1. Lap Band in patients with BMI</= 35 kg/m2: is it a good indication? A.Sérgio Instituto Cuf - Porto

2. Obesity

3. NIH Guidelines BMI >40 Kg/m2 BMI >35 Kg/m2 and comorbidities Gastrointestinal Surgery for Severe Obesity NAtional Institutes of HealthConsensus Development Conference Statement March 25-27 1991

4. Obesity Obesity  Is a serious,commom, chronic and relapsing disease  Medical treatment as changing eating behaviour, lifestyle, drugs or any other fail to keep the weight lost in long time  Surgery is the best therapy we have for morbid obese patients and gastric banding has already prove it’s efficacy.  What to do when we have a moderate obese patient (>30 30<35 BMI?)

5. 25% of Western World has more than 30 of BMI

6. Several authors showed already the utility of gastric banding in patients with low BMI Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index Jenny ChoiM.D, Marc Bessler (SOARD 6 (2010) 367-372 Italian group for Lap-Band system: resultsof multicenter study on patients with BMI< 35kg/m2 Angrisani L, Favretti F, Furbetta F. et al. Obes. Surg. 2004;14:415-18 Laparoscopic adjustable gastric banding for patients with body mass index of </= 35 kg/m2 SOARD vol. 2, 5, 518-522 Three-year Follow-up of Laparoscopic Adjustable gastric banding for patients with a BMI < 35 kg/m2. George A. Fielding, SOARD vol.2, 3, 293 2011/02/16 approval expanded by FDA to include obese individuals with a BMIof 30 to 34 with existing condition related to their obesity

7. Aim of the study : To evaluate the effects of Lap Band in patients with BMI between 30-35 Kg/m 2, evaluating it’s efficacy and efficiency

8. Methods  Between 03 January 2005 and 31 December 2010  92 consecutive patients were submited to Adjustable Gastric Banding with Lap-band  Inclusion criteria  BMI < 35 kg/m2  BMI > 30 kg/m2

9. Methods  Exclusion criteria:  Age under 13 years  History of alcool or drug abuse  Mental disease not controled as schizophrenia or maniac disorders  Inability to understand necessary follow-up and operative procedures  Assessment by a multidisciplinary team – Surgeon, dietitian/nutritionist, psychologist.

10. Follow-up  At the first year patients were seen every months, thereafter as it was judge necessary (at least 3 times/year).  Inflation of the band four weeks postoperatively with a saline solution  More adjustments were made every two weeks till we reach sensation of satiety or loose weight between 2 – 3 kgs/month  Deflation was made for disphagia, food intolerance, nightly regurgitation

11. Follow-up  Recomendations to Physical Activity are done to every patient for our Consultant for Physical Activity.

12. Follow-up – 95,7% (88 patients)

13. Mean age ----------------- 39,5 years min. -------------------- 19 years max. ------------------- 66 years females – 90.2% males -9.8%

14. Middle weight ---------- 91,5 Kg mínimal 70 Kg máximal 126 Kg Body Mass Index (BMI) --------33,4Kg/m2 minimal 30 Kg/m2 maximal 35 Kg/m2

15. Follow-up  3 meses----- 92/92  6 meses---- 92/92  9 meses----- 88/92  12meses-----88/92  24meses-----64/66  36meses-----48/48  48meses---- 35/35  60meses---- 25/25 95,7% 95,7%

16. COMORBIDITIES 38 comorbidities in 25 patients – (41.3%) Osteoartrophaty (joint pain) ----------------- 10.5% HTA ---------------------------------------------- 21.1% Diabetes mellitus tipe II ---------------------- 15.8% Roncopaty -------------------------------------- 15.8% Sleep apnea ------------------------------------ 5.3% Hiatal hernia and GERD --------------------- 23.7% Colelitiase -------------------------------------- 8% Hepatite B -------------------------------------- 2.6% Asthma ----------------------------------------- 5.3% Inferior venous thrombosis ------------------ 8%

17. Surgery Pars flacida Technique Same surgeon Follow-up same team

18. Associated Surgeries  Colecistectomy  Three patients with colelitiasis  Hiatal dissection and crurapexia  Nine patients with hiatal hernia and/or reflux disease

19. Complications(88pts) Kind Nº pts % Sur. min Surg. major Regurgitation635.3% Tubing/port related 529.4%5.7% Band Intolerance 211.8%2.3% Colelitiasis15.9%1,15% Pouch Dilatation 211.8%2,3% Intragastric migration 15.9%1.15% Total (19.3%) 17100%5.7%6,9%

20. Explanted Bands  Three bands were removed Two for intoleranceTwo for intolerance Conversion into gastric bypass – 1 patiensConversion into gastric bypass – 1 patiens One for intragastric migrationOne for intragastric migration By endoscopyBy endoscopy

21. Rebanding  Two patients were rebanding for pouch dilatation

22. Weight evolution  3 months----- 81.7 kgs (58.5 – 112)  6 months----- 77 kgs (53 – 109)  9 months----- 75.1 kgs (53 – 105)  12months-----73.9 kgs (53 – 109)  24months-----71.9 kgs (54.5 – 104)  36months-----73.8 kgs (54.5 – 104)  48months---- 74.5 kgs (54.5 – 104)  60months---- 75.4 kgs (57.5 – 109)

23. BMI evolution  3 months----- 30 kgs/m2 (24.3 – 34.6)  6 months----- 28.3 kgs/m2 (22 – 33.7)  9 months----- 27.5 kgs/m2(20.9 – 33.7)  12months-----26.9 kgs/m2(20.3 – 33.7)  24months-----26 kgs/m2 (19.5 – 30.8)  36months-----26.4 kgs/m2 (20 – 32)  48months---- 26.2 kgs/m2 (20.8 – 30.8)  60months---- 26.2 kgs/m2 (20.8 – 31.4)

24. %EWL evolution  3 months----- 32.1 (0 – 81)  6 months----- 48.5 (6 – 114)  9 months----- 56.7 (6 – 119)  12months-----61.6 (6 – 119)  24months-----67.8 (23-118)  36months-----65.7 (13 – 122)  48months---- 67.8 (24 – 110)  60months---- 68.6 (24 – 110)

25. Evolution Weight, BMI e %EWL

26. Evolution weight, BMI,%EWL and %EBMIL

27. Comorbidities evolution Comorbidities Nº Patients Without Disease ImprovedUnchanged Colelitiasis3 3 (100%) Hepatitis B 11(100%) Hiatal hernia/GERD9 9 (100%) Diabetes6 4 (66.7%) 2 (33.3%) Arterial Hypertension 8 5 (62.5%) 3 (37.5%) Sleep apnea 2 1 (50%) Asthma2 osteoartrophaty4 2 (50%) Venous insuficiency 3 1 (33.4%) 2 (66.6%)

28. Summary  LAGB is a safe and efective procedure in moderately obese patients with a BMI between 30 and 35, with great benefits for this patients and with an acceptable rate of complications, and should be considered in this group of patients