Postoperative issues and corrective surgery for laparoscopic adjustable gastric bandage connection tubes

How to prevent

The subcutaneous pump should be placed to the side of the puncture site.

Create a subcutaneous area as the subcutaneous pump site to avoid sudden twisting of the connecting tubing.

Alternatively, a 5mm trocar or hemostatic agent may be used to establish a gradual path into the abdominal cavity to obtain a smooth path and avoid sharp turns or bends in the catheter, or a subcutaneous tunnel may be created to allow the connecting tube to enter the abdominal cavity through a second trocar.

The subcutaneous pump is usually placed on the left hypochondrium and sutured with four stitches on the rectus abdominis fascia.

Thanks to recent improvements in the design of the subcutaneous pump and connecting tubing, we expect fewer problems with the injection pump and connecting tubing in the future.

Poor compliance/unsatisfactory results

For patients who are dissatisfied with the results or have poor compliance, we offer them a second option or remedial surgery.

The procedure involves adding a duodenal transposition to the bandage, known as the Bandinaro procedure, with the same intestinal loop length as the Scopinaro bile-pancreatic diversion procedure.

Basic principles

In 1997, Vassallo et al. proposed a method of duodenal transposition with complete preservation of the stomach, except for short-term gastrectomy or the use of absorbable polydioxanone bandages.

None of these patients experienced diarrhea or protein deficiency.

Sleeve gastrectomy combined with duodenal transposition reduces the incidence of marginal ulcers and increases the effect of restricting food intake.

The results of De Meester et al. demonstrated that preserving 3-4 cm of viable duodenum is sufficient to significantly reduce the incidence of marginal ulcers.

In addition, the Lap-Band can be used to restrict food intake, thus avoiding the irreversibility, bleeding risk, fistula and stenosis risks associated with sleeve gastrectomy.

Incidence and etiology

It is estimated that 25% of patients cannot maintain long-term weight loss after adjustable gastric banding surgery.

Aside from issues such as gastric prolapse, gastric sac dilatation, erosion, or problems with the gastric duct system, the main reason is the patient's lack of adherence to the Lap-Band system.

symptom

Aside from dissatisfaction with weight loss several years after the bandage surgery, the patient had no other obvious symptoms.

They cannot change their eating habits to comply with the requirements of weight-loss surgery that restricts food intake.

diagnosis

An upper gastrointestinal contrast radiography and an upper gastrointestinal endoscopy must be performed to rule out the problem of the bandage.

result

From 1994 to 2003, our institution performed the Bandinaro procedure on 40 patients as a second-line procedure or a corrective procedure after failure of food restriction surgery.

(4 cases were after vertical gastric banding (VBG), 22 cases were after open surgery with adjustable gastric banding using silicone material, and 14 cases were after laparoscopic adjustable gastric banding using Lap-Band).

The Bandinaro procedure was performed laparoscopically in 12 patients.

In the open surgery group, there was one case of pancreatitis and one case of internal hernia, both of whom required reoperation.

Two cases of duodenal and ileal anastomotic leakage occurred in the laparoscopic group, both of which were cured through conservative treatment.

The weight loss results were satisfactory, with these patients losing an average of over 60 kg and achieving an %EWL of 75%.

Corrected to other weight loss surgeries

If a food restriction surgery fails, it can be converted to a gastric bypass or a surgery that simply reduces nutrient absorption.

Failed VBG and adjustable gastric banding can be effectively converted to gastric bypass.

Despite the high technical requirements, several series have reported the safety and efficacy of switching to gastric bypass surgery for those who have failed to lose weight or have complications associated with laparoscopic adjustable gastric banding.

In a report of 70 cases of conversion from laparoscopic adjustable gastric banding to Y-type gastric bypass, the early complication rate was 14%, the long-term major complication rate was 9%, and there were no perioperative deaths.

Three patients underwent open surgery due to extensive adhesions.

The indications for conversion to gastric bypass surgery were insufficient weight loss (25%) or weight gain (49%), symptomatic gastric sac dilatation (20%), gastric erosion (5%), and one patient with psychological intolerance to the bandage.

The average operation time is 240 minutes.

The average %EWL was 70% during the 18-month follow-up period after surgery, and 60% of the patients had a BMI below 33.

Weber et al. retrospectively analyzed 62 cases over 7 years of laparoscopic adjustable gastric banding failure, followed by banding repositioning (n=30) or laparoscopic gastric bypass surgery (n=32).

Both surgeries had low complication rates and no deaths.

One year after the corrective surgery, the mean BMI in the laparoscopic gastric bypass group decreased from 42 to 32, while the mean BMI in the repositioning bandage group remained unchanged at 38.

These scholars concluded that gastric bypass is a rescue procedure for failed laparoscopic adjustable gastric banding.

Modified cholecystopancreatic diversion is another option for patients who have failed laparoscopic adjustable gastric banding.

Dolan and Fielding reported 1439 cases of laparoscopic adjustable gastric banding, of which 85 underwent band removal postoperatively. The main reasons were persistent dysphagia (29%), recurrent slippage (28%), weight loss failure (16%), and intolerance (14%).

A total of 6 cases of gastric erosion occurred (7% of all cases where the bandage was removed).

A total of 79 patients underwent removal of the bandages and modification to biliary-pancreatic diversion or biliary-pancreatic diversion plus duodenal transposition (open or laparoscopic).

The average BMI at the time of the corrective surgery was 46.

Thirty-eight patients underwent simultaneous bandage removal and laparoscopic cholecystopancreatic diversion.

No major complications occurred in this group of patients.

One year post-surgery, the percentage of end-whole blood volume (%EWL) was 37%, lower than that of patients undergoing initial cholecystopancreatic diversion. Eight patients (21%) experienced weight loss failure after laparoscopic cholecystopancreatic diversion and required shortening of the absorption intestine.

21 patients underwent laparoscopic cholecystopancreatic diversion combined with duodenal transposition.

There was one case of leakage at the gastric resection suture, with an 12-month %EWL of 28%.

Six patients (18%) required their absorptive intestinal segments to be shortened to 40 cm.

Besides laparoscopic cholecystopancreatic diversion or cholecystopancreatic diversion combined with duodenal transposition to shorten the absorptive intestinal tract, 14 patients still failed to lose weight, and 5 patients still experienced little or no weight loss.

Experienced doctors can safely perform weight-loss surgery that reduces nutrient absorption while removing the bandages.

Dolan's research has confirmed this, although a small percentage of patients do not respond to any weight loss surgery.

For patients whose banding procedure has failed, laparoscopic correction of the adjustable gastric banding procedure to gastric bypass is an effective strategy.

With the accumulation of experience in these corrective surgeries, treatment options after failure of laparoscopic adjustable gastric banding will become clearer.

in conclusion

Laparoscopic adjustable gastric banding has been proven to be quite safe.

For these high-risk patients with risks associated with anesthesia and surgery, it is hard to imagine any other surgery being safer.

The characteristics of this minimally invasive surgery, including the absence of incisions, anastomoses, or anatomical alterations, keep the incidence of complications, especially serious complications, at a low level.