Reducing complications with improving gastric band design

Reports of Gastric Banding and Bowel Obstruction: A Narrative Review of the Literature

The utilization rates of laparoscopic gastric banding (LAGB) declined worldwide from 42.3% in 2008 to 1.8% in 2018. Rates of complications requiring removal may reach 40-50% in the medium to long term. Bowel obstruction is a rare but severe complication that occurs after LAGB. A comprehensive literature search in PubMed was carried out to identify all available case reports of intestinal obstruction after gastric banding. The search terms were as follows: "intestinal obstruction", "small bowel obstruction", "gastric band", "gastric banding", "gastric band complications", and "laparoscopic gastric band obstruction". The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flowchart was used. Forty-three case reports were included in our review. Laparotomy was necessary in 18/43 (41%) of patients. Vomit was not always reported, while abdominal pain was constantly present. A CT scan was the preferred diagnostic tool. The main causes of occlusion were found to be the erosion of the gastrointestinal tract or internal hernia due to a loose tube loop. Forty-six percent of cases occurred within 5 years from insertion. Even if rare, small bowel obstruction after LAGB requires surgical intervention often with an open approach. The absence of vomit masks symptoms, but an obstruction must be always suspected in the case of severe colicky abdominal pain. A CT scan is recommended for making diagnoses.

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.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding

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Although most complications following LAGB are confined to the stomach and port site, some may envolve the entire bowel causing extensive damage.

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One must be wary of the presentation of long term complications, as it may initially present as an unrelated pathology, such as acute pancreatitis.

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Long term complications may be asymptomatic for years despite extensice damage, including multiple contained perforations.

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The surgical procedure performed to treat long term complications should be planned and performed by physicians experienced in foregut surgery.

Introduction

Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported.

Presentation of case

A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum.

Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21.

Discussion

Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature.

Conclusion

Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Is there an indication left for gastric band? A single center experience on 178 patients with a follow-up of 10 years

Background

Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL < 25%) and rate of band removal.

Methods

Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss.

Results

After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL < 25), 32 (18%) had an insufficient weight loss (25 < %EWL < 50) and 34 (19.1%) underwent band removal. Among these, 6 (3.4%) were removed for complications and 28 (15.7%) for insufficient weight loss. Weight regain occurred in 38 out of 144 (26.4%) subjects with the band in place at 10 years. Only one case of early vomiting with readmission for medical treatment was recorded. Slippage, erosion/migration and port/tube complications occurred in 4 (2.2%), 2(1.1%) and 9(5%) cases respectively.

Conclusion

LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

Laparoscopic adjustable gastric banding, the past, the present and the future

The laparoscopic implantation of an adjustable gastric banding (LAGB) was first described in 1993. Thereafter, the LAGB underwent to a lot of modifications, revision and refinements to become as it is currently defined. This procedure quickly became one of the most common bariatric surgical operations in the world in the first decade of the 2000s but, over the last few years, it has turned into the fourth more common procedure. A series of more or less clear reasons, led to this decrease of LAGB. The knowledge of the history of the LAGB, of its evolution over the years and its limitations can be the key-point to recognize the reasons that are leading to its decline. The adjustability and the absolute reversibility characteristic of LAGB, make this surgical procedure a “bridge treatment” to allow the specific goal of eradicating obesity.