Adjustable Gastric Banding

Aka: Adjustable Gastric Banding, Laparoscopic Adjustable Gastric Banding, Adjustable Gastric Banding Surgery, Gastric banding

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II. Indications

  1. Morbid Obesity

III. Epidemiology

  1. Most common form of Bariatric Surgery in U.S.

IV. Background

  1. Images
    1. bariatricSurgery.jpg
  2. Introduced in 2006
  3. Band applied around the distal Esophagus or proximal Stomache
  4. Reversible and tension can be adjusted via subcutaneous port
  5. Replaces Vertical Banded Gastroplasty

V. Efficacy

  1. Weight loss 21% at 1 year and 13% at 10 years

VI. Prognosis: Outcomes

  1. Reoperation is required in 50% of cases
  2. Major late complication rate: 25%
  3. Dissatisfaction with surgery (would not choose it again): 73%

VII. Complications: Failed Weight Loss (<20% of excess weight lost)

  1. Diet evaluation
    1. Meal volume
    2. Between meal snacks
    3. Excess liquid calories
  2. Band Evaluation
    1. Evaluate for band leakage

VIII. Complications: Early Postoperative (<1 month postoperative)

  1. See Bariatric Surgery
  2. Life threatening
    1. Pulmonary Embolism
    2. Myocardial Infarction
  3. Common
    1. Infection
    2. Stomal stenosis
    3. Hernia

IX. Complications: Gastric Band Slippage

  1. Risk Factors
    1. Overeating
    2. Earlier procedure prior to pars flacida technique
      1. Prior to this technique posterior band slippage was more common
  2. Presenting symptoms
    1. Nausea or Vomiting
    2. Dysphagia
    3. Abdominal Pain
  3. Step 1: Diagnosis
    1. Imaging Studies
      1. Abdominal XRay
      2. Upper gastrointestinal contrast (Gastrograffin Upper GI Series)
    2. Imaging suggests pouch dilation
      1. Reinforce dietary management
    3. Imaging suggests band slippage
      1. Go to Step 2
  4. Step 2: Gastric Band Slippage confirmed
    1. Deflate gastric band urgently
    2. Symptoms improve
      1. Routine follow-up
    3. Symptoms persist but are stable
      1. Reinforce dietary management
      2. Consider gastric band removal
    4. Symptoms persist and worsen
      1. Go to Step 3
  5. Step 3: Surgical evaluation (laparoscopy, laparotomy)
    1. Band slippage with full thickness erosion, necrosis or abscess
      1. Gastric band removal AND
      2. Excision of affected tissue
    2. Band slippage without erosion or necrosis
      1. Gastric band removal OR
      2. Unbuckle band
  6. References
    1. Hamdan (2011) Br J Surg 98(10): 1345-55 [PubMed]

X. Complications: Port or tubing malfunction

  1. Causes
    1. Leakage of saline (saline keeps band inflated)
    2. Port rotation or migration
  2. Presentations
    1. Inability to access port
    2. Inadequate weight loss or regained weight
  3. Evaluation
    1. Device evaluation under fluoroscopy
  4. Management
    1. Endoscopic port replacement or
    2. Intra-abdominal surgical correction

XI. Complications: Pouch dilation

  1. Causes
    1. Band overinflation
    2. Overeating
  2. Presentations
    1. Loss of satiety
    2. Gastroesophageal Reflux or regurgitation
  3. Management: Initial
    1. Deflate band
    2. Reinforce dietary management
  4. Management: Re-evaluate at 4-6 weeks
    1. Anticipate pouch size return to normal in 4-6 weeks
    2. Consider gastric band replacement or removal

XII. Complications: Port site prominence

  1. Weight loss results in decreased subcutaneous fat
  2. Port rubs on overlying clothing resulting in irritation, pain and Skin Erosions
  3. Consider port replacement (smaller, low profile)

XIII. Complications: Stomal obstruction

  1. Gastric pouch outlet obstruction
  2. Causes
    1. Swallowing large food boluses
  3. Presentation
    1. Dysphagia
    2. Reflux
    3. Postprandial Vomiting
    4. Abdominal Pain
  4. Management
    1. Attempt to correct with band deflation or endoscopic release of obstruction
    2. Gastric band removal if other corrective measures not effective

XIV. Complications: GERD

  1. Causes
    1. Hiatal Hernia (consider repair prior to Gastric banding)
    2. Pouch dilation
    3. Noncompliant with dietary management
  2. Management
    1. Reinforce dietary management
    2. Proton Pump Inhibitor (or other acid suppression)
    3. Surgical management (e.g. gastric band removal) if refractory to other measures

XV. Complications: Port Infection

  1. Early
    1. Local tenderness, warmth, redness
  2. Late
    1. Abscess or fistula formation (with Abdominal Pain or failed weight loss)
    2. Diagnosed by exam, Ultrasound or endoscopy

XVI. Complications: Band Erosion

  1. Presentation
    1. Weight gain
    2. Abdominal Pain
    3. Dysphagia
    4. Hematemesis
    5. Sepsis
    6. Abscess at port site (migrating from Stomach)
  2. Diagnosis
    1. Upper GI Study
    2. Abdominal CT
  3. Management
    1. Band removal (may be replaced at 3 months)
    2. Gastric wall repair

XVII. References

  1. Carucci (2007) Radiol Clin North Am 45(2): 261-74 [PubMed]
  2. Kodner (2014) Am Fam Physician 89(10):813-8 [PubMed]
  3. Snow (2011) Surg Clin North Am 91(6): 1249-64 [PubMed]

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