complications of laparoscopic gastric banding of gastric... · patient underwent gastric lavage, two intact suture lines, no bleeding, large amount of clot. PATIENT PRESENTATION .

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


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



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, two intact suture lines, no bleeding, large amount of clot. PATIENT PRESENTATION .

Documents