Avoiding complications after laparoscopic esophago-gastric banding: experience with 400 consecutive patients

Laparoscopic Adjustable Gastric Band Slippage Rates Following Laparoscopic Gastric Band Insertion: a Single Centre Experience

INTRODUCTION

Laparoscopic adjustable gastric bands (LAGB) are placed around the superior aspect of the stomach to aid weight loss and co-morbidity resolution in morbidly obese patients. Slippage of the LAGB from its original position to lower in the fundus of the stomach leads to gastric obstruction, and sometimes ischaemia or perforation, necessitating LAGB repositioning or removal. This study aimed to identify the incidence of LAGB slippage, as well as predisposing factors that may influence its development.

METHODS

All LAGBs inserted at one centre, via a pars flaccida technique, by four Bariatric specialist consultants, were reviewed utilising a prospectively maintained Bariatric database, computer records and case notes review.

RESULTS

Seven hundred nineteen LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip rate 3.1 %). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 years slip vs. 45 years non-slip; p = 0.027), higher median total excess weight loss (64 % slip vs. 36 % non-slip; p < 0.001) and higher mean excess weight loss per month (2.41 % slip vs. 1.00 % non-slip; p < 0.001). There was no significant effect by sex, BMI at insertion or band type.

CONCLUSIONS

Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.

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.

Erosions after laparoscopic adjustable gastric banding: diagnosis and management

OBJECTIVE

To define the changing prevalence of erosion after Laparoscopic Adjustable Gastric Banding (LAGB), describing the range of clinical presentations, the approaches to treatment and the outcomes from these approaches over a 15-year study period.

BACKGROUND

A recent systematic review of the literature of erosion after LAGB identified 25 relevant studies and reported a total of 231 erosions in 15,775 patients giving an overall incidence of 1.46%. The review highlighted a broad variation of incidence from 0.2% to 33%. The review was unable to identify either common presentations or an optimal pattern of management.

METHODS

Patients who underwent a primary LAGB operation between September 1994 and January 2010 by 2 surgeons (P.O.B. and W.B.) were identified in a prospectively maintained database. Those patients who had an erosion of their LAGB were identified. Presentation, operative details, demographics, body mass index, weight history, and perioperative problems were analyzed.

RESULTS

In total, 2986 patients were identified. All bands placed were Lap-Bands (Allergan, CA). Hundred erosions were experienced by 85 patients (2.85%) at a median time of 33 months from initial surgery to the erosion (range: 11-170 months). The rate of erosion was highest when the band was placed by the perigastric approach at 6.77%. Since the adoption of the pars flaccida approach, the rate of erosion has dropped to 1.07%. The majority of patients who had experienced an erosion (71 patients; 83.5%) experienced only 1 erosion, 13 patients (15.3%) had 2 erosions, and 1 patient had 3 erosions. The most common presentation was loss of satiety. The band has been successfully replaced in 56 patients. It has been explanted in 27 patients and 2 patients were converted to other bariatric procedures. The weight loss in patients who had a LAGB reinserted after erosion was not significantly different to the background cohort.

CONCLUSIONS

Erosion of LAGB is uncommon and its clinical course is benign. It is best treated with a staged surgical approach; initially, with removal and repair followed later by replacement. With this approach, weight loss is maintained and reerosion is uncommon.

Is fixation during gastric banding necessary? A randomised clinical study

Anterior fixation via a gastro-gastric suture in laparoscopic adjustable gastric banding (LAGB) is commonly performed to prevent band-related complications. However, the necessity of this common technique has never been proven. Not fixing the band would be time sparing and would reduce adhesions on the stomach and probably make revisional surgery easier. This study was conceived as a 3-year randomised clinical trial to test the safety and efficacy of the non-fixation technique. From December 2006 to December 2007, 81 patients undergoing LAGB were randomly distributed into two groups: group A, with gastro-gastric sutures (n = 41) and group B, without gastro-gastric fixation (n = 40). The two groups were equivalent regarding initial body mass index (BMI), age and sex ratio. The main outcome was postoperative complications and secondary outcomes were operative time and weight loss expressed by the percentage of excess BMI loss (%EBMIL). All patients were prospectively followed up for 2 years. The mean preoperative BMI was 42.5 kg/m² (35-56). All patients were available for follow-up at 2 years. The mean overall preoperative time was 82 ± 20 min for the fixation group and 72 ± 20 min for the non-fixation group (p = 0.13). The mean hospital stay was 4.1 ± 1.5 days (no significant difference between the two groups). The 2-year %EBMIL was 35.9 for group A and 39.4 for group B (p = NS). The mean BMI at 2 years was 36.3 and 36.1, respectively, with no statistical difference. We observed three early band slippages in the non-fixation group and none in the fixation group. Three bands were removed during the second year of follow-up for causes other than band slippage (no significant difference between the two groups). This study was interrupted before a statistical significance could be reached, under the general agreement of all participating surgeons, because of the three unexpected early band slippages. For the patients who did not suffer from this complication, we did not observe any differences between the two groups in terms of late complications and weight loss. The operative time was shorter in the non-fixation group. This randomised clinical trial suggests that care should be taken when not fixating the LAGB because of the risk of early postoperative band slippage. We suggest that fixing the LAGB by gastro-gastric sutures should remain common practice.

Bariatric emergencies for non-bariatric surgeons: complications of laparoscopic gastric banding

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has gained popularity for treatment of morbid obesity worldwide. With the widespread use of LAGB, an increasing number of medical specialists are dealing with the potentially life-threatening complications of this procedure.

METHODS

More than 6,000 LABGs were performed by our surgeons during the past 11 years, during which various complications of LAGB were observed, including band slippage, erosion, gastric pouch dilatation, port infection, and disconnection. Complicated cases requiring emergency surgical intervention were collected. We present and discuss the diagnostic and therapeutic possibilities of these complications.

RESULTS

Fourteen cases were identified: six with acute band slippage, two with small bowel obstruction, and one each with band slippage and fetal intrauterine growth restriction during the 36th week of pregnancy, perforated gastric ulcer, upper gastrointestinal bleeding, connecting tube penetration into a stomach ulcer, connecting tube penetration into the colon, and port disconnection. All patients had gastrointestinal symptoms at admission. Band reposition was performed in four cases; eight patients required band removal for band contamination. The band was open and still in place in one case. Open and laparoscopic gastric resections for necrotic stomach were performed in two cases. Suture of perforated gastric ulcer was combined with cesarean section. Connection of disconnected port and suture of colonic and gastric penetrations and perforation of fundus were completed laparoscopically. Small bowel resection and enterotomy required an additional minimal laparotomic incision. No mortality was observed in our series. Four patients elected to have the LAGB reinserted at a later time.

CONCLUSION

The increasing number of bariatric procedures has resulted in emergency physicians' knowledge of serious complications of LAGB that require urgent surgical intervention. Treatment algorithms require early diagnosis and a surgical approach to solving these conditions.

Right-sided upper abdomen single-incision laparoscopic gastric banding

BACKGROUND

Single-incision laparoscopic surgery (SILS) was recently implemented for performing gastric banding. However, concern exists regarding the safety of single-incision laparoscopic adjustable gastric banding (SILS-LAGB) compared to standard laparoscopy, and the operative technique is still evolving. We describe our preliminary experience of a new technique for SILS gastric banding based on a unique incision location, which allows a better view and improved dissection capability.

METHODS

During a period of 6 months, ten patients underwent SILS-LAGB in our institution. The operative technique consisted of a 4-cm skin incision placed in the right upper quadrant (RUQ), starting from the midline and extending to the right, located above the mid-distance between the xiphoid and umbilicus. Through that incision, three trocars (two 5-mm trocars and one 15 mm) are inserted. The liver retraction was achieved through the additional subxiphoid skin puncture wound using Nathanson retractor.

RESULTS

Ten patients (eight females, two males) underwent SILS-LAGB. Mean age was 31.4 years (21-49) and mean BMI 40.9 kg/m(2) (39-44). In nine out of ten patients, the procedure was completed through the original skin incision. In one case, one additional trocar was inserted due to poor surgical field visualization. The operative time declined from 80 to 60 min along the learning curve. The mean hospital stay was 1.1 days (1-2). There was no mortality or morbidity.

CONCLUSION

The location of the incision in the RUQ enabled a better view of the retrogastric tunnel and facilitated the dissection, and therefore should be of comparable safety to a standard laparoscopic procedure.

Reducing band slippage in laparoscopic adjustable gastric banding: the mesh plication pars flaccida technique

BACKGROUND

Band slippage is a significant complication of laparoscopic adjustable gastric band (LAGB) surgery for the treatment of morbid obesity. This involves prolapse of part of the stomach, with varying degrees of gastric obstruction. The original perigastric technique (PGT) was associated with slippage rates of up to 25%. The pars flaccida technique (PFT) is the more commonly used technique today, reducing slippage rates to as low as 1.4%. We report a technique not previously described, the modified PFT with the use of mesh, and compare slippage rates between these three techniques for band placement.

METHODS

A prospectively entered, retrospective review of 1,446 consecutive patients undergoing LAGB by a single surgeon was undertaken. Patients were divided into five consecutive groups: PGT learning curve (PGTLC) (n = 68), PGT (n = 19), mesh PFT (MPFT) (n = 415), mesh plication PFT (MPPFT) (n = 131), and MPPFT with inadequate follow-up (n = 813). Patient characteristics, band slippage, and other complication rates were compared between groups.

RESULTS

The slippage rates for each group were: PGTLC (10%), PGT (5%), MPFT (0.8%), and MPPFT (0%). This demonstrated a statistically significant difference between the slippage rates for each group (p < 0.001). Combining the MPFT and MPPFT groups, there was a statistically significant difference in band slippage compared to the PGT group (p < 0.001).

CONCLUSION

While the MPFT is associated with low band slippage rates, the MPPFT results in further reductions in band slippage. The routine use of this modification to the MPFT is safe and may reduce operative morbidity. A randomized comparison of these techniques is warranted.