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Jeff W. Allen MD, FACSNorton Surgical Specialists
Louisville, KY
ComplicationsCommon
Anterior prolapseConcentric dilation
Port Problems
Uncommon
Posterior Prolapse
ErosionRemovalsManagement / failure
Posterior Gastric ProlapseSeen almost exclusively with perigastric approachTrial/patients from foreign medical centersUnusual condition where perigastric technique is used (n=4 for my experience)
May be seen in pars flaccida technique, especially if a very generous retrogastric dissection is performed
Posterior Gastric Prolapse
Posterior Gastric Prolapse
Management of Posterior ProlapseTake down plication
Transect band (unless band designed to be opened)
New pars flaccida tunnel
New Band
Unusual Band Complications54 year old woman with an initial bmi of 48 kg/m2
Excellent weight loss over 2 years to a BMI of 29 kg/m2
Develops latent port infection 6 weeks after an outpatient band adjustment
EGD performed by surgeon- no erosion Good visualization of band in retroflexed position
Unusual Band ComplicationsNo response to antibiotics
Port removed
? Laparoscopy at time of port removal? Repeat endoscopy?UGI
Tubing ErosionUnless in proximal jejunum, may not be seen on endoscopy
Generally requires laparoscopy to identify
Management= band removal +/- staged band replacement
Etiology puzzling and unclear
“Ascending Erosion”Common dogma that an infected port is the harbinger of an eroded band
Provost first identified the possibility that a port infection can cause total band infection/abscess and eventual erosion
Diagnosis made by laparoscopy after EGD negative
Latent port infectionTreat with anbiotics initiallyRemove port/EGDIf negative, consider eroded tubing, contaminated adjustment, additional septic source (infected hernia mesh) and “ascending erosion”
Laparoscopy to diagnose
Explants Subhepatic abscessesSubphrenic ObstructionsDilationsProlapses ErosionExcessive weight loss HIV conversionPerforated ulcer 6 months after placement
Inadequate weight loss- patient choice
Port Complications: Leakage6 patients
Inadequate weight lossNo aspirate on port access
All at the port/tubing interface
No diagnostic studies performed, only operative intervention
Port Complications: Pain3 patients
Injections offered temporary relief in all
Operative replacement relieved pain in all three
Should I take the band out?Other intra-abdominal problems such as appendicitis, diverticulitis, ovarian torsion
Decided on a case by case basis
O.P.I.EO: Overall health of the patient
30 year old now with a BMI of 22 and no co-morbidities 66 year old lost 18 pounds with band, BMI 55 kg/m2 and
NIDDM and COPD
P: Proximity to the band Non-ruptured appendicitis Perforated ulcer
I: Infectious agent Transverse colon flora from perforation Skin flora (from a stab wound)
E: Exposure 6 days after failed conservative management of diverticulitis
6 hours after diagnosis of ovarian torsion
Managing the plateau patient
• Make sure it is the patient with the problem– Ensure a closed system– No leaks– Adjuster is hitting the port
• Patient understands program• No undiagnosed psychopathology/sabotage• Identify what may have changed when the plateau began– Less exercise– New medications, especially anti- depressants
Band ProblemsLeak in the system
At the portAt the bandIn the tubingSlow leak
ErosionErroneous placement of the band initiallyUnbuckling of the band
Leak in the System?Fill the band half full with certainty
Use fluoro if necessaryRe-check in 1-2 weeks
All fluid should still be thereIf all- not a leakIf none-need surgical repairIf significantly decreased
Measurement error or Slow leak
Repairing a LeakLocalize vs Non-LocalizeTo localize use x-ray and a small amount of dilute gastrograffin OR methylene blue
I prefer not to localize Can be misleading Still need an operation Use general anesthesia anyway Commonly a needle stick or kink in tubing
Worried about band-no leakVideo Esophagram- with pre and post-injection shots
EGD to evaluate for erosion
Laparoscopy to check for unbuckling, erroneous placement (use calibration tube)
Video54 year old woman, initial BMI 44 kg/m2
Excellent initial weight loss
Plateau 6 months outAll fluid (9/10 cc) still in bandNo erosionNo indentation on EGD or UGI with 9 cc in
Vitamin Deficiencies after BandVitamin DProtein deficiencyVitamin CVitamin B12
All are usually a combination of maladaptive eating and lack of supplements