastrointestinal continuity,but it needs closed flow up secondary surgical procedures in some patients .It is becomes onne of the most populler obesity surgery in world ,it is preferred by Australian,Europian as well as Asian surgeons [1 ,7,8,12 ,13 ].

Otherwise LRYGB advantages are rapid reduction of weight relive of comorbidities,it is cocederd to be superior to LAGB by American surgeons, some cosedered it as one of the more technically challenging procedure to be performed in ahiegh-volium centers.It is the procedure of choice in united state for morbid obesity [2,4].

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