Esophageal Dilatation after Laparoscopic Adjustable Gastric Banding: Definition and Strategy

Background: Laparoscopic adjustable gastric banding (LAGB) has become a method of choice worldwide to treat morbid obesity. Long-term complications such as esophageal dilatation require that a relevant strategy for treatment be defined. Esophageal dysmotility is commonly described in morbidly obese patients. Methods: 1,232 patients have undergone LAGB over 9 years (1995–2004), and 162 (13.1%) have had a reoperation for complications (excluding access-port problems): slippage (109), erosion (28), intolerance (25). 80 patients (6.4%) had their band removed, and 10 had a switch to another procedure. Esophageal dilatation has been an isolated cause for removal in 2 patients and an associated cause in 6 patients. Results: There was no significant correlation between esophageal dilatation and insufficient excess weight loss (<25%) after 5 years (37/257:14.3%). 4 stages of dilatation were identified, with the relevant treatment for each, the ultimate alternative being conversion to a laparoscopic gastric bypass. We suggest that esophageal dilatation be a separate issue from pouch dilatation and gastric erosion, and that it be classified as a complication only in severe cases requiring band removal. Most cases can be handled through deflation of the band under radiological control. Conclusion: LAGB can lead to significant esophageal troubles which must remain under scrutiny but generally respond to "radiological management", which also makes LAGB more demanding than other operations in terms of follow-up.     

Adjustable Gastric and Esophagogastric Banding: A Randomized Clinical Trial

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands? were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.     

Esophageal Perforation during Laparoscopic Gastric Band Placement

Esophageal perforation is a serious complication that requires prompt recognition and treatment. We present the case of a patient with lower esophageal perforation that apparently resulted from orogastric calibration-tube passage during laparoscopic placement of a gastric band. The complication was diagnosed early postoperatively, and was able to be successfully treated by laparoscopy,debanding, drainage, and parenteral nutrition.     

Laparoscopic Gastric Banding in Adolescents

Background: Adolescent obesity has undesirable short- and long-term effects. Laparoscopic adjustable gastric banding has been considered a procedure of choice for adolescent morbid obesity. We retrospectively evaluated our single-team banding experience in the adolescent population. Methods: We reviewed the medical and clinic records and conducted telephone questionnaire interviews, to evaluate the results of banding using the Swedish adjustable gastric band (SAGB^?) in the 60 adolescents at our institution who had been followed ≥3 years. Results: An average of 39.5 months of follow-up has been conducted in the patients who have been followed ≥3 years. Mean age at the time of the operation was 16 years (9 to 18). 60% reported a family history of obesity. Associated co-morbidities included hypertension, diabetes, sleep apnea and asthma. Mean preoperative BMI was 43 (35-61) kg/m². Mean postoperative BMI after 39.5 months follow-up was 30 (20-39) kg/m². No co-morbidities have existed after the operation. 6 patients (10%) underwent band repositioning and 2 patients underwent band removal, due to slippage; 7 of the 8 slippages occurred with an earlier perigastric technique which transgressed lesser sac. There was no mortality. Average postoperative hospital stay was 24 hours. Conclusions: Gastric banding in adolescents is a safe, satisfactory and reversible weight reduction procedure.     

Thirty Months Experience with Laparoscopic Adjustable Gastric Banding

Introduction: Since June 1996 we performed laparoscopic adjustable silicone gastric banding (LASGB), because of low invasivity,absence of malabsorption, reversibility, and postoperative regulation. Materials and Methods: Criteria included body mass index (BMI) >40 or >35 with serious obesity-related conditions. 154 patients underwent LASGB. BMI ranged from 35 to 65.7 (mean 43.7±6.2). Results:The laparoscopic procedure was successfully completed in 150 patients (97.4%). One patient was converted to the laparotomic procedure because of hepatomegaly; 4 patients had to be converted for gastric laceration during the laparoscopic approach. In one of these patients, the band was removed 7 days later for sepsis, followed by an uneventful post-operative course. The mean length of postoperative hospitalization was 2.3±0.9 days. Per cent of excess weight loss was 42.5±22.4 after 1 year. Conclusions: LASGB was feasible and effective.     

Outpatient Laparoscopic Gastric Banding: Initial Experience

Background: Laparoscopic adjustable gastric banding (LAGB) has usually been performed as an inpatient procedure with an average hospital stay of 2-4 days. The aim of this study was to assess the feasibility of LAGB as an ambulatory procedure in selected patients. Methods: Potential candidates for ambulatory LAGB were recruited from patients consulting for obesity surgery. The main inclusion criteria were BMI >35 kg/m² with co-morbid conditions, living within a reasonable distance from the hospital, and adult company at home. The patients were admitted at 0700 hours on the day of surgery, underwent laparoscopic placement of a Lap-Band^? system and were discharged home that evening. Results: 9 women and 1 man underwent outpatient LAGB. Mean age was 36 (range 18-52) years and mean BMI was 38.4 kg/m² (range 35.1-43.3). Co-morbidities included functional dyspnea (6), osteoarthritis (4), arterial hypertension (4), type 2 diabetes (2) and dyslipidemia (1). 7 patients had undergone previous abdominal surgery: cesarian section (4), appendectomy (3), cholecystectomy (1) and hysterectomy (1). All patients had an American Society of Anesthesiologists (ASA) classification of II. The average operating time was 87 minutes (range 65-115). The mean time lapse between the end of the operation and discharge from hospital was 9.6 hours. There were no readmissions, and no complications were noticed at 1 month postoperatively. The patients' satisfaction with the ambulatory LAGB procedure was high. Conclusion: The present study demonstrates that LAGB for obesity may be performed on an ambulatory basis without complications.     

Gastric Bezoar Complicating Laparoscopic Adjustable Gastric Banding with Band Slippage

Gastric bezoars may develop in the proximal pouch after gastric restriction, eg. by laparoscopic adjustable gastric banding (LAGB). To date, only two centers have reported this rare complication. We report an additional case with band slippage, to emphasize that bezoars should be considered in the differential diagnosis in patients presenting with new onset nausea and vomiting after LAGB.     

Long-Term Pulmonary Complications after Laparoscopic Adjustable Gastric Banding

Early pulmonary complications following laparoscopic adjustable gastric banding (LAGB) have been rare, while long-term pulmonary complications have not been reported. Herein, we report two patients who presented 2 and 3 years after LAGB with unexpected pulmonary complications. The first patient had aspiration pneumonia secondary to stomal obstruction and esophageal reflux. The second patient had left lobar pneumonia, in which the connecting catheter appeared as a linear structure within the consolidation. This may be due to migration of the connecting catheter through the diaphragm, piercing lung parenchyma. Both complications presented as asthma-like symptoms. Diagnosis could have been missed if not evaluated properly. A high index of suspicion and long-term follow-up are important for diagnosing such complications after LAGB.     

Late Gastric Prolapse with Pouch Necrosis after Laparoscopic Adjustable Gastric Banding

One of the most significant complications of the gastric banding procedure is gastric prolapse. However, pouch necrosis after gastric prolapse is an extremely rare complication. We present the case of a morbidly obese 41-year-old woman who had had a laparoscopic adjustable gastric banding procedure 3 years before. She developed a pouch necrosis after a late gastric prolapse. After failure of conservative treatment, a diagnostic laparoscopy was performed. This resulted in removal of the band and the diagnosis of pouch necrosis. A laparotomy was indicated and a sleeve gastrectomy was performed. A delay in the diagnosis of gastric prolapse can lead to major complications. Initial referral to a specialized center is necessary for proper care of this complication. Failure of conservative treatment mandates early operative intervention.     

Prevention of Pouch Dilatation after Laparoscopic Adjustable Gastric Banding

Background: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. Methods: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. Results: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. Conclusion: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.     

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.     

Gastro-esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients

Background: Morbid obesity has long been considered as a contributing factor to gastro-esophageal reflux, but the literature contains conflicting data on the subject. The authors studied a large number of morbidly obese candidates for bariatric surgery with objective means, in order to better define the incidence of gastro-esophageal reflux disease (GERD) and esophageal motility disorders in this population. Methods: Morbidly obese patients, in whom indication for bariatric surgery was confirmed after complete evaluation, were included consecutively during a 4-year period. The evaluation included history of reflux symptoms, upper GI endoscopy, 24-hour pH monitoring, and stationary esophageal manometry. Results: 345 patients were studied, of whom 35.8% reported reflux symptoms. Endoscopy showed a hiatus hernia in 181 patients (52.6%), and reflux esophagitis in 108 (31.4%). 24-hour pH monitoring revealed an elevated De Meester score in 163 patients (51.7%). Manometry was normal in 247 patients (74.4%), and showed a decreased lower esophageal sphincter pressure in 59 (17.7%). Esophagitis and abnormal pH testing were more common in patients with symptoms or hiatus hernia, and the incidence of esophagitis was higher with abnormal pH testing. Esophagitis was associated with increased weight and abdominal obesity. Conclusions: This study confirms the increased prevalence of GERD in the morbidly obese population. Upper GI endoscopy should be performed routinely during evaluation of morbidly obese patients for bariatric surgery. When both conditions coexist, effective treatment is probably best provided by Roux-en-Y gastric bypass, which produces effective weight loss and correction of pathological reflux.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Aberrant Left Hepatic Artery in Laparoscopic Gastric Banding

Background:The aberrant left hepatic artery (ALHA) is an anatomic variation which may be an obstacle in the laparoscopic gastric banding operation. Based on our experience, our mission was to answer the questions: How frequently is an ALHA encountered? Is division necessary? Are there any additional complications in cases where the ALHA is preserved? Methods: In a prospectively collected database of 270 patients undergoing laparoscopic gastric banding in our unit, information including presence of an ALHA, clinical data, diagnostic work-up, operative reports, laboratory data, and follow-up data were collected. Results: In 48 patients (17.7%) (39 women, 9 men, mean age 39.2 years) an ALHA was observed. Hiatal dissection was not impaired in any of these patients, and none required division of the ALHA. In all but two cases, the band was placed above the ALHA, offering additional stability to the band positioning. In 2 patients (4.1%), the artery was injured during dissection and was divided due to ongoing bleeding. Twenty-two (45.8%) of the ALHAs were of intermediate or large size. Neither pouch dilatation nor band slippage occurred in the above-mentioned group. The two patients with divided hepatic arteries had no postoperative symptoms related to impaired liver function. Conclusions: ALHA is not an uncommon finding during laparoscopic gastric banding and may be found in approximately 18% of patients. Division can nearly always be avoided and may be required only in selected cases due to bleeding. Patients do not experience clinical complications after division, although liver enzymes may be temporarily elevated, and no monitoring is necessary.     

Access-Port Complications after Laparoscopic Gastric Banding

Background: The aim of this retrospective study was to identify complications related to the access-port, after Lap-Band^? system placement by laparoscopy. Methods: The records of 333 morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) were reviewed for the overall surgical complications. Data was further analyzed regarding the complications related to the access-port. Results: From January 1999 to December 2001, the overall complication-rate with the LAGB was 25.8%. 45 complications (13.5%) were related to the accessport in 34 patients following LAGB placement.The 45 access-port complications were distributed as follows: infection 51.1%, tubing disconnection 17.7%, dislodgment of the access-port 15.6%, leak of the reservoir 11.1%, and skin ulceration by the port 4.45%. Conclusion: The integrity of the Lap-Band^? system is essential to achieve the objective of the operation: weight loss. Complications related to the access-port were relatively frequent, but preventable.     

Port Complications following Laparoscopic Adjustable Gastric Banding for Morbid Obesity

Background: Laparoscopic adjustable gastric banding (LAGB) has gained widespread acceptance. However, the technique has problems intrinsic to the material wear and tear around the port and connecting tubing that can lead to failure. Port complications are considered to be minor; however, few studies have analyzed them, and the optimal technique of port implantation and management has not been elucidated. Methods: All patients who suffered from complications involving the tubing or access-port were included in this study. Their complaints, imaging studies, operative reports and hospitalization files were retrospectively reviewed. Results: 1,272 of the patients were available for a mean follow-up period of 37 months. During this time, 91 patients (7.1%) experienced port complications that required 103 revisional operations. Of these patients, 62 had system leaks, 19 infectious problems, and 10 miscellaneous problems requiring operative correction. Overall port problems led to band removal in 6 patients, and replacement in 1 patient. Conclusion: Access-port complications after the Lap-Band? procedure are among the most common and annoying ones, and can render the device susceptible to failure. Careful surgical technique and routine use of radiologic guidance for band adjustments are the keys to avoiding complications.     

The Influence of Laparoscopic Adjustable Gastric Banding on Gastroesophageal Reflux

Background: Laparoscopic adjustable gastric banding (LAGB) influences gastroesophageal reflux. Methods: 26 patients undergoing gastric banding were assessed by a questionnaire for symptom analysis, 24-hour pH monitoring, endoscopy and barium swallows, preoperatively, at 6 weeks and at 6 months after operation. Results: Gastric banding had minimal effect on heartburn scores, but regurgitation and belching scores increased significantly during follow-up. Use of acid-reducing drugs decreased significantly at 6 weeks and increased significantly at 6 months. Pathological reflux was present in 13 of the 26 patients preoperatively. At 6 months pathological reflux was found in only 6 of these 13 patients, but 4 of the 13 patients with preoperative normal reflux patterns had developed pathological reflux. 6 months after the operation esophagitis had disappeared in 6 patients and was increased in 9 patients. In 9 patients, a pouch was found at 6 months. Pouch formation was significantly correlated with the presence of pathological reflux, esophagitis and the use of acid-reducing medication. Preoperative presence of a hiatal hernia did not influence pouch formation or pathological reflux. Conclusion: LAGB decreases gastroesophageal reflux if there is no pouch formation during follow-up.     

Pregnancies after Adjustable Gastric Banding

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.     

Re-operations Following Laparoscopic Adjustable Gastric Banding

Background: Re-operations after laparoscopic adjustable gastric banding operation (LAGB) are band-associated or due to complications of the access-port. Symptoms, diagnostics, operations, and follow-up of patients with re-operations were analyzed. Methods: Between December 1996 and January 2002, 250 morbidly obese patients were treated with LAGB and prospectively evaluated using a standardized protocol. Since June 2000 the pars flaccida technique was applied, since October 2000 with the new 11-cm Lap-Band^?. All adjustments of the band were done under radiological control. Results: Of 250 patients, 39 had to be re-operated because of band-associated complications: 27 laparoscopic re-gastric bandings after 12 (3-26) months because of slippage; 6 laparoscopic removals of the band (band intolerance- 4, pain- 1, pouch dilatation- 1); 12 biliopancreatic diversions with duodenal switch (BPD-DS) after 29 (18-43) months due to pouch and/or esophageal motility disorders (9) or insufficient weight loss (3), in 6 patients after having already performed a re-banding for slippage. 9 revisions of the access-port were done after 6 (2-53) months (disconnection- 3, dislocation- 6). The morbidity of the re-operations was 5.3%: 1 hematoma in the abdominal wall and 1 temporary dysphagia after re-banding, 1 pulmonary embolism following BPD-DS. There have been no deaths. In patients with a minimal follow-up of 3 years (n=92), the yearly re-operation rate was 11-12%. No slippage has occurred with the new 11-cm Lap-Band^?. Conclusion: Re-operations after LAGB for bandassociated complications were frequent but could be performed safely with little morbidity. When the new 11-cm Lap-Band^? was employed, the high slippage rate dropped.     

Laparoscopic Gastric Banding in Morbidly Obese Adolescents

Background: 4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents? Methods: Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery,then at 3 monthly intervals.Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss. Results: 17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m² at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI <35 kg/m² at 24 months following surgery. Conclusion: LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.