Fig. 7.5. Radiograph demonstrating gastric herniation through the Lap-Band device with obstruction.
more proximal placement of the band immediately below the gastroesophageal junction causes esophageal dilation, whereas more distal placement on the proximal stomach causes pouch dilation followed by esophageal dilation over time.
The long-term risks of esophageal dilatation are unknown but could include achalasia-like symptoms, esophageal pulsion diverticulae, or progressive development of a sigmoid esophagus that may not respond to band decompression. Appropriate management of this problem is not clear. Long-term follow-up will be required. We believe that all patients should undergo routine contrast studies at three years after device insertion. Management of the progressively dilating esophagus should include deflation of the device, despite the fact that weight re-gain is likely. Failure of the esophageal contour to return to normal should probably be treated by band removal. We have found most of our patients to have significant concern about the possible long-term health affects of esophageal dilatation, despite the lack of data on this topic. We advise such patients to undergo conversion to proximal gastric bypass.
Kuzmak developed the concept of silicone gastric banding in the 1980s. He performed procedures using open surgical techniques for band placement in 311 severely obese patients. In 1986, the silicone band he used was modified to include an adjustable portion that enhanced weight loss. He reported that 57% of his adjustable banding patients achieved > 60% reduction in excess body weight in 36-month follow-up.
Kuzmak's adjustable silicone gastric band is currently called the Lap-Band (Fig. 7.1) manufactured by BioEnterics, Corp (Carpinteria, California). Another adjustable band referred to as the Swedish Adjustable Gastric Band (SAGB, AB Obtech) was developed in the 1980s in Sweden. Forsell and Hellers reported 4-year follow-up in 50 patients in whom the SAGB was placed via laparotomy. Body mass index (BMI) decreased from 46 to 27.5 kg/m2 with a mean weight loss of 80 kg. However, other authors using this device have been disappointed with the results, particularly due to the need for reoperation in 35% of patients, with band erosion and erosive esophagitis being the most common reason for surgical revision. Other reasons for reoperation in this series included pouch dilatation, invagination of distal gastric wall through the band, leakage from the balloon, and patient dissatisfaction. When questioned two years postoperatively more than half of the patients reported vomiting, heartburn and regurgitation but 78% still pronounced themselves satisfied with the operation. Esophagitis was found in 56% of the patients at gastroscopy after two years.
Belachev and colleagues began performing adjustable banding procedures in 1991 in Belgium. They reported a favorable comparison of 200 open ASB to 210 open vertical banded gastroplasties. They subsequently performed the first laparoscopic placement of the band in 1993. Their series of 350 patients after laparoscopic implantation included patients weighing between 92 and 200 kg (mean 118 kg) with a mean BMI of 43 kg/m2 (range 35-65 kg/m2). The overall open conversion rate was a low 1.4%, a tribute to the authors' laparoscopic surgical expertise. Technical recommendations were made to decrease complications of pouch dilatation and gastric prolapse through the band by creating a very small proximal pouch and placing gastro-gastric sutures anteriorly to secure the band in position.
Numerous authors have now reported series of Lap-Band patients with outcome data. Most of these reports suggest that the procedure can be done with laparoscopic techniques in a high percentage of cases both safely and expeditiously as the surgeon gains the necessary technical experience over time. A few series are worth noting in detail as representative of the best available literature on the procedure.
Fielding and colleagues from Australia reported their results in 335 patients undergoing the Lap-Band procedure. Gastric herniation through the band, alternatively referred to as 'slippage', occurred in 12 patients requiring reoperation. Five bands were removed due to reflux symptoms or food intolerance. One late gastric perforation in the fundus mandated band removal. Weight loss in 58 patients followed for 18 months postoperatively was 62% of excess weight.
O'Brien and colleagues, also from Australia, evaluated the Lap-Band adjustable gastric banding system prospectively in a consecutive series of 302 patients, with data on perioperative outcome and weight loss pattern up to 4 years. Three hundred two patients (89% women; mean age 39 years, mean weight 124 kg) were entered into the study. Laparoscopic placement was used in 277 patients. The incidence of significant early complications was 4% and included two perforations of the stomach after open placement. The mean length of stay after laparoscopic placement was 3.9 days and only one complication (infected reservoir site) occurred in these patients. The principal late complication of prolapse of the stomach through
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