A Unique Case of Gastric Band Tubing Eroding Into the Vaginal Cuff.

We present here the case of a woman in her 40s with a history of an adjustable gastric band placed a decade ago. After the initial procedure, she had issues with a port-site hernia, mesh placement, and explantation secondary to mesh infection. Her port was removed at the time, with the tubing left in situ with hopes of future salvage. She then presented to her gynecologist with the tubing eroding through her vaginal cuff. This case highlights the importance of having a high index of suspicion in patients with a history of gastric bands given the varying presentation in the event of a complication.

Resolution of Sigmoid Esophagus After Laparoscopic Adjustable Gastric Band Removal.

Pseudoachalasia is a known complication following a gastric band placement that is reversible with band removal. However, the development of a sigmoid esophagus is uncommon. Sigmoid esophagus is considered late-stage achalasia and is associated with worse outcomes with myotomy compared to earlier-stage achalasia. A 53-year-old male with a laparoscopic adjustable gastric band (LAGB) placed 15 years ago presented to the clinic with persistent dysphagia after the band was deflated for symptoms of dysphagia. The upper gastrointestinal series showed a 6.6-cm-diameter, tortuous, sigmoid-shaped esophagus. Esophagogastroduodenoscopy confirmed a diagnosis of sigmoid esophagus proven via the presence of inflamed mucosa, tortuous esophagus, and high lower esophagus sphincter pressure consistent with pseudoachalasia, all secondary to LAGB. The patient then underwent band removal, resulting in rapid resolution of his symptoms. The postoperative barium study showed improvement in dilatation. At the three-month postoperative follow-up, manometry demonstrated normal motility, indicating resolution of the pseudoachalasia and sigmoid esophagus. This case demonstrated band removal as an effective treatment option despite late-stage pseudoachalasia with a sigmoid esophagus.

Causes of Death After Bariatric Surgery: Long-Term Study of 10 Years.

BACKGROUND: There is a lack of up-to-date research addressing the causes of death and predictors of long-term mortality after bariatric surgery. METHODS: This was a single-centre retrospective study. Trust records were used to identify deceased patients and their medical history. The demographic data, comorbidities, cause of death, and time since surgery were retrieved and tabulated. Data was recoded to allow for use in IBM SPSS. RESULTS: There were 39 deaths amongst 891 patients who underwent bariatric surgery between 15th June 2010 to 18th September 2022. The main cause of death was pneumonia and respiratory causes with 15.4% of the cohort. A history of asthma/COPD had an association with the cause of death (p = 0.021). A history of hypertension, ischaemic heart disease (IHD), and smoking were all associated with a higher age at death, whilst a history of IHD was associated with a higher number of days from operation to death. Age at operation and number of comorbidities both correlated with age at death, and multiple linear regression of age at death with age at operation and number of comorbidities as predictors was significant (p < 0.001). A Cox regression found age at operation to have a significant effect on survival, with a hazard ratio of 1.063 (95% CI:1.027 to 1.100, p < 0.001). CONCLUSION: Pneumonia and respiratory causes are the largest causes of long-term mortality after bariatric surgery. The only factor found to have a detrimental effect on all-cause mortality was age at operation which reduced survival. Hypertension, IHD, and smoking are indirect factors that are associated with mortality.

Revisional One-Step Bariatric Surgical Techniques After Unsuccessful Laparoscopic Gastric Band: A Retrospective Cohort Study with 2-Year Follow-up.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has high reported rates of revision due to poor weight loss (WL) and high complication rates. Yet, there is yet to be a consensus on the best revisional procedure after unsuccessful LAGB, and studies comparing different revisional procedures after LAGB are still needed. METHODS: This was a retrospective cohort study that compared the outcomes of one-step revisional Roux-en-Y gastric bypass (rRYGB), one-anastomosis gastric bypass (rOAGB), or laparoscopic sleeve gastrectomy (rLSG) after LAGB. WL, complications, resolution of associated medical conditions, and food tolerance were assessed with a post hoc pairwise comparison one-way analysis of variance (ANOVA) throughout a 2-year follow-up. RESULTS: The final analysis included 102 (rRYGB), 80 (rOAGB), and 70 (rLSG) patients. After 2 years, an equal percentage of excess weight loss was observed in rOAGB and rRYGB (both >90%; p=0.998), significantly higher than that in rLSG (83.6%; p<0.001). In our study, no leaks were observed. rRYGB had higher complication rates according to the Clavien-Dindo classification (10.8% vs. 3.75% and 5.7% in rOAGB and rLSG, respectively, p=0.754), and re-operations were not statistically significant. Food tolerance was comparable between rOAGB and rRYGB (p = 0.987), and both had significantly better food tolerance than rLSG (p<0.001). The study cohorts had comparable resolution rates for associated medical problems (p>0.60). CONCLUSION: rOAGB and rRYGB had better outcomes after LAGB than rLSG regarding WL, feasibility, food tolerance, and safety. rOAGB had significantly higher rates of nutritional deficiencies.

Significance of Hormone Alteration Following Bariatric Surgery.

The prevalence of obesity has increased significantly over the last several decades, and with its increase comes a wide variety of comorbidities, such as diabetes and cardiovascular disease. Traditionally, diet and exercise have been prescribed for individuals to try and regain control of their weight and health status. Despite this successful method, the compliance rate is significantly below the desired amount. Over the last few decades, a new treatment has been offered to significantly decrease an individual's weight to an optimal BMI between 18 and 25 kg/m2. Bariatric surgery has been proposed to be the most appropriate treatment for obesity, and there are several different types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), adjustable gastric band (AGB), and sleeve gastrectomy (SG). Hormones may be significantly involved in losing and maintaining weight loss. This paper aims to evaluate hormone changes in appetite suppression, appetite activation, glycemic control, and lipid metabolism and how these impact overall weight loss concerning the most prominent surgeries. The hormones assessed were ghrelin, insulin, leptin, GLP-1, PYY, and adiponectin, and their levels before and after each surgery were compared. RYGB is one of the most successful types of bariatric surgeries, and this correlates with it having the most suppressed levels of ghrelin, insulin, and leptin following surgery with a slow return to normal. RYGB has also led to the most significant increased levels of PYY, pre- and post-prandial GLP-1, and adiponectin. Hormones following SG followed the hormone trend after RYGB but were not as prominent. BDP-DS has the highest success rate. However, numerous adverse effects have limited the amount of studies assessing the surgery. What was present was not as significant as RYGB, possibly due to manipulation.

Discitis and Osteomyelitis Caused by a Migrated Laparoscopic Adjustable Gastric Banding (LAGB) Catheter.

Laparoscopic adjustable gastric banding (LAGB) is a popular bariatric surgical procedure used to aid in weight loss. Although significant complications may occur after LAGB, they are rare. LAGB causing discitis and osteomyelitis are incredibly rare, with only one other reported case. In this case report, we describe the case of a middle-aged woman who experienced discitis and osteomyelitis due to a disengaged LAGB catheter, which had eroded through her stomach and a part of her cecum. Overall, this case highlights the rare but potential complication of LAGB causing discitis and osteomyelitis. Patients with a history of LAGB placement should be monitored for this possibility and further investigation is needed to identify and mitigate risk factors.

Laparoscopic Banded Gastric Bypass: A Case Report of a Successful Weight Loss Despite Gastro-Gastric Fistula.

Obesity is a global health issue, Roux-en-Y gastric bypass (RYGB), is an effective treatment for weight loss. However, some patients experience insufficient weight loss after RYGB, leading to alternative strategies such as adding an adjustable gastric band to the bypass. This case reports a 43-year-old female with morbid obesity who underwent open RYGB in 2004, achieving significant weight loss. However, she experienced weight regain, indicating RYGB failure. A laparoscopic band was placed around her bypass with no post-operative complications and successful steady weight reduction. During follow-up, an upper gastrointestinal series revealed a gastro-gastric fistula. Despite the fistula, the patient maintained a steady weight, with a significant excess weight loss of 40.2% since the banded gastric bypass surgery. The development of a gastro-gastric fistula, which typically affects weight loss outcomes, was managed conservatively without impacting the patient's steady weight maintenance. This highlights an unexpected weight loss outcome in a patient who underwent laparoscopic banding following RYGB failure and later developed a gastro-gastric fistula. Despite the initial RYGB failure, the patient achieved significant weight loss, surpassing the average reported in previous studies.

Endoscopic Gastric Band Removal.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) procedures have declined worldwide in recent years. A known complication is the intraluminal erosion of the prosthetic material. The endoscopic management of gastric band erosion represents the recommended approach nowadays, and it avoids any additional trauma to the gastric wall already damaged by the migration. The purpose of our study was to assess the feasibility of endoscopic management for intraluminal gastric band erosion following LAGB. METHODS: From January 2009-December 2020, a total of 29 patients were retrospectively reviewed after undergoing endoscopic gastric band removal. The study included all consecutive patients who underwent endoscopic gastric band removal in this period. No patients were excluded from the study. Data on patient demographic characteristics, case history, operative details (procedural time, adverse events), and complications were reviewed retrospectively. RESULTS: Twenty-nine patients underwent endoscopic gastric band removal: 22 women (75.8%) with a mean age of 45 years (range: 28-63) and mean Body Mass Index (BMI) of 31 ± 4.7 kg/m2 (range: 24-41). The average time to the identification of erosion after LAGB was 42 months (range: 28-137). The initial upper endoscopy found a migrated band of more than half of the diameter in 21 cases, less than a half but more than a third in seven cases and in one case, less than a third (use of a stent). Twenty-seven patients were successfully treated with endoscopic removal, and in two cases, the endoscopic approach failed, and laparoscopy was further performed. CONCLUSIONS: The endoscopic management of intraluminal erosion after LAGB can be safe and effective and should be considered the procedure of choice when treating this complication. The percentage of the band migration is important for the timing of the endoscopic removal.

A Rare Case of an Incidental Near-Complete Gastric Band Erosion Without Perforation.

Laparoscopic gastric banding has been favored for the treatment of morbid obesity because it is minimally invasive, effective, and reversible. One of the complications is gastric band erosion which can cause abdominal pain, hematemesis, and hematochezia. Erosions can be partial and can lead to intra-abdominal free air, peritonitis, and sepsis. Endoscopic removal of the gastric band can be done safely and effectively using a wire and a mechanical lithotripter. We describe a patient with a rare case of an incidental near-complete gastric band erosion without perforation and subsequent endoscopic removal.

Laparoscopic management of a left hepatic vein injury during one -step laparoscopic Roux-en-Y gastric bypass after adjustable gastric banding removal: A case report.

INTRODUCTION AND IMPORTANCE: The occurrence of a left hepatic vein injury during laparoscopic removal of an adjustable gastric band is exceptional and should be known by any surgeon approaching the hiatal region. We report here the laparoscopic control of such a wound. CASE PRESENTATION: A 39-year-old morbidly obese woman (body mass index 47.7 kg/m2) presented the failure in weight loss following a laparoscopic adjustable gastric banding. It was decided to perform a one-step laparoscopic Roux-en-Y gastric bypass. Laparoscopic exploration showed post-surgical tissular retraction and adhesions. After the lap-band™ removal the left hepatic vein was accidentally bluntly injured while freeing adhesions between left hepatic lobe and the stomach. After a direct hemorrhagic control, intraoperative diagnosis of left hepatic vein injury was confirmed. A laparoscopic repair was performed by two running sutures using absorbable monofilament 4/0. Then, a Roux-en-Y gastric bypass was performed without any other complications. Operative time was 119 min; intraoperative blood loss was estimated as 200 cm3. No blood transfusion was necessary. The total hospital stay was 48 h. The excess weight lost after 10 years was 87,9%. CLINICAL DISCUSSION: Adjustable gastric band can modify anatomic landmarks, leading to a wrong dissection path, with possibility of left hepatic vein injury. CONCLUSION: The left hepatic vein injury can occur during revisional surgery for laparoscopic adjustable gastric banding failure. Its laparoscopic management can be done safely, in trained hands without increasing morbidity.

Gastric Band Insertion to Revise Sleeve Gastrectomy: A Case Report.

Bariatric surgery for the treatment of obesity, first introduced in the 1950s and 1960s, is now relatively commonplace. Often patients will first have an adjustable gastric band inserted, as this does not require altering or removing parts of the gastrointestinal tract. This procedure is associated with short hospital stays and quick recoveries and may be adjusted without further surgery. Typically only after banding fails mechanically or fails to bring about a satisfactory reduction in body mass index (BMI) do patients undergo further bariatric procedures which involve altering or removing parts of the gastrointestinal tract. Recent research has suggested that gastric banding is associated with greater weight reduction results as a secondary or follow-up procedure following a failed initial bariatric surgery. Here we report the case of a 43-year-old female with a history of cryptogenic organizing pneumonitis, gastroesophageal reflux disease (GERD), asthma, obesity, and prior sleeve gastrectomy who underwent a laparoscopic gastric band insertion to revise the prior sleeve gastrectomy, in reverse of the typical sequence of bariatric surgeries.

A Comparison of One- and Two-Stage Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding Using the BAROS Score.

INTRODUCTION: Revision of a failed band can be done by laparoscopic sleeve gastrectomy (LSG). It can be performed synchronously with band removal or during two separate procedures. AIM: Comparing single- and two-staged LSG following a failed LAGB in terms of short- and mid-term outcomes, with an emphasis on postoperative quality of life. METHODS: A retrospective cohort study comparing revisional LSG's safety and efficacy after failed LAGB removal. Data included patients' medical files, as telephone interviews. We compared demographics, weight loss, complications, long-term outcomes, and quality-of-life measures, including the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Ninety-three patients were enrolled, of which 68 (73.1%) underwent a single-stage revisional LSG. Of these, 40 were males (35.1%) with a mean age of 44.9 years (± 12.9). The two-staged group were older. The reasons for band removal differed between the groups: whereas in the two-stage surgery, the common causes were slippage (29.2%) or band intolerance (25%); in the single-stage group, it was weight gain (51%). There were no differences in short- and mid-term complications, weight loss, and quality of life. CONCLUSION: In selected cases, laparoscopic sleeve gastrectomy as a revision of failed gastric banding in one stage is as safe as a two-stage procedure in terms of short- and mid-term complications, weight loss, and quality of life. We believe that there is little benefit in performing elective surgery in two stages unless there are clinical indications. Exceptions for two-stage revision should include cases of band erosion and acute slippage with patient preference for band removal.

Alterations of digestive motility after bariatric surgery.

Bariatric surgery can induce changes in digestive motility that are de novo or secondary to an improvement or aggravation of previous disorders due to obesity. Alterations of digestive motility are frequently part of the mechanism of action and a result of surgery. They are not rare and they are not always associated with an increase in weight loss but can lead to the negative consequences on quality of life, which are more or less reversible as a real surgical complication. Knowledge of these complications has become essential, especially in this period when bariatric surgery often concerns patients who have already undergone an operation. Thus, the changes in digestive motility after bariatric surgery and the complications that may result from them must be known and considered to adapt surgical techniques to each patient, both in the case of a first intervention and in the case of a reoperation, which is becoming more and more frequent. The objective of this review is to synthesize alterations of esophageal and gastro-intestinal motility secondary to bariatric surgical procedures.

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study.

BACKGROUND: Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH. OBJECTIVES: To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors. SETTING: Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers. METHODS: A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors. RESULTS: In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting. CONCLUSION: Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.

Revision Laparoscopic Adjustable Gastric Band as a Successful Alternative Over Sleeve Gastrectomy After Failed Initial Weight Loss Therapies.

Bariatric surgery is one of the most successful treatment options for morbid obesity and related comorbidities that is reserved for patients when lifestyle modifications and medical treatments fail. Bariatric surgeries are proven to result in weight reduction and improve obesity-related complications; however, there still are some reported failures. We report the case of a 35-year-old woman with morbid obesity and diabetes mellitus who had failed laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG) when done individually. The patient finally had a successful weight loss after undergoing revision LAGB over LSG. Although the present literature reports LAGB being an unsuccessful weight loss procedure, this case highlights the significance of LAGB as an effective bariatric surgery compared to other procedures. Our patient not only lost her weight successfully but also resolved her comorbid conditions and mental illness following the LAGB.

Is Staple Line Reinforcement Necessary in Conversion From Laparoscopic Adjustable Band to Laparoscopic Sleeve Gastrectomy?

BACKGROUND: Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015-2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied. RESULTS: Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups. CONCLUSION: Choice of SLR does not affect number of bleeding events or staple line leak rate.

Safety and effectiveness of REALIZE adjustable gastric band: 5-year prospective study.

BACKGROUND: The long-term safety results of the REALIZE (Ethicon Endo-Surgery, Inc., Cincinnati, OH) adjustable gastric band collected in this prospective, multicenter study in patients with morbid obesity are presented. OBJECTIVES: To determine the reoperation rate, including band revisions, replacements, and explants, resulting from a serious adverse device-related event through years 4 and 5. Various efficacy measures were also assessed as secondary objectives. SETTING: Nine academic and/or private institutions. METHODS: The participating institutions enrolled 303 patients, who were then assessed on an annual basis, with 231 patients completing 5 years of follow-up. The study parameters included reoperation rates, changes in percentage of excess weight loss (%EWL), and changes in body mass index (BMI), as well as parameters of diabetes and dyslipidemia. Quality of life was assessed using the Short Form (SF)-36 and the Impact of Weight on Quality of Life-Lite questionnaires. RESULTS: The reoperation rate due to a serious adverse event in this population at 5 years after implantation with the REALIZE gastric band was 8.9%. The most common serious adverse event was band slippage, which affected 6.9% of the study population. The mean %EWL was 35.6% ± 26.84%, and the decrease in mean BMI was -7.01 ± 5.45 kg/m2 at 5 years. Patients experienced improvements in mean glycated hemoglobin and serum lipid levels, in addition to improvements in the quality of life measures. CONCLUSION: No new safety concerns were identified during the 5 years of follow-up. Although the results of this study did not meet the predefined safety criteria of 8% or less, the safety profile and long-term effectiveness observed in this study are consistent with those in the current literature.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding.

INTRODUCTION: Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported. PRESENTATION OF CASE: A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum. Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21. DISCUSSION: Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature. CONCLUSION: Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Unstable Lumbar Spine Osteomyelitis Caused by Trans-Foraminal Migration of Laparoscopic Adjustable Gastric Band Connection Tubing: A Case Report.

Background: Disconnection of the tubing between the port and LAGB is a well-known complication in general surgery and accounts for up to 17% of LAGB complications. Typically, when this complication occurs patients present with abdominal or pelvic complaints. A complication of spinal infection due to trans-foraminal migration has not been previously reported. The aim of this study is to highlight an unusual infection of the thoracolumbar spine due to laparoscopic adjustable gastric band (LAGB) intragastric erosion, and migration into the lumbar spine causing epidural abscesses, discitis, and osteomyelitis. This case underscores the importance of a thorough surgical history, complete imaging, and multi-disciplinary approach in management of complex spine infections. Methods: We report a case of LAGB tubing migration into the spinal canal through the left L2/L3 neural foramen resulting in symptomatic epidural abscesses and osteomyelitis. Results: Although dislodgement and migration of LAGB tubing has been reported previously, this is the first report of trans-foraminal migration and erosion of lumbar vertebrae, causing osteomyelitis of the spine and epidural abscess formation, subsequent instability and neurologic deficit requiring urgent operative intervention. Conclusions: Dislodgement and migration of LAGB tubing is a known complication. While it most commonly leads to abdominal and pelvic sequelae, in rare circumstances it may acutely affect the spine. Careful history, imaging, and multidisciplinary approach are paramount for the successful management.Level of Evidence: V.