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Clinical Question: What is most effective dissection
pathway pars flaccida (PF) or traditional perigastric (PG) pathway for the
treatment of obesity?
Bottom Line: The PF pathway is as effective as the PG pathway in
generating substantial weight loss, improved health and improved quality of
life and is significantly less likely to be associated with prolapse
(slippage). It is recommended as the primary dissection pathway.
Reference: A prospective randomized trial of placement of
the laparoscopic adjustable gastric band: comparison of the perigastric and
pars flaccida pathways. O'Brien PE, Dixon JB, Laurie C, Anderson M. Obes
Surg. 2005 Jun-Jul;15(6):820-6.
Study Design: Randomized Controlled trial
Synopsis: Laparoscopic adjustable gastric banding (LAGB) is
a safe and effective method for the treatment of obesity. The most common
problem after LAGB has been the occurrence of prolapse (slippage) of the
stomach through the band. It has been proposed that the pars flaccida (PF)
pathway (dissection from the base of the right crus, along the left crus to
the angle of His) is less likely to be associated with prolapse than the
traditional perigastric (PG) pathway (dissection between the lesser
curvature of stomach and lesser omentum, across the apex of the lesser sac,
to the angle of His). We have tested this hypothesis using a randomized
controlled trial format. They performed a randomized controlled trial to
compare the outcomes after LAGB using PF and PG pathways. 202 patients (mean
age 40 years, mean weight 123 kg, mean BMI 45) were randomly allocated to
the PF or PG pathway and followed for 2 years. At 24 months, there have been
16 revisional procedures for prolapse, 4 in the PF group (all anterior
prolapse) and 15 in the PG group (12 posterior and 3 anterior). This
difference is significant (P<0.001). The mean % excess weight lost was 53%
for the PF group and 46% for the PG group. There was equally significant
improvements in the metabolic syndrome in both groups (59% preoperatively
and 19% at 2 years). All 8 paired domain scores of the SF-36 measures of
quality of life were improved significantly in both group (P<0.001).
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