title: Standardized Technique of Laparoscopic Adjustable Gastric Banded Plication with 4-Year Results.
abstract: BACKGROUND
  No bariatric procedure is perfect, and a plethora of such procedures itself is a proof for the same. Laparoscopic adjustable gastric banding has a high safety profile, but also a high rate of re-operation has been reported (Schouten, Wiryasaputra, van Dielen et al. Obes Surg 20(12):1617-26, 2010). Laparoscopic sleeve gastrectomy (LSG) is becoming popular, but has its own set of complications and is irreversible. We introduced laparoscopic adjustable gastric banded plication (LAGBP) in 2009 (Huang, Lo, Shabbir et al. Surg Obes Relat Dis 8(1):41-5, 2012) In a case matched comparative study with LSG, LAGBP showed similar results at 2 years in terms of weight loss, comorbidity resolution, and complications. (Huang, Chhabra, Goel et al. Obes Surg 23(8):1319-23, 2013). Several authors have reported variations in their technique, bougie size, and suture material used to perform plication. (Ramos, Galvao Neto, Galvao et al. Obes Surg 20(7):913-8, 2010, (Mui, Lee, Lam et al. Obes Surg 23(2): 179-83, 2013, Brethauer, Harris, Kroh et al. Surg Obes Relat Dis 7(1):15-22, 2011) Our initial technique of placing the band first and then plicating the stomach resulted in higher incidence of gastric fundus herniation compared to that reported in a systematic review (Abdelbaki, Huang, Ramos et al. Obes Surg 22(10):1633-9, 2012). After the first 65 cases, we reversed the order by performing the gastric plication first which ensures proper plication of the fundus and a more uniformly placed plication line. This technique has become our standard, and the same is described in this video in a stepwise fashion.
  
  
  METHODS
  We performed LAGBP in 202 cases over the last 4 years and recorded the findings. Our standardized technique is shown in this video. The T-suspension technique was used for liver retraction. (Zachariah, Tai, Chang et al. J Laparoendosc Adv Surg Tech A 23(4):311-5, 2013) Gastric plication formula is shown in Fig. 1. Fig. 1 Gastric plication formula
  
  
  RESULTS
  Two hundred two (69 male, 133 female) patients in over the last 4 years underwent LAGBP. Follow-up at 1 year was 168 patients, and 56 patients reached 4-year follow-up. Age was 16-60 years (mean = 31.1). Mean BMI was 39.5 ± 3.18 and body weight 110 kg ± 19.4. Mean operative time was 104 min ± 39 and length of hospital stay after surgery 2.1 ± 2.3 days. No mortality was recorded. Excess weight loss at 1 year was 57.84 % and at four years 68 %.
  
  
  CONCLUSIONS
  LAGBP has been proven to be an effective bariatric procedure in the midterm results. Standardization with plication first and then placement of the band could be important to achieve best outcomes.
authors.affiliation: Bariatric and Metabolic International (BMI) Surgery Center, E-Da hospital, 1, E-Da Road, Kaohsiung City, 82445, Taiwan.
authors.forename: Jasmeet Singh
authors.initials: JS
authors.lastname: Ahluwalia
authors.forename: Hsin-Chih
authors.initials: HC
authors.lastname: Kuo
authors.forename: Po-Chih
authors.initials: PC
authors.lastname: Chang
authors.forename: Po-Lin
authors.initials: PL
authors.lastname: Sun
authors.forename: Kuo-Chuan
authors.initials: KC
authors.lastname: Hung
authors.forename: Chih-Kun
authors.initials: CK
authors.lastname: Huang
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D015391:Gastroplasty / Q000379:methods / Q000592:standards*; D006801:Humans; D010535:Laparoscopy / Q000592:standards; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D016896:Treatment Outcome; D015431:Weight Loss; D055815:Young Adult