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