Report Shows Laparoscopic Sleeve Gastrectomy has Morbidity and Effectiveness Positioned Between the Band and the Bypass

| May 17, 2011

Dear Bariatric Times fans:

I would like to start this editorial by commenting on the article by Bartholomay on weight loss surgery in patients with chronic kidney disease (CKD). There is a large patient population in the United States whom cannot receive kidney transplants because they have morbid obesity. Not only is obesity a risk factor for poor surgical outcomes, it is also well known that graft survival of any kind is decreased in recipients who have morbid obesity. When choosing the right procedure for a kidney transplant candidate, “rapid weight loss” should be a consideration since losing weight quickly postoperatively will prepare the patient for kidney transplantation when a graft becomes available. For the renal bariatric patient, gastric bypass or sleeve gastrectomy should be the first choices since they result in rapid weight loss postoperatively; however, because some insurance carriers limit their coverage of sleeve gastrectomy, most patients choose gastric bypass. It has been our published experience that either procedure has excellent results in this patient population before or after the transplantation and that there are no differences in dosage of immunosuppressive agents in either surgical approach. I personally do not recommend adjustable gastric banding in this patient population because weight loss is slow, and in 20 percent of the patients, the bands have to be removed, which would require transplanted patients to undergo another surgical procedure.

Clark and Black present another interesting paper in this issue on skin problems in patients with morbid obesity. They discuss prevention and management of common skin disorders in the bariatric patient—pressure ulcers, intertriginous dermatitis (ITD), incontinence-associated dermatitis (IAD), and deep tissue injury (DTI). Also of importance is management of skin disorders in the pre- and postoperative setting of bariatric patients. If short-term complications, such as decubital ulcers, are not prevented in patients with super-super morbid obesity, they may result in more serious problems for the nursing staff. In the long term, lower-extremity and panus cellulitis are other a major problems.
Contrary to what many people may think, I personally believe that the use of laparoscopic adjustable gastric banding (LAGB) in the United States will continue to increase. I make this statement for the following reasons: 1) We cannot compete with mass media advertising, and patients are getting a biased impression about this procedure; 2) If insurance companies one day approve surgery for patients with a body mass index (BMI) 30 to 35kg/m2, banding will become an excellent option; and 3) If the pharmaceutical industry comes up with a good anorectic drug that can be combined with LAGB, I am sure the results will be more promising, and even the most pessimistic bariatric surgeons will believe in this approach. In my practice, only eight percent of patients are candidates for LAGB, 16 to 20 percent of implanted bands have to be removed, and, for the remaining 84 percent of implanted bands, I believe a large amount of these patients are just “band carriers,” meaning that they do not come for adjustments because they live too far away, are not able to pay for the adjustment, or are not willing to change their lifestyle, resulting in poor weight loss. It is not the band that fails, but the patient.

In my opinion, gastroesophageal reflux disease (GERD) is always a sign of trouble. In this month’s installment of Ask the Experts: Dilemmas in Bariatric Surgery, featured expert Natan Zundel, MD, FACS, discusses GERD after LAGB, and this column is a must read. It gives us a wonderful step-by-step approach to this not so unusual problem, and Dr. Zundel is, in my opinion, one of the most experienced LAGB surgeons in the world.

Also is this issue, Maller et al present us with an outstanding overview of physician compensation. Surgeons sometimes (all the time?) wonder how much more money they should be earning based on the work load and long hours. Maller et al’s article is a preview of a course that will be taught during the annual meeting of the American Society for Metabolic and Bariatric Surgery (ASMBS) taking place in Orlando, Florida, June 2011. Don’t miss it!

Finally, I’d like to bring attention to a report that was presented at the American Surgical Association meeting that took place April 14–16, 2011, in Boca Raton, Florida. Hutter et al presented the first report from the American College of Surgeons Bariatric Surgery Center Network (ACS BSCN) on laparoscopic sleeve gastrectomy (LSG). During the study, 109 hospitals submitted data for 28,616 patients from July 2007 to September 2010. The researchers found that LSG had higher risk-adjusted morbidity and readmission rates compared to the LAGB, but lower readmission and reoperation/reintervention rates compared to the laparoscopic Roux-en-Y gastric bypass (LRYGB) and open Roux-en-Y gastric bypass (ORYGB). There were no differences in mortality. Reduction in BMI for the LSG also lies between that of the LAGB and the LRYGB/ORYGB. This report reflects good news for LSG, a procedure that continues to collect good reports.

I hope you enjoy reading this month’s issue of Bariatric Times, and I look forward to seeing you all in Orlando, Florida at the annual meeting of the ASMBS.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

References
1. Hutter, Schirmer, Jones et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy (LSG) has morbidity and effectiveness positioned between the band and the bypass. Presented at American Surgical Association 131st annual meeting; April 14–16, 2011, Boca Raton, Florida. http://meeting.americansurgical.
info/abstracts/2011/1.cgi. Accessed May 10, 2011.

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