Outcomes after laparoscopic adjustable gastric band repositioning for slippage or pouch dilation

Hiatus Hernia as a Complication of Gastric Banding: A Systematic Review and Meta-Analysis

Worsening hiatus hernia (HH) symptoms have been well recognized as a complication of gastric banding, however, it has not yet been explored whether gastric banding plays a role in the development of HH de novo in patients undergoing gastric banding. From the 696 studies identified, five studies met the eligibility criteria and were included. Data was extracted from PubMed, Embase, Medline, HMIC, and Web of Science databases. The pooled complication rate was evaluated along with 95% confidence intervals (95% CIs). The meta-analysis was performed using the Cochrane RevMan tool (Cochrane, London, UK). Heterogeneity was tested using the I² index for each outcome. All the included studies assessed HH incidence among followed-up patients who needed a re-operation for upper gastrointestinal symptoms. Between-study variability was high (I² = 94%, Chi² = 68.92, df = 4, < 0.00001, Tau2=1.91). Complication rate ranged between 0.24% to 5.55%; pooled complication rate was 2.17% CI 95% (0.90 - 3.44%) P = 0.0008. The included studies show a comparable rate of post-operative HH; the fact that HHs can become symptomatic following the adjustable gastric banding (AGB) procedure indicates that AGB plays a role in creating symptomatic hiatal hernias at the very least. Further research is needed to underpin the mechanism and confirm causation. However, this complication should potentially be discussed with patients opting for this kind of operation as it can be a reason for re-operation.

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

INTRODUCTION

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

METHODS

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

RESULT

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

CONCLUSION

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

Laparoscopic adjustable gastric banding on 3566 patients up to 20-year follow-up: Long-term results of a standardized technique

BACKGROUND

As obesity is a chronic disease, any bariatric procedure should be validated by long-term results.

OBJECTIVE

To present our long-term results after laparoscopic adjustable gastric banding over a period of >20 years and to investigate the outcomes in terms of efficacy, complications, and reoperations.

SETTING

Private practice, Italy.

METHODS

From October 1995 to February 2018, 3566 laparoscopic adjustable gastric banding were performed by a single surgeon. Data were retrieved from a prospectively collected computer database and retrospectively analyzed. Furthermore, patients were stratified according to body mass index and age and results are evaluated for each subgroup.

RESULTS

All the operations were performed laparoscopically without any mortality and/or major specific complications. Nine hundred twenty-six patients (71.6%) completed at least 10-years follow-up and 180 (58.4%) reached 15-years follow-up. There was a mean of 49%, 52.6%, and 59.2% of excess weight loss at 10, 15, and 20 years, respectively. Major late complications were pouch herniation-dilation (5.8%) and erosion (2.5%), both solved by a replicable, less invasive operation. Total reoperation rate was 24.1%.

CONCLUSION

Our experience suggested that the combination of a standardized surgical technique and close patient follow-up, performed in collaboration with an interdisciplinary team, may make the laparoscopic adjustable gastric banding system a powerful long-term surgical tool in the treatment of morbid obesity. The best results were obtained in young patients with high body mass index but results were also satisfactory in elderly patients and in those with low body mass index.

Management modalities in slipped gastric band

BACKGROUND

Gastric band slippage is one of the possible complications of the laparoscopic gastric band (LGB). Band slippage can present as an emergency and have drastic consequences. We herein report the different treatment modalities of slipped gastric band.

MATERIAL AND METHODS

A retrospective study of all patients presenting with slipped gastric band between May 2013 and January 2015 at our University hospital is described. All patients were evaluated at the time of presentation by radiological studies and upper gastrointestinal endoscopy. On diagnosis, all bands were deflated in an attempt to relieve symptoms. After patient counseling and band position evaluation, patients were consented for either removal or repositioning of the band.

RESULTS

This study included 100 patients. Gastric band slippage rate was 8%. All patients presented with signs of gastric obstruction and expressed a long history of intermittent vomiting attacks. All patients were subjected to a complete gastric band deflation on presentation. Band deflation successfully relieved symptoms and reversed band slippage in 2 patients. However, both patients returned with band reslippage within the same month. The other 6 patients had persistent band slippage despite complete band deflation. Three of the 8 patients had a successful band repositioning, and the rest had their gastric bands removed.

CONCLUSION

Gastric band slippage can be a serious LGB complication. Repeated vomiting can be a significant risk factor for band slippage. Moreover, band repositioning can be a well-tolerated and feasible option in the management of slipped gastric band.

Sustained weight loss after gastric banding revision for pouch-related problems

OBJECTIVE

To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months.

BACKGROUND

There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose.

METHODS

A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation.

RESULTS

Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision.

CONCLUSIONS

Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Location and number of sutures placed for hiatal hernia repair during laparoscopic adjustable gastric banding: does it matter?

BACKGROUND

It has been demonstrated that hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects (location and number of sutures) are not standardized. It is unknown whether such technical details are associated with differing rates of reoperation for band-related problems.

METHODS

A retrospective analysis was performed from a single institution, including 2,301 patients undergoing LAGB with HHR from July 1, 2007 to December 31, 2011. Independent variables were number and location of sutures. Data collected included demographics, operating room (OR) time, length of stay (LOS), follow-up time, postoperative BMI/%EWL, and rates of readmission/reoperation. Statistical analyses included ANOVA and Chi squared tests. Kaplan-Meier, log-rank, and Cox regression tests were used for follow-up data and reoperation rates, in order to account for differential length of follow-up and confounding variables.

RESULTS

There was no difference in length of follow-up among all groups. The majority of patients had one suture (range 1-6; 55 %). Patients with fewer sutures had shorter OR time (1 suture 45 min vs. 4+ sutures 56 min, p < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant. Anterior suture placement (vs. posterior vs. both) was most common (61 %). OR time was shorter in those with anterior suture (41 min vs. posterior 56 min vs. both 59 min, p < 0.0001). Patients with posterior suture had a longer LOS (84 % 1 day vs. anterior 74 % 1 day vs. both 74 % 1 day, p < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postoperative BMI/%EWL.

CONCLUSIONS

Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postoperative weight loss were unaffected by number or location of suture. The technical aspects of HHR did not appear to be associated with readmission or reoperation, and therefore a standardized approach may not be necessary.

Insulin sensitivity and secretion modifications after bariatric surgery

Type 2 diabetes mellitus is increasing over time as result of the obesity epidemics. In fact, the prevalence of Type 2 diabetes across Europe in 2010 was estimated to be 8.2% of the population and its projection for 2030 sees figures of 10.1%. This increase in the number of diabetic individuals has also dramatically raised the health expense, with spending on diabetes in Europe in 2010 accounting for 10% of the total healthcare cost. A meta-analysis of the literature evidenced that the clinical and laboratory manifestations of Type 2 diabetes are resolved in 78.1%, and are improved in 86.6% of obese patients (body mass index >35 kg/m²) after bariatric surgery. However, a gradation of effects of different surgical techniques in improving glucose control does exist, with the largest and durable effects observed in prevalently malabsorptive procedures. The outcome of bariatric surgery on insulin sensitivity and secretion is different in relation to the type of operation performed. In fact, while Roux-en-Y Gastric Bypass enhances insulin secretion after a meal thus improving glucose metabolism, Bilio-Pancreatic Diversion acts through the amelioration of insulin sensitivity allowing a subsequent reduction of insulin hypersecretion, which is a typical feature of the insulin resistance state. Gastric banding action is mediated uniquely through the weight loss, and the effect of sleeve gastrectomy is still to be elucidated. Incretin secretion is dramatically increased under nutrient stimulation after gastric bypass leading, probably, to an overstimulation of pancreatic β-cells resulting in the increase of insulin secretion.

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.

Laparoscopic revision of gastric band surgery

AIM

To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL).

METHODS

Analysis of a prospective database was then performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure.

RESULTS

All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage excess weight loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow-up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow-up for those who had the existing band repositioned, and 42% at an average of 23 months follow-up for those who had a new band repositioned.

CONCLUSION

Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow-up period of 19 months.

Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding

BACKGROUND

With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States.

METHODS

We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass.

RESULTS

Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%.

CONCLUSION

Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass.