Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass

Banded Versus Non-banded Sleeve Gastrectomy: 5-Year Results of a 3-Year Randomized Controlled Trial

PURPOSE

Banded sleeve gastrectomy (BSG) has been shown to enable better weight loss than non-banded sleeve gastrectomy (SG) in retrospective analyses. These findings were supported by two randomized controlled trials (RCT). However, to date, mid-term prospective data is not available.

MATERIALS AND METHODS

We invited all 94 patients of an RCT comparing banded to non-banded sleeve gastrectomy at 3 years (DRKS00007729) for a 5-year follow-up visit. Eighty-two patients (BSG n = 42; SG n = 40) came for evaluation. Outcome measures were identical with the RCT to allow longitudinal comparison. Data analysis was descriptive and focused on biometric data, development of comorbidities, mid-term complications, quality of life, and type of body contouring surgery (BCS).

RESULTS

The per-protocol analysis revealed a treatment difference of 9% (CI - 1.5 to 19.6) excess weight loss (EWL). Total weight loss (TWL) was 27.4% (CI 23.5-31.3) after SG and 31.6% (CI 27.3-35.5) after BSG. Twenty percent of patients after SG and 11.9% following BSG had been converted to a gastric bypass. Type 2 diabetes went into remission in most patients (SG 66.7% vs. BSG 63.6%). Antihypertensive medication was stopped or reduced in 81.3% after SG and 80% after BSG. Reflux symptoms were similar in both groups (symptoms [Formula: see text] 1/ week: SG 28.2% vs. BSG 26.8%). Frequency of postprandial regurgitation was higher after BSG (SG 23% vs. BSG 59%). Forty percent of patients had undergone BCS at time of follow-up.

CONCLUSION

Five-year weight loss after BSG was 9% EWL and 4.2% TWL higher compared to SG. The main added morbidity following BSG was postprandial regurgitation.

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.

Closed loop small bowel obstruction due to herniation through silastic ring after bariatric surgery

Bariatric surgery is an effective treatment for obesity and obesity-related complications. Weight regain after surgery plagues all methods of bariatric procedures including the minigastric bypass. The use of a 'silastic ring' around the gastric pouch has been shown to reduce weight regain. We present here a very rare complication of silastic ring use, in which a loop of small bowel had herniated through the ring and produced a closed loop small bowel obstruction. The patient was successfully treated with an emergency laparotomy to resect the silastic ring and release the herniated bowel. This case highlights the hernia risk that silastic rings pose and cautions careful consideration before their use.

Weight loss and complications of the banded Roux-en-Y gastric bypass: lessons learned from a prospective case control study

OBJECTIVE

Obesity is a growing global health burden which is particularly challenging to manage. Bariatric surgery is considered the most effective means of sustained weight loss, and Roux-en-Y gastric bypass is considered the most effective treatment for morbid obesity. The additional benefit of placing a non-adjustable band to form a banded Roux-en-Y gastric bypass has gained interest as a measure to improve weight loss; however, comparative data are few, and complications can be high.

METHODS

We conducted a prospective case-control study of 484 patients aged 18 and over who received either banded Roux-en-Y gastric bypass with a non-adjustable silastic ring or Roux-en-Y gastric bypass. Patients were followed up for five years and evaluated for weight loss, percentage excess weight loss (%EWL), BMI, and band-related complications.

RESULTS

No significant difference was detected in %EWL or BMI between BRYGB and RYGB. The mean raw weight loss, %EWL, and BMI for BRYGB verse RYGB were as follows: 27.49 SD (17.11) kg verse 34.46 SD (18.18) kg, 65.7% SD (30%) verse 62.2% SD (37%), and 32.33 SD (6.9) kg/m² verse 32.43 SD (7.2) kg/m². A total of 80 (21.7%) patients had the non-adjustable band removed for complications.

CONCLUSION

There is little difference in weight-loss results when comparing BRYGB to RYGB and non-adjustable bands may cause significant complications.

Banded RYGB Ring Slippage Endoscopic Removal with Self-expandable Stents: a Comparative Study Between Metallic and Plastic One

PURPOSE

Banded Roux-en-Y gastric bypass (RYGB) was a common bariatric procedure in the 2000s, and the ring slippage is one of its late adverse events. Both plastic and metallic stents have been reported as adjunct methods to induce erosion and facilitate endoscopic removal of the ring.

OBJECTIVE

To compare the safety and effectiveness of self-expanding metallic stents (SEMS) and plastic stents (SEPS) to treat ring slippage.

MATERIALS AND METHODS

We conducted a retrospective longitudinal study analyzing consecutive patients with ring dysfunction treated with stents plus endoscopic removal.

RESULTS

Ninety patients were enrolled (36 SEMS vs. 54 SEPS). The mean age was 48.56 ± 13.07 and 45.6 ± 12.1 in the SEMS and SEPS groups, respectively. All patients had band slippage, but 24 from SEMS group and 23 from SEPS group had further complications. There were more complications in metallic stent concerning mean absolute number of therapy-related adverse events (1.33 ± 0.48 vs. 1.72 ± 0.5, p > 0.05) and time until erosion (14.9 ± 1.6 vs. 13.8 ± 1.4 days, p > 0.05). Female sex and age > 41 years old correlated with longer time to band erosion and higher incidence of adverse events in SEMS patients. In SEPS group, only female sex was a risk factor for adverse events.

CONCLUSION

Both procedures were efficient at inducing band erosion with similar safety profiles. Older and female patients are at a higher risk of treatment-related adverse events, especially those receiving SEMS.

Revision of a Previous Capella Bypass due to dysphagia, GERD and Candy Cane Syndrome

BACKGROUND

Capella ringed gastric bypass is a technical variant of gastric bypass which seeks to improve long-term outcomes with a greater restriction. Frequent complications are due to the band, due to its inclusion or slippage, without being able to reject others. Our purpose is to present the video of a revisional bariatric surgery made by laparoscopic approach in a patient with a previous open retrogastric retrocolic Capella gastric bypass.

MATERIALS AND METHODS

The patient presents dysphagia, gastroesophagic reflux disease (GERD), and pain, with a BMI of 36 kg/m². Her supplementary tests show a hiatal hernia, GERD, and a Candy Cane Syndrome. The surgery was difficult due to multiple adhesions. Hiatal hernia was repaired and pillars were closed. The band was visualized intraoperatively close to the gastrojejunal anastomosis, although the high endoscopy did not detect neither stenosis nor difficulty of passage to the gastric pouch. It showed the retrogastric gastrojejunal anastomosis with a normal food loop and a 15-cm widened blind loop (Candy Cane Syndrome), which was resected.

RESULTS

She had a left pneumonia and damage in left hepatic lobe (LHL). She was discharged after antibiotic treatment for 7 days. The patient has improved clinically, without dysphagia nor GERD. Her current BMI is 29.8 kg/m².

CONCLUSIONS

In conclusion, bariatric revisional surgery can lead to serious complications, but it is justified in patients with poor quality of life. A ringed retrocolic retrogastric bypass poses more difficulties in revisional procedures. It is mandatory to know which technique was performed before. The duration of the procedure can result in more complications like liver damage.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Impact of Laparoscopic Banded Gastric Bypass on Weight Loss Surgery Outcomes: 5 Years' Experience

OBJECTIVE

Evaluate 5-year outcomes of banded gastric bypass (BRYGB) as a primary and conversion bariatric procedure.

METHODS

Retrospective review of BRYGB between January 2011and March 2013. Outcomes included percentage of total weight loss (%TWL), weight loss maintenance, and band-related complications.

RESULTS

One hundred forty-two patients underwent BRYGB, 106 primary and 36 conversions. Indications for conversion to BRYGB were complications of the primary procedure (n = 19), insufficient weight loss (n = 5), and weight regain (n = 12). In the primary group, mean preoperative BMI was 44.8 kg/m² (± 6.9 kg/m²). Compared with preoperative weight, mean %TWL was 33.9% (n = 95), 34.1% (n = 82), 34.0% (n = 70), 33.9% (n = 62), and 31.8% (n = 75) after 1, 2, 3, 4, and 5 years, respectively. In conversions secondary to failed primary procedure (insufficient WL and weight regain), mean preoperative BMI was 40.8 kg/m² (± 6.01 kg/m²). Despite one patient gaining weight, mean %TWL was 25.7% (n = 13), 28% (n = 11), 23.9% (n = 8), 18.3% (n = 8), and 15.1% (n = 12) after 1, 2, 3, 4, and 5 years, respectively. In conversions secondary to primary procedure complications (n = 19), mean preoperative BMI was 28.4 kg/m² (± 3.5 kg/m²). After 1, 2, 3, 4, and 5 years, mean BMI was 28.1 (n = 15), 29 (n = 10), 29.8 (n = 9), 30.6 (n = 10), and 30.9 (n = 12) kg/m², respectively. Band-related complications after 5 years: three erosion and five patients complained of persistent dysphagia. One band needed reposition. Perioperative surgical complications: two bleeding, one leakage, one port-site hernia, and one food impaction.

CONCLUSION

Banded gastric bypass has good results in terms of weight loss and weight loss maintenance in both primary and conversional bariatric procedures with acceptable incidence of band-related complications.

Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Bariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications.

OBJECTIVES

This study aims to compare the safety and efficacy of banded versus nonbanded RYGB.

SETTING

Meta-analysis of randomized controlled trials (RCTs).

METHODS

A meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications.

RESULTS

Three RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m². Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26-8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27-6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups.

CONCLUSION

Findings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different.

Endoscopic versus laparoscopic management of an eroded mesh in vertical banded gastroplasty: video case series and literature review

Vertical banded gastroplasty (VBG) was one of the most common bariatric surgeries worldwide in the beginning of the 21st century. However, recently we have increasingly encountered its long-term complications. We present two cases of VBG mesh erosion, alongside videos for their management. The first is of a 35-year-old female that presented 10 years after her VBG, while the second is of a 38-year-old female presenting 9-years post hers. Patient one presented with weight regain, regurgitation, epigastric pain, and dysphagia. CT imaging showed staple-line dehiscence and foreign body inside the stomach. Patient 2's presentation was of weight regain. Upon further workup, she was diagnosed with mesh erosion. In case 1, an endoscopic approach was taken using Soehendra lithotriptor device, while for case 2, a laparoscopic approach was undertaken. Endoscopic management of mesh erosion post-VBG is not only safe and feasible but also less invasive and time-consuming than the laparoscopic technique.

Conversion of Vertical Sleeve Gastrectomy to a Functional Single-Anastomosis Gastric Bypass: Technique and Preliminary Results Using a Non-Adjustable Ring Instead of Stapled Division

BACKGROUND

Recent data show that some patients will have insufficient weight loss or experience weight regain after sleeve gastrectomy. Dilation of the sleeve over time or use of an inadequate technique may contribute to relapse of morbid obesity. Repeat sleeve gastrectomy is the most obvious option but requires stapling of scarred tissue, has a higher risk of leakage, and is prone to re-enlargement with time. We herein describe a simple and innovative technique with which to revise vertical sleeve gastrectomy (VSG) into functional single-anastomosis gastric bypass (f-SAGB).

MATERIALS AND METHODS

Twelve VSGs were converted to f-SAGB by placing a GaBP Ring (Bariatec Corp., Palos Verdes Peninsula, CA, USA) at the base of the "sleeve" and performing the anastomosis above the ring. The length of the biliopancreatic loop was chosen according to the volume of the pouch and the patient's residual eating capability.

RESULTS

All procedures were completed by laparoscopy and were uneventful. The average decrease in the body mass index was from 41.0 to 29.5 kg/m² at the 12-month follow-up. No ring-related complications were reported.

CONCLUSION

f-SAGB is a low-risk and effective option with which to revise VSG in patients with inadequate weight loss. Avoiding detachment of the pouch from the antrum assures full reversibility of the procedure and preserves the chance to explore the remnant stomach and biliary tree.

Endoscopic management of erosion after banded bariatric procedures

BACKGROUND

Prosthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes.

OBJECTIVES

We will describe our methods and experience with endoscopic management of intraluminal gastric band erosions after bariatric procedures.

SETTING

University hospital in the United States.

METHODS

A retrospective review of our bariatric surgery database identified patients undergoing removal of gastric bands. A chart review was then undertaken to confirm erosion of prosthetic material into the gastrointestinal tract. Baseline characteristics, operative reports, and follow-up data were analyzed.

RESULTS

Sixteen patients were identified with an eroded gastric band: 11 after banded gastric bypass, 3 after laparoscopic adjustable gastric band (LAGB), and 2 after vertical banded gastroplasty. All patients were successfully treated with endoscopic removal of the prosthetic materials using either endoscopic scissors or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a postoperative gastrointestinal bleed requiring repeat endoscopy, 1 patient with asymptomatic pneumoperitoneum requiring observation, and 1 with seroma at the site of LAGB port removal.

CONCLUSIONS

Endoscopic management of intraluminal prosthetic erosion after gastric banded bariatric procedures can be safe and effective and should be considered when treating this complication. Erosion of the prosthetic materials inside the gastric lumen allows for potential endoscopic removal without free intraabdominal perforation. Endoscopic devices designed for dividing eroded LAGBs may help standardize and increase utilization of this approach.

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.

A Comparative, Prospective and Randomized Evaluation of Roux-en-Y Gastric Bypass With and Without the Silastic Ring: A 2-Year Follow Up Preliminary Report on Weight Loss and Quality of Life

BACKGROUND

Currently, Roux-en-Y gastric bypass (RYGB) is one of the most widely used bariatric surgeries. Banding the pouch forms a banded gastric bypass operation, an accepted and frequently used variant. Placing a silastic ring around the pouch to band the gastric bypass operation increases the restriction mechanism. However, the ubiquitous use of the banded gastric bypass remains controversial. One of the controversies is the effect of the silastic ring on patients' perception of their well being after surgery because of the frequency of vomiting. A prospective, blindly randomized, comparative trial was undertaken to resolve this controversy.

METHOD

Four hundred subjects scheduled for gastric bypass surgery were randomized into two arms of the trial, 200 with a silastic ring (WR) and 200 without (NR). After 2-year follow-up, the variables associated with the scores of Bariatric Analysis and Reporting Outcome System (BAROS) were analyzed.

RESULTS

The initial median weight (125 kg), BMI (47), and age (36 years) were the same in both the NR and WR groups. The median excess weight loss, weight regain, and incidence of vomiting were 71, 10.5, and 7.75%, respectively, in the NR group vs. 75.4 and 1.1, and 24.4% in the WR group. The mean QOL score was 79% in the NR group vs. 80% in the WR group.

CONCLUSION

After 2-year follow-up, silastic ring placement in the RYGB resulted in greater weight loss and weight stability and a threefold greater incidence of vomiting. There was no difference in the scores in the quality of life analysis.

Role of the gastroenterologist in the management of the obese patient

Obesity is a highly prevalent disease worldwide, and one in which gastroenterologists can play an important role. Some digestive diseases are more common in obese patients, and preoperative evaluation may be required in some cases. Additionally, bariatric surgery can lead to digestive complications in the short and long term that require intervention, and endoscopic treatment can be an important factor in weight loss. The aim of this review is to highlight the role of the gastroenterologist in the management of obese patients who are either scheduled for or have undergone surgical or endoscopic treatment for obesity.

Comparison Between Banded and Nonbanded Roux-En-Y Gastric Bypass with 2-Year Follow-Up: a Preliminary Retrospective Analysis

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is one of the most widely used bariatric surgeries for treatment of moderate and severe obesity. Placing a band around the pouch to band the gastric bypass operation has been reported to increase the restriction resulting in better weight loss and weight loss maintenance. A retrospective comparative study of banded versus nonbanded gastric bypass was done to see if banding the pouch made a difference in the weight loss and quality of life outcome in the patients.

METHODS

Data from all patients who had a gastric bypass in the year 2012 at our centre were reviewed. They were divided into two groups the banded and the nonbanded groups. Patients with complete 2-year follow-up were analysed in terms of weight loss, weight regain and quality of life changes.

RESULTS

Two hundred ten patients had gastric bypass in 2012; 165 had complete 2-year follow-up; 64 were banded and 101 nonbanded. The preoperative patient profile in terms of weight, gender and comorbid conditions was similar in both groups except the body mass index (BMI) was significantly higher in the banded group. The perioperative and postoperative complication rates were similar. The weight, BMI and percentage excess weight loss (PEWL) at 2 years were 80.93 kg, 29.45 kg/m2 and 60.76 % in the nonbanded group and 77.06 kg, 27.66 kg/m2 and 71.45 % in the banded group, respectively. Resolution of comorbid conditions was the same in both groups. The overall Gastrointestinal Quality of Life Index went from 88.98 preoperatively to 109.33 postoperatively in the nonbanded group and 92.5 to 112.81 in the banded group, respectively.

CONCLUSIONS

The patients with banded gastric bypass had significantly better results in terms of weight loss, weight stability and Gastrointestinal Quality of Life Index scores at 2 years.

Laparoscopic Band-Separated One Anastomosis Gastric Bypass

BACKGROUND

This video demonstrates laparoscopic band-separated one anastomosis gastric bypass-combining the advantages of banding and gastric bypass without stapler and cutter use. This is basically a gastrojejunal loop bypass above an obstructive band in the upper stomach.

MATERIALS AND SURGICAL TECHNIQUE

An adjustable low pressure "Medsil" gastric band was introduced in the abdomen and retracted through the retrogastric tunnel. The front wall of the stomach below the band was displaced in the upward direction through the ring band, increasing the size of the anterior portion of the stomach pouch so that a gastroenteroanastomosis could be created at this point. Gastro-gastric sutures were placed to create a gastro-gastric plication around the band and hold it in position. The band tubing was exteriorized and connected to a special port, which was secured to the abdominal wall fascia. A jejunal loop was created about 200 cm from the ligament of Treitz and anastomosed to the gastric pouch by hand using Vicryl 2/0 sutures.

RESULTS

Between November 2015 and February 2016, the study was performed on 10 patients. The average operating time for all cases was 75 min (range 63-87). There was no morbidity or mortality. No complications were observed, including band erosion and band infection. Operation costs were about $2000 lower with this method than with standard gastric bypass surgery. Postop the patients lost weight by 3-4 kg per month.

CONCLUSION

Preliminary results show that laparoscopic band-separated one anastomosis gastric bypass have feasibility, safety, efficacy, and reduced operating costs.

Endoscopic management of bariatric surgery complications: what the gastroenterologist should know

Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.

Primary banded Roux-en-Y gastric bypass: a systematic review

Primary banding of Roux-en-Y gastric bypass remains controversial. Though there are surgeons who believe it should be the standard practice as it results in superior weight loss and prevents weight regain in the long term, there are others who are concerned about the risk of food intolerance and complications related to band. This review investigates published English language literature systematically to find out the advantages and disadvantages of primary banding of a Roux-en-Y gastric bypass.

Laparoscopic removal of gastric band after laparoscopic gastric bypass and following placement of adjustable gastric band

Banded gastric bypass is a bariatric surgical intervention that has been regularly performed in many centers. According to some series, banded gastric bypass is safe and feasible. We describe the case of a 42-year-old woman undergoing laparoscopic gastric bypass in 2008. Subsequently, she underwent surgery in order to place adjustable gastric banding on previous bypass because of gastric pouch dilatation. Five months later, patient showed anorexia and signs of malnutrition. For this reason, she underwent laparoscopic removal of gastric banding. In our opinion, placing a device to restrict an already dilated gastric pouch must be avoided.

Banded gastric bypass - four years follow up in a prospective multicenter analysis

Background

The gastric bypass is the gold standard of bariatric surgery. Nevertheless some patients show insufficient weight loss or weight regain. Dilation of the pouch or the pouch outlet may be the cause. The banded gastric bypass tries to overcome dilation by placing an implant around the pouch or pouch outlet. In this study we describe our results using the GaBP™ ring system in banded gastric bypass operations in 3 bariatric centers.

Methods

183 patients in 3 bariatric reference centers received a banded gastric bypass operation using the GaBP™ ring system. Up to 4 years follow up was evaluated including weight loss and complications.

Results

Mean EWL after 6 Months was 60% with a mean BMI of 30.1 kg/m². After one year mean EWL reached 75.3% with a mean BMI of 27 kg/m² (110 patients). After two and three years the EWL was 78.8% (n = 49) and 79.9% (n = 35). There was a mean EWL of 85% after 4 years. Thirteen patients finished a 4 year follow up period and mean BMI after 4 years was 25.2 kg/m². In the perioperative and early postoperative period there was a low complication rate (4.3%). Stenosis or dysphagia was observed in only one patient. There was only one ring related complication.

Conclusion

Banded gastric bypass using the GaBP™ ring system allows good weight loss with no regain of weight in a four year follow up. The complication rate is low. A randomized controlled trial is currently underway to compare banded and conventional 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.

Laparoscopic silastic ring mini-gastric bypass: a single centre experience

BACKGROUND

Laparoscopic mini-gastric bypass (MGBP) represents a simpler alternative to Roux-en-Y gastric bypass. The placement of a silastic ring (SR) may enhance excess weight loss and minimize weight regain. This study reports on the results of a consecutive cohort of patients undergoing SR-MGBP in a single centre.

METHODS

Short- and medium-term outcomes of 156 consecutive patients undergoing surgery between August 2005 and January 2008 were analysed. Weight loss, comorbidity resolution and morbidity/mortality were assessed.

RESULTS

A total of 156 patients (78% female, 22% male) with a mean (range) age of 44 years (18-63), pre-operative weight of 129 kg (83-197) and body mass index of 46 kg/m(2) (35-64) underwent surgery. Eighty-seven percent had pre-operative comorbidities, and median (range) follow-up was 35 months (6-72). Mean (SD) % excess weight loss (EWL) at 6, 12, 24, 36 and 60 months was 74.6 (19.5), 93.4 (21.1), 98.8 (27.6), 93.5 (20.1) and 89 (16.1) respectively. Thirty-seven percent had complete resolution of comorbidities and 67.3% required vitamin/mineral supplementation. Overall, 10.3% patients suffered early complications, of which 7.7% were minor and 2.6% were major. A total of 45.5% patients suffered late complications, of which 34.6% were minor and 10.9% were major. Food intolerance/vomiting, bile reflux and stomal ulcer were seen in 18.6, 10.3 and 7.7% of patients, respectively. Surgical re-intervention was required in 12.8% of patients. There were no deaths.

CONCLUSIONS

Whilst SR-MGBP achieves excellent EWL with low mortality, there is a high incidence of food intolerance/vomiting likely related to the silastic ring. The majority of complications were managed with pharmacological and endoscopic intervention, although 13% required reoperation within 5 years.

Endoscopic findings of asymptomatic patients one year after Roux-en-Y gastric bypass for treatment of obesity

BACKGROUND

In the late post-operative period, the necessity of performing an upper gastrointestinal endoscopy (GIE) to check for complications is controversial. Some authors suggest it should be routine for all patients, others selectively, but not all patients with endoscopic abnormalities are symptomatic and some abnormalities are potentially severe. The study was conducted to evaluate the endoscopic findings from asymptomatic obese patients after Roux-en-Y gastric bypass (RYGB) and correlate them with the demographic data and the presence of Helicobacter pylori (Hp).

METHODS

A total of 715 asymptomatic patients were prospectively submitted to an upper GIE at the end of their first post-operative year. These examinations were evaluated for the presence of abnormalities, their prevalence and their potential severity.

RESULTS

Abnormalities were found in 189 patients (26.5 %). Eighty-four (11.7 %) presented esophageal abnormalities, with 72 (10.1 %) characterized as esophagitis and 12 (1.7 %) as hiatal hernia. Forty-five patients (6.3 %) presented abnormalities of the stomach and the anastomosis, with 26 (3.6 %) characterized as anastomotic ulcers, nine (1.3 %) as stenosis of the gastrojejunal anastomosis, ten (1.4 %) as band erosion and 72 (10.1 %) as jejunitis. There was a statistically significant correlation between super obesity and band erosion.

CONCLUSIONS

An upper GIE at the end of the first year of RYGB plays an important role, even for asymptomatic patients. One fourth of these asymptomatic patients had their treatment modified after the upper GIE was performed.

Food intolerance after banded gastric bypass without stenosis: aggressive endoscopic dilation avoids reoperation

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) controls obesity and comorbidities. However, there is no consensus on ring placement due to its complications. Surgical ring removal has been the standard approach, despite its inherent morbidity risks. Endoscopic dilation with achalasia balloon is a novel and minimally invasive option. We aimed to evaluate safety and efficacy of aggressive dilation as an outpatient procedure to treat food intolerance after banded RYGBP without stenosis; we also analyzed long-term weight regain.

METHODS

This prospective study included 63 patients presenting with more than four vomiting episodes per week. Therapeutic endoscopy with a 30-mm balloon (Rigiflex®) was performed with radioscopic guidance in the first 16 patients (25.4 %). Four dilation sessions were performed in 12 patients (19 %), three in 14 (22.2 %), two in 24 (38 %), and one in 13 (20.6 %).

RESULTS

Complete symptom improvement was achieved in 59 patients (93.6 %), partial improvement in 2 (3.2 %), and failure in 2, leading to ring removal by laparotomy. Complications rate was 9.5 %, including three cases of bleeding, two intragastric ring erosions, and one pneumoperitoneum; all treated clinically with no need for reintervention. Mean preoperative body mass index (BMI) was 42.4 kg/m(2) and postoperative (before endoscopic treatment) BMI was 25.3 kg/m(2). At a mean follow-up of 46.1 months after endoscopic intervention, mean BMI was 27.8 kg/m(2).

CONCLUSIONS

Aggressive endoscopic dilation for food intolerance is a safe and minimally invasive method that promotes symptom improvement. It avoided reoperation in 96.8 % of patients and led to a low rate of weight regain.

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center.

METHODS

A matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications.

RESULTS

Between January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m(2), respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients.

CONCLUSION

Banding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.

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.

Liver abscess as a complication of laparoscopic gastric banding bariatric surgery

BACKGROUND

The World Health Organization has identified the rapidly growing prevalence of obesity as one of today's serious health problems. Various surgical interventions categorized collectively as bariatric surgery now play an ever-increasing important role as the only known effective treatment for severe obesity. Laparoscopic gastric bypass is currently the most frequent bariatric surgical procedure performed. However, the laparoscopic adjustable gastric band (LAGB) is rapidly gaining in popularity as a minimally invasive surgical option with anticipated similarly efficacious outcomes. Gastric band erosion following LAGB is an uncommon yet potentially serious complication unique to this form of weight loss surgery.

METHODS

Case report and literature review.

RESULTS

We report a case of a pyogenic liver abscess related to a LAGB procedure. Apropos to this case, we review the presumed pathophysiologic mechanism of this particular infectious process, and discuss this and other complications associated with LAGB operations.

CONCLUSIONS

As LAGB bariatric procedures become more popular, clinicians need to be aware of uncommon, but potentially serious complications unique to this form of weight loss surgery.

Role of the gastroenterologist in managing obesity

Obesity has become a major public health problem as a consequence of its prevalence, negative impact on morbidity, mortality and quality of life and its associated direct and indirect healthcare costs. The etiology of obesity is multifactorial and reflects complex interactions of genetic, neurohumoral, environmental, behavioral and possibly, microbial factors. Available treatments for obesity include diet and exercise, behavioral modification, medications and surgery. Gastroenterologists are becoming increasingly involved in the care of obese patients. Although much of this care has historically centered on the preoperative and postoperative care of the bariatric patient, gastroenterologists are also evaluating and managing a variety of gastrointestinal symptoms and disorders that occur more commonly among obese individuals and are increasingly involved in the primary treatment of obesity. In this review, the gastrointestinal symptoms and disorders that are associated with obesity will be reviewed, the gastrointestinal contribution to the pathogenesis of obesity will be described and the current treatment options of obesity and where the gastroenterologist typically plays a role in the management will be discussed.

Caution in using a unique technique of banded revision gastric bypass: Successful endosopic and surgical management of a rare complication

INTRODUCTION

Revision surgery is increasingly performed as result of the increase in primary bariatric procedures. We describe a new technique of revision Roux-en-Y gastric bypass (RYGB) acombining stapled gastroenterostomy with fixed band placement. We report two cases of unique complications and its successful endoscopic and surgical management.

PRESENTATION OF CASE

Two out of twenty patients undergoing this revision RYGB procedure presented with gastric outlet obstruction due to band erosion within 10 weeks. Endoscopic band retrieval was successful in the first patient but the second patient required surgical removal.

DISCUSSION

We report the new complication of band erosion in 10% patients using a unique revision RYGB technique combining restriction of the gastric outlet and band placement. We advise using one or the other technique but not both in combination. Surgeons need to be aware of this as erosion which occurs early due to close proximity of band with fresh staple line. We report successful endoscopic and surgical management.

CONCLUSION

Revision surgery using this technique predisposes to bande erosion, presenting as gastric outlet obstruction. Endoscopic management should be attempted prior to surgical removal.

Ten years experience of banded gastric bypass: does it make a difference?

Many surgeons support some sort of restriction of the gastric pouch outlet by placing a ring around the gastric reservoir. Previous studies have shown positive results of banded gastric bypass (BGBP); however, there are not many comparative long-term studies to assess the real advantage of placing a ring during gastric bypass (GBP) surgery. This study aims to evaluate the long-term outcome of patients subjected to BGBP and nonbanded GBP procedures. We studied 260 retrospective, nonrandomized obese patients who underwent BGBP and 218 patients without the ring (i.e., GBP). They were followed up for 10 years, and the following parameters were evaluated: excess weight loss (EWL), quality of life (QOL), food tolerance, and correction of comorbidities. The study was approved by the Committee on Ethics, and all the patients gave their informed consent. There is a significant difference in %EWL from the third year until the tenth year of observation, with the proportion being 82% in BGBP versus 63% in nonbanded GBP patients at the end of the study. Although there was some increased intolerance to food intake in the BGBP patients, this was not felt to reduce the QOL. The outcome in terms of comorbidities was not conclusive. There is a clear advantage in terms of %EWL in the BGBP patients. No differences in QOL were found in both groups. Further, selecting the right type of material and the right size of the ring is important to improve results and avoid complications.

Revisionary bariatric surgery: indications and outcome of 100 consecutive operations at a single center

BACKGROUND

A growing number of revisionary and secondary bariatric operations have been performed in recent years, with the number of operations doubling each year at the authors' center. Diagnostics, indications, and most revisionary operations should be performed by an experienced bariatric surgeon. This study was undertaken to evaluate indications and outcomes of revisionary bariatric operations at a specialized center.

METHODS

At the Centre of Obesity and Metabolic Surgery (University of Freiburg, Germany), 100 consecutive revisionary bariatric operations performed between March 2007 and September 2009 were analyzed concerning indications and outcomes.

RESULTS

Only 9 of the 100 revisions were due to early complications (<30 days after the primary operation). The indication for most revisions was poor weight loss (n = 55). A mean body mass index reduction of 10 points could be achieved in 1 year, which equals a 56% excess weight loss (EWL). No significant difference in weight reduction between restrictive and malabsorptive revisions was observed. Revisions due to implant-related problems also were frequent (n = 25). Laparoscopic revision was possible in 95% of the cases.

CONCLUSION

Insufficient weight loss is the most frequent indication for revisionary bariatric surgery. The surgery can be performed laparoscopically in most cases, and a significant EWL (> 50%) can be achieved in 1 year if the right revisionary procedure is chosen.

Derivações gástricas em y- de- roux com anel de silicone para o tratamento da obesidade: estudo das complicações relacionadas com o anel

RACIONAL: O anel de silicone é utilizado como fator de contensão do bypass gástrico em Y-de-Roux para induzir maior perda ponderal. No entanto, ele pode ter alguns inconvenientes nesta restrição forçada. OBJETIVO: Analisar as complicações relacionadas ao anel em pacientes submetidos à operação de bypass gástrico em Y-de-Roux. MÉTODOS: De 1994 a 2005, 7 000 pacientes foram submetidos à bypass gástrico em Y-de-Roux com anel de silicone para o tratamento da obesidade mórbida. Apenas 50% foram acompanhados de dois a 11 anos. A perda média de peso em excesso foi de cerca de 85%. Mas complicações do anel foram registrados em 160 pacientes (2,28% do total e 4,56% dos pacientes seguidos). Assim, esta série é composta de 38 pacientes do sexo masculino (23,8%) e 122 pacientes do feminino (76,2%) com idade média de 44 anos e IMC de 54,4 kg/m². RESULTADOS: Cinco tipos de complicações do anel foram encontradas. A mais frequente foi o de deslocamento (61%) causando sintomas de obstrução. A segunda, foi a erosão do anel de luz (22%), causando dor epigástrica e náuseas. A presença de anel estreito, anel aberto e a inadequação do mesmo são outras complicações que acorreram, porém em menor percentual. CONCLUSÕES: As complicações do anel ocorrem em baixa frequência. Sua remoção, cirúrgica ou endoscópica, é o tratamento mais usual, mas com sua realização o paciente tende a recuperar o peso perdido.

Management of late postoperative complications of bariatric surgery

Background

The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon.

Methods

A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included.

Results

The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention.

Conclusion

The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary.

Banded sleeve gastrectomy using the GaBP ring--surgical technique

Laparoscopic sleeve gastrectomy (LSG) has been described as the first step of a two-step laparoscopic Roux-en-Y gastric bypass (LRYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) in extremely obese patients. It has also been used as an independent bariatric procedure. Recently a banded sleeve gastrectomy using human dermis was published. Gastric sleeve dilatation is one of the unfavorable postoperative courses that may limit weight loss. Our technique of a banded sleeve gastrectomy using the GaBP Ring Autolock(TM) System to calibrate the sleeve and prevent distal sleeve dilatation is described in this article.

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos)

BACKGROUND

Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery.

OBJECTIVE

To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass.

DESIGN

Case series.

SETTING

Federal University of Pernambuco and São Paulo University.

PATIENTS

This study involved 39 consecutive patients who were screened for inclusion.

INTERVENTION

Endoscopic dilation with an achalasia balloon.

MAIN OUTCOME MEASUREMENTS

Technical success and safety of the procedure.

RESULTS

Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months).

LIMITATIONS

This was not a randomized, comparison study, and the number of patients was relatively small.

CONCLUSION

The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal.

Endoscopic foreign body removal for treatment of chronic abdominal pain in patients after Roux-en-Y gastric bypass

BACKGROUND

Common endoscopic findings in patients who have undergone Roux-en-Y gastric bypass (RYGB) with chronic abdominal pain have included marginal ulceration, gastrogastric fistula, and jejunal erosion. However, suture or staples eroding into the gastric pouch can also contribute to abdominal pain. Redundant suture is typically regarded as a normal part of the postoperative anatomy. The objectives of the present study were to assess the effects of endoscopic foreign body removal of partially exposed sutures and staples in post-RYGB patients with chronic abdominal pain at a university hospital in the United States.

METHODS

We performed a retrospective study of consecutive patients from January 2006 to July 2007. Post-RYGB patients with chronic abdominal pain underwent endoscopic foreign body removal of exposed sutures/staples. Pain scores were obtained before the procedure, immediately after the procedure, and at the telephone follow-up (median 7.2 months).

RESULTS

Of 21 patients, 15 (71%) reported immediate symptomatic improvement. Specific endoscopic accessories were found to be more useful than others in managing the various foreign materials. Of the 21 patients, 15 (71%) were available for telephone follow-up. Of these 15 patients, 13 (87%) reported continued symptomatic improvement, with 9 (60%) reporting complete pain resolution and 4 (27%) reporting partial improvement. Eroded foreign material was seen in association with marginal ulcers in 3 patients (14%), gastritis in 7 patients (33%), and an inflammatory polyp in 1 patient (5%).

CONCLUSIONS

Eroded suture and staples can cause chronic abdominal pain in post-RYGB patients. In symptomatic patients, visible suture or staples should be considered a potential etiology of chronic pain, instead of normal postoperative findings. Endoscopic foreign body removal might be of therapeutic benefit in these patients.

Management of band erosion with omental plugging: case series from a 5-year laparoscopic gastric banding experience

BACKGROUND

Although reports on band erosion management after laparoscopic adjustable gastric banding (LAGB) agree that in most cases the affected band will need to be removed, there is no consensus on the technique of removal. We report a minimalistic, laparoscopic technique which is safe and avoids management delay.

METHODS

We retrospectively reviewed the operative log of our obesity surgery unit to find all operations performed on LAGB patients for erosion from Jan 2003 to Dec 2007. The cases that underwent this particular technique were identified. Case notes and electronic records were then reviewed for postoperative morbidity and outcomes. The operative technique and indications of this particular method is described which to our knowledge has not been reported before.

RESULTS

From 2003 to 2007, there were 865 LAGB performed. We identified 17 operations performed for erosions in this period; some referred from elsewhere. Among these, an omental plugging technique was used in five patients (median preoperative body mass index 46.5; median age 47; all female). Median timing of presentation was 8 months, with pain/pyrexia in all five (with coexisting obstructive symptoms in four) patients. At endoscopy, three were posterior, partial erosions. Intraoperatively, all were partial erosions (three posterior and two anterior). In theater, we removed the band in all cases and closed the defect with a vascularized omental plug, fashioned using a harmonic scalpel. There were no immediate postoperative complications. On follow-up, two patients stayed the same weight, but in three, the weight increased leading to two needing rebands (at 6 and 8 months).

CONCLUSIONS

Omental plugging is a way of managing LAGB erosion, which in our hands has led to an uneventful postoperative course and future rebanding without undue delay. It is suited patients with incomplete erosion when the endoscopic option is difficult, thereby removing the need for a surveillance period awaiting complete band erosion.

Laparoscopic placement of non-adjustable silicone ring for weight regain after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch.

METHODS

From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg +/- 12.3 and 36.3 +/- 3.0 kg/m(2), respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 +/- 14.2 months, patients presented a weight regain of 4.7 +/- 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 +/- 13.1 kg, 29.5 +/- 3.9 kg/m(2), and 47.0 +/- 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL.

RESULTS

Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 +/- 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 +/- 1.5 days. After a mean follow-up of 14.0 +/- 9.2 months, the six patients presented a mean weight loss of 9.1 +/- 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 +/- 13.7 kg, 26.4 +/- 4.2 kg/m(2), and 70.4 +/- 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 +/- 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up.

CONCLUSION

One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss.