11-cm Lap-Band® System Placement after History of

8/12/2019 11-cm Lap-Band System Placement after History of

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FD-Communications Inc. Obesity Surgery, 13, 2003 435

Obesity Surgery, 13, 435-438

Background: Intragastric migration (erosion) of the

band after laparoscopic adjustable silicone gastric

banding (LAGB) is a serious late complication. It

requires removal of the entire system. Subsequent

recurrence of obesity can be treated by laparoscopic

placement of a larger band: the 11-cm Lap-Band

System.Methods: In 727 laparoscopic gastric bandings

using the 9.75 Lap-Band, 10 cases presented with

intragastric migration of the band. The same compli-

cation was encountered in an additional 4 patients

who had previously been implanted with an Obtech

band in another hospital. Laparoscopic removal of the

band was performed in all cases. In 9 cases, after a

delay of 6 months, a new gastric band was placed

using the 11-cm Lap-Band, because of uncontrol-

lable recurrence of obesity.

Results: No complication was observed during the

laparoscopic removal of the system.The placement ofa new band required conversion to laparotomy in 1

patient who had previously received an Obtech band

which had been placed using the pars flaccida tech-

nique. After a mean follow-up of 21 months, no intra-

gastric migration of the new bands was noted.

Conclusions: Laparoscopic placement of an 11-cm

Lap-Band in patients with a history of intragastric

migration is a safe procedure. It allows effective con-

trol of recurrent obesity. The laparoscopic procedure

was easier in patients initially operated using the peri-

gastric technique.

Key words:Morbid obesity, intragastric migration, erosion,

gastric banding, laparoscopy, bariatric surgery

Introduction

Laparoscopic adjustable gastric banding (LAGB)

has reportedly been associated with a 1% incidence

of intragastric migration (erosion) of the band.1-4

The etiology of this complication remains obscure.

Its occurrence, sometimes 3 years after the initial

placement of the band, cannot be only explained as

a technical problem encountered perioperatively.5

Several theoretical hypotheses have been proposed:

gastric perforation due to a gastric peptic ulcer ordue to gastric wall ischemia, too tight adjustment, or

the implantation of an initially infected device.2,6-8

In most cases, the only symptom is sudden and

unexplained infection of the port. Gastroscopy con-

firms the intragastric migration of the band.

The most reasonable treatment is the laparoscopic

removal of the system and the closure of the perfo-

ration in the same way as a perforated ulcer is treat-

ed.2,3 Removal of the band through gastroscopy has

been suggested but required an almost total intra-gastric migration.6

The reversibility of LAGB allows postoperative

care without complications but cannot prevent sub-

sequent recurrence of obesity. The laparoscopic

placement of a new band can be proposed as an

interesting alternative to control the obesity trend.

This band placed at a correct level will surround a

thickened gastric wall. Therefore, a larger band (11-

cm Lap-Band System) has been chosen to prevent

postoperative dysphagia.

Materials and Methods

Patients

Between October 1993 and May 2002, 727 patients

(657 female and 70 male) underwent LAGB using

the Lap-Band System 9.75 (INAMED Health,

Santa Barbara, CA, USA). They had mean age 41

years (17-65) and mean body weight 118 kg (92-

262) corresponding to mean BMI of 45 kg/m2 (35-

11-cm Lap-Band System Placement after History of

Intragastric Migration

M. Vertruyen, MD1; G. Paul, MD2

1Deptartment of Laparoscopic GI Tract Surgery; 2Deptartment of Gastroenterology, Europe St-

Michel Clinic, Brussels, Belgium

Reprint requests to: Marc Vertruyen, MD, 255, rue de la Station,

6210 Rves, Belgium. Fax: 00 32 2 737 84 05;

e-mail : [email protected]


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69). All patients had been operated using the peri-

gastric dissection. No systematic screening for band

erosion was performed in this series. Patients with a

previous history of vertical banded gastroplasty

with staple disruption were excluded from this

study.

Band erosion with partial intragastric migration

was encountered in 14 cases: 10 cases (1.4 %) with

a previous Lap-Band System and 4 cases with an

Obtech band placed in another hospital by the pars

flaccida technique.

The only clinical feature was the sudden and

unexplained occurrence of a port infection with

local tenderness and tumefaction. No other sign

such as fever, dysphagia, hematemesis or epigastric

pain was observed. A Gastrografin swallow

demonstrated no leakage, fistulas or proximal pouch

dilatation. Gastroscopy allowed us to confirm the

intragastric migration of the band. An immediate

laparoscopic removal of the entire system was per-

formed in all cases. The acute pain and abscess per-

mitted us no delay in the surgical treatment.

The placement of a new band was proposed in 9

patients (7 with a previous Lap-Band System and 2

with a previous Obtech band) due to uncontrollable

recurrence of overweight.A postoperative delay of 6 months was required to

secure the healing of the sutures and to expect a

softening of the adhesions. A larger band (11-cm

Lap-Band System) was chosen, to avoid postoper-

ative dysphagia because of potential thickening of

the gastric wall.

Surgical Technique

Laparoscopic Removal of the Band forIntragastric Migration

Five trocars were necessary for the laparoscopic

removal of the bands (2 of 10 mm and 3 of 5 mm).

The scar from the initial procedure were used for the

reoperation. All the cases first required an adhesiol-

ysis between the left liver lobe and the anterior part

of the stomach. The inflammatory capsule sur-

rounding the catheter and the locking system were

incised in the direction of the band. A part of the

inflatable portion of the band was freed and trans-

sected. The removal of the band through its tunnel

demonstrated the gastric wall perforation. This was

closed with 2 stitches of 2-0 silk. An omentoplasty

covering the suture was performed and peritoneal

lavage with saline ended the laparoscopic proce-

dure. The entire system was removed from the

abdomen through the scar above the port, and the

infected capsule around the port was excised. An

external drainage in front of the sutures was main-tained for 2 days. Nasogastric aspiration and intra-

venous antibiotics were applied for 5 days.

Laparoscopic Placement of the 11-cmLapBand

Five trocars (2 of 10 mm and 3 of 5 mm) were also

necessary for the laparoscopic placement of the 11-

cm Lap-Band System. The same scars used for the

removal procedure were used for the redo. All cases

first required an important adhesiolysis between the

left liver lobe and the anterior part of the stomach.

A proximal pouch was then calibrated with 15 cc

of saline. The pars flaccida was used in patients who

had had a previous band placement using the peri-

gastric technique. In these cases, the lesser sac was

free of adhesions. A classical pars flaccida dissec-

tion close to the diaphragmatic pillars was per-

formed in order to reach the angle of His. Patients

who had had a previous Obtech band placement

using the pars flaccida technique presented a lot of

scar tissue on the posterior part of the esophagogas-

tric junction. A careful dissection was necessary to

create a channel at the right level. The 11-cm Lap-

Band System was pulled through the channel and

stabilized in good position with 4 sero-serous

sutures placed between the proximal pouch and the

distal part of the stomach. The procedure ended with

the fixation of the port on the anterior sheath of the

left rectus abdominis muscle below the costal mar-

gin.

Results

Fourteen patients required a laparoscopic removal

of the band for intragastric migration: 10 Lap-Band

Systems of a total series of 727 patients and 4

Obtech bands placed previously in another hospital.

Intragastric migration occurred after a mean delay

of 27 months (range 17-39) for the Lap-Band

System and 15 months (12-21) for the Obtech

Vertruyen and Paul

436 Obesity Surgery, 13, 2003


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bands. The level of the erosion was the lesser curva-

ture in 9 cases and the posterior gastric wall in 5

cases. The erosion led to a gastric fistula progress-

ing along the catheter to the port. The infection was

covered with omentum, and no signs of peritonitis

were observed during the procedure. No particular

intra- or postoperative complications were observedfor this procedure. The mean operative time was 35

minutes (20-45). No conversions to laparotomy

were necessary. All the patients were able to be dis-

charged from the hospital after 5 days. A gas-

troscopy at 1 month postoperatively confirmed the

good healing of the perforation.

After a follow-up of 6 months, 5 patients (35.7 %)

succeeded in stabilizing their BMI near its pre-ero-

sion level and did not require an additional

bariatric procedure.In 9 patients (64.2%) (7 previous Lap-Band and

2 previous Obtech), recurrence of morbid obesity

was noted with a mean preoperative BMI of 34

kg/m2 at the time of the band erosion, reaching 43

kg/m2 6 months later. These cases benefited from

the placement of an 11-cm Lap-Band. The mean

operative time was 70 minutes (30-120). Liver lac-

eration was observed in 3 cases (33.3%) and treated

by spray coagulation. Conversion to laparotomy

was necessary in one case (11.1%) whose initial

band placement used the pars flaccida technique;

the laparoscopic approach did not allow a safe dis-

section through the scar tissue in the posterior

esophagogastric region, so a hand-assisted dissec-

tion allowed the creation of the retrogastric tunnel.

Deep venous thrombosis was observed in one

patient (11.1%), who required a laparotomy. No

complaints of postoperative dysphagia were noted

in this series. A Gastrografin swallow at Day 1

confirmed good positioning of the band and good

passage through the stoma. The mean hospital stay

was 1.2 days (1-3). The same postoperative diet as

after the initial procedure was prescribed. After a

mean follow-up of 21 months (6-45), there was no

recurrence of intragastric migration and no late

proximal pouch dilatation has occurred in these 9

cases. Connecting tube disruption was observed in

one case (11.1 %) and required reconnection under

local anesthesia. Review of these 9 patients con-

firmed the return of the initial postprandial satiety

sense. A mean BMI of 33 kg/m2 was obtained after

a mean follow-up of 21 months.

Discussion

Intragastric migration of an LAGB is a serious late

complication, because it leads to the removal of the

entire system and results in a high rate of obesity

recurrence. It is not, however, a dangerous compli-cation because no signs of peritonitis were

observed during the removal procedure. Moreover,

in this series, no technical difficulties or particular

complications were encountered from removal.

The lesser curvature and the posterior gastric wall

were the most affected areas.

Laparoscopic placement of a new band in cases

with a history of intragastric migration is a safe,

effective and reproductible procedure. No particular

complications were observed during this procedure.Moderate liver laceration was due to the adhesioly-

sis and was easily controlled by spray electrocoagu-

lation.

Previous band placement by the perigastric tech-

nique permitted a safer posterior dissection because

of the untouched resection plane at the right crus

and behind the esophagus after opening the pars

flaccida. Previous band placement by the pars flac-

cida technique, generating a lot of adhesions,

required conversion to an open procedure in 50% ofthe cases. This may be an additional argument for

initial perigastric placement of the band.

The use of a band with a larger stoma (11-cm Lap-

Band) has probably prevented postoperative dys-

phagia. After a mean follow-up of 21 months, a

noticeable and durable decrease in BMI was

observed and there was no recurrence of intragastric

migration of the band. A larger band inducing less

pressure against the gastric wall and the presence of

scar tissue can be considered as protective factors.No difference in postprandial satiety sense was

noted between the 9.75 and 11-cm Lap-Band.

In this series, no relationship was observed

between band erosion and proximal pouch dilata-

tion.

References

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(Received August 31, 2002; accepted December 2, 2002)

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11-cm Lap-Band® System Placement after History of