complications of laparoscopic gastric banding of gastric... · patient underwent gastric lavage,...

COMPLICATIONS OF LAPAROSCOPIC GASTRIC BANDING

BRIAN TIU - PGY 5 KING COUNTY HOSPITAL

www.downstatesurgery.org

PATIENT PRESENTATION

HISTORY

▸ 36 yo female

▸ morbid obesity, laparoscopic gastric banding 2008

▸ Mar 2015 – small bowel resection, removal of band

▸ d/c from outside hospital 3 days prior

▸ hematemesis and syncope

▸ EGD x2; no active bleed, ulcers at the level of the band

▸ 2 units PRBC; discharge H/H of 7.9/25.6


Presenter

Presentation Notes

lost approximately 100 lbs Remove Mar 2015


WORKUP

▸ 2015.OCT.24 - BIBEMS with hematemesis, AMS, melena

▸ BP96/61 P85 R23

▸ admitted to MICU, intubated

▸ abdomen obese, well healed scars, melena on DRE

▸ H/H 5.0/16.6; blood products given – 10 / 8 / 2

▸ EGD - unable to visualize source of active bleed

▸ BP dropped to 50s systolic



OPERATING ROOM

▸ MTP activated

▸ exploratory laparotomy

▸ adhesiolysis

▸ gastrotomy, two ulcers oversewn

▸ evacuation of 1.5L blood/clot

▸ blood products given 2 / 4 / 2 / 2


Presenter

Presentation Notes

gastrotomy proximal body of the stomach, two ulcers at posterior wall at proximal body/caradia


PATHOLOGY

▸ body type gastric mucosa w/ hemorrhage and mild chronic inflammation

▸ blood vessels w/ congestion and dilatation

▸ h pyl negative

▸ consistent with submucosal vascular malformation



POST OPERATIVE COURSE

▸ POD#0 - H/H 9.7/27.4

▸ POD#4 - H/H 7.5/22.3, tolerating diet, ambulating, BM+

▸ POD#5 – nausea, hematemesis, tachycardia

▸ transfused 4 / 1 / 0

▸ intubated

▸ bedside EGD


Presenter

Presentation Notes

POD#4 H/H 7.5/22.3 - stable at this level for three days


Presenter

Presentation Notes

patient underwent gastric lavage, two intact suture lines, no bleeding, large amount of clot



▸ POD#6 - repeat EGD

▸ POD#8 - re-bleed, transfused 6/2/0, repeat EGD, angio

▸ embolization of the L gastric artery for pseudoaneurysm

▸ POD#10 - OR to secure ETT, repeat EGD, Blakemore tube placement




▸ POD#18 - H/H 9.3/27.8, no further transfusions

▸ POD#22 - discharged home

▸ POD#25 - seen in clinic


QUESTIONS


BARIATRIC SURGERY

OUTLINE

▸ overview

▸ indications

▸ bariatric surgery

▸ laparoscopic adjustable gastric banding

▸ complications


BARIATRIC SURGERY

GOALS OF METABOLIC & BARIATRIC SURGERY ▸ treatment of severe obesity, i.e. weight loss

▸ treatment of metabolic conditions, e.g. DM


BARIATRIC SURGERY

OBESITY

▸ second leading cause of preventable death in the US

▸ epidemic proportions in the US

▸ ~35% obese (78.6 million people)


Presenter

Presentation Notes

behind smoking


Presenter

Presentation Notes

I like to focus on colorado as the last bastion of hope, but as of 2010,

BARIATRIC SURGERY

MEDICAL MANAGEMENT

▸ ↓caloric intake, ↑energy expenditure

▸ safest

▸ lifestyle changes must continue through surgery

▸ identify/manage co-morbidities

▸ pharmacologic therapy

▸ after failure of lifestyle changes and dietary therapies


Presenter

Presentation Notes

Sibutramine - norEpi and 5-hydroxytryptamine reuptake inhibitor - appetite suppressant Orlistat inhibits gastric/pancreatic lipase enzymes that promote lipid absorption in the intestine

BARIATRIC SURGERY

INDICATIONS


Presenter

Presentation Notes

NIH Consensus Conference of 1991

BARIATRIC SURGERY

INDICATIONS

▸ BMI ≥ 40


Presenter

Presentation Notes

NIH Consensus Conference of 1991

BARIATRIC SURGERY

INDICATIONS

▸ BMI ≥ 40

▸ BMI ≥ 35 & co-morbid medical condition

▸ sleep apnea, cardiomyopathy, DM, HTN

▸ quality of life - employment, family, ambulation


BARIATRIC SURGERY

INDICATIONS

▸ BMI ≥ 40




▸ failed attempted weight loss treatments


BARIATRIC SURGERY

INDICATIONS

▸ BMI ≥ 40




▸ failed attempted weight loss treatments

▸ psychologically stable


Presenter

Presentation Notes

low cal diet, exercise, behavioral modification

BARIATRIC SURGERY

CONTRAINDICATIONS

▸ ASA class IV

▸ psychologic instability

▸ drug/EtOH addiction

▸ eating disorders, e.g. bulimia


BARIATRIC SURGERY

PRE-OPERATIVE ASSESSMENT

▸ multidisciplinary team evaluation

▸ PCP, nutritionist, psychologist/psychiatrist, surgeon

▸ optimize medical condition

▸ work-up CAD , OSA, hypothyroidism


BARIATRIC SURGERY

POST-OPERATIVE CARE

▸ short term follow-up - 2 years

▸ assist adjusting to new eating, exercise, and lifestyle patterns

▸ early identification of postoperative complications;

▸ trend weight loss, change in BMI

▸ resolution or improvement in medical co-morbidities


Presenter

Presentation Notes

Immediate short term follow-up is paramount

BARIATRIC SURGERY

SURGERY

▸ restrictive


▸ sleeve gastrectomy


BARIATRIC SURGERY

SURGERY

▸ restrictive



▸ malabsorptive

▸ biliopancreatic diversion

▸ jejunoileal bypass


BARIATRIC SURGERY

SURGERY

▸ restrictive



▸ malabsorptive



▸ combined

▸ roux-en-Y gastric bypass

▸ biliopancreatic diversion with duodenal switch


BARIATRIC SURGERY

SURGERY

▸ restrictive



▸ malabsorptive



▸ combined




Presenter

Presentation Notes

three most commonly performed procedures today

BARIATRIC SURGERY

SURGERY

▸ restrictive

▸ laparoscopic adjustable gastric banding ▸ sleeve gastrectomy

▸ malabsorptive



▸ combined




LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

HISTORY

▸ 1993 - Belachew, 1st laparoscopic adjustable gastric banding operation

▸ 2001 - approved in the US by the FDA

▸ Current - 25% of bariatric procedures performed



OUTCOMES

▸ up to 50% weight loss in 24 months

▸ up 25% fail to lose weight within 5 years

▸ type II DM improved in up to 90%, medications eliminated in 64%

▸ inferior to roux-en-y gastric bypass in overall weight loss

▸ superior in morbidity and mortality


Presenter

Presentation Notes

Operation30–day mortality Overall complicationsMajor complications Lap AGB0.05-0.4%9%0.2% Lap RGB0.5-1.1%23%2%


SURGERY

▸ pars flaccida approach

▸ retrogastric tunnel

▸ pars flaccida medially

▸ angle of His laterally

▸ decreased rate of band slippage

▸ more extraneous tissue (lesser curvature fat pad) incorporated into the band


Presenter

Presentation Notes

Inferior portion of the hepatogastric ligament


SURGERY

▸ peroral calibration balloon placed

▸ fill to 15-25 cc of saline

▸ band fastened below this level

▸ create 15-25 cc pouch



POST-OPERATIVE CARE AND FOLLOW-UP ▸ exercise and diet progression plan

▸ band adjustments - ↑band restriction by adding fluid

▸ <2 lb wt loss wk

▸ easily eat solid foods, little satiety, pronounced appetite

▸ over 2 year period


Presenter

Presentation Notes

Operation30–day mortality Overall complicationsMajor complications Lap AGB0.05-0.4%9%0.2% Lap RGB0.5-1.1%23%2%


COMPLICATIONS

▸ pouch enlargement

▸ band slippage

▸ port-site infections

▸ port breakage

▸ band erosion


COMPLICATIONS

POUCH ENLARGEMENT

▸ dilation of the proximal gastric pouch

▸ with or without change in the angle of the band

▸ no signs of obstruction

▸ seen with band overinflation or overeating

▸ sx - lack of satiety, heartburn, regurgitation, chest pain

▸ tx - band deflation, low-calorie diet, portion control


Presenter

Presentation Notes

follow-up contrast study in 4–6 weeks

COMPLICATIONS

BAND SLIPPAGE

▸ cephalad prolapse of the stomach or caudad movement of the band

▸ 2º insufficient anterior fixation or ↑pressure in the pouch

▸ sx - dysphagia, vomiting, regurgitation. food intolerance

▸ necrosis, perforation, UGIB, aspiration

▸ tx - require operative intervention, removal/repositioning of the band


Presenter

Presentation Notes

follow-up contrast study in 4–6 weeks Not as common with the pars flaccida approach

COMPLICATIONS

PORT SITE

▸ infection - erythema, pain, edema

▸ tx - antibiotics, removal of port

▸ leakage

▸ damaged port septum or tubing

▸ loss of the injected fluid volume, loss of restriction

▸ local exploration, port replacement


Presenter

Presentation Notes

follow-up contrast study in 4–6 weeks

COMPLICATIONS

BAND EROSION

▸ rare

▸ gastric-wall injury or tight anterior fixation

▸ most patients are asymptomatic

▸ epigastric pain; sepsis, bleeding

▸ weight gain, multiple band adjustments, port infection

▸ tx - complete removal of the eroded gastric band


COMPLICATIONS

BLEEDING

▸ 2º to migration/erosion; rare

▸ chronic ischemia 2º pressure

▸ chronic inflammation 2º reaction to silicon gastric band

▸ case reports

▸ regular follow-up - gastroscopy, barium swallow


Presenter

Presentation Notes

6? case reports tx of pain may be misleading → nsaid use differential

COMPLICATIONS

reoperation rate 36.5%

repositioning 5.4

replacement 6.2

port related 13.9

band removal 10.0

conversion to other bariatric procedure 10.2


Presenter

Presentation Notes

2014 review article


SUMMARY

▸ profound weight loss and improvement of metabolic derangements are possible with LAGB

▸ LAGB is a safe and reversible procedure

▸ re-operation rates are high

▸ close post-operative follow-up is paramount


Presenter

Presentation Notes

6? case reports tx of pain may be misleading → nsaid use differential


QUESTION

Which of the following is not among the requirements for bariatric and metabolic surgery?

A. BMI ≥ 40

B. failed attempted weight loss treatments

C. BMI ≥ 35 with co-morbid medical conditions

D. age ≥ 18

E. psychologically stable



REFERENCES

‣ Bruce Schirmer; Philip R. Schauer. Chapter 27 The Surgical Management of Obesity. Schwartz's Principles of Surgery, 9e. The McGraw-Hill Companies, Inc. 2010.

‣ Eid, Iyad et. al. Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guide. Canadian Journal of Surgery. FEB 2011. 54(1). p61-66.

‣ Shen, Xiaojun et. al. Long-term complications requiring reoperations after laparoscopic adjustable gastric banding: a systematic review. Surgery for Obesity and Related Diseases. 2015. 11. p956–964

‣ Society of American Gastrointestinal and Endoscopic Surgeons

‣ Torab, FC et. al. Delayed life-threatening upper gastrointestinal bleeding as a complication of laparoscopic adjustable gastric banding: Case report and review of the literature. Asian Journal of Surgery. 2012. 35. p127-130


complications of laparoscopic gastric banding of gastric... · patient underwent gastric lavage,...

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