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ab
I.M.C. Janssen and F.J. Berends
Adjustable band converted into
Illustration 24.1 ( a , b ) Complications of the gastric band with dilatation of the gastric pouch and
the esophagus should be converted to gastric bypass
Gastric bypass
gastrointestinal contrast series demonstrated a very tight band, a pouch, and
esophageal dilatation. The band was defl ated slightly. As a result intake improved,
but her weight increased with 5 BMI points. Control contrast series demonstrated a
decrease in pouch diameter. The patient was referred to lifestyle training again to
regain weight loss, but instead she gained another 3 BMI points. On reinfl ating the
band her vomiting and dysphagia returned immediately. The patient was operated
and the band was laparoscopically removed and converted to a gastric bypass
(Illustration 24.1 ). Her recovery was uneventful and in the following year her BMI
dropped again to 27 kg/m 2 .
Discussion
Adjustable gastric banding is one of the most frequently performed bariatric operations in morbidly obese patients. Laparoscopic adjustable gastric banding (LAGB)
is a safe and effective method of weight loss and reduction of comorbidities associated with obesity. Despite its good safety profi le compared with Roux-en-Y gastric
bypass, patients with LAGB can manifest unique complications that are distinctive
to the LAGB and need a special assessment and treatment. The most common complications are: Pouch enlargement, band slip, band erosion, esophageal dilatation,
refl ux, port rotation, port-site infection, and breakage of the tubing [ 1 ].
In the assessment of a patient with a LAGB, one should make an upper gastrointestinal radiograph series. The band is placed just below the gastroesophageal junction. The pouch in the fi rst year is hardly visible but will extend to a size of
appropriately 50–80 mL. The right position of the band is seen on the radiography
if it has an angle of approximately 45° toward the left shoulder.
24 Case on Complication of Adjustable Gastric Band Converted in a Gastric Bypass
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133
Band slip and pouch dilatation—The most important cause of slippage is an
increased pressure in the pouch due to vomiting. In a lot of cases overfi lling is the
real cause. Most patients feel that they have the best support of the band if they can
hardly eat. They will ask for fi lling of the band if they don’t lose weight. Prevention
of overfi lling is prevention of pouch dilatation and helps to get a good long-term
result. The patient with a band slippage and obstruction usually presents with dysphagia, vomiting, regurgitation, and food intolerance. The diagnosis is easily made
by an upper gastrointestinal series. Complications related to band slip include gastric perforation, necrosis of the slipped stomach (type-V prolapse), upper gastrointestinal bleeding, and aspiration pneumonia.
Pouch enlargement or prolapse is diagnosed when dilation of the proximal gastric pouch is present with or without change in the angle of the band on an upper
abdominal radiograph and in the absence of signs of obstruction. The lower esophagus may or may not be dilated. Pouch enlargement is also a pressure-related phenomenon that may be surgically induced by band over infl ation or overeating with
vomiting, resulting in high pressure in the pouch. Primary placement of the band
with too much fundus above the band gives a high risk of pouch dilatation. Symptoms
of pouch enlargement can be: lack of satiety, heartburn, regurgitation, and occasional chest pain. The diagnosis is made with an upper gastrointestinal series [ 1 ].
Band slip and pouch dilatation can be classifi ed depending on the part of the
body of the stomach that moves though the band or on the dilatation of the stomach
or placement of the band [ 1 ].
Incidence of slippage varies in literature. O’Brien and Dixon reported 25 % of
band slip in their fi rst 500 patients using the perigastric approach (accessing the
right crus perigastrically) and only 4.8 % of slippage in the last 600 patients with the
pars fl accida technique (accessing the right crus through the pars fl accida) [ 2 , 3 ].
Other published literature reports an incidence of slip of 1–22 %.
Since the amount of tissue of the stomach in the band is bigger at the body of
the stomach than at the angle of His (normal band position), obstruction of the
gastrointestinal tract can occur when the band slips. Band slip can be posterior or
anterior, depending on whether the anterior or posterior region of the stomach
herniates through the band. In all patients with obstructive complaints and pain not
responding to emptying of the band, a gastroscopy is mandatory to rule out gastric
ischemia or necrosis. These conditions require an immediate surgical
intervention.
Laparoscopic removal or repositioning of the band is the preferred method of
treatment for both slippage and pouch dilatation. In patients who were successful
in losing weight with the gastric band repositioning can be considered. If the
patient did not experience signifi cant weightloss, removing the band and creating
a gastric bypass in one or two tempi is the preferred option. In situations of substantial prolapse where reduction is not possible or when evidence of intra abdominal infection is present, the most prudent management is removal of the gastric
band.
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I.M.C. Janssen and F.J. Berends
References
1. Berends FJ, Janssen IMC. Prevention and treatment of complications after bariatric surgery. In:
Cuesta MA, Bonjer HJ, editors. Treatment of complications after digestive surgery, chapter 10.
London: Springer; 2013.
2. Eid I, Birch DW, Sharma AM, et al. Complications associated with adjustable gastric banding
for morbid obesity: a surgeon’s guides. Can J Surg. 2011;54:61–6.
3. O’Brien PE, Dixon JB. Weight loss and early and late complications – the international experi-
ence. Am J Surg. 2002;184:42S–5.
Chapter 25
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Case on Problems with Laparoscopic
Adjustable Gastric Band: Erosion
and Migration
Ignace M.C. Janssen and Frits J. Berends
Keywords Gastric band • Laparoscopy • Morbid obesity • Band erosion •
Adjustable gastric band • Band migration
First Patient
Operation, Identifi cation and Treatment of the Complication
Three weeks after receiving a laparoscopic adjustable gastric band, a 42- year-old
woman returned to the hospital with an infection of the wound where the port
connected to the band’s tubing was placed. The patient was initially treated with
antibiotics; however, after a few days the wound spontaneously opened and a
collection of pus leaked out. At the bottom of the wound the port and tubing
were visible. The patient was reoperated and the port was removed. The tubing
was cut, fi lled with antibiotics, and pushed back into the abdominal cavity. Three
months later the patient had not lost any weight. She could eat normally, but
complained of abdominal discomfort. Blood examination demonstrated elevated
CRP and leukocytosis. Gastroscopy revealed a band that had eroded into the
stomach and was visible for one-third of the circumference. It was suggested to
the patient to remove the band laparoscopically but she insisted on being referred
to another hospital where the band was removed gastroscopically (Fig. 25.1 and
Illustration 25.1a ). Three months later a biliopancreatic diversion was done from
which she recovered uneventfully. After 1 year she had an excess weight loss
of 90 %.
I.M.C. Janssen , M.D. (*) • F.J. Berends , M.D.
Department of Surgery , Rijnstate , Arnhem , The Netherlands
e-mail: ijanssen@alysis.nl; fberends@alysis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_25,
© Springer International Publishing Switzerland 2014
135
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Fig. 25.1 Erosion of the
band in distal esophagus.
Attempt to removal
by endoscopy
Second Patient
Diagnosis and Indication for Surgery
I.M.C. Janssen and F.J. Berends
A 42-year-old woman had been operated 3 years previously because of obesity, having a BMI of 35. A laparoscopic gastric band was then performed without technical
problems. In the course of the following year, the patient had importantly reduced
her weight until she gained a BMI of 26. She was happy with the outcome of the
operation. Three years later and now 3 months before the referral to us, she began
to have extra diffi culties with passing food. She felt that something had changed as
she had lost an additional four kg. At gastroscopy it was observed that the connection tube has migrated in distal direction. The CT scan showed that the band was
fi xed in the fi rst loop of jejunum and a kind of fi xed triangle was formed between
the band, connection tube, and the port (Figs. 25.2 and 25.3 ).
Operation
At operation, after cutting the connection tube fi rst the port was taken out. Then by
laparoscopy we could see the tube and the infl ammatory reaction around the proximal part of the stomach. The duodenum and proximal part of jejunum were localized, but it was impossible to see in which part of these the band was fi xed. Through
a small subcostal incision and a pyloroplasty the band that was fi xed between duodenum and jejunum could be taken out. After this, pyloroplasty was closed in horizontal direction and the incision closed after leaving a drain (Illustration 25.1b ).
Postoperative course went uneventful.
25 Case on Problems with Laparoscopic Adjustable Gastric Band: Erosion and Migration
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Fig. 25.2 CT scan, migration
after erosion of the gastric
band up to the fi rst part
of jejunum
137
Fig. 25.3 Plain X-ray
showing the migration
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a
Erosion
I.M.C. Janssen and F.J. Berends
Endoscopy
Lumen
b
Illustration 25.1 ( a ) Adjustable gastric band showing erosion on the proximal stomach. Gastric
band was removed by gastroscopy using a gastric band cutter. ( b ) Adjustable gastric band showing
fi rst erosion through gastric wall and then migrating until the duodeno-jejunal junction. Removed
by pyloroplasty
25 Case on Problems with Laparoscopic Adjustable Gastric Band: Erosion and Migration
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139
Discussion
Band erosion—Band erosion is an uncommon complication of LAGB. The band
gradually erodes through the stomach wall into the gastric lumen. The reported
incidence is around 1 %, with an estimated prevalence varying from 0 to 11 % [ 1 ,
2 ]. Band erosion may be the result of gastric-wall injury during band placement or
tight anterior fi xation.
A high index of suspicion is required for diagnosis of band erosion as most
patients are asymptomatic. When symptomatic, complaints related to erosion
include loss of restriction, nonspecifi c epigastric pain, gastrointestinal bleeding,
intra-abdominal abscesses, or port-site infection. The diagnosis is often made at the
time of gastroscopy.
The recommended treatment is complete removal of the eroded gastric band,
gastroscopically and laparoscopically or via laparotomy. Removing a band that has
eroded into the stomach can be diffi cult owing to the extensive infl ammatory
response around the proximal stomach and left lobe of the liver. This is the rationale
for a gastroscopic approach: With the scope a thin metal wire is positioned around
the band. The two ends of the wire are brought through a thin fl exible shaft which is
gently brought down through the esophagus to the band. The wires are pulled with
force against the fl exible shaft thus cutting through the silicone band. From the outside, the port must be surgically removed and the tubing cut. After this, the band can
be removed orally, most of the times. This procedure can only be performed when
the band is well visible within the stomach [ 1 – 3 ].
Because of the diffi cult direct laparoscopic approach, transgastric techniques
have been proposed to facilitate band removal. Using distal transgastric ports, the
band can be removed with a combined laparoscopic/endoscopic approach. It is surgically easier to operate and close a gastrotomy in normal gastric tissue than near an
eroded band. In the case of acute gastric perforation, laparotomy with wide drainage
is necessary.
Port-site infection—Port-site infections can be classifi ed as early and late. Early
infections will manifest with the cardinal signs of erythema, swelling, and pain.
These infections typically occur in the immediate postoperative period. These infections with cellulitis alone may be treated with oral antibiotics. If the response is
inadequate, then intravenous antibiotic use is warranted. When the infection does
not respond to intravenous antibiotics and is limited to the port, the port can be
removed and the tubing knotted and left inside the abdomen. A new port may be
placed when all signs of infection are gone. The tubing can be connected with laparoscopic guidance.
Late port site infections are often caused by band erosion with ascending infection. This usually manifests several months after surgery and can be associated with
loss of restriction. Gastroscopy must be done to confi rm the diagnosis of band erosion. In each case of erosion, removal of the band is necessary.
Tube breakage—Breakage or damage of the tube typically refers to leakage of
the tubing leading into the port or a place where there is a metal connector. To prevent leakage from the port, the use of a standard coring needle is strongly
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I.M.C. Janssen and F.J. Berends
discouraged, and only Huber (noncoring) needles should be used to access the port.
If port access is diffi cult or if the tubing connected to the port is at risk of perforation, then band adjustment under fl uoroscopy is advised. Tube breakage usually
manifests as a slow leak with the loss of the injected fl uid volume on aspiration and
the absence of restriction. It can be diffi cult to identify the leak site, but local exploration of the port site can confi rm the diagnosis.
Leakage from the intra-abdominal tubing is more diffi cult to diagnose. Injection
of dilute nonionic iodinated contrast into the port under fl uoroscopy can help to
identify the site of the leak. Another approach is to inject diluted methylene blue
into the port under direct laparoscopic visualization of the tubing and the band. Port,
tubing, or band replacement is usually necessary depending on the site of the leakage and type of band used [ 1 ] .
References
1. Berends FJ, Janssen IMC. Prevention and treatment of complications after bariatric surgery. In:
Cuesta MA, Bonjer HJ, editors. Treatment of complications after digestive surgery, chapter 10.
London: Springer; 2013.
2. Abu-Abeid S, Szold A. Laparoscopic management of Lap-Band erosion. Obes Surg.
2001;11:87–9.
3. El-Hayek K, Timratana P, Brethauser SA, Chand B. Complete endoscopic/transgastric retrieval
of eroded gastric band: description of a novel technique and review of the literature. Surg
Endosc. 2013;27:2974–9.
Chapter 26
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Case on Jaundice and Hepatic Failure After
Major Hepatic Resection
Miguel A. Cuesta
Keywords Jaundice • Hepatic failure • Hepatic resection • Rectal cancer •
Liver insuffi ciency • Liver metastases • RFA • Liver cyst
First Patient
Diagnosis and Indication for Surgery
A 75-year-old male patient was operated at the end of 2009 because of proximal
rectal cancer, stage III, by means of low anterior resection.
Six months later, a CT scan revealed two liver metastases on segments 1 and 2 of
the liver.
Patient was proposed to be treated by resection of segments 2 and 3 and radiofrequency (RFA) of the lesion located on segment 1.
Operation
Through a subcostal incision, after inspection and US, fi ve metastases were found, the
two known ones and another three between 8 and 15 mm: one in segment 4a, another
in 4b, and the last in segment 8. An attempt was made to resect segment 1, but because
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_26,
© Springer International Publishing Switzerland 2014
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