It is important to differentiate a slipped band from gastric pouch dilation, which can bemanaged non-operatively. We describe a patient that highlights this challenge and we discuss existing approaches to diagnosis and management. Methods: A case-based analysis and literature review were completed. Results: We analysed acase of a patient presenting with increasing dysphagia and intolerance of liquids approximately 3 years following placement of an adjustable gastric band LAGB.
Her family physician had prescribed motility agents, antacids and proton pump inhibitors with minimal impact. She was ultimately referred to the Weight Wise Program in Edmonton, Alberta, a multidisciplinary obesity management program with a Bariatric Surgery team. She was admitted to hospital from the Bariatric surgery clinic and a barium swallow was completed. The contrast study demonstrated a dilated esophagus and gastric pouch with near-complete obstruction at the band, which had assumed a horizontal position.
Weight loss was insufficient in 2, dilatation recurred in 2, and band infection or erosion developed each in 1 patient. The mid-term results are disappointing in two-thirds of the patients. In some patients, pouch dilatation could result from poor adjustment to diet restriction rather than merely from original malplacement.
Conversion to gastric bypass may be a better option in these cases. Abstract Background: Pouch dilatation with or without slippage of the band is a serious complication of gastric banding, often attributed to initial malpositioning of the band. Based on the outcomes of the study, we attempted to answer the four following questions: 1 what is the incidence of these complications, especially at the beginning of the practice?
In addition, we compared outcomes of the gastric plication technique, which was performed primarily during the later period among our cohort of patients. We followed the operative techniques used in previous studies reported by large-scale bariatric centers.
First, a very small pouch was formed by placement of the band on top of the stomach just below the gastroesophageal junction. A calibration tube with a 25 cc balloon was used for proper band placement and detection of the hiatal defect. Second, the pars flaccida technique was performed, in which entry into the lesser sac was avoided by placement of the band suprabursally around gastric vessels and fat instead of close to the gastric wall.
Finally, anterior fixation of the gastric fundus was performed using three to four nonabsorbable sutures between above and below the band. In addition, for patients who underwent LAGB during the later period of the study, we performed routine oblique plication of the anterior gastric wall below the band after noting that the angle of the band appeared to be stabilized in patients despite the variable degree of food trouble Fig. Intraoperative band adjustment was not performed, and bands were left unfilled at the end of the procedure.
Oblique plication technique. The protocol for band adjustment was as follows. The band was left empty at completion of band placement. The first fill was performed around four weeks postopertaively, at which time the postoperative edema subsided and patients began to regain initial small changes in weight.
Subsequent band adjustments were performed at intervals of at least two weeks. Three initial adjustments were performed under fluoroscopy. Thereafter, depending on the amount of change in body weight, portion size of food, and hunger, small volume adjustments were performed without a barium swallow usually, 0. For particular symptoms, such as vomiting, reflux, and abdominal pain, we also performed a barium swallow study during the adjustment period.
Pouch dilatation was classified as concentric and eccentric. Eccentric pouch dilatation was always accompanied by band slippage, which was classified as anterior and postoperative slippage. Conservative treatment included total or near-total removal of saline in the band and gradual readjustment with great care for any recurrent abnormal clinico-radiologic signs and symptoms.
Strict dietary education was also administered during the 'rest' period. Readjustment was usually started around three to four weeks after total removal of saline. Patients who did not respond to the initial conservative management underwent revision. This revision always involved laparoscopic non-destructive removal of the band and its repositioning at a proper level; however, a more proximal retrogastric tunnel and more proximal to the enlarged proximal pouch, as described previously.
During postoperative management, as with the original operation, patients underwent a gastrograffin esophagogram the morning after surgery and were discharged after demonstrating tolerance on a liquid diet. Concentric pouch dilatation. Normal band position and normal band angle were noted. The pouch was dilated concentrically. The pouch appears to have migrated to the intrathoracic level, suggesting the presence of a coexisting hiatal hernia.
Upper GI study of eccentric pouch dilatation. A EPA1, eccentric pouch with a normal band angle with a ring-like band configuration.
Radiologically, this type is early anterior slippage. B EPA2, eccentric pouch with a more horizontal band angle. This type of dilatation usually results in a progressive chronic symptom of acid reflux.
C EPA3, eccentric pouch with excessive clockwise rotation of the band. This type of dilatation usually manifests as acute, total food intolerance with severe reflux and epigastria pain. D EPP, eccentric pouch with posterior band slippage. This type of dilatation is associated with use of poor surgical techniques e. Arrow indicate outlines of the dilated pouch above band. Laparoscopic non-destructive removal of the band and its repositioning at a proper level in an EPA3 patient patient A In patients with pouch enlargement with severe reflux, a variable degree of hiatal hernia was usually observed, and we performed concomitant repair using figure of eight sutures of the anterior crura muscle.
Plicated neofundus was anchored to the crural muscle fascia short arrow , and gastogastric suture was also performed long arrow. Asterisk: newly formed pouch. B Repositioning of the gastric band through the newly formed retrogastric tunnel above the previous band position circular area.
Anterior plication of the gastric wall below the band was performed arrow. Preop C and postop D gastrograffin swallow study showed that the band angle and pouch shape arrows were normalized. During the study period, a total of 14 patients out of patients Thirteen of these patients were female.
The median time interval between primary band surgery and diagnosis of pouch dilatation was Conservative management was initially attempted for all patients, except for two cases of posterior slippage cases 12 and 14 that were corrected by immediate band replacement.
All four patients cases with CP showed a good response to conservative management. After a median follow-up period of three months range, months , no recurrence of clinic-radiologic signs and symptoms was observed.
However, two patients cases 2 and 4 experienced a slight increase in body weight during the follow-up period. Conservative management was also administered to seven patients with eccentric pouch dilatation with anterior slippage EPA Three EPA1 patients cases showed a positive response to conservative management without operative intervention.
Although no recurrence of clinico-radiologic signs and symptoms were observed in these patients, band adjustment with proper saline volume was not possible, and they experienced regain of weight during the follow-up period. These two patients did not respond to initial conservative management.
Severe night time reflux and postprandial epigastric discomfort were the primary reasons for revisions; the other two patients cases 9 and 11 recovered well after conservative management without discomfort. All three EPP patients cases underwent reoperation. Evidence of lesser sac penetration with redundant posterior fundus was observed during revision in two patients cases 12 and Comparison of pre- and post-intervention data of each group conservative treatment group vs.
In our practice, we used the gastric plication technique below the band in 27 patients Fig. Among 27 patients, only one patient was diagnosed as having concentric pouch dilatation, and there was no single episode of eccentric pouch dilatation. Their median follow-up period was 13 months range, months.
Surgery Group. Pouch enlargement and band slippage have been reported as the most common complications after adjustable gastric band placement. However, we still observed three cases of posterior slippage during our study period.
Two patients were within the first ten patients in our practice, and, band placement was not adequate in one patient due to a scar from a previous operation.
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