Systematic Review of Erosion after Laparoscopic Adjustable Gastric Banding

Late-Onset Gastric Band Erosion Following Heavy Nonsteroidal Anti-inflammatory Drug Use

Laparoscopic adjustable gastric band (LAGB) surgery is now an uncommon bariatric procedure; however, complications may still be encountered. A 64-year-old man with a history of LAGB placement 13 years prior presented with 2 months of epigastric pain. He endorsed chronic heavy nonsteroidal anti-inflammatory drug use. Computed tomography showed inflammation around the LAGB tubing with near-complete, circumferential erosion of the LAGB into the fundus. Upper endoscopy confirmed erosion of the LAGB along with port tubing into the gastroesophageal junction and fundus. The patient was referred to a foregut surgeon who performed robotic band removal.

Retrieval of Gastric Band Eroding Into the Stomach: A Gastrointestinal Fistula Case Managed Through a Combined Laparoscopic and Colonoscopic Approach

Obesity is an important public health concern worldwide. In Saudi Arabia, the overall prevalence of obesity has increased in both men and women in recent decades. The laparoscopic approach to bariatric surgery was first reported in the 1990s, with laparoscopic adjustable gastric banding (LAGB) developed soon after. The performance of bariatric procedures has increased rapidly in recent years, with safety and efficacy data available for the surgical treatment of obesity and related metabolic disorders. Herein, we report a challenging condition of a female patient who underwent LAGB insertion in 2013. The patient presented with a complaint of a foreign body passing through her rectum during defecation that was manually pushed back by the patient. Radiological imaging and upper/lower endoscopy confirmed the diagnosis of complete gastric band erosion into the stomach, and the reservoir with the remaining tube was observed inside the colon near the splenic flexure. This case was complicated by complete band erosion and gastrointestinal (GI) fistula formation following the delivery of her second child in January 2022. Colonic band erosion is a rare complication of LAGB. Most patients with gastric band erosion are asymptomatic or exhibit nonspecific symptoms. The definitive management of gastric band erosion involves band removal. Several approaches are commonly used in clinical practice. In our case, the band was removed using a combined laparoscopic and endoscopic retrieval approach, which is the first such report in the literature.

Bariatric Surgery Emergencies in Acute Care Surgery

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Endoscopic Gastric Band Removal

BACKGROUND

Laparoscopic adjustable gastric band (LAGB) procedures have declined worldwide in recent years. A known complication is the intraluminal erosion of the prosthetic material. The endoscopic management of gastric band erosion represents the recommended approach nowadays, and it avoids any additional trauma to the gastric wall already damaged by the migration. The purpose of our study was to assess the feasibility of endoscopic management for intraluminal gastric band erosion following LAGB.

METHODS

From January 2009-December 2020, a total of 29 patients were retrospectively reviewed after undergoing endoscopic gastric band removal. The study included all consecutive patients who underwent endoscopic gastric band removal in this period. No patients were excluded from the study. Data on patient demographic characteristics, case history, operative details (procedural time, adverse events), and complications were reviewed retrospectively.

RESULTS

Twenty-nine patients underwent endoscopic gastric band removal: 22 women (75.8%) with a mean age of 45 years (range: 28-63) and mean Body Mass Index (BMI) of 31 ± 4.7 kg/m² (range: 24-41). The average time to the identification of erosion after LAGB was 42 months (range: 28-137). The initial upper endoscopy found a migrated band of more than half of the diameter in 21 cases, less than a half but more than a third in seven cases and in one case, less than a third (use of a stent). Twenty-seven patients were successfully treated with endoscopic removal, and in two cases, the endoscopic approach failed, and laparoscopy was further performed.

CONCLUSIONS

The endoscopic management of intraluminal erosion after LAGB can be safe and effective and should be considered the procedure of choice when treating this complication. The percentage of the band migration is important for the timing of the endoscopic removal.

Protective effect of intraluminal fecal diverting device against colonic wall erosion induced by wrapping bands: A post-hoc pathological analysis

Objectives

Materials wrapping the bowel elicits tissue erosion gradually. We experienced several bowel wall erosions with no serious clinical consequences in our two previous animal experiments aimed at the safety and efficacy of the COLO-BT developed for intra-luminal fecal diversion. We tried to find out why the erosion is safe by investigating histologic changes of the tissue.

Material and Methods

Tissue slides at the COLO-BT fixing area from the subjects which had COLO-BT over three weeks acquired from our two previous animal experiments were reviewed. For the classification of the histologic change, microscopic findings were classified for six stages (from minimal change of stage 1 to severe change of stage 6).

Results

A total of 26 slides of 45 subjects were reviewed in this study. Five subjects (19.2%) had stage 6 histological change; three of stage 1 (11.5%), four of stage 2 (15.4%), six of stage 3 (23.1%), three of stage 4 (11.5%), and five of stage 5 (19.2%). All subjects which had a stage 6 histologic change survived. The phenomenon from which the back of the band is passed through is replaced by a relatively stable tissue layer due to fibrosis of the necrotic cells in the stage 6 histologic change.

Conclusion

We found that thanks to the sealing effect of the newly replaced layer, no leakage of the intestinal content occurs even if perforation by erosion develops according to this histologic tissue evaluation.

Revision Laparoscopic Adjustable Gastric Band as a Successful Alternative Over Sleeve Gastrectomy After Failed Initial Weight Loss Therapies

Bariatric surgery is one of the most successful treatment options for morbid obesity and related comorbidities that is reserved for patients when lifestyle modifications and medical treatments fail. Bariatric surgeries are proven to result in weight reduction and improve obesity-related complications; however, there still are some reported failures. We report the case of a 35-year-old woman with morbid obesity and diabetes mellitus who had failed laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG) when done individually. The patient finally had a successful weight loss after undergoing revision LAGB over LSG. Although the present literature reports LAGB being an unsuccessful weight loss procedure, this case highlights the significance of LAGB as an effective bariatric surgery compared to other procedures. Our patient not only lost her weight successfully but also resolved her comorbid conditions and mental illness following the LAGB.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding

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Although most complications following LAGB are confined to the stomach and port site, some may envolve the entire bowel causing extensive damage.

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One must be wary of the presentation of long term complications, as it may initially present as an unrelated pathology, such as acute pancreatitis.

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Long term complications may be asymptomatic for years despite extensice damage, including multiple contained perforations.

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The surgical procedure performed to treat long term complications should be planned and performed by physicians experienced in foregut surgery.

Introduction

Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported.

Presentation of case

A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum.

Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21.

Discussion

Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature.

Conclusion

Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Is there an indication left for gastric band? A single center experience on 178 patients with a follow-up of 10 years

Background

Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL < 25%) and rate of band removal.

Methods

Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss.

Results

After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL < 25), 32 (18%) had an insufficient weight loss (25 < %EWL < 50) and 34 (19.1%) underwent band removal. Among these, 6 (3.4%) were removed for complications and 28 (15.7%) for insufficient weight loss. Weight regain occurred in 38 out of 144 (26.4%) subjects with the band in place at 10 years. Only one case of early vomiting with readmission for medical treatment was recorded. Slippage, erosion/migration and port/tube complications occurred in 4 (2.2%), 2(1.1%) and 9(5%) cases respectively.

Conclusion

LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

Eroded Gastric Band: Where to Next? An Analysis of the Largest Contemporary Series

PURPOSE

Erosion of a laparoscopic adjustable gastric band (LAGB) is a devastating problem. There is no clear evidence in literature to guide the choice of revisional procedure following an eroded LAGB. The purpose of this study is to analyse the largest series of erosions following LAGB published to-date with an aim to share our experience with this rare complication and how we managed this cohort of patients following explantation of their LAGB.

MATERIALS AND METHODS

This is a retrospective cohort study. Patient data is maintained prospectively in a surgical database. The study period was from January 1996 to January 2019. The outcomes of patients who underwent an erosion of LAGB were studied.

RESULTS

Gastric band erosion was encountered in 4.7% of patients. Sixty patients opted for a revisional procedure which included 37 repeat LAGBs, 6 laparoscopic sleeve gastrectomies (LSG), 7 Roux-en-Y gastric bypasses (RYGB), 1 intragastric balloon, and 9 failed revisional procedures. Re-erosions were noted in 27% of patients who underwent a repeat gastric banding. Median %TWL at a 1-year follow-up was significantly higher in LSG and RYGB groups compared with that in LAGB (P < 0.008 and P < 0.000, respectively). There was no significant difference between the LSG and RYGB groups.

CONCLUSION

The risk of re-erosion is increased in patients who undergo repeat AGB following a previous episode of erosion. Repeat LAGB should not be offered after a previous erosion. LSG and RYGB should be considered as appropriate revisional procedures in a patient who experience weight regain following explantation of an eroded LAGB.

A case report of an adjustable gastric band erosion and migration into the jejunum resulting in biliary obstruction

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LAGB can rarely erode into the stomach and migrate into the small bowel.

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Migration of the LAGB can result in bowel and biliary obstruction.

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Band erosion should be managed by removal of the LAGB.

Introduction

Laparoscopic adjustable gastric band is a bariatric operation which has lost popularity due to its high rate of reoperation and complications such as band erosion. Erosion may be partial or complete with intragastric migration of the band. Once in the stomach lumen, the band has the potential to migrate into the small bowel.

Presentation of case

A 43-year-old male with history of morbid obesity and laparoscopic adjustable gastric band placement presented with abdominal pain secondary to biliary obstruction. Endoscopic retrograde cholangiopancreatography revealed eroded gastric band tubing into the lumen of the stomach and duodenum with resultant distortion of the ampulla. Upon surgical exploration, the band was found to have migrated into the jejunum and was removed through an enterotomy. The patient did well and was discharged home on postoperative day 8.

Discussion

Once completely eroded into the gastric lumen, a gastric band can migrate into the small bowel with the distance traveled being limited by the length of the connecting tube. The stretched tubing can result in distortion of the ampulla leading to biliary obstruction. Band erosion should be managed with band removal which can be completed using endoscopic, laparoscopic, or open approach.

Conclusion

Band migration should be suspected in patients with a history of gastric band placement presenting with bowel or biliary obstruction. Its management depends on the location of the band as well as the expertise of the surgical team.

Technical Details and Result of a Minimally Invasive Management of Gastric Band Erosions: a Series of 47 Patients

INTRODUCTION

Laparoscopic adjustable gastric banding (LAGB) is proven to be a safe and effective treatment option for obesity in the long term. However, in recent decades, LAGB prevalence progressively decreased worldwide principally due to the incidence and the management of the complications. Understanding the optimal management of the complications becomes therefore of primary importance. The aim of this study is to describe a personal technical, laparoscopic solution of band erosion and to analyze outcomes in 47 patients.

METHODS

From October 1995 to January 2019, 3697 LAGB were performed at our institution. Since November 2011, an original laparoscopic gastric banding removal technique was introduced. All the bands placed in these patients were Lap-Band AP System (Allergan, Irvin, CA). The data of the patients who underwent gastric band removal because of band erosion were retrieved from a prospectively collected institutional database, and used for the present retrospective evaluation.

RESULT

Ninety-four patients (2.5% of the entire casuistic) with eroded band were diagnosed and treated at our institution. Forty-seven patients were treated with the laparoscopic gastric banding removal technique introduced in November 2011. All the operations have been performed laparoscopically with no conversion or intraoperative complications. There were neither major complications nor peri-operative (30 days) mortality.

CONCLUSION

Proper preoperative management and a standardized minimally invasive technique could help to cope with erosion, the most frightening complication of LAGB. Understanding the optimal management of complications and safe reoperation techniques can contribute to a rational use of the LAGB, reversing the current declining tendency.

Simultaneous gastric and colonic erosions from gastric band and its tubing in the setting of recurrent intra-abdominal infection

Chronic abdominal pain is often a diagnostic dilemma. We present a 59-year-old female with chronic generalized colicky abdominal and altered bowel habits. She was investigated with colonoscopy and CT abdomen. Patient has a history of recurrent diverticulitis and insertion laparoscopic adjustable gastric band. The colonoscopy revealed a tubular foreign body and diverticular disease. The tubular structure was confirmed to be gastric band tubing on CT abdomen, also showing simultaneous gastric and colonic erosions. She denies any gastric band port related infection or previous issues with gastric band. This case suggest that the cause of the erosion is due to recurrent episodes diverticulitis. She underwent wedge resection of large bowel and laparoscopic removal of gastric band. She had uneventful post-operative recovery.

A 13-year journey of a gastric band - ultimate destination terminal jejunum: a case report

BACKGROUND

Laparoscopic adjustable gastric banding has been the gold standard for surgical management of obesity over the last decades in USA and Europe. However, significant complications have been documented due to foreign body placement, including band erosions. Our treatment approach for erosions is rather observant with regular follow-up until the band has sufficiently perforated the gastric wall which facilitates endoscopic removal. Consequences of a not followed-up band erosion may present even after a long time following initial diagnosis with more severe complications.

CASE PRESENTATION

A 51-year-old Caucasian woman presented to our out-patients' clinic with a 2-week history of worsening abdominal pain in her left upper quadrant, exacerbated by abdominal flexion and extension maneuvers. Here we describe a case involving gastric penetration and subsequent downward migration of a band into distal jejunum causing small bowel obstruction, which occurred more than 10 years following initial diagnosis of erosion. The perforation was missed due to cessation of endoscopic follow-up.

CONCLUSION

Prospective and long-term follow-up is mandatory in those with partial band erosion to avoid further complications.

Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications

The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Migration of eroded laparoscopic adjustable gastric band causing small bowel obstruction and perforation

We present an unusual and rare complication caused by gastric band erosion into the stomach after band placement 15 years ago. The complication was only picked up after the band had subsequently migrated from the stomach at the site of erosion, to the distal ileum causing acute small bowel obstruction and focal perforation requiring emergency laparotomy.Abdominal pain in patients with gastric band should always be treated as serious until proven otherwise.

Gastric and colonic erosion caused by laparoscopic gastric band: a case report

Laparoscopic adjustable gastric banding is commonly used to treat obesity. It rarely results in complications, one of which is gastrointestinal erosion. Simultaneous erosion of the stomach and colon is a rare finding that has been documented in only a few case reports. We present a 62-year-old female with abdominal pain, nausea, and hematochezia. She was found to have simultaneous gastric and colonic erosion identified on CT scan. Imaging findings were confirmed and device was removed during surgery.

Endoscopic Approach for Major Complications of Bariatric Surgery

As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.

Laparoscopic transgastric removal of eroding gastric band: a different approach

Gastric banding is a popular method for the treatment of morbid obesity. Amongst complications, gastric erosion remains uncommon but could prove fatal. Multiple techniques, from open surgery to endoscopic and standard laparoscopic technique for their removal, have been previously detailed in the literature. However, only a few reports have mentioned their total laparoscopic transgastric removal in the literature. Herein, we report a successful removal of an eroding gastric band with its technical suggestion in a 43-year-old female patient 22 months following its application.

Laparoscopic Adjustable Gastric Banding: a Prospective Randomized Clinical Trial Comparing 5-Year Results of two Different Bands in 103 Patients

BACKGROUND

Various types of adjustable gastric bands are used during LAGB, but there is insufficient data comparing different bands in the long term. We carried out a prospective randomized study to compare two different bands.

METHODS

Between January 1, 2009 and January 31, 2010, 103 morbidly obese patients were randomized between SAGB and MiniMizer Extra adjustable gastric bands. The SAGB was used in 49 and MiniMizer Extra in 54 patients. Weight loss, comorbidities, long-term complications, and quality of life were evaluated after 5 years.

RESULTS

Patient baseline characteristics were similar in the two groups. The mean patient age was 45.9 ± 11.7 years, and mean preoperative BMI was 47.5 ± 7.3 kg/m². A total of 90 of 103 patients (87.3 %) completed the 5-year follow-up. The mean excess weight loss was 44.1 and 50.3 % in SAGB and MiniMizer groups, respectively (p = 0.14). A proportion of patients who reached a BMI < 35 kg/m² was significantly larger in MiniMizer Extra group (52.9 vs 25.5 %; p = 0.01). Complications developed in 15 patients (14.5 %) and consisted of 5 band erosions, 4 port-related complications, 3 band slippages, and 3 band intolerances. All five band erosions developed in MiniMizer Extra group, but the difference was not significant (p = 0.058). No difference was found regarding postoperative complications, resolution of comorbidities, and quality of life between compared groups.

CONCLUSIONS

SAGB and MiniMizer Extra bands demonstrated similar long-term results regarding the weight loss, resolution of comorbidities, morbidity, and quality of life.

[Conversional and endoscopic procedures following bariatric surgery]

The Roux-en-Y gastric bypass (RYGB) is the therapy of choice in bariatric surgery. Sleeve gastrectomy and gastric banding are showing higher rates of treatment failure, reducing obesity-associated morbidity and body weight insufficiently. Moreover, gastroesophageal reflux disease (GERD) can occur refractory to medication. Therefore, a laparoscopic conversion to RYGB can be reasonable as long as specific conditions are fulfilled.Endoscopic procedures are currently being applied to revise bariatric procedures. Therapy failure following RYGB occurs in up to 20 % of cases. Transoral outlet reduction is the minimally invasive method of choice to reduce gastrojejunal anastomosis of the alimentary limb. The diameter of a gastric sleeve can be unwantedly enlarged as well; that can be reduced by placement of a longitudinal full-thickness suture.Severe hypoglycemic episodes can be present in patients following RYGB. Hypoglycemic episodes have to be diagnosed first and can be treated conventionally. Alternatively, a laparoscopic approach according to Branco-Zorron can be used for non-responders. Hypoglycemic episodes can thus be prevented and body weight reduction can be assured.Conversional and endoscopic procedures can be used in patients with treatment failure following bariatric surgery. Note that non-invasive approaches should have been applied intensively before a revisional procedure is performed.

Management of laparoscopic adjustable gastric band erosion

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) was a popular procedure in the USA and Europe in the past decade. However, its use has currently declined. Band erosion (BE) is a rare complication after LAGB with a reported incidence rate of 1.46 %. Controversies exist regarding the management, approach and timing for the band removal. The aim of this study is to describe the rate, clinical presentation and perioperative outcomes of BEs at our institution and provide overall recommendations regarding the diagnosis and management of BE.

MATERIALS AND METHODS

This study is a single-center, retrospective review of a prospectively maintained database. Data were collected from all consecutive patients who underwent a LAGB and band revisional surgeries at the University of Illinois Hospital and Health Sciences System from December 2008 to September 2015. We identified patients who underwent gastric band removal due to a BE and analyzed their outcomes.

RESULTS

A total of 576 LAGBs were performed at our institution. Nine patients underwent surgery for BE at our hospital. The average time between the primary surgery and the removal of the band was 68.5 (42.9) months. Abdominal pain, nausea and/or vomiting were the most frequently mentioned symptoms. In all patients, a minimally invasive approach was used to remove the band. The mean length of hospitalization was 2.6 (1.1) days. The only complication was a pneumonia (n = 1).

CONCLUSIONS

BE is one of the most severe complications of LAGB. The minimally invasive approach provided us with the opportunity to repair the fistula, and it was associated with a prompt recovery with very little morbidity. In general, it is recommended that the band be removed at the time of the diagnosis of the BE. Endoscopic band removal can be utilized with patients who have a more advanced BE and migration into the gastric lumen.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

Background

Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.

Objective

The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.

Methods

Institutional experience and systematic review from the literature on revisional bariatric surgery.

Results

Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.

Conclusion

Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

Concurrent Large Para-oesophageal Hiatal Hernia Repair and Laparoscopic Adjustable Gastric Banding: Results from 5-year Follow Up

OBJECTIVE

The objective of the study is to identify the efficacy and safety of combining laparoscopic adjustable gastric banding with repair of large para-oesophageal hernias.

BACKGROUND

Para-oesophageal hernias are more common in the obese with higher recurrence rates following repair. The effect and safety of combining para-oesophageal hernia repair with laparoscopic adjustable gastric banding is unknown.

METHODS

One-hundred fourteen consecutive patients undergoing primary laparoscopic adjustable gastric banding with concurrent repair of a large para-oesophageal hernia were prospectively identified and matched to a control group undergoing primary laparoscopic adjustable gastric banding only. Weight loss and complication data were retrieved from a prospectively maintained database, and a standardised bariatric outcome questionnaire was used to assess post-operative symptoms, satisfaction with surgery and satiety scores.

RESULTS

At a mean follow up of 4.9 ± 2.1 years, total weight loss was 16.4 ± 9.9% in the hernia repair group and 17.6 ± 12.6% in the control group (p = 0.949), with 17 vs. 11% loss to follow up rates (p = 0.246). No statistically significant difference in revisional surgery rate and symptomatic recurrence of hiatal hernia was documented in four patients in the hernia repair group (3.5%). No statistically significant difference in mean reflux (9.9 vs. 10.3, p = 0.821), dysphagia (20.7 vs. 20.1, p = 0.630) or satiety scores was identified.

CONCLUSIONS

Concurrent repair of large para-oesophageal hiatal hernia and laparoscopic adjustable gastric banding placement is safe and effective both in terms of symptom control and weight loss over the intermediate term. In obese patients with large hiatal hernias, consideration should be given to combining repair of the hernia with a bariatric procedure.

[Gastric band erosion: Alternative management]

BACKGROUND

Obesity is a public health problem, for which the prevalence has increased worldwide at an alarming rate, affecting 1.7 billion people in the world.

OBJECTIVE

To describe the technique employed in incomplete penetration of gastric band where endoscopic management and/or primary closure is not feasible.

MATERIAL AND METHODS

Laparoscopic removal of gastric band was performed in five patients with incomplete penetrance using Foley catheterization in the perforation site that could lead to the development of a gastro-cutaneous fistula.

CLINICAL CASES

The cases presented include a leak that required surgical lavage with satisfactory outcome, and one patient developed stenosis 3 years after surgical management, which was resolved endoscopically. In all cases, the penetration site closed spontaneously.

DISCUSSION

Gastric band erosion has been reported in 3.4% of cases. The reason for inserting a catheter is to create a controlled gastro-cutaneous fistula, allowing spontaneous closure.

CONCLUSIONS

Various techniques have been described: the totally endoscopic, hybrid techniques (endoscopic/laparoscopic) and completely laparoscopic. A technique is described here that is useful and successful in cases where the above-described treatments are not viable.

Critical Care Management of Bariatric Surgery Complications

Obesity remains a major medical disease that often requires surgical intervention in morbidly obese patients. Surgical procedures have evolved and are performed routinely in most major medical centers. Outcomes are often dependent on patient characteristics, type of procedure, and preoperative planning. Risk stratification often depends on screening and optimizing known comorbidities often encountered in this patient population. A thorough understanding of the physiologic changes seen in obese patient and the commonly performed operations will allow the physician to perform optimal treatment strategies.

Informed decision-making for bariatric surgery: benefits, risks, uncertainties and choices

Decision-making is a critical aspect of good surgical care, and this principle is particularly important in bariatric surgery. Adequate communication of information to patients is essential in order to facilitate optimal uptake of bariatric surgery and choice of the most suitable procedure. This article reviews the most relevant advances in understanding of long-term efficacy associated with gastric banding, gastric bypass and sleeve gastrectomy.

Laparoscopic adjustable gastric band: how to reduce the early morbidity

BACKGROUND

Laparoscopic adjustable gastric band insertion is a safe weight reduction procedure, but serious complications can develop. The aim of this study was to evaluate our technique in preventing early band complications.

METHODS

Patients were given the choice of procedure according to body mass index, the presence of diabetes, and preference. Weight loss data were not considered, as our aim was to evaluate the morbidity of band surgery using a specific technique. A pars flaccida approach and plication technique were used for all patients. Postoperative follow-up was provided at 1 month, 2 months, and every 3 months for the first year and then yearly for a further 2 years. Thereafter, general practitioners referred patients if late complications arose.

RESULTS

From January 2007 to August 2011, 1149 patients (245 men [21.32%], 904 women [78.67%]) underwent laparoscopic adjustable gastric band insertion under the care of a single bariatric surgeon. Patients were hospitalized for 1 night only unless they developed early complications. The primary and secondary outcomes were major and minor band complications, respectively. Patients' age range was 18 to 64 years (mean, 44 years). Body mass index ranged from 33 to 62 kg/m2 (mean, 42 kg/m2). There were 2 band erosions (0.17%), 6 cases of band prolapse (0.52%), 4 port problems (0.34%), 1 band leak (0.08%), 3 tight bands (0.26%), 2 port infections (0.17%), and no deaths. Five procedures (0.43%) were abandoned and excluded from this study, and 1 (0.17%) was converted to minilaparotomy to control abdominal wall bleeding. The duration of follow-up ranged from 16 to 60 months.

CONCLUSIONS

A combined pars flaccida and plication technique is associated with a low early complication rate.

Laparoscopic repair of gastro-duodenal fistula secondary to band erosion

Laparoscopic gastric banding is one of the most common surgical treatments for morbid obesity performed worldwide. The procedure, however, has many well-documented risks and complications, including band erosion. We present here a gastric banding patient who was referred to our tertiary care centre after secondarily forming an entero-enteric fistula with complaints of pain, nausea, vomiting and severe reflux. She was successfully treated with laparoscopic dissection and due to her existing anatomy, and the patient's desire for continued weight loss, she was converted to Roux-en-Y gastric bypass.

The cooperation between endoscopists and surgeons in treating complications of bariatric surgery

The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.

Simultaneous Gastric and Duodenal Erosions due to Adjustable Gastric Banding for Morbid Obesity

Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy.

Endoscopic management of gastric band erosions: a 7-year series of 14 patients

BACKGROUND

Intragastric band migration is an unusual but major complication of gastric banding. We review our experience with endoscopic removal of eroded gastric bands.

METHODS

We retrospectively evaluated the cases of 110 morbidly obese patients who underwent adjustable gastric banding between 2005 and 2012 to identify those who experienced band erosion. To remove the migrated band, we used an endoscopic approach with a Gastric Band Cutter.

RESULTS

Band or tube erosion occurred in 14 patients (12.7%). The median time interval from the initial gastric band placement to the diagnosis of band erosion was 32 (range 18-52) months. Upper abdominal pain, port site infection, loss of restriction and weight regain were the most common symptoms. We used the Gastric Band Cutter to remove the band endoscopically. It was able to cut the band successfully in all but 1 patient, in whom twisting of the cutting wire required conversion from endoscopy to laparotomy. In 2 patients, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 1 patient, we performed surgery for intragastric penetration of the connecting tube broken close to the band.

CONCLUSION

The Gastric Band Cutter was successful in dividing the band in all but 1 patient, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be effective and safe for band erosion.

Minimally invasive endogastric removal of migrated gastric band after endoscopic failure: how I do it

Intragastric band migration is a rare and late complication of laparoscopic -adjustable gastric banding and should be recognized by all digestive surgeons. Endoscopic removal is most commonly performed, but surgery is an alternative in cases of endoscopic failure. Many different procedures have been reported. We show here (see Video) a fully laparoscopic endogastric procedure through two 5-mm antral gastrotomies. This technique can also be used to remove benign endogastric tumors. The procedure is safe and provides a large endogastric operative area, with no particular morbidity. Endogastric removal through a fully laparoscopic approach should be considered as the first alternative to endoscopic approach.

Connecting tube colonic erosion and gastrocolic fistula formation following late gastric band erosion

Band erosion is a rare complication of laparoscopic adjustable gastric banding (LAGB) with a reported prevalence varying from 0.3% to 14%. Intraluminal colonic erosion of the connecting tube is very rare, as only isolated cases have been described. Consequently, simultaneous gastric band erosion and connecting tube colonic erosion is an extremely rare event. Herein, we present a case of a woman with morbid obesity, who submitted to LABG 4 years ago. The patient presented with symptoms and signs of right lower quadrant peritonitis. Computed tomography (CT) demonstrated migration of the band into the gastric lumen, inflammation around the intra-abdominal course of the connecting tube and an inflammatory mass surrounding the tube at the right lower quadrant. Laparotomy revealed the eroded band, the eroded transverse colon from the connecting tube, a gastrocolic fistula along the course of the tube and a right lower quadrant phlegmon. The connecting tube was mobilized from the surrounding adherent tissues, the gastric band removed, the stomach and colon walls closed, and the gastrocolic fistula excised. To our knowledge this is the second case of concurrent band erosion and connecting tube colonic erosion along with gastrocolic fistula formation in a patient with morbid obesity treated with LAGB.

Bariatric surgery trends in France: 2005-2011

BACKGROUND

Bariatric surgery underwent a dramatic change in the past decade in France. The objective of this study was to examine elective bariatric surgical procedures from 2005 to 2011 in France and to determine trends in the use of the procedure.

METHODS

Data were extracted from the National Hospital Database. All admissions involving a bariatric surgery procedure were included. Procedures authorized by the Public Health Authority for the treatment of morbid obesity, including the adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), gastric bypass (GB), sleeve gastrectomy (SG), and biliopancreatic diversion (BPD), either by laparotomic or laparoscopic approach, were retrieved. Revisional procedures, such as band removal or repositioning, band changing, and access device revisions, were also evaluated.

RESULTS

We observed a 2.5-fold increase in bariatric procedures, from 12,800 in 2005 to 31,000 in 2011. Sleeve gastrectomy and gastric bypass became the most common bariatric procedures in France in 2011, whereas adjustable gastric banding has been decreasing since 2007. During the analysis period, about 50,000 revisional procedures were performed. The number of hospitals (private or public) providing bariatric surgery has considerably increased. However, most of the activity remains confined to a small number of centers, as 50% of all bariatric surgeries are carried out in 12% of hospitals. Bariatric procedures are predominantly performed in private hospitals.

CONCLUSIONS

In France the number of bariatric procedures increased considerably between 2005 and 2011. The type of procedures changed, with a constant decrease of AGB and an important increase of SG and GB. Most bariatric procedures are still performed in low volume activity hospitals and in private hospitals.

Laparoscopic adjustable gastric banding: a report of 228 cases

Objective: To evaluate the surgical outcomes and complications after laparoscopic adjustable gastric banding (LAGB) in obese patients.

Methods: This retrospective study included 228 patients (73 males and 155 females, mean age, 32.5 ± 10.3 years) who underwent LAGB at the Changhai Hospital of the Second Military Medical University from June 2003 to June 2011. The body weight and postoperative complications were followed up.

Results: The pre-operative mean body mass index (BMI) was 39.5 ± 6.3 kg/m². Except in one case of inadequate exposure of the stomach, all laparoscopic procedures were successfully accomplished, with no conversion to open surgery. The mean operation time was 65.0 ± 20.3 min. The mean hospital stay was 2.7 ± 0.9 days. Early postoperative complications (<30 days) occurred in five cases (2.2%) and late complications (>30 days) occurred in 75 cases (32.9%), including 56 cases (24.6%) with band-associated complications. The percentage of excess weight loss (EWL%) at 1, 3 and 5 years was 40.5 ± 30.5%, 59.5 ± 41.5% and 58.9 ± 46.4%, respectively. The percentages of patients with EWL% >25%, >50% and >75% were, respectively, 60%, 33% and 0% at 1 year follow-up, 43%, 39%, and 16% at 3 years follow-up and 40%, 34% and 16% at 5 years follow-up.

Conclusion Although LAGB has low peri-operative mortality and morbidity rates, it is associated with a high late complication rate and unsatisfactory weight loss. It may be optional, but not the first choice, for the treatment of obesity.