Poor weight loss despite biliopancreatic diversion and subsequent revision to a 30-cm common channel after initial laparoscopic adjustable gastric banding: an analysis of 8 cases.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) fails in 5% of patients due to band-related complications or patient intolerance. A subset of patients subsequently managed with biliopancreatic diversion (BPD) have failed to achieve a percentage of excess weight loss (%EWL) > 50% or a body mass index (BMI) < 35 kg/m(2) even after a further procedure shortening the common channel to 30 cm.

METHOD: A computerized obesity database was used to identify the study group and collect preoperative and outcome data. Patient outcomes were analyzed in 2 groups: LAGB removed either because of a failure to lose weight (FTLW) or because of a band-related complication (eg, recurrent gastric prolapse, gastric erosion, intractable dysphagia).

RESULTS: A total of 2300 patients underwent LAGB between 1996 and 2003. LAGB failed in 95 (4%) of these patients, 79 of whom had subsequent BPD. Of these 79 patients, 8 (10%) failed to lose further weight and had their common channel shortened to 30 cm. Six patients were identified who, despite this revision surgery, still had a BMI > 35 kg/m(2) or %EWL < 50 and are considered failures. Two further patients failed to lose any weight after revision for what they saw as an unsatisfactory outcome. There was minimal evidence of malabsorption in these 8 patients, and 4 had slow intestinal transit down the alimentary limb of the BPD.

CONCLUSION: The reasons for the failure of malabsorption and restrictive surgery in these patients appear to be physiological, not psychological. Uncontrolled hunger, particularly in the patients with FTLW, and an abnormally slow metabolism are likely to be important.