Failed Gastric Bypass: What You Need to Know – Obesity News Today

Adjustable gastric band complications

Most band complications are related to mechanical problems with the band itself (eg, band slippage and band, balloon, or tubing breakage). Other and more serious late complications include band erosion, acute obstruction, ischemia, and megaesophagus or pseudoachalasia.

Band slippage

Band slippage occurs when one wall or side of the stomach slips through the orifice of the band, resulting in a larger than normal gastric pouch superior to the band. The usual anatomic derangement is characterized as ‘cephalad prolapse of the body of the stomach or caudal movement of the band.’34 Slippage is considered the most common complication after laparoscopic adjustable gastric band35 and occurs in 8% of patients.36 Although fundoplication around the band and the pars flaccida technique for placement of the band are thought to reduce the likelihood of band slippage,37 it may still occur even after these technical precautions are done at the time of band placement.38 Band slippage presents as a dilated gastric pouch superior to the band. These patients often report symptoms of immediate or delayed vomiting after meals, a feeling of fullness only relieved by vomiting, and occasional pain or irritation in the upper abdomen.

Workup should include a plain abdominal X-ray. The expected band position is to the left of the spinal column with an oblique angle of approximately 15°. This is from 8 o’clock to 2 o’clock when scanning the X-ray from the patient’s right to the left. The “phi angle,” the angle between the vertical spinal column and the band, is normally between 45° and 58° (figure 1). Phi angles greater than 58° usually indicate a slipped band. Seeing the entire ring of band on a plain anterior-posterior abdominal X-ray (the “O sign”)39 should also raise suspicion for a slipped band. Additional radiographic signs sensitive for band slippage are inferior displacement of the superior lateral band margin more than 2.4 cm from the diaphragm and the presence of an air-fluid level above the gastric band.40

Figure 1

Figure 1Lap band phi angle (ɸ). (A) Angle of 45° indicating good position. (B) Angle greater than 58° indicating slipped band.

In more severe cases of band slippage, the excess stomach wall herniated through the band orifice may result in swelling and obstruction at the band outlet, resulting in severe dilation and ischemia of the stomach wall above the band. This is like a strangulated hernia. These patients often are completely obstructed and have severe, unrelenting pain, tachycardia, fever, and leukocytosis.

The first treatment step when dealing with a patient with a suspected band complication is to completely empty the band of fluid. In many circumstances, this intervention may resolve the slippage and relieve symptoms. Resolution of band slippage (return of the stomach to its normal position) can be confirmed with a follow-up UGS. Patients who experience relief of symptoms and resolution of band slippage with emptying of the band should be temporarily restricted to a liquid diet and referred to a bariatric surgeon for elective retrieval. Patients who continue to have abdominal pain, systemic signs, or in whom follow-up contrast UGS reveals the band remaining in a slipped position will likely require emergency surgery for band removal and possibly resection of ischemic or necrotic stomach.

Laparoscopic band removal can be challenging. The surgeon will often encounter extensive adhesions of the left lobe of the liver to the upper third of the stomach and a band which appears completely engulfed in stomach tissue. The surgeon’s only indication of the presence of a band may be the band tubing coursing into this area. Careful, persistent dissection allows the left lobe of the liver to be mobilized off the upper stomach and usually is accomplished easily. The next step is identification of the band buckle, which can generally be found on the medial or lesser curvature side of the stomach. Since the band tubing enters near the buckle, following the band tubing will lead to the buckle. Dissection on the buckle itself is necessary to get the band mobile, as there is usually ingrowth of scar tissue in and around the buckle. The silastic balloon portion of the band itself usually resists extensive adhesion formation and will be relatively mobile and easy to slide around the stomach once the buckle is free. Because the buckle is not typically covered with the gastric plication, it is also the area of dissection that is least likely to result in a gastric wall injury.

Once the gastric band is free of adhesions and can be freely rotated around the stomach, it may simply be cut with scissors and removed. The cut band can usually be extracted either through a 15 mm port or via dilation of a smaller port. The tubing and subcutaneous port should also be entirely removed. Prior to completing the exploration, inspection of the posterior gastric wall for ischemia or perforation may identify the need for additional procedures. Plications do not necessarily need to be taken down in the acute setting, although doing so may help assess stomach tissue integrity and potential need for resection. Takedown of the plication in the setting of normal gastric tissue can be safely done either with careful sharp dissection or the use of a linear stapler, with the anvil or narrow side of the stapler placed in the “tunnel” created by the fundoplication and the cartridge side outside the tunnel. The operation is completed with removal of the band’s port in the subcutaneous tissue of the abdominal wall.

Band erosion

Although band erosion sounds like an ominous complication, it is rarely a surgical emergency. Erosions occur in a relatively small percentage of patients, ranging from 0.31% to 1.96%.41 42 Symptom onset is frequently insidious, vague, and non-specific. Patients may describe upper abdominal or back pain, loss of food restriction, melena, new onset of reflux, or “spontaneous” infection of the subcutaneous band port (from bacteria from the gastric erosion tracking along the band tubing to the subcutaneous port). Plain abdominal X-rays can sometimes document band malposition, and CT scan or upper intestinal contrast series may suggest an intraluminal band and inflammatory changes in the upper stomach. Because the process is slow, adhesion formation around the site of erosion usually limits contamination of the abdomen or peritonitis. Upper endoscopy may document partial or complete erosion of the band into the stomach. When such patients present without sepsis, which is typically the case, they may be started on antibiotics and referred to a bariatric surgeon for management.

Options for treatment depend on the degree of erosion. Complete or near-complete intraluminal bands can be removed endoscopically by cutting the tubing and extracting the band from the mouth.43 44 The resultant erosion almost invariably seals quickly due to the slow nature of the erosion and the amount of inflammation present. Similarly, patients with partial erosion may have laparoscopic removal of the band as described above. If a hole is visible, patching with omentum or fundus is usually sufficient to seal it. If a hole is not visible, closed suction drainage, intravenous antibiotics, and a period of nothing by mouth is usually sufficient to seal the erosion. Follow-up UGS can confirm no leak prior to resuming oral intake.

Megaesophagus or pseudoachalasia

Megaesophagus or pseudoachalasia rarely requires acute treatment. Patients typically present with worsening dysphagia, regurgitation, or vomiting. Plain X-rays often show the band in normal position, but UGS reveals an esophagus dilated beyond the outer limit of the band. The dilation is attributed to chronic overeating despite having a band to limit intake. As the esophagus expands and the capacity increases, patients describe loss of restriction, which may prompt augmenting the band fill. Additional fill worsens the outlet obstruction and increases the chronic stretching of the esophagus. Initial evaluation and treatment for patients presenting acutely should consist of plain films and UGS to document the problem. Treatment is emptying of the band. These patients should undergo elective band removal.

Balloon complications

Acute care surgery providers should probably be familiar with the management of acute complications of balloons used for weight loss. Balloon placements account for less than 1% of bariatric procedures.

They are placed endoscopically in the stomach and restrict food intake. They are meant to stay for 6 months or less. Patients will frequently report symptoms of reflux, nausea, and abdominal discomfort even when the balloon is in proper position.

Enteric perforation and migration of the balloon leading to a bowel obstruction are two complications which may require acute management and may result in death. Information is sparse, but there does not appear to be anything unique about the presentation of balloon patients with a perforation or bowel obstruction.

Deflating a balloon for removal is normally done endoscopically with specialized equipment to puncture the balloon, aspirate the saline, and deflate the balloon. In the instance of migration, the balloon is likely deflated already, but even in the deflated state these balloons are large and may require a sizeable enterotomy to remove them from the intestines.

Of note, balloons are inflated with blue-dyed saline, so patients could note blue or green urine if the balloon spontaneously deflates and the blue dye is absorbed from the gastrointestinal tract.31 Balloons left in place longer than 6 months are at a higher risk for perforation.32

Perforations usually result from pressure necrosis and ulceration from the balloon, and treatment starts with deflating the balloon. In an unstable patient, any large bore needle can be used to deflate the balloon, but a gastrotomy may be needed to gain access to the balloon.

The balloon can be decompressed with a large bore endoscopic needle and a snare to extract the balloon. This may cause the dyed saline to spill, making visualization difficult. After the balloon(s) is deflated and removed, the perforation must still be addressed, which can be done with a Graham patch or resection.

Band erosion

Although band erosion sounds like an ominous complication, it is rarely a surgical emergency. Erosions occur in a relatively small percentage of patients, ranging from 0.31% to 1.96%.41 42 Symptom onset is frequently insidious, vague, and non-specific.

Patients may describe upper abdominal or back pain, loss of food restriction, melena, new onset of reflux, or “spontaneous” infection of the subcutaneous band port (from bacteria from the gastric erosion tracking along the band tubing to the subcutaneous port).

Plain abdominal X-rays can sometimes document band malposition, and CT scan or upper intestinal contrast series may suggest an intraluminal band and inflammatory changes in the upper stomach. Because the process is slow, adhesion formation around the site of erosion usually limits contamination of the abdomen or peritonitis.

Upper endoscopy may document partial or complete erosion of the band into the stomach. When such patients present without sepsis, which is typically the case, they may be started on antibiotics and referred to a bariatric surgeon for management.

Options for treatment depend on the degree of erosion. Complete or near-complete intraluminal bands can be removed endoscopically by cutting the tubing and extracting the band from the mouth.43 44 The resultant erosion almost invariably seals quickly due to the slow nature of the erosion and the amount of inflammation present.

Similarly, patients with partial erosion may have laparoscopic removal of the band as described above. If a hole is visible, patching with omentum or fundus is usually sufficient to seal it. If a hole is not visible, closed suction drainage, intravenous antibiotics, and a period of nothing by mouth is usually sufficient to seal the erosion. Follow-up UGS can confirm no leak prior to resuming oral intake.

Band slippage

Band slippage occurs when one wall or side of the stomach slips through the orifice of the band, resulting in a larger than normal gastric pouch superior to the band. The usual anatomic derangement is characterized as ‘cephalad prolapse of the body of the stomach or caudal movement of the band.

34 Slippage is considered the most common complication after laparoscopic adjustable gastric band35 and occurs in 8% of patients.36 Although fundoplication around the band and the pars flaccida technique for placement of the band are thought to reduce the likelihood of band slippage,37 it may still occur even after these technical precautions are done at the time of band placement.

38 Band slippage presents as a dilated gastric pouch superior to the band. These patients often report symptoms of immediate or delayed vomiting after meals, a feeling of fullness only relieved by vomiting, and occasional pain or irritation in the upper abdomen.

Workup should include a plain abdominal X-ray. The expected band position is to the left of the spinal column with an oblique angle of approximately 15°. This is from 8 o’clock to 2 o’clock when scanning the X-ray from the patient’s right to the left.

The “phi angle,” the angle between the vertical spinal column and the band, is normally between 45° and 58° (figure 1). Phi angles greater than 58° usually indicate a slipped band. Seeing the entire ring of band on a plain anterior-posterior abdominal X-ray (the “O sign”)39 should also raise suspicion for a slipped band.

Additional radiographic signs sensitive for band slippage are inferior displacement of the superior lateral band margin more than 2.4 cm from the diaphragm and the presence of an air-fluid level above the gastric band.40

Figure 1

Figure 1Lap band phi angle (ɸ). (A) Angle of 45° indicating good position. (B) Angle greater than 58° indicating slipped band.

In more severe cases of band slippage, the excess stomach wall herniated through the band orifice may result in swelling and obstruction at the band outlet, resulting in severe dilation and ischemia of the stomach wall above the band.

The first treatment step when dealing with a patient with a suspected band complication is to completely empty the band of fluid. In many circumstances, this intervention may resolve the slippage and relieve symptoms.

Resolution of band slippage (return of the stomach to its normal position) can be confirmed with a follow-up UGS. Patients who experience relief of symptoms and resolution of band slippage with emptying of the band should be temporarily restricted to a liquid diet and referred to a bariatric surgeon for elective retrieval.

Patients who continue to have abdominal pain, systemic signs, or in whom follow-up contrast UGS reveals the band remaining in a slipped position will likely require emergency surgery for band removal and possibly resection of ischemic or necrotic stomach.

Laparoscopic band removal can be challenging. The surgeon will often encounter extensive adhesions of the left lobe of the liver to the upper third of the stomach and a band which appears completely engulfed in stomach tissue.

The surgeon’s only indication of the presence of a band may be the band tubing coursing into this area. Careful, persistent dissection allows the left lobe of the liver to be mobilized off the upper stomach and usually is accomplished easily.

The next step is identification of the band buckle, which can generally be found on the medial or lesser curvature side of the stomach. Since the band tubing enters near the buckle, following the band tubing will lead to the buckle.

Dissection on the buckle itself is necessary to get the band mobile, as there is usually ingrowth of scar tissue in and around the buckle. The silastic balloon portion of the band itself usually resists extensive adhesion formation and will be relatively mobile and easy to slide around the stomach once the buckle is free.

Once the gastric band is free of adhesions and can be freely rotated around the stomach, it may simply be cut with scissors and removed. The cut band can usually be extracted either through a 15 mm port or via dilation of a smaller port.

The tubing and subcutaneous port should also be entirely removed. Prior to completing the exploration, inspection of the posterior gastric wall for ischemia or perforation may identify the need for additional procedures.

Plications do not necessarily need to be taken down in the acute setting, although doing so may help assess stomach tissue integrity and potential need for resection. Takedown of the plication in the setting of normal gastric tissue can be safely done either with careful sharp dissection or the use of a linear stapler, with the anvil or narrow side of the stapler placed in the “tunnel” created by the fundoplication and the cartridge side outside the tunnel.

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