The ideal way to perform gastric band

Perch ancora il Bendaggio Gastrico?Fabrizio Bellini Chirurgia Briatrica e Metabolica Desenzano

Perch il Bandaggio GastricoWhy such a success?All over the world more than 800.000 Gastric Bands have been placed!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."Perch il Bandaggio GastricoSafe : the lowest % of mortalityEffective : - 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 Gastric Band is still a major bariatric surgical procedure for obesityPerch il Bandaggio Gastrico 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 obeseNo other Bariatric Surgical Approach has these peculiaritiesPerch il Bandaggio Gastrico Relatively poor design of bands/ports (rigid, tiny, no cincunferential pressure ......)

Was the report from pioneer bariatric surgeons!Too many complications??Perch il Bandaggio Gastrico

marlex mesh, dacron vascular prosthesis, silicone covered mesh, Gore-Tex, silicon drains.The materialshas changedPerch il Bandaggio Gastrico

Perch il Bandaggio Gastrico

Perch il Bandaggio GastricoIn the earlies the band pressure was not circumferential! And that was considered a So the band has changed and now the pressure is circumferential8

Which technique, for the best results?

Pars FlaccidaPerigastricStitched BandFlopping BandApproachBand settingTwo stepsThe fusion of the two techniquePerch il Bandaggio GastricoTechnical guidelines Minimal dissection of the gastrophrenic ligament The two-steps technique The band fixation Gastro-gastric Rossetti-like stitch The new life stile . The scrupulous follow up

Perch il Bandaggio GastricoThese are the tips we are following and Im going to examine each of them10Minimal Dissection of the gastro-frenic ligament

Perch il Bandaggio Gastrico

OLD TECHNIQUEone step

NEW TECHNIQUE two steps The peri and retrogastric tunnel was performed in a single stepThe two steps perigastric technique1 step: retrogastric tunnel2 step: perigastric tunnelPerigastricapproach

with high risk of cauterization and gastric wall injuryPerch il Bandaggio GastricoI have to stress the completely different technique between the two ways The complications are relayed not to the perigastric technique BUT to the way this technique is performed!!!!12

The two steps techniqueFirst stepSecond stepThe same of the pars flaccidaPeculiar

No risk of damaging the gastric wall.No complications.

SICOB 2013, CagliariPerch il Bandaggio GastricoThe two steps techniqueWhy are we still performing the perigastric technique?Perch il Bandaggio Gastrico

PerigastricPars Flaccida

5-10% acute postoperative stenosis in Pars Flaccida Technique!!The two steps technique

Perch il Bandaggio GastricoPerigastricPars FlaccidaThe two steps technique Correct band use Homogeneous calibration NO homogeneous calibration Early risk of acute obstruction

Perch il Bandaggio GastricoThe two step is less familiar and not well-known, but can cover all different anatomical situation!!

The two steps techniqueThe perigastric technique is considered abandoned by many, but most surgeons have not even tried this approach in theirs gastric Band experience!Perch il Bandaggio Gastrico17No openings forPosteriorSlippage!!!No possibilities forPosteriorSlippage!!!

The two steps perigastric techniquePerch il Bandaggio GastricoBand FixationTwo stitches from the gastric fundus to the cardial region

Very near to the band

Gastro-gastric stitch

No stitches on the left crus!!!

Perch il Bandaggio Gastrico With the stitches we reduce the slippage although the patient behaviour Band fixation > Band stabilityVomiting : the initial and the main cause of the BAND slippage!!Band Fixation

SICOB 2013, CagliariPerch il Bandaggio GastricoA. Bcaud, 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%

Band Fixation2008 a new study A. Bcaud, J.M. ZimmermannSICOB 2013, CagliariPerch il Bandaggio GastricoIn literature I dont know a case of acute postoporative slippage of fixed Band!!!Gastro-gastric stitch

The Rosseti-like stitch avoids slippage of the gastric wall trough the band.The same as performed in the Nissen fundoplicatio

Perch il Bandaggio GastricoWhen we perform Nissen Fundoplicatio for Hiatal Hernia, we place an additional stitch to avoid slipping of the stomach into the fundoplicatio

22are critical for successful weight reduction following LAGB.The new life stile and scrupulous follow up

Motivationlong-term commitment, and SICOB 2013, CagliariPerch il Bandaggio GastricoThe new life stile and scrupulous follow upWe must be partners with our patients!

Best Patient Care: Better OutcomesBetter Outcomes = Lower Exposure to complicationsTeaching the new eating behaviour Small bite Good food Chew well Swallow Wait a minuteSICOB 2013, CagliariPerch il Bandaggio Gastrico

Medical SurgeryPsychologyEducationExerciseNursingSupport GroupsNutritionPerch il Bandaggio Gastrico25 Obesity Surgery Center Policlinico MonzaDr P. PizziBariatric and Metabolic Unit DesenzanoDr F. Bellini200220123236

Heliogast SystemPerch il Bandaggio Gastrico26

Perch il Bandaggio Gastrico27Perch il Bandaggio GastricoPerch il Bandaggio GastricoNumberRate of ComplicationsSurgical approachNumberRate of Reoperation Slippage(only anterior) 1374,23% Removal Repositioning55821.69%2.53%Erosion140.43% Removal140.43%Psychological Intolerance190.58% Removal160.49%Incisional hernia 270.83% Repair250.77%Port change/repositioningCatheter leak repair411,26 Repair411.26Total2357.26%Total2337,20%Unsatisfactory ResultsLack of Compliance