Yonsei Med J.  2014 Jan;55(1):149-156. 10.3349/ymj.2014.55.1.149.

Three-Year Experience of Pouch Dilatation and Slippage Management after Laparoscopic Adjustable Gastric Banding

• Lee WK
• Kim SM

• KMID: 1779899
• DOI: http://doi.org/10.3349/ymj.2014.55.1.149

Abstract

PURPOSE
Pouch dilatation and band slippage are the most common long-term complications after laparoscopic adjustable gastric banding (LAGB). The aim of the study is to present our experience of diagnosis and management of these complications.
MATERIALS AND METHODS
The pars flaccida technique with anterior fixation of the fundus was routinely used. All band adjustments were performed under fluoroscopy. We analyzed the incidence, clinico-radiologic features, management, and revisional surgeries for treatment of these complications. We further presented the outcome of gastric plication techniques as a measure for prevention of these complications.
RESULTS
From March 2009 to March 2012, we performed LAGB on 126 morbidly obese patients. Among them, 14 patients (11.1%) were diagnosed as having these complications. Four patients (3.2%) had concentric pouch dilatations, which were corrected by band adjustment. Ten (7.9%) had eccentric pouch with band slippage. Among the ten patients, there were three cases of posterior slippage, which were corrected by reoperation, and seven cases of eccentric pouch dilatation with anterior slippage. Three were early anterior slippage, which was managed conservatively. Two were acute anterior slippage, one of whom underwent a revision. There were two cases of chronic anterior slippage, one of whom underwent a revision. The 27 patients who underwent gastric plication did not present with eccentric pouch with band slippage during the follow-up period.
CONCLUSION
The incidence of pouch dilatation with/without band slippage was 11.1%. Management should be individualized according to clinico-radiologic patterns. Gastric plication below the band might prevent these complications.

Keyword

Pouch dilatation; band slippage; laparoscopic adjustable gastric band

MeSH Terms

Adult
Female
Gastroplasty/adverse effects/*methods
Humans
Laparoscopy
Male
Middle Aged
Obesity, Morbid/*surgery
Postoperative Complications
Treatment Outcome

Figure

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  Fig. 1 Oblique plication technique. After placement of three gastrogastric sutures above the band, we placed four or five seromuscular stitches of 2-0 Ethibond® (Ethicon, Somerville, NJ, USA) on the anterolateral gastric wall, thereby enabling further stabilization of the band and gastric wall.

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  Fig. 2 Concentric pouch dilatation. Normal band position and normal band angle were noted. The pouch was dilated concentrically. The pouch appears to have migrated to the intrathoracic level, suggesting the presence of a coexisting hiatal hernia.

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  Fig. 3 Upper GI study of eccentric pouch dilatation. (A) EPA1, eccentric pouch with a normal band angle with a ring-like band configuration. Radiologically, this type is early anterior slippage. (B) EPA2, eccentric pouch with a more horizontal band angle. This type of dilatation usually results in a progressive chronic symptom of acid reflux. (C) EPA3, eccentric pouch with excessive clockwise rotation of the band. This type of dilatation usually manifests as acute, total food intolerance with severe reflux and epigastria pain. (D) EPP, eccentric pouch with posterior band slippage. This type of dilatation is associated with use of poor surgical techniques (e.g. entering the lesser sac with a redundant posterior gastric wall). Arrow indicate outlines of the dilated pouch above band.

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  Fig. 4 Laparoscopic non-destructive removal of the band and its repositioning at a proper level in an EPA3 patient (patient #10). (A) In patients with pouch enlargement with severe reflux, a variable degree of hiatal hernia was usually observed, and we performed concomitant repair using figure of eight sutures of the anterior crura muscle. Plicated neofundus was anchored to the crural muscle fascia (short arrow), and gastogastric suture was also performed (long arrow). Asterisk: newly formed pouch. (B) Repositioning of the gastric band through the newly formed retrogastric tunnel above the previous band position (circular area). Anterior plication of the gastric wall below the band was performed (arrow). Preop (C) and postop (D) gastrograffin swallow study showed that the band angle and pouch shape (arrows) were normalized.

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