|Year : 2020 | Volume
| Issue : 2 | Page : 139-142
Weight Regain After LABG: Ponder to Intra-gastric Migration of Adjustable Gastric Band
Lovenish Bains, Pawanindra Lal, Anubhav Vindal, Kamal Kishore Gautam
Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, New Delhi, India
|Date of Submission||01-Oct-2019|
|Date of Decision||23-Mar-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||29-Aug-2020|
Dr. Lovenish Bains
Associate Professor, Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive bariatric procedure. However troublesome complications can arise later with this procedure including band slippage and erosion. Intra-gastric erosion is a rare but major bothersome late complication after LAGB and requires band removal. A 35-year-old lady with BMI of 45.03 and hypertension as co-morbidity opted for LAGB. The patient started losing significant weight, however patient noticed sero-purulent discharge from epigastric port site after three months. Investigations were not suggestive of any leak, but persistent discharge led to wound exploration and infected band tubing was removed. The patient again noticed discharge from the port site after 20 months of primary surgery along with weight regain. Oral gastrograffin study was performed, which showed no evidence of contrast leak, however band seemed lower in position. Upper gastrointestinal (UGI) endoscopy showed a part of circumference of the band in the gastric cavity confirming intra-gastric migration and not retrieved due to adhesions with gastric wall. The band was removed by laparoscopic converted to open procedure due to dense adhesions. The patient recovered well. Migration of the band through the stomach wall is an uncommon late complication that may remain asymptomatic but must be thought in presence of weight regain or port-related complications. UGI endoscopy is diagnostic and therapeutic in most cases, rest of the cases require laparoscopy or laparotomy for band removal, depending upon surgeon or endoscopist expertise.
Keywords: Erosion, intra-gastric migration, laparoscopic adjustable gastric band (LAGB), lap band, upper gastro-intestinal (UGI), weight regain
|How to cite this article:|
Bains L, Lal P, Vindal A, Gautam KK. Weight Regain After LABG: Ponder to Intra-gastric Migration of Adjustable Gastric Band. MAMC J Med Sci 2020;6:139-42
|How to cite this URL:|
Bains L, Lal P, Vindal A, Gautam KK. Weight Regain After LABG: Ponder to Intra-gastric Migration of Adjustable Gastric Band. MAMC J Med Sci [serial online] 2020 [cited 2020 Oct 1];6:139-42. Available from: http://www.mamcjms.in/text.asp?2020/6/2/139/293893
| Introduction|| |
Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive procedure with lowest morbidity and mortality rates among the common bariatric procedures. The advantage of LAGB is that it does not permanently modify the anatomy of the stomach and maintains the natural continuity of the alimentary tract, thereby permitting other bariatic procedures in case of failure to lose weight or complications in morbidly obese patients. However troublesome complications can arise later with this procedure including band slippage and erosion. Intra-gastric erosion is a rare but major bothersome late complication after LAGB and requires band removal. Band migration usually occurs within the first two postoperative years. Major erosion or intra-gastric migration is defined as the presence of at least 50% of the circumference of the adjustable band within the gastric cavity. Intra-gastric erosion is rare and rates vary widely across various institutions the world from 0.2% to 11.1%.,
| Case Report|| |
A 35-year-old lady presented to our metabolic surgery clinic with progressive weight gain for last 8 years. The patient had sedentary lifestyle with BMI of 45.03 and hypertension as co-morbidity. Clinically the patient was euthyroid with central and peripheral obesity, weight 96 kg, and height 146 cms. Pulse rate was 78/min, blood pressure 136/84 mm Hg (on tablet amlodipine 5 mg daily for last 2.5 years) and laboratory parameters were within normal range. Sonography revealed enlarged liver, electrocardiogram, echocardiography, pulmonary functions, and upper gastrointestinal (UGI) endoscopy were normal. After 4 months of diet regime and 3 kg weight loss, the patient opted for LAGB. The patient underwent LAGB by pars flaccida technique, 50 cc gastric pouch was created using Lap BandTM. The patient recovered uneventfully and discharged on day 3 with dietary advice.
The patient started losing weight with 83 kg at 6 weeks and 75 kg at 3 months. However patient noticed sero-purulent discharge from epigastric port site after three months, oral gastrograffin study was performed which was normal. Persistent discharge led to wound exploration and infected band tubing was removed. The patient recovered well and kept following at regular intervals. The patient again noticed discharge from the port site after 20 months of primary surgery along with weight regain. Oral gastrograffin study was performed, which showed no evidence of contrast leak, however band seemed lower in position as compared to previous gastrograffin series [Figure 1].
UGI endoscopy showed a part of circumference of the band in the gastric cavity confirming intra-gastric migration and was not retrieved due to adhesions with gastric wall. In view of recurrent discharge and patient’s request (weight 68 kg), band removal was planned. The procedure was started laparoscopically, intra operative dense adhesions were found between the left lobe of liver and anterior wall of stomach, the band was not visualised. The procedure was converted to open after no progress with dissection due to dense adhesions. After meticulous dissection around the stomach, the band was felt in the lumen of stomach. The band was delivered out through gastrotomy made on anterior wall and stomach closed in two layers [Figure 2] and [Figure 3]. The patient recovered well and was discharged on day 6. The patient is healthy in follow-up and all wounds healed well.
| Discussion|| |
LAGB is an effective and safe surgical treatment for morbid obesity which does not alter the continuity of alimentary tract and is reversible. However, high complication rates resulted in a marked decline in LAGB insertion of 68% from its peak in 2008 to 2013 (10%) in a worldwide survey and whereas it was just 5% of all bariatric procedure for the period 2014–2018 as per fourth IFSO Global Registry Report 2018. Long-term complications include band slippage, gastric pouch dilatation, and gastric erosion.
The overall rate of postoperative complications was approximately 9% which includes 1.1% of erosions, 2.2% of slippage of the band, and 3.2% of port-related complications which along with the progress of time seems to increase. A systematic review of the literature in 2011 identified 25 relevant studies and reported a total of 231 erosions in 15,775 patients giving an overall incidence of 1.46%., It revealed that in four reports involving less than 100 patients, there were 27 erosions in a total of 270 patients (10%) compared with 180 erosions in 12,978 patients (1.386%) in the remaining 21 reports.
An analysis of 53,000 patients over 7 years revealed an annual band removal rate of 6% with more than two-thirds of patients requiring provisional surgery after removal. Female sex, body mass index >50 kg/m, type 2 diabetes, hypertension, dyslipidemia, and sleep apnea were found to be significantly associated with band removal. Furthermore, recent meta-analysis puts weighted mean % excess weight loss (EWL) as 45.9 % for LAGB at 10 or more years which means that LAGB provides lesser long-term solutions for obesity as compared to 55.4% EWL for Roux-en-Y gastric bypass (RYGB) and 80.9% EWL for one anastomosis gastric bypass (OAGB).
Migration of the band through the stomach wall is a late complication that may jeopardize the aim of the treatment − permanent weight reduction. The most common presentation was non-specific abdominal pain followed by weight regain and port-site discharge. Few patients presented with fistulisation, however, none of the patients experienced peritonitis. The median time to presentation was 7 months (range, 1–60 months), but majority 55% of the erosions occurred within the first year, and only 10% occurred after the second year. In another series, the mean time from band placement to the diagnosis of erosion was 31.5 months and a median time of 33 months from initial surgery to the erosion (range: 11–170 months).
Erosion that leads to intra-gastric band migration is usually a slow, chronic process where the band abrade constantly and slowly against the lumen and is eventually engulfed by the stomach, where it is exposed to gastric content.,, One study showed that 7.5% of asymptomatic patients had intra-gastric migration of band on routine screening with gastroscopy in the years following LAGB. In most cases, no leak was demonstrated by computerized tomography (CT) and barium meal. The diagnosis of band erosion was confirmed by UGI endoscopy, which demonstrated part or whole of the band inside the stomach. However, the radiologic appearance of band erosion when on an upper gastrointestinal series is pathognomonic and allows initial imaging diagnosis. In patients with extraluminal air or prosthesis infection, CT findings also are suggestive of this postoperative complication. It is possible that a minute injury to the gastric wall during the initial procedure is the underlying cause of this complication.
In our case, port site sepsis was found at 3 months, remained dormant for 2 years. Repeated upper GI study was normal without any leak. The band had eroded into the lumen of stomach without any leak into peritoneal cavity, perhaps leak into skin and subcutaneous plane due to dense adhesions. The patient recovered well after the band removal.
In the meta-analysis, the pars flaccida group and the perigastric group were compared for erosion and slippage and the mean rates of erosion and slippage were 1.03 and 4.93, respectively. The results demonstrated a statistically significant overall correlation between erosion and slippage rates (r = 0.48, P = 0.032). The high correlation rate between erosion and slippage for the perigastric group strongly suggests that these complications share a common pathophysiology whereas correlation is reduced with the pars flaccida technique, suggesting that perhaps a different etiology is associated with erosion in these studies.
Similarly in another study by Brown et al., the rate of erosion was highest when the band was placed by the perigastric approach at 6.77% and the rate of erosion has dropped to 1.07% with the adoption of the pars flaccida approach. Multiple regression analysis showed that erosion rate was significantly predicted by number of patients and number of years of surgeon experience.
UGI endoscopy is diagnostic and therapeutic however the treatment depends on position of the band. Endoscopic removal earlier was a bit difficult due to limitations of instruments, additional technology, and endoscopic technique, however, advances in endosurgical techniques now have allowed removal of eroded bands by ligation, band cutters, mechanical lithotripters, argon beam, YAG laser, and endosurgical devices., Many available series regarding endoscopic management of LAGB erosions do not describe any management directed at this mucosal defect as there are slow migrations with dense adhesions which seal off the defect.The best approach to management should be tailored on case to case basis with characteristics of the erosion and individual surgeon or endoscopist expertise. Endoscopic removal whenever amenable and laparoscopic band removal with suturing of the stomach wall are the current treatment options.,,,, One author has reported that laparoscopic omental plugging and band removal through a separate anterior gastrotomy may be an effective method for dealing with band erosions.
| Conclusion|| |
LAGB is an effective and safe surgical treatment for morbid obesity, however, high complication rates resulted in a marked decline in LAGB insertion. Migration of the band through the stomach wall is a late uncommon complication that may remain asymptomatic but must be thought in presence of weight regain or port-related complications. UGI endoscopy is diagnostic and therapeutic in most cases, rest of the cases require laparoscopy or laparotomy for band removal, depending upon surgeon or endoscopist expertise.
Ethics approval and consent to participate
Written consent for the publication of this case report was obtained from the patient. Approval for case report by the institutional ethics committee is not required.
Consent for publication
Written informed consent for the publication of this case report and for the accompanying images was obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Availability of data and materials
LB, PL conceptualized the manuscript, reviewed the literature, analysed data, and made major contribution to the writing of the manuscript. LB, PL, AV, KKG performed the clinical examination, surgical treatment, and clinical follow-up. All authors have read and approved the final version of the manuscript.
Financial support and sponsorship
Conflicts of interest
The authors declare that they have no conflicting interests.
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[Figure 1], [Figure 2], [Figure 3]