Intrathoracic Sleeve Migrations After Sleeve Gastrectomy: A Compilation of Case Reports.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature. Methods: We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019. Results: Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation. Conclusion: In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development.

Medium-term outcomes of converting laparoscopic adjustable gastric band to Roux-en-Y gastric bypass in patients with body mass index <35 kg/m2: a uniquely Australian perspective.

BACKGROUND: The rates of primary laparoscopic adjustable gastric banding (LAGB) have declined in the last 5 years due to band removal secondary to complications and the subsequent weight regain that requires revisional procedures. OBJECTIVES: This study aimed to present medium-term weight loss results and the safety profile of converting LAGB to Roux-en-Y gastric bypass in patients with body mass index (BMI) <35.0 kg/m2 who presented with LAGB intolerance or complications. Many health services do not permit such procedures on low BMI patients. SETTINGS: Single-surgeon series, including public and private practice, Brisbane, Australia. METHOD: A prospectively maintained database was reviewed and retrospectively analyzed for LAGB patients with a BMI <35.0 kg/m2 who underwent conversion to Roux-en-Y gastric bypass by a single surgeon. Indications for conversion, weight loss data, and early (30 d postoperative) and late complications were recorded with follow-up out to 5 years. RESULTS: One hundred thirty-two adult patients with a BMI <35.0 kg/m2 underwent conversion from 2009 to 2016. The main indications for conversion were reflux and band complications. Median BMI at bypass was 32.8 kg/m2 (23.1-35.0). Median percentage excess weight loss was 77%, 90%, 73%, 47%, 49%, and 44% at 1, 2, 3, 4, and 5 years, respectively among patients who were eligible and present at follow-up. Median BMI was <30.0 kg/m2 (29.1-40.9) at 5 years with only 1 subject exceeding >35.0 kg/m2. Mortality was 0%. Early morbidity occurred in 31.8% of patients. The most common late complication was gastrojejunostomy stricture requiring endoscopic dilation. CONCLUSIONS: In combination with our 2014 study showing morbidity data in the short-term period being comparable to patients with BMI >35.0 kg/m2, our study demonstrates that converting LABG to Roux-en-Y gastric bypass in low BMI patients is a feasible and safe option that avoids weight regain and maintains adequate weight loss at 5 years, with acceptable morbidity and no mortality.

Reducing complications with improving gastric band design.

BACKGROUND: Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types. OBJECTIVES: To compare complication rates among different types of adjustable gastric bands at a single institution. SETTING: University-affiliated hospital, United States. METHODS: We performed a retrospective cohort study of adult patients with a body mass index ≥ 35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure. RESULTS: For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND™ 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%. CONCLUSION: First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band.

Previous weight loss as a predictor of weight loss outcomes after laparoscopic adjustable gastric banding.

INTRODUCTION: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients. METHODS: A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age ≥18 years, initial body mass index (BMI) ≥35 kg/m(2), intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL ≥ 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB. RESULTS: In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0-175). These patients were divided into four previous weight loss groups (0, 1-20, 21-50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (≥40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively. CONCLUSION: Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

Procedural changes to decrease complications in laparoscopic gastric bypass.

BACKGROUND AND OBJECTIVES: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a complex procedure performed in a patient population with significant medical comorbidities. Evaluation and modification of surgical techniques can minimize the complications associated with the lengthy learning curve for this procedure. The purpose of this study was to evaluate a single surgeon's decade-long experience with LRYGB, to determine whether complications decreased with experience and surgical modifications improved perioperative outcomes. METHODS: A retrospective review of all procedures performed by a fellowship-trained surgeon (MK) from December 1, 2000, to October 31, 2013, identified patients who underwent LRYGB. We evaluated perioperative outcomes in 1117 patients and examined the impact of modification of surgical techniques on complications. The patients were divided into 4 groups: cases 1-100 (group 1), cases 101-400 (group 2), cases 401-700 (group 3), and cases 701-1117 (group 4). RESULTS: Operating time decreased significantly after the initial 100 cases, from 179.1 minutes for group 1 to 122.1 minutes for group 4. With experience, early complication rates improved from 25.0% to 5.0%, but the rates of early reoperation increased from 1.0% to 2.2% over the 4 case groups. Late complication and reoperation rates increased from 4.0% to 10.5%. However, rates of bleeding, early stricture, internal hernia, and wound infection all decreased after the modification of surgical techniques. CONCLUSIONS: Operating time and early complication rates decreased with operative experience, but late complication and early and late reoperation rates increased. However, after modifications of surgical technique, common complications of LRYGB decreased to rates lower than those reported in several gastric bypass case series in the literature. The findings in this study will be helpful to fellow bariatric surgeons who are refining their strategies for reducing morbidity related to LRGYB.

Sustained weight loss after gastric banding revision for pouch-related problems.

OBJECTIVE: To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months. BACKGROUND: There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose. METHODS: A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation. RESULTS: Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision. CONCLUSIONS: Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding is one of several weight loss procedures in the bariatric surgeon's armamentarium to treat morbid obesity. Laparoscopic gastric banding has the lowest perioperative risk compared to laparoscopic gastric bypass, sleeve gastrectomy, and duodenal switch (Buchwald et al., JAMA 292:1724-1737, 2004). The adjustable gastric band results in approximately 50% excess weight loss at 5 years (O'Brien and Dixon,J Laparoendosc Adv Surg Tech A 13:265-270, 2003). In the long-term, reoperation rates can be high with the percentage of reoperations varying enormously in reported studies from 2% to 80% (Schouten et al., Surg Obes Relat Dis 7:99-109, 2011), although with changes in technique, reoperation rates after gastric banding have decreased (O'Brien et al., Obes Surg 15:820-826, 2005). Aftercare is critical to the success of the banded patient, in terms of adjusting the band as well as monitoring the patient's symptoms (Weichman et al., Surg Endosc 25:397-403, 2011). Several studies have shown that patients who are seen more than six to seven times in the first postoperative year have better weight loss.

Penetrating liver injury managed with a combination of balloon tamponade and venous stenting. A case report and literature review.

AAST-OIS grade V complex hepatic injuries are often fatal as a result of exsanguination. We report a patient presenting in extremis with a penetrating injury to the right kidney, liver, middle hepatic vein, diaphragm, and lung. A combination of intrahepatic balloon tamponade and hepatic venous stenting was used to control exsanguinating haemorrhage, the first time this combination has been reported. Rapid assessment and treatment and a team approach, together with the innovative application of haemostatic techniques, allowed a multidisciplinary team to salvage this patient.