1. Perché ancora il Bendaggio Gastrico?

2. Why 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."

3. Safe : the lowest % of mortality Effective : - 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 obesity

4. 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 obese No other Bariatric Surgical Approach has these peculiarities

5. Relatively poor design of bands/ports ( rigid, tiny, no cincunferential pressure...... ) Was the report from pioneer bariatric surgeons! Too many complications??

6. marlex mesh, dacron vascular prosthesis, silicone covered mesh, Gore- Tex, silicon drains……. The materials has changed…

9. Which technique, for the best results? Pars Flaccida Perigastric Stitched Band Flopping Band Approach Band setting Two steps The fusion of the two technique

10. Technical guidelines 1. Minimal dissection of the gastrophrenic ligament 2. The two-steps technique 3. The band fixation 4. Gastro-gastric Rossetti-like stitch 5. The new life stile. The scrupulous follow up

11. 1. Minimal Dissection of the gastro-frenic ligament

12. OLD TECHNIQUE one step NEW TECHNIQUE two steps The peri and retrogastric tunnel was performed in a single step 2. The two steps perigastric technique 1° step: retrogastric tunnel 2° step: perigastric tunnel Perigastric approach Perigastric approach with high risk of cauterization and gastric wall injury

13. SICOB 2013, Cagliari 2. The two steps technique First step Second step The same of the pars flaccida Peculiar No risk of damaging the gastric wall. No complications.

14. 2. The two steps technique Why are we still performing the perigastric technique?

15. Perigastric Pars Flaccida 5-10% acute postoperative stenosis in Pars Flaccida Technique!! 5-10% acute postoperative stenosis in Pars Flaccida Technique!! 2. The two steps technique

16. PerigastricPars Flaccida 2. The two steps technique - Correct band use - Homogeneous calibration - NO h omogeneous calibration - Early risk of acute obstruction

17. The two step is less familiar and not well-known, but can cover all different anatomical situation!! 2. The two steps technique The perigastric technique is considered abandoned by many, but most surgeons have not even tried this approach in theirs gastric Band experience!

18. No openings for Posterior Slippage!!! No possibilities for Posterior Slippage!!! 2. The two steps perigastric technique

19. 3. Band Fixation Two stitches from the gastric fundus to the cardial region Very near to the band Gastro-gastric stitch No stitches on the left crus!!!

20. SICOB 2013, Cagliari With the stitches we reduce the slippage although the patient behaviour Band fixation > Band stability Vomiting : the initial and the main cause of the BAND slippage!! 3. Band Fixation

21. SICOB 2013, Cagliari A. Bécaud, 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% 3. Band Fixation 2008 a new study A. Bécaud, J.M. Zimmermann

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

23. SICOB 2013, Cagliari are critical for successful weight reduction following LAGB. 5. The new life stile and scrupulous follow up Motivation long-term commitment, and

24. SICOB 2013, Cagliari 5. The new life stile and scrupulous follow up We must be partners with our patients! Best Patient Care: Better Outcomes Better Outcomes = Lower Exposure to complications Teaching the new eating behaviour Small bite Good food Chew well Swallow Wait a minute

25. Medical Surgery Psychology Education Exercise Nursing Support Groups Nutrition

26. Obesity Surgery Center Policlinico Monza Dr P. Pizzi Bariatric and Metabolic Unit Desenzano Dr F. Bellini 2002 2012 3236 Heliogast System®

30. NumberRate of Complications Surgical approach NumberRate of Reoperation Slippage ( only anterior ) 137 4,23% Removal Repositioning 55 82 1.69% 2.53% Erosion 14 0.43% Removal14 0.43% Psychological Intolerance 19 0.58% Removal16 0.49% Incisional hernia27 0.83% Repair25 0.77% Port change/repositioning Catheter leak repair 41 1,26 Repair41 1.26 Total 235 7.26% Total233 7,20% Unsatisfactory Results Lack of Compliance <25%EWL 201 6,6% Removal RYGBP: BPD 1 74 11 2.65% Major and Minor Complications Requiring SURGERY 3236 Patients: 10 Years Results

31. The two-step technique is not the perigastric technique as commonly thought!!! Conclusion

32. 1.The minimal dissection of the gastro-frenic ligament avoids slippage of the gastric fundus 2.The two-step technique is: technically simple avoids intimate posterior gastric wall dissection facilitates tight posterior band support dramatically reduces posterior slippage 3.The band fixation avoids early slippage and reduction of slippage percentage although the patient behaviour 4.The Rossetti-like stitch avoids stomach slippage trough the band 5.The new Port with 360° accessibility, avoids problems with rotation/malposition Conclusion

33. Learn from experience of others! Need not repeat mistakes…...