Ask the Experts: Dilemmas in Bariatric Surgery

| May 17, 2011

This Month’s Dilemma: Severe Abdominal Pain, Vomiting, and Nocturnal Reflux Caused by a High-placed Gastric Band

This Month’s Featured Expert: Natan Zundel, MD, FACS

Dr. Zundel is Clinical Professor of Surgery, Florida International University College of Medicine, Miami, Florida.

Bariatric Times. 2011;8(5)14–15

The Dilemma
A 29-year-old woman (body mass index [BMI] 42.2kg/m2), who had no known comorbidities, underwent a laparoscopic adjustable gastric band procedure in 2006. Her weight reduced from a preoperative weight of 95kg to 68kg within the first year post surgery. She gradually became unable to tolerate solids and requested all the fluid to be removed from her band. Over a year after having the fluid removed from her band, she still experienced severe abdominal pain and vomiting and developed nocturnal reflux. Investigations were organized, and both a computed tomography (CT) scan and a gastroscopy suggested a “high” placed band.
How would you treat this case?

Expert Commentary
by Natan Zundel, MD, FACS
It is difficult to analyze/discuss a case like the one presented here without having all the facts and previous history. It would be, for example, very important to know whether the patient lost close to 30kg in the first year postoperatively with the “help” of any of the symptoms described, such as dysphagia, vomiting, and reflux, or if her weight loss was completely asymptomatic. Also, it would be helpful to know how many adjustments/fills she had and the amount of fluid used. These are important factors to consider in order to better understand what is really happening to this patient.

One year after having the fluid removed from her band, the patient was still experiencing abdominal pain and vomiting and started to experience reflux. This spurred the treatment team to perform a CT scan and gastroscopy, but not a fluoroscopy. It is unclear to me whether any diagnostic testing was performed on the patient at the initiation of her symptoms but prior to removal of the fluid from her band. A patient with persistent symptomatology, such as the one described here, should have a barium swallow study and, if necessary, a gastroscopy to determine what is causing the symptoms. In cases like this, barium swallow or upper gastrointestinal series would help the treatment team better define whether they are dealing with a true high-placed band or a posterior slipped band, band erosion (with the endoscopy), motility problem, adhesions, or a constricting capsule “ring.” It is important to determine the cause of the problem, especially if the fluid removal and changes in alimentary habits do not seem to solve/alleviate the symptoms.

Every time I suspect a high-placed band, I first look for evidence that the band actually was placed there and did not migrate. I view the video of the original operation, if possible, and any previous x-rays that show the position of the band and other details of the operation. I also consider the differential diagnoses, which include the following:

1.    Posterior slippage of the band may cause the change of angle of the band in such a way that it will look like it is very high in the gastroesophageal (GE) junction. If it is a small slippage or only a CT Scan was performed (like in this case), we would see the change on the position of the band but would miss the slippage.
2.    An adhesion or constricting capsule “ring” usually explains the “late” dysphagia and vomiting, which will not improve after fluid removal. In my experience, a high-placed band will usually have at least some mild symptoms from the very beginning following initial placement. That seems to not be the case here. A constricting ring might better explain the symptoms.
3.    An esophageal motility problem should also be considered, but the symptoms usually appear early and constantly increase, without much improvement as long as the band is in place.
4.    An erosion (e.g., migration, penetration) should also be ruled out because it can present with similar symptoms. In this case, the CT scan, but more specifically the gastroscopy, did not show any evidence of an eroded band.

From a practical point of view, I would tell this patient that her band has to be removed. We have seen good results, following band removal, performing another restrictive procedure (specifically a sleeve gastrectomy) without the need to perform a bigger operation, like a gastric bypass. Our group will perform a gastric bypass if a band is not working at the time of the removal, but it is important to recognize that revisional surgery will increase the possibility of complications. Some surgeons might prefer to place another band, but I would not because I do not know exactly what has been causing the complications. Furthermore, in the case of a constricting “ring,” the complication will likely happen again, even with a new band.

If the patient accepts the conversion to a sleeve gastrectomy, I would remove the band, all the stitches and the anterior gastroplasty, and as much as possible of the anterior constricting “ring,” that, in this case, would probably be wide and very high in the GE junction. I would then proceed with the sleeve using only green cartridges.

On the other hand, if the patient does not want another procedure, I would remove the band, but while in surgery, after removing the band, I would either pass a bougie or perform an intraoperative (IO) endoscopy to determine if there is some degree of obstruction that would make the symptoms continue after surgery. If there is no obstruction, I do not see the need to remove that ring if no other procedure will be performed. If a partial obstruction or difficulty arose passing the bougie or scope, I would remove the anterior capsule.

Finally, I think that any patient who is going to have a gastric band removed should understand the following:

1.    If no other procedure is performed, the chances of regaining weight are very high.
2.    Conversion of a band to another bariatric procedure increases the risks of complications
3.    Complications may arise during surgery. The physician should then explain the options.

Follow up from the treating surgeon on the case presented
On discussion with the patient, she opted purely for removal of her gastric band despite the risk of weight regain. Having placed the ports and gained access to the peritoneal cavity (Figure 1), the operation started with significant adhesiolysis between the left lobe of the liver and the gastric band. Further sharp and blunt dissection enabled exposure of the GE junction, and the band was noted to be proximal in position (high), and was dissected out, with division of the gastrogastric plication stitches. It was then cut open and removed (Figure 2). The patient was discharged home on the same day and made a good postoperative recovery.

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