腹腔镜可调节捆扎带胃减容术操作要点

目的探讨腹腔镜下可调节捆扎带胃减容术的安全性、可行性、有效性。方法对122例单纯性肥胖患者施行腹腔镜可调节捆扎带胃减容术（LAGB），年龄16～62岁，体重指数（BMI）32～52不等的资料进行分析。结果全组无死亡病例，并发症3例，胃排空障碍1例，经保守治疗后好转；皮下注水泵移位2例，经再次手术固定后未再移位。术后随访2～54月，减重10～70kg，平均25kg，无体重反弹及营养不良病例。结论LAGB术操作简便、手术风险小、不对胃进行任何破坏，生理改变较小，且可在体外经胃捆扎带通过水囊进行按需调节调节减重、减重效果持久而明显的优点。     

Mediastinalemphysema after laparoscopic gastric banding

From January 1996 to July 2001, 530 patients underwent a laparoscopic gastric banding operation at the University Hospital of Innsbruck. In one of these patients, a pneumomediastinum developed 17 months after surgery. Unable to swallow, the 28-year-old patient suddenly felt sick and reported left chest pain. Additionally, recurrent vomiting and later hematemesis were reported. A band migration was excluded via endoscopy. After the diagnosis of a mediastinalemphysema was established, the patient was treated conservatively. The causes of mediastinalemphysema are heterogeneous and sometimes not exactly clear. In our patient it is a question whether vomiting led to an esophageal tear, which in turn was responsible for the mediastinalemphysema.     

Gastric prolapse with pseudocysts following laparoscopic adjustable gastric banding

Introduction:

Laparoscopic adjustable gastric banding (LAGB) is a reversible method of surgical gastric restriction. Following LAGB, the adverse event most commonly necessitating subsequent reoperation is prolapse of the gastric corpus or fundus above the band. A review of the medical literature reveals no reports of nonpancreatic pseudocysts being associated with this adverse event. Nonpancreatic pseudocysts, encountered during revisional bariatric surgery should be considered a cause of irreducible gastric prolapse.

Case Report:

We report the case of a 41-year-old Caucasian female who underwent laparoscopic surgery to revise an adjustable gastric band and to repair an anterior gastric prolapse. Intraoperatively, 2 pseudocysts were found on the gastric fundus above the band in association with the gastric prolapse. The pseudocysts were resected, the gastric prolapse was reduced, and the band was left in place. The patient recovered uneventfully.

Conclusion:

Nonpancreatic pseudocysts may be associated with gastric prolapse in patients who have undergone LAGB. These pseudocysts can often be excised laparoscopically without violating the gastric lumen. This atypical presentation of gastric prolapse may pose a diagnostic and therapeutic challenge as these patients may present to an outpatient clinic or emergency room with nonspecific symptoms.     

Peritoneal oleogranulomatosis after laparoscopic gastric banding

Laparoscopic adjustable gastric banding is one of the most frequently performed bariatric operations worldwide owing to its low incidence of iatrogenic complications. Peritoneal oleogranulomatosis, a sequelae of mineral oil contact with tissues, has not been reported in the context of bariatric surgery. We present the case of a 52-year-old woman with an incidental finding of peritoneal oleogranulomatosis at laparoscopic cholecystectomy, who had previously undergone laparoscopic gastric banding. A potential mechanism linking the two is postulated and the importance of histological diagnosis highlighted, given the macroscopic resemblance to carcinomatosis peritonei.     

Esophageal dilation after laparoscopic adjustable gastric banding

BACKGROUND: Esophageal dilation can occur after laparoscopic adjustable gastric banding (LAGB). There are few studies in the literature that describe the outcomes of patients with esophageal dilation. The aim of this article is to evaluate weight loss and symptomatic outcome in patients with esophageal dilation after LAGB. METHODS: We performed a retrospective chart review of all LAGBs performed at Columbia University Medical Center from March 2001 to December 2006. Patients with barium swallow (BaSw) at 1 year after surgery were evaluated for esophageal diameter. A diameter of 35 mm or greater was considered to be dilated. Data collected before surgery and at 6 months and 1, 2 and 3 years after surgery were weight, body mass index (BMI), status of co-morbidities, eating parameters, and esophageal dilation as evaluated by BaSw. RESULTS: Of 440 patients, 121 had follow-up with a clinic visit and BaSw performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of 40.9 +/- 4.6 mm. There were no significant differences in percent of excess weight lost at any time point; however, GERD symptoms and emesis were more frequent in patients with dilated esophagus than in those without dilation. Intolerance of bread, rice, meat, and pasta was not different at any time during the study. CONCLUSIONS: In our experience the incidence of esophageal dilation at 1 year after LAGB was 14%. The presence of dilation did not affect percent excess weight loss (%EWL). GERD symptoms and emesis are more frequent in patients who develop esophageal dilation.     

Device-related reoperations after laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding (LAGB) is considered a relatively safe weight loss procedure with low morbidity. When complications occur, obstruction, erosion, and port malfunction require reoperation. We retrospectively reviewed our experience with 270 consecutive patients who underwent LAGB. Device-related reoperations were performed in 26 (10%) patients. Reoperations were related to the band in 13, to port/tubing in 11, and related to both in 2 patients. Of the 15 band-related problems, it was removed in 5 (2%): slippage (3), intra-abdominal abscess (1), and during emergent operation for bleeding duodenal ulcer (1). Revision or immediate replacement was performed in 10 (4%): slippage (5), obstruction (4), and leak from the reservoir (1). Port/tubing problems were the reason for reoperations in 13 (5%): infection (5), crack at tubing-port connection (6), and port rotation (2). Port removal for infection was followed later by port replacement (average 9 months). Overall, slippage occurred in 8 (3%), obstruction in 4 (1.5%), leak from reservoir in 7 (3%), and infection in 5 (2%) patients. Fifteen device-related problems occurred during our first 100 cases and 12 subsequently (P = 0.057). Permanent LapBand loss was only 5 per cent, leading to overall rate of 95 per cent of LapBand preservation as a restrictive device.     

腹腔镜可调节胃束带术后行胃束带取出术影响因素分析

目的 探讨哪类单纯性肥胖患者适宜采用腹腔镜可调节胃束带术.方法 回顾性分析2003年11月-2013年3月上海第二军医大学长海医院微创外科40例行腹腔镜下胃束带取出术患者的临床资料,并收集2006年1月-2008年10月行LAGB手术目前无再次手术的40例病例作为对照组进行病例对照研究.采用x2检验和多因素Logistic回归分析方法对需接受胃束带取出术常见危险因素进行分析.结果 病例组与对照组年龄、性别差异无统计学意义(P＞0.05);使用非条件Logistic回归进行分析得出体重指数≥35 kg/m2、术后就诊次数＜3次/年和存在基础上消化道疾病为胃束带取出术的危险因素(Wald值=3.908、7.375、5.209,P＜0.05).结论 胃束带取出术的主要危险因素有体重指数、术后年就诊次数、基础上消化道疾病,在使用该术式治疗单纯性肥胖时应充分考虑上述因素.     

腹腔镜可调节胃束带术后并发症及治疗

目的探讨腹腔镜可调节胃束带术（LAGB）后并发症及治疗方法。方法回顾性分析2005年9月至2011年6月天津市南开医院行LAGB随访2年以上的83例肥胖症患者的临床资料。腹腔镜下放置胃束带,使束带上方形成1个容量约20～30ml胃小囊,将注水泵埋于剑突下腹直肌前鞘浅面。在术后4周根据患者体质量变化、餐后症状及上消化道造影情况,对胃束带进行注水调节。采用门诊和电话方式进行随访,随访时间截至2013年7月。结果83例患者并发症发生率为44．6％（37／83）,其中早期并发症（1个月内）6例、远期并发症31例。早期并发症主要表现为进食后呕吐,5例患者通过减慢进食速度、减少进食量后缓解;1例患者症状严重,予禁食水并营养支持,5d后症状缓解。远期并发症中,25例患者发生束带腐蚀胃壁并向胃腔内移位（其中6例合并注水泵处感染）,通过腹腔镜手术（早期1例行开腹手术）将胃束带取出,并缝合胃壁穿孔处获得治愈;10例患者发生注水泵相关并发症（6例为上述注水泵感染者,4例为注水泵移位）,通过手术将注水泵取出;2例发生束带滑动移位,通过抽净注水泵内生理盐水,改为流质饮食,减少进食量后,1例患者束带位置恢复正常,另1例患者无变化,行腹腔镜手术取出胃束带。结论LAGB术后并发症发生率较高,并随着术后时间的延长而增高,远期并发症多数需要再次手术治疗。     

Revisional surgery after failed laparoscopic adjustable gastric banding

BackgroundLaparoscopic adjustable gastric banding (LAGB) is a restrictive procedure that achieves weight loss without anatomic alteration. However, morbidity requiring surgical reintervention can occur.MethodsA retrospective review of a prospectively maintained database of primary LAGB and revisional surgery after failed LAGB was performed from January 2001 to October 2006 at an academic private clinic.ResultsOf 2467 bariatric procedures, primary LAGB was performed in 242 patients. A total of 53 revisional procedures were performed in 40 patients and 16 in 9 patients who were referred from other centers after failed primary LAGB. The mean follow-up was 45.7 ± 15.8 months (range 9.5–70). The early surgical reintervention rate was 6.1%. The revisional procedures included band removal only in 27 (39%), band removal and conversion to sleeve gastrectomy in 10 (14.5%), band removal and conversion to Roux-en-Y gastric bypass in 5 (7.2%), band repositioning in 7 (10%), device-related reintervention in 6 (8.7%), subsequent conversion to another bariatric procedure in 3 (4.3%), and other procedures in 11 (15.9%). Of the 49 patients, 21 (43%) presented with acute band-related morbidity. A total of 55 procedures (96.5%), amenable to minimal invasive surgery, excluding wound and port site-related procedures, were completed laparoscopically. The major early and late complication rate was 4.1% and 2%, respectively.ConclusionPrimary LAGB was associated with acceptable major early complication and surgical reintervention rates. However, a late surgical reintervention rate of 15.2% was observed. Band removal was required in 14% of our primary LAGB patients because of band-related morbidity, with conversion to another bariatric procedure in 6.2%. Our results have shown that LAGB can be associated with significant morbidity and that revisional surgery is common.     

Port function after laparoscopic adjustable gastric banding for morbid obesity

Background: Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited. Methods: In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years. Results: Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m². Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).Conclusion: The high number of complications suggests that the port is the Achilles heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.     

Surgical revision after failure of laparoscopic adjustable gastric banding

BACKGROUND: This paper reports the outcome of surgical revision for complications following laparoscopic placement of an adjustable silicone gastric band (AGB) to treat morbid obesity. METHODS: Seventy-three (19.1 per cent) of 382 patients who underwent laparoscopic AGB placement between January 1996 and March 2001 presented with complications within 6 years after operation. Revision was carried out with the intention of reinstating the functional device in all patients. RESULTS: Successful surgical revision or gradual balloon deflation was performed in 53 patients (29 port-related complications, 14 pouch dilatations, 12 band leakages, three oesophageal dilatations, two symptomatic hernias, one late migration, one intracerebral bleed). Of these patients, 51 (96.2 per cent) had a successful outcome according to the Bariatric Analysis and Reporting Outcome System following significant additional postinterventional weight loss. AGB removal was carried out in 20 patients (13 early or late migrations, five pouch dilatations, three port-related complications, two psychiatric disorders, one band leakage). The final failure rate for complicated AGB procedures was 30.1 per cent. CONCLUSION: AGB placement is associated with a variety of complications. In most cases surgical complications can be treated with minimally invasive surgery, which should allow further weight loss and improvement of quality of life during long-term follow-up. Alternative bariatric procedures should be reserved for patients with poor outcome after surgical revision of the AGB.     

Prevention of catheter disconnection after laparoscopic adjustable gastric banding

In a consecutive series of 138 laparoscopic adjustable gastric bandings (LAGB) we observed disconnection of the gastric band catheter at the site of the port connector in 17 patients. During operative revision we established a new port position with a minimal distance of 10 cm between the connector and the entrance of the catheter to the abdominal cavity. Using this technique no complications and no catheter disruptions occurred during a median followup period of 25 months.     

Causes of early mortality after laparoscopic adjustable gastric banding

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is 1 of the most used surgical procedures to treat obesity, with > 120,000 bands positioned around the world. LAGB is considered a safe and technically simple procedure, but it has many longterm complications, such as erosion, bleeding that requires reoperations, and sometimes even death of the patient. STUDY DESIGN: This article reviews the deaths after LAGB reported in the literature. Eight hundred eighty articles were reviewed from 1994 to May 2006, using the PubMed Web site and French, English, and Australian health Web sites. RESULTS: Data from 9,682 patients were collected from 24 articles and 48 (0.51%) deaths were reported. Twenty-eight patients died within 30 days of the operation, including 3 intraoperative deaths; 16 patients died 30 or more days after operation; and in 4 patients, the timing of death was not stated in the articles. Pulmonary embolism was the most frequent cause of death, in 11 (22.9%) patients, followed by myocardial infarction in 6 (12.5%) patients. Nine (18.7%) deaths were directly related to band positioning. Longterm mortality rates from LAGB, or reoperations from inadequate weight loss, could not be assessed. CONCLUSIONS: Although technically simple, LAGB has both short- and longterm complications that can be fatal for patients. We recommend surgeons consider perioperative pulmonary embolism prophylaxis and preoperative coronary evaluations on all patients.     

Analysis of poor outcomes after laparoscopic adjustable gastric banding

Background  

Recent studies document excess weight loss (EWL) of more than 50% with the laparoscopic adjustable gastric band (LGB). This study reviews the LGB experience at an urban academic center in terms of complications, reoperative rates, and comorbidities.     

Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity

BackgroundLaparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.MethodsA retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.ResultsOf 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.ConclusionAlthough reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.