Adjustable Gastric Band Revisions

Gastric Banding or Adjustable Gastric Banding was the “gold standart” treatment of morbid obesity from 1990’s which it was first performed till the last two decades. However short and long term complications and significant weight regain ratios started to be reported for gastric banding. A silicone prosthesis which is placed at the entrance of the stomach which aims to restrict the gastric capacity; triggers a foreign body reaction of stomach to overcome this restriction. Due to this struggle of stomach towards the band, the technique is prone to failure and complications more than most of the bariatric operations.

Adjustable Gastric Band Complications

1. Band Erosion

The gastric capacity of the new pouch of band is about 40-50 cc. This allows patients to be able to hardly swallow solids. If slightly bigger bites are swallowed than patients feel nausea and vommit most times. If the patient frequently vomits than with every contraction the pressure of bang to stomach Wall increases and this leads to stomach erosions due to ischemia. Many times this event takes place and progress as a closed erosion of band into the gastric lumen without forming any infection. Patients start to regain weight  but do not have any infectious symptom. Rarely this ischemic close erosion might complicate with intra-abdominal perforation leading to severe intra-abdominal sepsis.

1. Pouch Enlargement

Dude to frequent nausea and vomitting the small gastric pouch formed by the band may dilate and enlarge in volüme. This typically leads to increased meals and weight regain.

1. Band Migration

The gastric band is placed in a very dynamic anatomical region of the body. The cardia (entrance of stomach) meets with esophagus just at the level of diaphragm in between thorax and abdominal cavities. The heart and the lungs contract and expand many times in a minute. This region has a stability in these dynamics under normal circumstances. However, band, as a foreign body, which  tries to restrict the physiological movements of cardia and fundus; acts like a barrier againts this dynamic equilibrium. This ongoing struglle between the cardioesophageal junction and gastric band, leads in some patients to the m,igration of band either proximally to distal esophagus or distally towards the gastric corpus. In most cases the migrating band does not cause any life-treathening complication but only loss of restriction and weight regain. However in some cases these migrations of band might cause significant complications such as obstruction, necrosis an deven perforation.

1. Port Site Infection

The Adjustable Gastric Band has a connection tube that end at subcutaneous tissue with a port that is used to inflate and deflate the inner layer ballon of the band.  That tube makes a connection with subcutaneous tissue and intra-abdominal cavity. Every punction to adjust the band, if not cared well, may carry the risk of port site infection. These complications are mostly seen in patients who try to adjust themselves. If not treated timely and cared well this subcutaneous infection easily might progress to a severe intraabdominal sepsis. Port resection should be considered at early stages to prevent further advancement of the complication.

1. GERD (Gastroesophageal Reflux Disease)

Reflux of gastric content and also regurgitation of food may easily be seen if the band is tight. Balloon deflation should be the first step with a diatetician consultation to check the food consumption habbits. If the problem exceeds these modifications than band removal may be an option.

1. Failure to Loose Weight / Weight Regain

Failure to loose weight (loss of less than 50 % of excess weight) and weight regain (regain of 25-30 % of total weight lost) can happen after adjustable gastric band. If the patient related factors such as sweet eating, bad eating habbits and inappropriate life style are eliminated, than the band should be removed and a revision surgery should be considered according to patients needs.

1. Dysphagia (Painful Swallowing)

This is mainly happens due to eating disorders and inappropriate eating habbits. The main issue is the patient education by specialist bariatric nutritionists and nurses to briefly explain the healty eating habbits. For patients who can not accomodate to these, band extractions should be considered. 

1. Esophageus Dysmotility (Esophageal Enlargement)

The band if migrated or placed directly to distal esophagus, than it increases the lower esophageal pressure which leads to enlargement and dysmotility (loss of contractions) of esophegus. These patients suffer from dysphagia (painful swallowing) and  regurgitation (undigested food coming to mouth). prompt band extraction is advocated to prevent further severe stenosis of distal esophagus.

Band Revision: Extraction or Re-position?

Gastric band, either adjustable or non-adjustable; is a silicon prosthesis. Its function is basicly to restrict the amount of food that can be consumed at a time. So it is mostly effective towards solid but almost purely non-efective to soft and liquid form sweets. For any of the above mentioned complications, the best thing to do is almost always to remove the band.

A conversion to another operation timing can be decided at the time of band removal. If the band had no infectious complications and the tissue scar damage is not severe; than a revisional surgery can be performed safely at the same setting. However many of the band complications form severe adhesions and fibrotic tissues. Only to remove the band and leave the region for healing for sometime is the best choice fort the patient for most times.

Which type of Band Revision or Conversion?

1. Conversion of Gastric Band to Duodenal Switch

Conversion to Duodenal Switch (DS) is mainly concerned in super obesity patients. In our practice we take the highest BMI as the basis of decision. If the patient has a BMI over 50 kg/m² even before the gastric banding procedure, then Duodenal Switch (DS) will be the best weight-loss surgery option for durable weight loss.

Especially patients with severe band complications such as band erosions, perforations whom have the risk of excess scarry tissue at the cardia region should be more precisely selected for Duodenal Switch (DS) . The main reason for this is that, no restriction is formed at cardia with Duodenal Switch (DS) with a liberate vertical sleeve gastrectomy. For those patients, technically less dissection brings less risk at the banded region of stomach. Duodenal Switch (DS) allows us to mannage the region with less dissection. This is because the Duodenal Switch (DS) Surgery mainly leans on intestinal bypass rather than gastric restriction of food.

Another group of patients that we recommend Duodenal Switch (DS) Surgery, is the sweet eaters. If a patient has bad eating habbits like binge eating and sweet eating than a restrictive surgery such as gastric banding will not work. These patients are evaluated for Duodenal Switch (DS) even they are not super obese.

For non super obese patients, Duodenal Switch (DS) is modified for each patients total bowel length and the alimentary and biliopancreatic limbs are adjusted for better weight loss and less malabsorptive complications.

2. Conversion of Gastric Band to R-Y Gastric Bypass (RYGB)

R-Y Gastric Bypass (RYGB) is one of the most prefered conversion techniques for gastric band revisions. The literature is controversial about the success of the R-Y Gastric Bypass (RYGB) after band failure. This has some rational basis. The R-Y Gastric Bypass (RYGB) procedure need to form a very tight and small  new gastric pouch to properly achieve the desired restriction. However, a problematic band, forms tough fibrosis and adhesions at the region of cardia which will be dissected and transected to form a “high-pressure” gastric pouch. These issues brings together an increased risk of leak.

To over come this increased leak risk, the surgeon chooses to transect from healty gastric wall which forms a big stomach pouch. Many patients refer to us with out any weight loss after revision to R-Y Gastric Bypass (RYGB) for their failed gastric band. Its obviously seen in endoscopy and barium swallow x-rays that the pouches are larger than they shoud be. I prefer to convert these patients to Duodenal Switch (DS) if appropirate.

R-Y Gastric Bypass (RYGB) may be a good option for sweet eating band patients who regain weight without a major band complication. We also recommend R-Y Gastric Bypass (RYGB) for mis-positioned bands especially when they are placed or migrated to distal esophagus.

3. Conversion of Gastric Band to Sleeve Gastrectomy

It seems much more easier for many surgeons to convert a band directly to sleeve gastrectomy. Again fort his choice the patient and band related factors play an important role. As in Gastric Band or R-Y Gastric Bypass (RYGB) the small gastric pouch is vital fort he success of the operation; its the same in Sleeve Gastrectomy also. For a proper sleeve, the fundus part of the stomach should be properly mobilised and resected for a beter and long lasting control of weightloss.

However especilly in gastric bands with major complications such as erosions, perforations or infections, the anatomical region may be surroundend by tough adhesions and stomach Wall might be severely fibrotic. These will comprimise the integrity of the staple line to increase the risk of leaks.

The through evaluation of the gastric band position, the history of the patient with band is vital for selection of the true technique for revision. If the band is placed or migrated earlier to distal esophagus than we perform sleeve gastrectomy securely. However in complicated band cases, due to tough fibrotic tissues and adhesions, sleeve has a significant leak risk. We choose to extract the band and wait at least 6-12 months for a better tissue healing as a staged surgery to plan a sleeve gastrectomy.

4. Conversion of Gastric Band to Ileal Interposition or Transit Bipartition

Both Ileal Interposition and Transit Bipartition are preferable metabolic surgeries for complicated band cases whom BMI is less than super obesity. Both techniques do not need strict gastric restrictions to achieve weight loss. The gastric sleeve that is performed for Ileal Interposition and Transit Bipartition is liberal and comparably wide for a standart sleeve gastrectomy. This allows to have a low pressure gastric tube that will be transected in healty gastric tissue.

Especially  Duodenoileal Interposition and Gastroileal Interposition surgeries uses  foregut supression of negative incretins and hindgut stimulation of satiety hormones of GLP-1 and PYY. Combined use of these two metabolic paths forms a strong feeling of satiety aloowing very low portions of food without forming a risk of severe malabsorption.

 

Things You Should Know Before Revision Surgery:

Revision Surgery is a complicated issue which needs high technical skills and accumulated experience in the vast majority of bariatric surgery. The above mentioned bariatric surgeries, should be the routine practice of the revision surgeon in order to choose the best option for each spesific patient. All of the mentioned revisions can be completed laparoscopically in more 90 % of patients. In some cases staged surgeries should be considered an done should be confident that staged surgery is life saving in certain cases. Altough we have a plan prior to surgery in most of the cases, the main decision can only be given at the time of surgery due to the surgical scene. The surgical team should be prepared to flexibly modify the surgery according to the patients’ anatomical conditions. That’s why being expertised in different bariatric operations increase the success rate of the revision surgery.

 

Further to read:

Cazzoni et. al. Roux-en-Y Gastric Bypass Versus Adjustable Gastric Banding to Reduce Nonalcoholic Fatty Liver Disease – A 5-Year Controlled Longitudinal Study

Annals of Surgery Vol. 260 Issue 5 pages 893-899, 2013.

 

Suter M, Calmes JM, Paroz A, Giusti V. Obes Surg. 2006 Jul;16(7):829-35.A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates.

Khan OA, Mansour S, Irukulla S, Reddy KM, Vasilikostas G, Wan AC.

Sleeve gastrectomy for gastric band failures - a prospective study.

Int J Surg. 2013;11(5):407-9. doi: 10.1016/j.ijsu.2013.03.005. Epub 2013 Mar 22.

 

Kothari SN, DeMaria EJ, Sugerman HJ, Kellum JM, Meador J, Wolfe L.

Lap-band failures: conversion to gastric bypass and their preliminary outcomes.

Surgery. 2002 Jun;131(6):625-9.

 

Poyck PP, Polat F, Gouma DJ, Hesp WL.

Is biliopancreatic diversion with duodenal switch a solution for patients after laparoscopic gastric banding failure?

Surg Obes Relat Dis. 2012 Jul-Aug;8(4):393-9. doi: 10.1016/j.soard.2011.09.012. Epub 2011 Sep 28.

 

Daskalakis M, Scheffel O, Theodoridou S, Weiner RA.

Conversion of failed vertical banded gastroplasty to biliopancreatic diversion, a wise option.

Obes Surg. 2009 Dec;19(12):1617-23. doi: 10.1007/s11695-009-9932-5.

 

Dapri G, Cadière GB, Himpens J.

Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch.

Surg Obes Relat Dis. 2009 Nov-Dec;5(6):678-83. doi: 10.1016/j.soard.2009.07.001. Epub 2009 Jul 10.

 

Keshishian A, Zahriya K, Hartoonian T, Ayagian C.

Duodenal switch is a safe operation for patients who have failed other bariatric operations.

Obes Surg. 2004 Oct;14(9):1187-92.