Laparoscopic Adjustable Silicone Gastric Banding Versus Vertical Banded Gastroplasty in Morbidly Obese Patients

To the Editor:

We read with interest the article by Morino et al.¹ We congratulate the authors on their nicely performed first randomized trial to compare different laparoscopic bariatric procedures. The study demonstrates that the laparoscopic restrictive procedure, either laparoscopic vertical banded gastroplasty (LVBG) or laparoscopic adjustable silicone gastric banding (LASGB) are safe, minimally invasive procedures. However, we have reservations about their conclusion that LVBG is more effective than LASGB in terms of late complications, reoperations, and weight loss. We want to provide 2 comments, which might result in this quire conclusion.

The author had a 0% late reoperation rate in LVBG which is very unusual. We started to perform LVBG since 1998 and had accumulated experiences over 600 cases. We had similar results with the authors that LVBG is a safe and effective mini-invasive bariatric operation with only 1% major complication rate reported previously.^2–4 Our procedure had been observed by Mason and regarded as a easy but standard procedure.⁵The excessive weight loss following surgery in our patients is 53.1% at 2 years following surgery, which is similar to the author's results and other studies from European patients.^1,6,7 However, LVBG has a major disadvantage of causing gastrointestinal symptoms, because patients are unable to eat regular food and the incidence of vomiting is very high. In our previous study, we found that the gastrointestinal quality of life improved significantly at 6 months after LVBG but returned to preoperative values at 1 year after surgery, despite an 81% patient satisfaction rate.⁸ In addition, some patients may regain body weight gradually after 2 years. Therefore, a reoperation surgery is unavoidable in patients with VBG either due to intolerance or inadequate weight loss.⁹ We had a 7.7% accumulated reoperation rate at 5 years after LVBG. Half of the revision surgeries were changing to gastric bypass and the other half were gastro-gastric bypass with regain of body weight, all by laparoscopic surgery. The 0% late reoperation rate in the authors’ series is unusual. The reasons might be that the follow-up period is not long enough or the surgeons tend to neglect the requirement from the patients.

On the other hand, the authors had a 24.5% reoperation rate in LASGB group and 20% of the bands were removed. This result is also unusual for an experience hand on LASGB. Following its introduction, the technique of LASGB underwent several modifications.^9,10 After the development of techniques of pars flaccida approach for band placement above the bursa omentalis and gastrogastric suturing knots, the reoperation rates of band are reported to decrease to less than 5%. Specifically, O'Brien et al from Australia reported a decreasing reoperation rate for band slippage from 12.5% to only 1% after a learning curve of 350 cases.¹¹ We started to perform the LASGB since 2001 after learning the technique from O'Brien. We had accumulated 81 cases of LASGB until now with a 0% major complication rate, 0% band slippage and only 2 (1.5%) reoperations are required until now. One patient received port refixation for dislocation of the port and the other required band removal because of intolerance. Therefore, the 18% of band slippage and 20% band removal rate in the authors’ study implicated that their techniques are not complete, correct, or are still in the learning curve.

Because the technique performance is not equal in the authors’ study, they would have a conclusion that LVBG was significantly superior to LASGB in terms of weight loss under the intension-to-treat principle. This result can not reflect the disparity of LVBG and LASGB but only the maturity of separate technique of the authors. In addition, the comparison of weight reduction between LVBG and LASGB should not be concluded earlier than 3 years following surgery because the different nature of the devices and disparity of the rate of weight loss. The rate of weight loss after LVBG is usually rapid in the first 6 months and then slows down until a plateau is reached 1 to 2 years after surgery. Patients with LVBG are expected to regain some weight after 2 to 5 years after surgery.⁸ On the contrary, the rate of weight reduction after gastric banding is slow and steady. The expected excess weight loss for banding is 30% to 40% at 1 year after surgery. The plateau can be reached 3 years after surgery with a 50% to 60% excess weight loss comparable to the best of LVBG and further weight loss can be expected even after 5 years.^9–12 Our experience with the LSAGB has been more similar to the above experience. Therefore, in contrast to the authors’ experience, we have suspend the routine clinical application of the LVBG, and use LSAGB in selected patients in which the advantages of a less complex and totally reversible procedure are the principle requirements determining the surgical technique.

In conclusion, randomized trials to compare different laparoscopic bariatric surgeries are essential for the continuing progress of bariatric surgery. However, because of the technique difficulties and prolonged learning curve of laparoscopic bariatric surgery, a good quality control of surgical procedures are mandatory before a conclusion is made.

Wei-Jei Lee MD, PhD
Weu Wang, MD
Ming-Te Huang, MD
En-Chu Kong Hospital,
Taipei Hsien, Taiwan
wjlee@eck.km.org.tw