Is the Morbidity Increased for Gastric Band Removal When the Band Is Placed Around the Esophagus?

Abstract

Introduction:

Laparoscopic adjustable gastric band (LAGB) procedures declined worldwide in the recent years. In the majority of the national registers, the numbers of gastric band removal and revisions following LAGB have surpassed the implants. Still a good knowledge of different techniques is important for young bariatric surgeons to diminish the morbidity of revisional surgery.

Methods:

From January 2015 to December 2016, a total of 139 patients were retrospectively reviewed after undergoing a gastric band removal. The study included all consecutive patients who underwent a gastric band removal in this period of time with no exclusion criteria. Sixteen patients (18.8%) received the perigastric technique, 57 patients (67.1%) received the pars flaccid technique, 54 patients (38.8%) received bands with periesophageal technique, and for 12 patients (14.1%), the operative reports did not allow to identify the techniques used. In the present study, the operative times and the reported complications of the three main bands techniques were compared.

Results:

There were 124 women (89.2%) and 15 men (10.8%), with a median age of 44 years (range: 24–71). The overall mean preoperative body mass index was 34 ± 7.6 kg/m² (range: 22–52 kg/m²), and the mean preoperative weight was 93.7 ± 24.9kg (range: 49–165 kg). One hundred and seventeen patients (84.2%) had procedures performed on an out-patient basis. The overall mean operative time was 23.9 ± 13.7 minutes (range: 7–83 minutes). We recorded three cases of bleeding with one conversion to laparotomy. The overall percentage of complications in the entire series was 6.5%. No mortality was recorded.

Conclusions:

Our study regarding the band removal revealed that no correlation was found for operative morbidity among the three different types of bands. The only proven difference was the operative time, which was greater for periesophageal approach. For the latter one, a particular attention should be paid to the risk of injury for diaphragmatic or left suprahepatic vein.

Introduction

Currently, obesity is a chronic disease. It is important for the patient and their health care providers to understand this fact. The surgical treatment for this disease should be considered as a staged approach. The laparoscopic adjustable gastric band (LAGB) is a less radical procedure compared with the Roux-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG) and, especially in the past, was chosen for the treatment of less extreme morbid obesity (body mass index [BMI] 35–50).^1–3

After the initial description of LAGB in 1993, it soon acquired popularity among patients and surgeons, which led at the beginning of 2000, together with the rising prevalence of morbid obesity, to a yearly increase in the number of band implantations.^4,5 The LAGB can be implanted with low morbidity and mortality. On average, good excess weight loss (EWL) is achieved as well as a decrease in comorbidities in the short term. The skepticism among some bariatric surgeons about the long-term weight loss results, complication rates, and patient satisfaction have been confirmed by many bariatric centers. For some years now, there has been a decline in the number of LAGB procedures in both Europe and, later, in the United States.^6,7 In the majority of the national registers, the numbers of gastric band removal and revisions following LAGB have surpassed the implants. The future of LAGB is not very difficult to predict.

Still, for the young bariatric surgeon, generation is important to know the different methods used for the LAGB and its long-term complications to decrease the morbidity of future revisional procedures.

Initially, the perigastric technique was the most frequent used for adjustable gastric.⁸ To decrease the complication rate later on, the band was placed using the pars flaccid technique.⁹ It is often suggested that the retrogastric or pars flaccid technique would have better results in terms of less slippage and less migration than the perigastric technique.

With the purpose to decrease more of these complications, in our region, an important number of bands were placed in a periesophageal manner. It was initially used only for patients with recurrence of band slippage, but later was used systematically for all LAGB procedures.

The purpose of our study was to describe an original periesophageal suprahepatic approach for LAGB and to evaluate the correlation between the technique of LAGB and the morbidity of gastric band removal.

Methods

From January 2015 to December 2016, a total of 139 patients were retrospectively reviewed after undergoing a gastric band removal. All procedures were performed by a single surgeon (M.D.) at a private hospital. The study included all consecutive patients who underwent a gastric band removal in this period of time. No patients were excluded from the study.

Data on patient demographic characteristics, operative variables, and postoperative complications were reviewed retrospectively. Patients were divided for analysis into three different groups, according to the technique used for gastric band placement: perigastric technique (group A); pars flaccid technique (group B), or periesophageal technique (group C). Of the 139 patients in this series, 85 received bands that were placed around the stomach. Of these, 16 (18.8%) received the perigastric technique, 57 (67.1%) received the pars flaccid technique, and for 12 patients (14.1%), the operative reports did not allow to identify the techniques used, but the gastric location was confirmed by preoperative upper gastrointestinal studies. The remaining 54 patients (38.8%) received bands with periesophageal technique. In the present study, the operative times and the reported complications of the three main bands techniques were compared.

Surgical technique

The assistant stand on the left side of the patient and the surgeon stands between the legs of the patient, who has been placed in the French position. The pneumoperitoneum is established by optical port technique by a 15 mm trocar situated in the place of port site. Then, a 10 mm port for the camera is placed at one third of the distance between the xiphoid process and the umbilicus 2 − 3 cm lateral to the midline on the left side, and one additional port (5 mm) is placed for the surgeon's left hand in the right hypochondrium. The band is identified, and the dissection is carried on through the left coronary ligament staying always in contact with the band. Once the mobilization is completed, the band is cut with a 10 mm scissors.

For perigastric bands, the liver is retracted with the standard liver retractor and the band is dissected and furthermore sectioned. For the periesophageal approach, no retraction of the liver is used and all the technical details of the suprahepatic approach are shown in the nonedited complete supplementary video. The two main technical details are the following: the optical port must be placed more in the upper part of the abdomen and a particular attention must be paid to the left suprahepatic vein.

Statistical analysis

Continuous demographic variables are expressed as mean ± standard deviation and range; categorical variables as well as complications were reported as number and percentage. Continuous outcome variables are generally reported as mean ± standard deviation and range. Fisher's exact test and Chi-square test were used to investigate relationships between categorical variables. Comparison of continuous outcomes between the three groups was carried out by means of parametric and nonparametric test, as appropriate (i.e., analysis of variance; Wilcoxon/Kruskal–Wallis tests). A P value <.05 was considered to be significant. Statistical analysis was performed using Statistical Package for Social Sciences^®, version 17 (SPSS, Chicago, IL).

Results

During the study period, 139 patients underwent gastric band removal at Saint Michel Private Hospital—“Centre Chirurgical de l'Obesite.” There were 124 women (89.2%) and 15 men (10.8%), with a median age of 44 years (range: 24–71). The overall mean preoperative BMI was 34 ± 7.6 kg/m² (range: 22–52 kg/m²), and the mean preoperative weight was 93.7 ± 24.9 kg (range: 49–165 kg). One hundred and seventeen patients (84.2%) had procedures performed on an out-patient basis. The rest of the patients were excluded from ambulatory setting in the preoperative workup due to cardio pulmonary comorbidities (8 cases) or long distance from the hospital (7 cases) or postoperatively for unexplained dysphagia (3 cases) and risk of infection with intravenous antibiotics (4 cases). Intravenous postoperative antibiotherapy was decided for 4 patients who presented with skin perforation at the level of port site. Intraoperatively, the connecting tube was covered by fibrotic membranes that create a channel to the gastric band. In these cases, the risk of migration is considered important and the removing of the band is recommendable by upper endoscopy.

Throughout the series, 23 patients (16.5%) underwent additional associated procedures, including ventral hernia repair (9 patients), cholecystectomy (7 patients), umbilical hernia repair (4 patients), and soft tissue mass excision (3 patients).

Concerning the intraoperative adverse events, three cases of bleeding were recorded. The first two cases from the diaphragmatic vessels were managed by bipolar cautery (one case) or suturing (one case). For the third case, the dissection was completed without any incidents. At the end of the procedure, during the removal of the band, the connecting tube was completely around the spleen. Unfortunately, the removal was done with complete avulsion of the spleen. The conversion to laparotomy was needed, and the splenectomy was performed. The postoperative outcome was favorable with hospital stay of 5 days. There were no mortalities recorded in this study.

The overall percentage of complications in the entire series was 6.5%. Three patients were readmitted for postprandial pain with unexplained dysphagia (normal gastrografin swallow) and observed for 24 hours with no surgical intervention required. Six patients (4.3%) presented with a wound infection. Two were treated by oral antibiotic with cotton swab probing of the wound in an outpatient clinic, and four patients required abscess drainage under local anesthesia.

The overall mean operative time was 23.9 ± 13.7 minutes (range: 7–83 minutes). For group A, the operative time was 18.4 ± minutes (range: 7–46 minutes), for group B 24.3 ± 12.5 minutes (range: 12–83 minutes), and 28.5 ± 17.4 minutes (range: 9–68 minutes) for group C, respectively (P > .05).

Discussions

It is very hard to define success in bariatric surgery. Of course, percentage of EWL is an often-used outcome measure, and a cutoff point of 50% EWL is widely accepted in the literature. Even after more than 20 years of LAGB experience, one would expect extensive data on its long-term sequelae. However, long-term clinical results for LAGB are still scarce and most articles claiming to present long-term follow-up usually present limited data of a small number of patients.^10–19 To evaluate the long-term success of LAGB, we should take into account only the patients with the band in place. The number of reoperations needed is very high and the index of gastric band removal is increasing every year. Most reoperations are performed for reasons not only of weight regain, despite intensive follow-up by the bariatric team and efforts and ‘back on track’ programs, but also due to complications. Himpens et al.¹⁹ concluded that nearly 1 out of 3 patients experienced band erosion, and nearly 50% of the patients required removal of their bands (contributing to a reoperation rate of 60%). To identify these long-term complications (migration, slippage), the follow-up of the patients with LAGB must include yearly gastrografin swallow. This investigation is mandatory in our activity, and it gives us information not only about identification of a complication but also it shows us the precise localization of the band to orientate more on our surgical approach. In case of suspicion of migration, an upper endoscopy is recommended.

The problem of slippage was reported up to 18.4% by Peterli and colleagues²⁰ in a cohort of 405 patients with up to 18 years' follow-up. In the early years of LAGB, our previous bariatric team had the same important rate of slippage with many patients who underwent revisions of LAGB for this complication. Initially, the band was replaced upper on the stomach through a different tunnel, and starting with 2002, an original particular solution was proposed: to insert the band periesophageal with a suprahepatic approach (Fig. 1). Initially, the technique was used only for patients with multiple revision of LAGB and ulteriorly it was proposed for all patients. This approach was interrupted in 2009, but considering the important number of bands performed in this manner, the revisions of this type of band will be still present in our activity for the next years. Our study revealed that the removal of periesophageal band is not associated with an increased rate of perioperative complications. The only proven difference, not statistically different, was regarding the operative time which was greater for periesophageal band. A secondary endpoint of our study was to illustrate different technical particularities: suprahepatic approach and a careful dissection of the right side of the band with caution for left suprahepatic vein. Equally the placement of the optical port higher in the abdomen is recommended. The surgical approach for band removal and the placement of the optical and working ports are influenced by the preoperative gastrografin swallow, mandatory in our daily activity.

FIG. 1.

Gastrografin swallow for periesophageal band.

In the recent years, beside the decrease in EWL, the number of reoperations is alarming. The numbers of gastric band removals have surpassed the numbers of LAGB, and the new generation of bariatric surgeons should be focused on the technical aspects of these revisional cases. Our article investigated different types of gastric band removal with the main purpose to present a particular approach for an original band removal situated periesophageal.

Conclusions

One of the most popular bariatric procedures was LAGB, due, in large part, to its technical simplicity, reversibility, and safety profile; but nowadays the number of revisions is continuously increasing. A good knowledge of different techniques of band is mandatory for the new generation of bariatric surgeons. Our study regarding the band removal revealed that no correlation was found for operative morbidity among the three different types of bands. The only proven difference was the operative time which was greater for periesophageal approach. A particular attention should be paid to the risk of injury for diaphragmatic or left suprahepatic vein.

Footnotes

Disclosure Statement

No competing financial interests exist.

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