Erosions after laparoscopic adjustable gastric banding: diagnosis and management

Foregut Erosion Related to Biomedical Implants: A Scoping Review

Introduction: Biomedical devices implanted transabdominally have gained popularity over the past 50 years in the treatment of gastroesophageal reflux disease, paraesophageal hiatal hernia, and morbid obesity. Device-related foregut erosions (FEs) represent a challenging event that demands special attention owing to the potential of severe postoperative complications and death. Purpose: The aim was to provide an overview of full-thickness foregut injury leading to erosion associated with four types of biomedical devices. Methods: The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, EMBASE, and Web of Science databases were queried until December 31, 2023. Eligible studies included all articles reporting data, management, and outcomes on device-related FE. Results: Overall, 132 articless were included for a total of 1292 patients suffering from device-related FE. Four different devices were included: the Angelchik antireflux prosthesis (AAP) (n = 25), nonabsorbable mesh for crural repair (n = 60), adjustable gastric banding (n = 1156), and magnetic sphincter augmentation device (n = 51). The elapsed time from device implant to erosion ranged from 1 to 480 months. Most commonly reported symptoms were dysphagia and epigastric pain, while acute presentation was reported rarely and mainly for gastric banding. The technique for device removal evolved from more invasive open approaches toward minimally invasive and endoscopic techniques. Esophagectomy and gastrectomy were mostly reported for nonabsorbable mesh FE. Overall mortality was .17%. Conclusions: Device-related FE is rare but may occur many years after AAP, nonabsorbable mesh, adjustable gastric banding, and magnetic sphincter augmentation implant. FE-related mortality is infrequent, however, increased postoperative morbidity and the need for esophagogastric resection were observed for nonabsorbable mesh-reinforced cruroplasty.

Protective effect of intraluminal fecal diverting device against colonic wall erosion induced by wrapping bands: A post-hoc pathological analysis

Objectives

Materials wrapping the bowel elicits tissue erosion gradually. We experienced several bowel wall erosions with no serious clinical consequences in our two previous animal experiments aimed at the safety and efficacy of the COLO-BT developed for intra-luminal fecal diversion. We tried to find out why the erosion is safe by investigating histologic changes of the tissue.

Material and Methods

Tissue slides at the COLO-BT fixing area from the subjects which had COLO-BT over three weeks acquired from our two previous animal experiments were reviewed. For the classification of the histologic change, microscopic findings were classified for six stages (from minimal change of stage 1 to severe change of stage 6).

Results

A total of 26 slides of 45 subjects were reviewed in this study. Five subjects (19.2%) had stage 6 histological change; three of stage 1 (11.5%), four of stage 2 (15.4%), six of stage 3 (23.1%), three of stage 4 (11.5%), and five of stage 5 (19.2%). All subjects which had a stage 6 histologic change survived. The phenomenon from which the back of the band is passed through is replaced by a relatively stable tissue layer due to fibrosis of the necrotic cells in the stage 6 histologic change.

Conclusion

We found that thanks to the sealing effect of the newly replaced layer, no leakage of the intestinal content occurs even if perforation by erosion develops according to this histologic tissue evaluation.

The importance of patient selection in bariatric surgery: One not fit for all. Case report of a preventable double severe complication after Laparoscopic gastric banding positioning

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LAGB presents many severe complications.

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Wedge resection could allow to preserve a tailored gastric pouch limiting postoperative nutritional defects.

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Strict postoperative follow-up reduce the risk of severe complications.

Introduction

Laparoscopic adjustable gastric banding (LAGB) is a minimal invasive, effective and reversible procedure, even if it is burdened by life threatening complications.

Presentation of the case

A 39 years-old female patient was admitted to our emergency department for abdominal pain and ileus and underwent an explorative laparoscopy. The LAGB was wrapped around the proximal portion of the stomach determining the erosion and ischemia of the great curvature region. It was removed and a large gastric resection of the great curvature was performed. Subsequently, a gastric leak with pleural abscess occurred with the beginning of the oral diet. It was successfully treated with fasting, intravenous antibiotics and a thoracic tube.

Discussion

LAGB is a restrictive procedure that compartmentalizes the upper stomach by placing a tight adjustable band around it. However severe and multiple complications can also occur. Slippage is one of the most frequent and dangerous complication. Partial gastric resection (comparable to sleeve gastrectomy) or total/subtotal gastrectomy on the limit of the scarring tissue is use requested in the latter case, with a high risk of postoperative leak. A strict postoperative follow-up is mandatory in order to early recognize any severe complications.

Conclusion

Strict follow-up in this special subset of patients, the bariatric ones, is mandatory in order to early identify and correct any postoperative complications, avoiding severe sequelae.

Endoscopic removal of eroded laparoscopic adjustable gastric bands: a preferred approach

BACKGROUND

Complications related to laparoscopic adjustable gastric banding (LAGB) have led to an increased number of removals. An uncommon but potentially devastating complication is gastric band erosion into the gastric lumen, which can be managed by open surgical, laparoscopic, and endoscopic approaches.

OBJECTIVE

A wide array of management techniques has been reported for removal of LAGB that have eroded into the stomach. We describe the preferred method for successful endoscopic band removal at our institution.

SETTING

Community tertiary-care referral hospital accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

METHODS

A single-center, retrospective review of a prospectively maintained database was used to identify patients who underwent LAGB removal from 2009 to 2019. We identified the subset of patients with band erosion. We analyzed patient characteristics, presenting symptoms, diagnostic modalities, and method of band extraction.

RESULTS

A total of 132 patients underwent LAGB removal, among whom 22 (16.7%) patients were diagnosed with erosion. Seven (32%) patients underwent laparoscopic removal, 14 (64%) patients underwent endoscopic removal, and 1 patient (4%) underwent combined laparoscopic and endoscopic approach. These latter patients had variable amounts of erosion and buckle visibility, but all underwent endoscopic retrieval. We found that using an endoscopic retrograde cholangiopancreatography guidewire with an endoscopic retrograde cholangiopancreatography mechanical lithotriptor for band transection and snare for retrieval have been effective.

CONCLUSIONS

A standardized, multidisciplinary, and minimally invasive endoscopic approach for LAGB erosion has been found to be successful without the need for further surgical intervention and may be offered to patients upon discovery of erosion.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

Eroded Gastric Band: Where to Next? An Analysis of the Largest Contemporary Series

PURPOSE

Erosion of a laparoscopic adjustable gastric band (LAGB) is a devastating problem. There is no clear evidence in literature to guide the choice of revisional procedure following an eroded LAGB. The purpose of this study is to analyse the largest series of erosions following LAGB published to-date with an aim to share our experience with this rare complication and how we managed this cohort of patients following explantation of their LAGB.

MATERIALS AND METHODS

This is a retrospective cohort study. Patient data is maintained prospectively in a surgical database. The study period was from January 1996 to January 2019. The outcomes of patients who underwent an erosion of LAGB were studied.

RESULTS

Gastric band erosion was encountered in 4.7% of patients. Sixty patients opted for a revisional procedure which included 37 repeat LAGBs, 6 laparoscopic sleeve gastrectomies (LSG), 7 Roux-en-Y gastric bypasses (RYGB), 1 intragastric balloon, and 9 failed revisional procedures. Re-erosions were noted in 27% of patients who underwent a repeat gastric banding. Median %TWL at a 1-year follow-up was significantly higher in LSG and RYGB groups compared with that in LAGB (P < 0.008 and P < 0.000, respectively). There was no significant difference between the LSG and RYGB groups.

CONCLUSION

The risk of re-erosion is increased in patients who undergo repeat AGB following a previous episode of erosion. Repeat LAGB should not be offered after a previous erosion. LSG and RYGB should be considered as appropriate revisional procedures in a patient who experience weight regain following explantation of an eroded LAGB.

A case report of septic shock and splenic abscess formation secondary to gastric band erosion: A rare complication of laparoscopic adjustable gastric banding

INTRODUCTION

With the rising burden of obesity, bariatric surgery is becoming more common as a treatment option. Laparoscopic adjustable gastric banding (LAGB) is considered safe and effective and is a popular procedure in Australia. However there are recognised complications to be aware of such as band erosion which can lead to infection and abscess formation.

PRESENTATION OF CASE

A 59-year-old caucasian female presented with fevers, rigors and feeling generally unwell. She was previously fit and well with her only past medical history being LAGB 14 years prior. Clinically the patient was in septic shock and required intensive care admission for inotropic support. On investigations the CRP was 227 and abdominal computed tomography (CT) revealed a splenic abscess. Follow up upper gastrointestinal endoscopy diagnosed an eroded gastric band in the stomach. The patient proceeded to laparoscopy, a gastrotomy was performed and the band was removed. The splenic abscess was concurrently drained and the patient treated with an extended course of intravenous and oral antibiotics.

DISCUSSION

Band erosion is a rare but serious complications of LAGB surgery along with band slippage, pouch dilatation and abscess formation. Patients are often asymptomatic making early diagnosis difficult. Upper gastrointestinal endoscopy is used to locate the band and recommended treatment is band removal via laparoscopy or laparotomy.

CONCLUSION

Band erosion should be suspected in patients with a history of LAGB presenting with nonspecific symptoms such as abdominal pain or fevers. This case also highlights the importance of appropriate patient follow up post operatively and counselling of operative risks and long-term complications.

Sengstaken-Blakemore Tube as a Rescue Treatment for Hemorrhagic Shock Secondary to Laparoscopic Adjustable Gastric Banding Erosion

Gastrointestinal bleeding is an uncommon but potentially life-threatening complication of laparoscopic adjustable gastric banding (LAGB) erosion. We present the use of a Sengstaken-Blakemore tube as a treatment device for severe gastrointestinal bleeding secondary to persistent LAGB erosion. A 72-year-old woman post-LAGB placement presented with hemorrhagic shock from gastric band erosion that was not responsive to endoscopic and angiographic interventions. A salvage attempt to tamponade with a Sengstaken-Blakemore tube resulted in successful resuscitation of the patient. When used judiciously, balloon tamponade serves as a replicable technique to control severe gastric band erosion refractory to standard management.

Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding

Introduction

Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up.

Methods

Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented.

Results

Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/− duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques.

Conclusion

All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.

Biofilm-sealed perforation of the gastric body: a rare sequela of gastric band erosion

Laparoscopic Adjustable Gastric Banding is one of the cardinal bariatric interventions and due to its early safety profile, became the mainstay. Major long-term complications of gastric banding include pouch-herniation-dilation and gastric erosion. A 59-year-old female presented to the emergency department with a 2-week history of progressive central abdominal pain and distention on a background history of a laparoscopic adjustable band insertion 11 years previously. Subsequent computed tomography demonstrated an intragastric band erosion. An exploratory laparotomy demonstrated a gastric band eroded through the stomach sealed by a biofilm. Secondary findings included small bowel ischemia and portal vein thrombosis. The gastric band was extracted, and the stomach was repaired. The ischemic small bowel was resected with primary anastomosis. The patient recovered uneventfully. Gastric band erosion should be considered in all patients presenting with abdominal pain and previous weight loss surgery. Prompt recognition may avoid fatal consequences.

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.

A 13-year journey of a gastric band - ultimate destination terminal jejunum: a case report

BACKGROUND

Laparoscopic adjustable gastric banding has been the gold standard for surgical management of obesity over the last decades in USA and Europe. However, significant complications have been documented due to foreign body placement, including band erosions. Our treatment approach for erosions is rather observant with regular follow-up until the band has sufficiently perforated the gastric wall which facilitates endoscopic removal. Consequences of a not followed-up band erosion may present even after a long time following initial diagnosis with more severe complications.

CASE PRESENTATION

A 51-year-old Caucasian woman presented to our out-patients' clinic with a 2-week history of worsening abdominal pain in her left upper quadrant, exacerbated by abdominal flexion and extension maneuvers. Here we describe a case involving gastric penetration and subsequent downward migration of a band into distal jejunum causing small bowel obstruction, which occurred more than 10 years following initial diagnosis of erosion. The perforation was missed due to cessation of endoscopic follow-up.

CONCLUSION

Prospective and long-term follow-up is mandatory in those with partial band erosion to avoid further complications.

Laparoscopic Adjustable Gastric Band Erosion Into the Stomach and Colon

Morbid obesity has reached epidemic proportions in the United States and constitutes a significant cause of morbidity and mortality. Bariatric surgery represents a viable and effective means of weight loss. Laparoscopic adjustable gastric band placement is the most commonly used and least invasive bariatric surgical technique. Although the complication rate is low, various complications have been described, including erosion of the gastric band into the stomach. The authors present a case of laparoscopic adjustable gastric band erosion, where both the band and the tubing eroded into the stomach and colon, and the tubing further eroded out of and back into the colon several times.

Laparoscopic adjustable gastric band erosion with intragastric band migration: A rare but serious complication

Although laparoscopic adjustable gastric banding is considered the most minimally invasive surgical technique for the treatment of morbid obesity, the procedure has a reported overall complication rate of up to 26%. Among the various complications, gastric band erosion with intragastric band migration is the most worrisome because of the risk of subsequent obstruction, peritonitis, and sepsis. Therefore, prompt and accurate diagnosis is crucial during imaging evaluation of these patients in the late postoperative setting. In this article, we report a case of a 47-year-old woman with a gastric band that had eroded into the gastric wall with intragastric migration demonstrating classic findings on fluoroscopic and computed tomography imaging.

Management of laparoscopic adjustable gastric band erosion

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) was a popular procedure in the USA and Europe in the past decade. However, its use has currently declined. Band erosion (BE) is a rare complication after LAGB with a reported incidence rate of 1.46 %. Controversies exist regarding the management, approach and timing for the band removal. The aim of this study is to describe the rate, clinical presentation and perioperative outcomes of BEs at our institution and provide overall recommendations regarding the diagnosis and management of BE.

MATERIALS AND METHODS

This study is a single-center, retrospective review of a prospectively maintained database. Data were collected from all consecutive patients who underwent a LAGB and band revisional surgeries at the University of Illinois Hospital and Health Sciences System from December 2008 to September 2015. We identified patients who underwent gastric band removal due to a BE and analyzed their outcomes.

RESULTS

A total of 576 LAGBs were performed at our institution. Nine patients underwent surgery for BE at our hospital. The average time between the primary surgery and the removal of the band was 68.5 (42.9) months. Abdominal pain, nausea and/or vomiting were the most frequently mentioned symptoms. In all patients, a minimally invasive approach was used to remove the band. The mean length of hospitalization was 2.6 (1.1) days. The only complication was a pneumonia (n = 1).

CONCLUSIONS

BE is one of the most severe complications of LAGB. The minimally invasive approach provided us with the opportunity to repair the fistula, and it was associated with a prompt recovery with very little morbidity. In general, it is recommended that the band be removed at the time of the diagnosis of the BE. Endoscopic band removal can be utilized with patients who have a more advanced BE and migration into the gastric lumen.

Acute Abdominal Pain in the Bariatric Surgery Patient

Obesity is present in epidemic proportions in the United States, and bariatric surgery has become more common. Thus, emergency physicians will undoubtedly encounter many patients who have undergone one of these procedures. Knowledge of the anatomic changes specific to these procedures aids the clinician in understanding potential complications and devising an organized differential diagnosis. This article reviews common bariatric surgery procedures, their complications, and the approach to acute abdominal pain in these patients.

[Gastric band erosion: Alternative management]

BACKGROUND

Obesity is a public health problem, for which the prevalence has increased worldwide at an alarming rate, affecting 1.7 billion people in the world.

OBJECTIVE

To describe the technique employed in incomplete penetration of gastric band where endoscopic management and/or primary closure is not feasible.

MATERIAL AND METHODS

Laparoscopic removal of gastric band was performed in five patients with incomplete penetrance using Foley catheterization in the perforation site that could lead to the development of a gastro-cutaneous fistula.

CLINICAL CASES

The cases presented include a leak that required surgical lavage with satisfactory outcome, and one patient developed stenosis 3 years after surgical management, which was resolved endoscopically. In all cases, the penetration site closed spontaneously.

DISCUSSION

Gastric band erosion has been reported in 3.4% of cases. The reason for inserting a catheter is to create a controlled gastro-cutaneous fistula, allowing spontaneous closure.

CONCLUSIONS

Various techniques have been described: the totally endoscopic, hybrid techniques (endoscopic/laparoscopic) and completely laparoscopic. A technique is described here that is useful and successful in cases where the above-described treatments are not viable.

Controversies in bariatric surgery

BACKGROUND

There are many controversies related to bariatric surgery. This review explores selected areas.

METHODS

A combination of randomized clinical trials (RCTs), systematic reviews and expert opinion have been brought together to highlight areas of importance or conflict.

RESULTS AND CONCLUSION

Metabolic surgery is an increasingly preferred term rather than bariatric or obesity surgery. Reporting should be standardized to include appropriate weight measures, valid disease measures and data on loss to follow-up. There are many putative mechanisms of effect of key bariatric procedures, but satiety and early satiation appear central. Weight loss must be durable. Long-term outcome studies (more than 10-year follow-up) show that biliopancreatic diversion is most effective, with 72 per cent excess weight loss (EWL). Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding (LAGB) are equally effective, with 54 per cent EWL. There are no long-term data on vertical sleeve gastrectomy. Type II diabetes is a common and serious disease, usually associated with increased weight. Multiple RCTs have shown that bariatric surgery provides clear benefits over continuing with non-surgical therapies. The earlier the treatment, the more likely and durable will be the remission. Bariatric surgery should be available to all who are obese (body mass index over 30 kg/m(2) ). LAGB, a safe, effective, reversible outpatient procedure, is the author's preferred primary option.

Laparoscopic repair of gastro-duodenal fistula secondary to band erosion

Laparoscopic gastric banding is one of the most common surgical treatments for morbid obesity performed worldwide. The procedure, however, has many well-documented risks and complications, including band erosion. We present here a gastric banding patient who was referred to our tertiary care centre after secondarily forming an entero-enteric fistula with complaints of pain, nausea, vomiting and severe reflux. She was successfully treated with laparoscopic dissection and due to her existing anatomy, and the patient's desire for continued weight loss, she was converted to Roux-en-Y gastric bypass.

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis

BACKGROUND

The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice.

METHODS

A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery.

RESULTS

There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group.

CONCLUSIONS

Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Laparoscopic sleeve gastrectomy as revisional surgery for adjustable gastric band erosion

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been increasingly adopted as a revisional surgery for failed gastric banding. However, little information is available regarding the outcome of revisional LSG for band erosion.

MATERIALS AND METHODS

A retrospective database analysis was performed to study LSG as revisional surgery for band erosion. For staged revision, we waited a minimum of 3 months after band removal, and for single-stage revision, the band was removed by gastrotomy, and sleeve gastrectomy was performed at the same time. Main outcome measures were success rates of therapeutic strategies, morbidity, and mortality rates, length of stay, and body mass index (BMI) (percentage excess weight loss [%EWL]) before and after revision.

RESULTS

From March 2011 to February 2013, 9 female patients underwent revisional LSG. Average age was 34.7 years. Six patients underwent a staged procedure, and the other 3 underwent a single-stage revision. Among the 6 staged patients, eroded bands had been removed by laparoscopy in 4 and by endoscopy in 2 without complications. Their LSGs were performed at a median of 4.4 months after band removal. Another 2 patients underwent single-stage revision. In the last patient, band erosion was incidentally found during a revisional LSG for insufficient weight loss. No mortality occurred. There were one stenosis and two proximal leaks. Two patients with leak underwent total gastrectomy and fistulojejunostomy. After a mean follow-up of 19.1 months, all 9 patients exhibited weight loss. The mean (±standard deviation [SD]) pre- and post-LSG BMIs were 34.0±4.4 and 25.6±2.1 kg/m(2), respectively, and their mean (±SD) %EWL from prebanding was 86.8±10.1%. Revisional LSG resulted in a further median %EWL of 28.0% (range, 7.9%-68.9%) versus weight at time of band removal.

CONCLUSIONS

Revisional LSG after band erosion was found to be feasible and effective. However, it is prone to severe complication. In selected cases of band erosion, LSG can be performed at the time of band removal in a single stage.

[Redo intervention and complication management in bariatric surgery]

Morbid obesity and the associated comorbidities are rapidly increasing worldwide. Bariatric surgery has proven to be an effective treatment option. In 2011 more then 340,000 bariatric procedures were performed worldwide which is accompanied by a growing demand for revision bariatric procedures due to complications or failure, such as insufficient weight loss or weight regain.Redo operation procedures as well as the management of complications require a profound preoperative medical history and diagnostic investigation in combination with an exact knowledge of the anatomical changes made in the primary procedure.

Simultaneous Gastric and Duodenal Erosions due to Adjustable Gastric Banding for Morbid Obesity

Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy.

Short-term morbidity associated with removal and revision of the laparoscopic adjustable gastric band

BACKGROUND

Laparoscopic adjustable gastric band (LAGB) insertion is a commonly performed bariatric procedure with low associated short-term risk. Given that a significant number of patients will require additional revision/removal procedures, overall morbidity may be underestimated. The objective of this study was to define the 30-day morbidity associated with LAGB removal and revision procedures.

METHODS

Patients undergoing revision or removal of LAGB were identified within The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) participant use file using current procedural terminology and ICD-9 coding. Patients having concurrent procedures were excluded. Primary outcomes included 30-day morbidity. The rate of complications in the removal/revision patients versus primary LAGB insertion was compared. We also analyzed trends over time.

RESULTS

A total of 3,236 patients underwent LAGB removal (n = 1,580), revision (n = 1,111) or port site revision (n = 545) from 2006-2011. The overall 30-day complication rate was 5.6% (95% confidence interval [CI]: 4.8%, 6.4%) and was higher in patients undergoing LAGB removal with a 6.8% (95% CI: 5.6%, 8.1%) adverse event rate (2.5% infectious, 2.3% wound, 2.4% reoperation). A total of 24,438 patients underwent primary LAGB insertion within the data set with a 30-day complication rate of 2.6% (95% CI: 2.4%, 2.8%). Patients undergoing LABG removal had a significantly higher complication rate than those having primary LAGB insertion with an odds ratio of 2.72 (95% CI: 2.18, 3.37). The proportion of LAGB revision/removal compared to primary placement increased annually over the study period (P for trend<.001).

CONCLUSION

The 30-day morbidity associated with LAGB revision is significant and higher than that associated with primary LAGB insertions. The potential need for future procedures and the associated additional morbidity should be considered when evaluating LAGB as a treatment option for morbid obesity.