Dr. Mehrdad BohlooliJam General Hospital

Tehran-Iranwww.drbohlooli.com

http://www.drbohlooli.com/

BMI>40 kg/m2BMI>35 kg/m2 with additional health problems (hypertension, diabetes, arthritis, sleep apnea etc.)Age: 12-60Failure in other medical treatments (diet, exercise, etc.)At least 5 years of obesity problem.

Psychological instabilityAlcohol / drug addictionUnwilling or incapable for diet (binge eaters, ………..)Acute inflammatory diseases of gastrintestinal system ( eosophagitis, Crohn’s disease, appendisitis….)PregnancyCurrent infection or high risk of contamination during surgeryİnternal organ failure (liver, kidney..)Potential of bleeding from upper gastrointestinal tract (portal hypertension)Necessity of aspirine or another NSAİ drug usePatients with brain cancer.

1. MalabsorbtiveA. İntestinal by-pass prosedures, 1950B. Biliopancreatic diversion, 1970C. Bilipancreatic diversion with duodenal switch

2. RestrictiveA. Horizontal gastroplasty, 1976B. Vertical stapling gastroplasty, 1979C. Vertical banding gastroplasty, 1980D. Gastric banding – ASGB, 1983

3. Restrictive and malabsorbtive proseduresA. Gastric by-passB. Roux-en-y Gastric by-pass

4. Gastric Pacing

BMIAgeSexBody Fat compositionDiabetes Mellitus type IIDyslipidemiaBinge eating disorderHiatal herniaLow IQGastroeosopahageal refluxPatient’s expectations

Interdiciplinary European Guidelines for Surgery of Severe Obesity. Obes Surg. 2007, 17: 260-270

In 1970, Dr. Angelchik used gastric band for the first time in distal eosophagus for gastroeosophageal reflux.In 1980, Dr. Molina suggested inadjustable gastric band. However , this method did not become popular.In 1984, Kuzmak and Hellers suggested adjustable gastric band and performed.In 1994, Belgian surgeon Blachew performed laparoscopic adjustable band operation.In 2001 with FDA approval, this method started working in USA.

Steinbrook R. Surgery for severe obesity. New England Journal of Medicine . 2004; 350:1075-1079

AGB started to be used in 1984 as a result of Kuzmak’s workMany problems (such as ideal pouch width and preventing it from getting wider) was all solved by using this method.By the invention of AGB, it became possible and less invasive to adjust the scale of the pouch without another anatomosis.Adjustment of the band is performed by a subcutaneous reservoire similarly to the intravenous port systems used in chemotherapy.

Form a tunnel over the omental bursa, under thegastroeosophageal junction.Tr y not to traumatize the stomach (especially on greater curvature, away from left crus)Minimalize the risk of trauma on posterior wall of stomach , liver and spleen.Try not to hold the band with sharp tools, hold the sharp tools away from the band as possible.Place the band on the stomach tightly but do not let the stomach restrict the adjustment mechanism of the band.

Provost David A. Laporoscopic Adjustable Gastric Banding: An Attractive Option. Surgical Clinics of North America 2005; 85: 789-805

Provost David A. Laporoscopic Adjustable Gastric Bandig: An Attractive Option. Surgical Clinics of North America 2005; 85: 789-805

By using perigastric technique, reaching the posterior wall of stomach through omentum minus, it is very likely that the posterior wall of stomach slides between the band; resulting in a symptomatic prolapsus. This condition is proved to be seen in 23% of the patients.Inflating the band 1 to 2 cc during the operation, in additon to the complication mentioned above, results in early vomitting which causes detachment of the fixage sutures.Wide pouche left leads to dilatation; near dissection by the minor curvature level causes deseresisation.As a result of deseresisation, multiple band erosions are seen.

According to some reasons mentioned above, perigastric technique is now abandoned; and therefore pars flaccida technique is considered to be the optimum method.

Provost David A. Laparoscopic Adjustable Gastric Bandig: An Attractive Option. Surgical Clinics of North America 2005; 85: 789-805

Misplacement of BandGastric PerforationEarly Slippage with Secondary Acute Dilatation

1- Pouch Dilatation2- Band Herniation3- Spontaneous Variation in Volume4- Erosion of the Gastric Wall5- Band Migration

- Inexperience of Surgeon is the most important factor.- most commonly it was placed in the perigastric fat, and less commonly it was placed in the lower parts of stomach, which can be cause serious G.O.O

Early perforations are due to operative traumaThe patient present with Pain, Fever, and Leukocytosis, and in late periods with loss of consciousWater-soluble contrast imaging may reveal the leakage from the stomach.Don’t use BariumCT is also Diagnostic

Early pouch dilatation has been described in low-positioned bands .Pouch dilatation is also a common late complication. After surgery, the pouch gradually increases in volume but retains a grossly concentric shape.Concentric dilatation may be secondary to reactive perigastric fibrosis as a result of tight fastening at surgery or of the natural reaction of the body to foreign implants (silicone)

Medial eccentric pouches are directly related to intraperitoneal band positioning in the transbursal operative technique where dissection is performed through the lesser sac and the band is placed on the stomach near the short gastric vessels. This is in contrast to the new technique, pars flaccida, where minimal dissection is performed and the band is placed in the hepatogastric ligament, leaving the lesser sac untouched. This leads to higher position of the band, away from the peristalting stomach .

Lateral eccentric pouches are secondary to posterior slippage of the band. Slippage is defined as herniation of the stomach from below the band upward, resulting in pouch enlargement.

Peternac et al. suggested that this complication is not dependent on the operative technique; rather it results from tears of the anterior sero-muscular fixative sutures .Other authors have encountered this complication only in the transbursal approach

Intermittent slippage due to an unstable band is a difficult diagnosis. It manifests by intermittent obstruction and abnormal band position only after filling the pouch. In these cases, the posterior slippage is discrete and the band returns to its normal position after deflating the system or emptying the pouch.

The spontaneous increase in the stoma diameter in the band is related to the semi-permeability of the silicone. The system, therefore, should be filled only with isoosmotic, isotonic solution.

The clinical presentation of chronic gastric erosion varies between asymptomatic conditions and acute abdominal emergency. Mechanical damage to the wall may be secondary to intraoperative trauma to the muscular layers, inflammatory reaction to foreign bodies, infection, and use of nonsteroidal anti-inflammatory medication.The passage of the contrast out of the lumen around the band is a certain indication of band erosion. Gastric erosion is highly likely if an open band is seen. Findings may be associated with a change in band position

Partial rotation of the access port may be most easily corrected by supportive manual compression when the patient is in a supine position. Completely inverted ports require surgical repositioning .

Disconnection can occur between the proximal and distal parts of the connector tube or at the junction of the connector with the band or with the access port. These disconnections are easily diagnosed on a radiograph (since the connector tube is usually made of silicone). Surgical treatment is mandatory .

Leakage is typically a late complication.It may occur at the level of the band or the connector tube or at the access port. It is first suspected when filling and insufficient deflating volume of the banding system combined with loss of eating restriction are observed.Leakage of contrast material is usually detected while adjusting the band diameter.However, contrast studies sometimes fail to detect the leakage even in typical clinical presentations [.

As around any foreign body, soft-tissue infection around the access port is possible. In addition, even the sterile puncture and adjustment of the stoma size may introduce infection, which then extends along the connector tube and along the band, with possible abscess formation. Infection increases the risk of perforation and fistulization and may necessitate surgical débridement and removal of the band .

Esophageal dysmotility represents an early stage of esophageal paresis and dilatation.The extreme form is esophageal gastrification(enhanced reservoir capacity of the esophagus).This indicates the end point of a successful restrictive bariatric surgery. Secondary achalasiahas also been described in association with preoperative lower esophageal sphincter insufficiency.Reflux and regurgitation are common complications associated with pouch dilatation and may be associated with esophagitis

Food Trapping: It presents with dysphagia and appears as an intraluminal filling defect within the stoma. small-bowel volvulus and obstruction : due to long intraperitoneal tract connector.Erosion of adjacent organs

Open/Laparoscopy 86/1426sex (Male/Female) 680/832Age 35.28+12.60Weight 132.5+22.77Height 168.32+10.32BMI (kg/m2) 46.99+7.88Ideal weight 61.48+6.80Over-weight (%) 130.3+33

Weight 74.6+16.8BMI (kg/m2) 29+6.1Over-weight (%) 62+21.9

In our series, one-month after the operation 12 kg, 3 months 24 kg, 6 months 33 kg, and 24 months after the operation 60 kilograms of weight loss is determined.

Wound infection 8Evisceration 1Atelectasia 12Pulmonary embolism 4Erosion of stomach wall 3Mortality 2

Incisional hernia 2Solid nutrient intoleration 15Reflux eosophagitis 12Band- slippage 5Outlet stenosis 2Reservoire leakage 30Gastrointestinal bleeding 3

In 75-85% of over 1000 patients treated by gastric restrictive prosedure were determined as “good” and “perfect” results according to Maclean and Reinhold Classifications.Our rate is 94.5% according to Reinhold classification.

In Kuzmak’s series first year average weight loss is 36 ± 10 kilograms.Taşkın et al. First year average weight loss is 32.55 ± 10.77 kilograms.

With Regards To Prof. Dr. Mustafa Taskin, who was planned to take part in this congress, but he could not do that due to his mother’s sudden death.

Complications of Gastric Band Surgery�Indications for Surgical TreatmentContrindications for Surgical TreatmentMorbid Obesity Surgery ProceduresChoosing Suitable MethodHistory of Gastric Band ProceduresSlide Number 8Adjustable Gastric BandTechniques in Placing LAGBPerigastric TechniquePars FlaccidaWhy Prefer Pars Flaccida Technique?Early Postoperative ComplicationsLate Postoperative ComplicationsBand Misplacement�Gastric Perforation�Pouch Dilatation������Pouche DilatationVariation in the Stoma SizeBand Erosion��Rotation Of The Access Port�DisconectionLeakage of the Banding System Infection �Esophageal Dysmotility and Reflux �Miscellaneous ��Preoperative Data of our AGB PatientsPost-op Results (for 24 months)Early ComplicationsLong-term ComplicationsConclusionConclusion 2Our PatientsOur PatientsOur PatientsOur PatientsOur PatientsOur Patients�