Follow-up, complications, and reflux issues of laparoscopic adjustable gastric banding
Postoperative follow-up
Follow-up is an interesting point of contention.
Laparoscopic gastric bypass surgery requires less postoperative follow-up than LAGB.
Patients with LAGB require adjustment of the gastric bandage and have a higher incidence of vomiting and discomfort. They also have poorer initial weight loss results compared to laparoscopic RYGB and BPD.
A few years ago, we performed five times more laparoscopic RYGB than LAGB, but we received five times more follow-up visits and postoperative telephone consultations for LAGB patients than for all RYGB patients.
Patients with LAGB surgery rarely experience nutritional complications, but this advantage is offset by the fact that patients need to adapt to new dietary habits, which they cannot maintain long-term.
There are frequent reports that many patients develop a craving for sweets due to limited food intake after surgery.
Dietary counseling can prevent these unhealthy eating habits.
Commonly, patients who crave sweets often experience unsatisfactory weight loss or weight rebound.
complication
Chevallier et al. reported their experience with over 1000 cases of LAGB.
In their report, intraoperative complications included gastric and esophageal perforation (n=3), liver injury (n=4), failed placement of the bandage (n=7), and conversion to open surgery (n=12).
More common postoperative complications included bandage slippage (n=104), bandage displacement (n=3), and esophageal dilatation (n=5).
Complications of the bandage itself occurred in 57 patients, including infection, bandage rupture, tubing leakage, and torsion.
In another 830 LAGB cases reported by Favretti et al., 4% of patients (36 cases) required reoperation due to major complications, including one case of gastric perforation, early (1 case) and late (17 cases) gastric prolapse, nine cases of poor bandage placement, four cases of gastric erosion, three cases of psychological intolerance, and one case requiring bandage removal due to AIDS.
Overall, the clinical results showed that among 479 patients followed for more than 3 years, 142 (30%) had poor weight loss (%EWL<30%), although this report incorrectly calculated this number as 20%.
Clearly, as this procedure becomes more widespread in the United States, the number of patients requiring repeat surgery due to complications and surgical failures will increase.
Other obvious complications will be discussed below.
esophageal dilatation
Few surgeons routinely perform gastrointestinal imaging during follow-up after LAGB surgery unless the patient has significant complications.
In the United States, the FDA-approved Trial A showed surprising results: 50% of patients were confirmed by X-ray examination after the procedure to have esophageal dilatation and symptoms of reflux and vomiting.
Once esophageal dilatation is confirmed, the bandages need to be loosened.
However, due to the persistent esophageal dilatation and peristalsis disorder after the bandage was loosened, 5 cases required conversion to gastric bypass surgery.
In 2002, a new technique described wrapping a bandage around the distal end of the esophagus.
This research team believes that artificially induced flaccidity and difficulty swallowing are important mechanisms of weight loss; therefore, the absence of these symptoms will lead to unsatisfactory weight loss results.
Why wasn't this finding reported by surgeons who performed a large number of LAGs?
Was the symptom not recorded, or was it considered unimportant?
Is dysphagia a tool that surgeons use to change patients' eating habits?
Postoperative patients rarely undergo X-ray imaging, so esophageal motility disorders/dilatation are often not diagnosed.
Esophageal motility disorders are a major point of contention surrounding adjustable gastric bandages, second only in importance to the debates surrounding weight loss.
How important is this?
Is loosening the straps the only way to control it?
Is this situation truly reversible?
Or, similar to trypanosomiasis in South America, it is caused by the presence of a foreign body at the gastroesophageal junction, resulting in electromyographic lesions. After a certain point, is this change irreversible?
Only long-term clinical follow-up results can answer these questions and provide important information about esophageal dilatation and dysphagia.
reflux
This issue is also the subject of much debate.
Many scholars, including Overbo et al. and Doherty et al., have described an increased incidence of acid reflux, vomiting, and regurgitation after LAGB surgery.
The symptom is that the person cannot tolerate food even after the straps are loosened.
What might be the mechanism behind this?
Narrow outlet and dilatation of the gastric pouch may be the cause.
However, the correlation between esophageal motility disorders and severe reflux is not obvious, or at least there are no reports of it.
On the other hand, O'Brien et al. and Favretti et al. did not even list reflux as an important factor in the poor quality of life of patients with bandages.
They did not consider a preoperative diagnosis of gastroesophageal reflux disease (GERD) with or without hiatal hernia (regardless of its severity) as a contraindication for LAGB.
In fact, Favretti and Cadiere et al. reported that 55% of gastroesophageal reflux disease patients improved after laparoscopic adjustable gastric banding.
In 2002, Schauer et al. reported that the best surgical approach for morbidly obese patients with gastroesophageal reflux disease was laparoscopic gastric bypass.
These different doctors still lack a unified and clear treatment strategy for morbid obesity.
Theoretically speaking, it is difficult to explain the logical relationship between laparoscopic adjustment of gastric bandage and improvement of gastroesophageal reflux.
How can a slow and gradual emptying be caused by implanting a gradually tightening foreign body at the gastroesophageal junction when the structure and physiological continuity are intact (e.g., normal gastric acid secretion)? Is this different from the gastric pouch after laparoscopic gastric bypass surgery?
This question remains unanswered.
In fact, if LAGB patients and patients after gastric bypass surgery are closely followed up to compare their gastrointestinal symptoms, LAGB patients will have more symptoms such as difficulty swallowing solids, vomiting, and heartburn.
Long-term follow-up may reveal problems such as esophageal motility disorders, gastroesophageal reflux, and vomiting after LAGB surgery.
Gastric sac dilatation and bandage slippage
A common reason for reoperation after LAGB is gastric pouch dilatation (GPD), with an incidence of 3% to 20% in different reports, which may or may not be accompanied by strap slippage.
The diagnosis of gastric sac dilatation is made by clinical symptoms of intolerance to food and by imaging examinations revealing proximal gastric sac obstruction, with food not passing through a bandage.
Sutter et al. believed that gastric sac dilatation was caused by incorrect placement of the initial gastric bandage.
In most cases, the effects of gastric sac dilation are not obvious, but large or asymmetrical dilation can eventually cause the bandages to slip or the axis to change, which may lead to a gradual increase in food intake, disordered eating habits, and eventual weight gain.
In Sutter's study, 20 out of 272 patients who underwent laparoscopic adjustable gastric banding experienced gastric sac dilatation or band slippage.
Nineteen of them had to undergo surgery again due to severe reflux, failed weight loss, and weight rebound.
Nine patients underwent repositioning via laparoscopic adjustable gastric banding, four patients had their gastric bands replaced, two patients underwent a second surgery to correct to vertical gastric banding, and four patients underwent laparoscopic gastric bypass surgery.
The average weight before surgery was 129 kg, and the average BMI was 44.5.
The average maximum weight loss after the first LAGB surgery was 38.7 kg, the average BMI was 32.6, and the average weight was 95 kg.
The average interval between the first surgery and the second surgery is 20 months.
After laparoscopic repositioning, 2 patients thought it was good, 1 was satisfied, and 6 thought it was poor.
Further reoperations resulted in the removal of gastric bandages in 3 patients, and 2 patients underwent laparoscopic gastric bypass surgery.
Risk factors for gastric pouch dilatation include early ingestion of solid foods, early tightening of the bandage, consumption of carbonated beverages, and vomiting, but the position of the bandage is the most important.