Primary objectives in the surgical care for morbidly obese patients with gastric band malposition

The gastric band is known to cause a certain number of long-term complications. A typical chronic complication is the pouch’s dilatation, linked either to pouch distension or band slippage. The diagnosis is based on the clinical history (gastric band system failure or total food intolerance) and confirmed by imaging studies. Food intolerance is a surgical emergency because of the risk of gastric pouch ischemia. Three examples of gastric band misplacement are shown here.

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Primary objectives in the surgical care for morbidly obese patients with gastric band malposition

Authors

M Vix, J Marescaux

Abstract

The gastric band is known to cause a certain number of long-term complications. A typical chronic complication is the pouch’s dilatation, linked either to pouch distension or band slippage. The diagnosis is based on the clinical history (gastric band system failure or total food intolerance) and confirmed by imaging studies. Food intolerance is a surgical emergency because of the risk of gastric pouch ischemia. Three examples of gastric band misplacement are shown here.

Keywords

Primary objectives, surgical care, morbidly obese patients, gastric band

Media type

Surgical video

Duration

06'00''

Publication

2005-06

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E-publication

WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en1739.htm

Primary objectives in the surgical care for morbidly obese patients with gastric band malposition

1. Case 1 - case presentation 00'07''

This video will illustrate the complications and appropriate treatment of gastric band malposition. Our first case is a 28-year-old female patient with a previous placement of a gastric band for morbid obesity 2 years ago. In 2 years’ time, her BMI has decreased from 35 to 28. She present with severe dysphagia and is hospitalized for dehydration. A full evaluation is commenced. The upper GI radiography shows the esophagogastric junction and distal to this, the band is noted to be out of position with a mechanical stenosis of the distal part of the gastric pouch. With the patient’s symptomatology and the radiographic evidence a laparoscopy is performed with the intention of removing the band.

2. Case 1 - band dissection 00'47''

The laparoscopy shows the adhesions between the stomach, the band, and the left side of the liver. We begin to expose the band with cutting the adhesions utilizing the scissors. We dissect the anterior fat pad free to allow for adequate exposure of the band. Our objective is to locate the locking mechanism of the band as shown here in order to lyze the adhesions associated with it. After the adhesions are taken down in this area, we see a gastrogastric stitch that we utilize to avoid band slippage during placement of the band. As dissection proves to be difficult here, we will utilize a GIA device to make sure we don’t inadvertently create a gastrotomy.

3. Case 1 - band removal 01'50''

The band is then cut and the locking mechanism is then dissected free.

4. Case 1 - restoration of normal anatomy 02'00''

We will now dissect the associated adhesions to attempt to retain a normal anatomy. We will also evaluate the posterior portion of the gastrum to confirm that there is no serosal change consistent with necrosis.

5. Case 2 - case presentation 02'25''

This second case highlights a band malposition and the resultant proximal dilated pouch in the inflamed edematous gastric wall.

6. Case 2 - band dissection 02'36''

As you can see, it is difficult to identify anatomic structures, and orientation in this view. We begin by grasping the catheter and dissecting toward the locking mechanism of the band.

7. Case 2 - band removal 02'47''

Although we make progress in our dissection, we believe that further dissection may cause injury to the gastrum, and therefore we cut the band where it is most visible.

8. Case 2 - restoration of normal anatomy 03'44''

The segments of the band are then placed in an endobag. We will now begin the arduous task of dissecting the adhesions to aid in alleviation of the edema and gastric pouch dilatation. As in all of our gastric band removal interventions,

9. Case 3 - pouch necrosis with band removal 04'08''

we will review the posterior aspect of the gastrum as well to make sure that there is no ischemic process developing.

10. Case 3 - gastrostomy and transabdominal gastroscopy 04'33''

We now move on to our third case. In this final case, the patient presents with a septic-like syndrome and concern for pouch necrosis warns further evaluation after the band is removed. During the time of the procedure, an endoscopist was not available. We therefore perform a gastrotomy.

11. Case 3 - conversion 04'59''

We will place a balloon-tipped trocar into the gastrotomy to perform a transabdominal gastroscopy. With a suture stays, we pull the gastrum to the anterior abdominal wall and place the trocar into the gastrum and diagnose the necrotic proximal gastrum consistent with pouch necrosis.

12. Final comments 05'18''

We then converted this patient to an open procedure and performed the proximal partial gastrectomy. The patient did well postoperatively. However, the possible morbidity associated with the banding procedure is once again shown in this case. In a gastric banding procedure, we must remember of the incidence of gastric band malposition although it is less than 5% in most series, it is a morbidity that we must treat appropriately. We note that the anatomy can be disfigured after the banding procedure and that we must return the anatomy to as close as possible to its virgin state. These principles are paramount to the treatment of these patients.