A simple technique for laparoscopic removal of silicone adjustable gastric banding

Conversion of failed gastric banding into four different bariatric procedures

BACKGROUND

The most common bariatric 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. The optimal conversion technique is unknown. Our objective was to report our experience in the conversions of failed laparoscopic gastric banding procedures to 4 different bariatric procedures at a university hospital.

METHODS

From March 2006 to December 2010, 630 bariatric operations were performed. Of these patients, 45 underwent conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7). Using a prospectively collected database, we analyzed these procedures.

RESULTS

The 45 patients underwent laparoscopic conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7) to 4 different procedures. Of the 45 patients, 18 underwent conversion to laparoscopic sleeve gastrectomy, 18 to laparoscopic Roux-en-Y gastric bypass, 7 to laparoscopic biliopancreatic diversion with duodenal switch, and 2 to laparoscopic biliopancreatic diversion. All conversions but 1 were completed laparoscopically. The mean operating time and hospital stay for laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic biliopancreatic diversion with duodenal switch, and biliopancreatic diversion was 111 ± 28 minutes and 4.3 ± 1.4 days, 195 ± 59 minutes and 3.9 ± 1.5 days, 248 ± 113 minutes, and 5.9 ± 2.6 days, and 203 minutes and 6.5 days, respectively. No patient died. Perioperative complications occurred in 4 patients (9.8%). The mean body mass index decreased from 41.5 ± 8 kg/m(2) to 31.3 ± 6.8 kg/m(2) during a mean follow-up period of 13.7 ± 9.6 months. Although laparoscopic biliopancreatic diversion with and without duodenal switch had the greatest preoperative body mass index, they achieved the greatest excess weight loss.

CONCLUSION

Conversion of LAGB or nonadjustable gastric banding to laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with or without duodenal switch is feasible and effective to treat the complications of LAGB and to further reduce the weight of morbidly obese patients.

Use of standard hypodermic needles for accessing laparoscopic adjustable gastric band ports

BACKGROUND

Laparoscopic adjustable gastric banding is a common and successful method of surgically treating morbid obesity. A recipient will have to attend their surgeon's rooms a number of times to optimally adjust the amount of fluid in the band and hence the amount of restriction. Manufacturers suggest that the ports should be accessed with special non-coring needles that may not always be available in regional or remote centers, and this could create a safety risk in cases where urgent band deflation is required.

METHODS

Ports of two different brands were repeatedly accessed over 100 times in the same location while containing fluid under pressure, using a standard beveled 21 g hypodermic needle (SN) and a 20 g Huber tipped non-coring needle (NCN). The path the needles types took through the port septum was also examined.

RESULTS

There was no leakage of fluid from any of the ports tested. Neither SN nor NCN passed through the port septum down their axis, but rather in a direction closer to that of their beveled surface.

CONCLUSIONS

There is no more risk of "coring" the septum with a SN than with a NCN. SN can be used safely and routinely to access laparoscopic adjustable gastric band ports.

Management of band erosion with omental plugging: case series from a 5-year laparoscopic gastric banding experience

BACKGROUND

Although reports on band erosion management after laparoscopic adjustable gastric banding (LAGB) agree that in most cases the affected band will need to be removed, there is no consensus on the technique of removal. We report a minimalistic, laparoscopic technique which is safe and avoids management delay.

METHODS

We retrospectively reviewed the operative log of our obesity surgery unit to find all operations performed on LAGB patients for erosion from Jan 2003 to Dec 2007. The cases that underwent this particular technique were identified. Case notes and electronic records were then reviewed for postoperative morbidity and outcomes. The operative technique and indications of this particular method is described which to our knowledge has not been reported before.

RESULTS

From 2003 to 2007, there were 865 LAGB performed. We identified 17 operations performed for erosions in this period; some referred from elsewhere. Among these, an omental plugging technique was used in five patients (median preoperative body mass index 46.5; median age 47; all female). Median timing of presentation was 8 months, with pain/pyrexia in all five (with coexisting obstructive symptoms in four) patients. At endoscopy, three were posterior, partial erosions. Intraoperatively, all were partial erosions (three posterior and two anterior). In theater, we removed the band in all cases and closed the defect with a vascularized omental plug, fashioned using a harmonic scalpel. There were no immediate postoperative complications. On follow-up, two patients stayed the same weight, but in three, the weight increased leading to two needing rebands (at 6 and 8 months).

CONCLUSIONS

Omental plugging is a way of managing LAGB erosion, which in our hands has led to an uneventful postoperative course and future rebanding without undue delay. It is suited patients with incomplete erosion when the endoscopic option is difficult, thereby removing the need for a surveillance period awaiting complete band erosion.

Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty

BACKGROUND

The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG.

METHODS

A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG.

RESULTS

Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m(2) (range 35.9-63 kg/m(2)), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4-76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion).

CONCLUSION

Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.