Bioring® gastric banding for obesity in a private South African hospital.

BACKGROUND: Obesity is a significant health problem in South Africa. Surgery is the most effective means of durable weight loss for the morbidly obese. Of the surgical options, laparoscopic adjustable gastric banding is the most controversial. We aimed to assess a single surgeon's experience with a specific band. METHODS: A retrospective observational study of a continuous cohort of laparoscopic adjustable gastric Cousin Bioring® band placements from a single private South African hospital was conducted. Three hundred and fifty bands were placed in 347 patients, 75% were female. Variables analysed were BMI obesity class, comorbidities, weight loss, diabetes resolution, adherence to aftercare, patient satisfaction, complications and death. RESULTS: Outcomes were assessed in 343 patients (4 patients lost to follow-up). The mean follow-up was 39 months (IQR 29-66 months). The mean preoperative BMI was 43.3 kg/m2 (IQR 37.4-47.6 kg/m2). Most weight loss occurred in the first year, and 66% achieved > 40% excess weight loss. Resolution of type 2 diabetes and prediabetes occurred in 56.4% and 89.8% of patients respectively. Increasing age (p = 0.002), class 3 obesity (p < 0.001) and suboptimal aftercare (p < 0.001) were associated with failure. One patient developed band erosion and 40 developed band slippage, 34 of whom underwent secondary surgery (32 removals, 2 revisions). All complications were grade I-III. There was no high grade complication, and no death. CONCLUSIONS: Bioring® gastric banding achieved moderately good weight loss and resolution of type 2 diabetes with a low complication rate. BMI > 60 and suboptimal aftercare predicted poor outcome.

Small bowel obstruction secondary to adipose tissue herniation through gastric band tubing loop. An unusual case presentation.

BACKGROUND: Laparoscopic adjustable gastric band complications like oesophageal dilatation, intractable nausea and vomiting, band migration, late slippages, and port problems with a cumulative rate of 19.2%. Rarely, LAGB complications may be related to the connection tube system and in this case the clinical presentation and the effects of the problem can generate difficulties in diagnosis. METHODS: A 47 years old woman who had a LAGB placed 2 years before the symptoms was admitted in our centre with nausea, vomit, leukocytosis and distended abdomen with a generalized tenderness. Computed tomography images showed an anomalous course of banding tube and a contemporary compression of a small bowel tract secondary to the traction exerted by an adipose tissue band attracted by the tube. RESULTS: A laparoscopic exploration of the abdominal cavity showed a tight loop of LAGB tubing causing a small bowel obstruction with an ischemic damage, so surgeons provided to LAGB removal and a 50 cm ileum resection CONCLUSIONS: Small bowel obstruction resulting from LAGB tubing is an uncommon complication which was reported in few cases. Although bariatric surgery currently represents the best treatment option for morbid obesity and its related- diseases, peri- and post-operative complications have always to be taken into account. KEY WORDS: Adjustable gastric band complications, Bariatric surgery, Bowel obstruction, CT scan, LAGB tube.

Gastroplastia de Collis robótica / Robotic approach for Collis gastroplasty

El verdadero esófago corto es una entidad que causa mucha controversia entre los cirujanos. Se han publicado estudios acerca de su diagnóstico y tratamiento laparoscópico, sin que a día de hoy existan publicaciones del tratamiento con abordaje robótico. Presentamos, en forma de caso clínico, nuestra experiencia en cirugía robótica de hernia de hiato con verdadero esófago corto tratada con gastroplastia de Collis y fundoplicatura de Toupet. La cirugía robótica en el verdadero esófago corto puede facilitar la disección mediastínica y permitir una técnica de sutura más precisa. Son necesarios estudios para comparar los resultados a largo plazo de esta técnica quirúrgica entre el abordaje laparoscópico convencional y el abordaje robótico

The true short esophagus is an entity of controversy among surgeons. Studies have been published about its diagnosis and laparoscopic treatment, without existing to date, publication of the treatment with robotic approach. We present, as a case report, our experience in robotic surgery for hiatal hernia with true short esophagus treated with Collis gastroplasty and Toupet fundoplication. Robotic surgery on the true short esophagus can facilitate mediastinal dissection and allow a more accurate suture technique. Studies are needed to compare the long-term results of this surgical technique between the conventional laparoscopic approach and the robotic approach

Robotic approach for Collis gastroplasty. / Gastroplastia de Collis robótica.

The true short esophagus is an entity of controversy among surgeons. Studies have been published about its diagnosis and laparoscopic treatment, without existing to date, publication of the treatment with robotic approach. We present, as a case report, our experience in robotic surgery for hiatal hernia with true short esophagus treated with Collis gastroplasty and Toupet fundoplication. Robotic surgery on the true short esophagus can facilitate mediastinal dissection and allow a more accurate suture technique. Studies are needed to compare the long-term results of this surgical technique between the conventional laparoscopic approach and the robotic approach.

Banding the Pouch with a Non-adjustable Ring as Revisional Procedure in Patients with Insufficient Results After Roux-en-Y Gastric Bypass: Short-term Outcomes of a Multicenter Cohort Study.

BACKGROUND: After laparoscopic Roux-en-Y gastric bypass (RYGB), approximately 10-35% of patients with morbid obesity regain weight after an initial good result or fail to achieve a sufficient amount of weight loss. Patients in which conservative measures are not successful may potentially benefit from revisional surgery. OBJECTIVE: To evaluate the effect of a non-adjustable ring placed around the gastric pouch in patients with insufficient weight loss or weight regain after RYGB. SETTING: Four specialized bariatric hospitals in The Netherlands, Germany, and Switzerland. METHODS: From 2011 to 2017, 79 patients underwent revisional surgery using a non-adjustable silicone ring because of insufficient results after RYGB. Data on weight loss and complications up to 2 years after revisional surgery was collected and analyzed retrospectively. RESULTS: A follow-up percentage of 86% after 1 year and 61% after 2 years was achieved. In 75% of patients, further weight regain was prevented. Percentage total body weight loss improved by 7 to 26% 1 year after revisional surgery and remained stable during 2 years of follow-up. The additional weight loss effect of placing a non-adjustable ring was more pronounced in patients with an initial good result after primary RYGB. Eighteen (23%) rings were removed, most often due to dysphagia. CONCLUSION: Especially for patients who experience weight regain after initial good weight loss, placing a non-adjustable silicone ring around the gastric pouch results in modest improvements in weight loss. To prevent the risk of ring removal due to dysphagia, surgeons should take notice not to place the ring too tight around the gastric pouch during revisional surgery.

The Use of the OverStitch for Bariatric Weight Loss in Europe.

Technological advances have permitted minimally invasive treatment of many gastrointestinal diseases. With the advent of endoscopic full-thickness suturing, it has become possible to replicate some of the surgical procedures. Endoluminal bariatric procedures to remodel and reduce the gastric volume similar to surgery is evolving as a treatment option for obesity. Some of these methods also have been extended to treat weight regain after gastric bypass surgery. There is a steep learning curve to gaining proficiency with different endoscopic gastric remodeling or gastroplasty techniques. This article describes a simplified technique of endoscopic sleeve gastroplasty using the OverStitch suturing device.

Conversion of Adjustable Gastric Banding to Adjustable Banded Roux-en-Y Gastric Bypass: Should We Leave the Band in Place?

OBJECTIVE: Laparoscopic adjustable gastric banding (LAGB) is rapidly becoming a deprecated bariatric procedure due to disappointing weight loss results and a high rate of band intolerance. Conversion to Roux-en-Y gastric bypass is a common revisional procedure after failed LAGB. The aim of this study was to evaluate the feasibility, safety, and risk profile of conversion to adjustable banded Roux-en-Y gastric bypass (ABRYGB). METHODS: A retrospective patient file review of all consecutive laparoscopic conversions of LAGB to ABRYGB 2008-2017. Pre/perioperative data, weight change, and long-/short-term complications were retrieved. RESULTS: Study population 98 patients. Mean BMI before revision was 40,15 kg/m2. Most revisional procedures were performed for band intolerance and/or weight regain or weight loss failure. All procedures were performed laparoscopically. During follow-up, 16 bands had to be removed due to one of the following reasons: infection, anastomotic leakage, anastomotic peptic perforation, adhesions around the anastomosis, internal hernia around the tubing, adhesions to the tubing, tubing failure, and erosion of the band. Three of those bands were replaced with a non-adjustable Silastic (Minimizer) ring. In total, issues with tubing requiring an intervention were found in 20 patients after conversion to ABRYGB. Seven revisional procedures had to be performed for symptomatic internal hernias not related to the tubing and incidental internal hernias were found in another 7 procedures. CONCLUSION: Although conversion of LAGB to ABRYGB is technically feasible, initially well-tolerated, and has good weight loss results, the number of additional procedures during follow-up is rather high, suggesting that leaving the band in place should not be advised.

Endoscopic Management of Anchor Erosion Adjacent to the Pylorus Following Duodenal-Jejunal Bypass Sleeve.

INTRODUCTION: Obesity is a pandemic associated with significant comorbidities such as type 2 diabetes (T2DM). RYGB is an effective treatment modality for obesity and T2DM. However, bariatric surgery is currently limited to a relatively small population of patients. The duodenal-jejunal bypass sleeve (DJBS) has recently emerged as a promising therapy for obesity and T2DM by providing similar physiological effects to RYGB. We describe a case of a patient with a previously placed DJBS presenting with abdominal pain from anchor erosion managed with an endoscopic approach. METHODS: A 58-year-old man with obesity and T2DM who had failed prior medical therapy for obesity was referred for DJBS placement. This was placed without complications. At 8 weeks follow-up, he developed abdominal pain and vomiting prompting immediate endoscopic evaluation. RESULTS: EGD revealed an anchor erosion resulting in mild stenosis of the pylorus. Additionally, hyperplastic tissue was found to be adhered to the device in the duodenal bulb. Endoscopic removal with balloon dilation was unsuccessful, and a stent was placed in a "stent-in-stent" fashion through the sleeve to compress the area of tissue ingrowth encouraging local tissue necrosis and device extraction. At 15 days follow-up, the stent was removed; however, the DJBS remained adhered and immobile. Next, the ingrowing hyperplastic tissue was resected in a piecemeal fashion. This resulted in mobilization of the sleeve anchors in the duodenal bulb and successful removal of the DJBS. CONCLUSIONS: DJBS endoscopic removal is safe and effective even in challenging cases, thus preventing the need for surgical intervention.

Gastric banding clip in the urinary bladder.

BACKGROUND AND AIM: A wide variety of foreign bodies have been found in the urinary bladder, most often due to self-introduction and autoerotism, or iatrogenically introduced during surgery in the anatomic region. We report the first case of a gastric banding clip found in the urinary bladder. CASE PRESENTATION: We describe the case of a 33-year-old Chinese female who had previously undergone gastric banding and subsequent removal of the band. She presented with lower urinary tract symptoms which followed a diurnal pattern, and investigations revealed a portion of a gastric banding clip in the urinary bladder. There was no sign of perforation or erosion of the bladder. The clip was surgically removed and the patient recovered without complications. DISCUSSION AND CONCLUSION: This is the first reported case of an intraperitoneal gastric banding clip migrating extraperitoneally into the urinary bladder. The use of the urinary bladder to expel foreign bodies has been documented in other vertebrates, and the mechanism by which this occurs without perforation or erosion of the urinary bladder warrants further investigation.

A 5-Year History of Laparoscopic Gastric Band Removals: an Analysis of Complications and Associated Comorbidities.

OBJECTIVE: This study was undertaken to examine the factors contributing to laparoscopic adjustable gastric band (LAGB) removals among adults > 18 years of age. We hypothesized that female patients with multiple comorbidities would have increased removals. DESIGN: This retrospective exploratory study uses internal records and standard statistical methods of analysis. RESULTS: Eighty-five bands were removed (11.8% males, 88.2% females). The average BMI was 40.7 (n = 83). 2.4% of patients had removals between 0 and 12 months, 18.8% between 39 and 51 months, and 35.3% between 39 and 64 months. 8.2% of treatment times were unknown. The average treatment time was 67.9 months. 48.2% of patients had ≥ 2 comorbidities, GERD (44.2%) being the most frequent. 49.4% of patients reported dysphagia as the reason for band removal. 22.4% of removals were associated with band failures, none with port complications. The reason for band removal was unknown in 21.2% of patients. 67.1%, 32.9%, and 23.5% attended 30-, 60-, and 90-day follow-up appointments, respectively. Weight post-band removal surgery at 30, 60, and 90 days was noted to be - 0.4%., 0.9%, and 0.4%, respectively. CONCLUSION: This study supports current literature suggesting LAGB may not be an effective long-term surgical intervention for obesity. Patients with > 2 comorbidities had increased rates of removal. Dysphagia was noted to be the primary reason cited for LAGB removal. Postoperative follow-up was found to be a significant challenge for LAGB removal patients. Further study is warranted to explore if these poor follow-up rates should be considered when risk stratifying LAGB patients for revisional surgery.

Gastric band migration to gastrointestinal lumen and possibilities of its surgical treatment.

BACKGROUND: Due to numerous late complications after laparoscopic adjustable gastric banding (LAGB), leading to band removal, a significant decrease of its application has been observed. OBJECTIVES: The objective of this study was to present complications after LAGB in our own material. MATERIAL AND METHODS: The study included 152 obese patients who underwent LAGB between 2005 and 2012. The group of women consisted of 91 patients (60%) with the following preoperative parameters: average body mass index (BMI) 42 ±3.66 kg/m2 and average body mass 122 ±12.8 kg. The group of men included 61 patients (40%) with a preoperative average BMI 43 ±3.81 kg/m2 and average body mass 125 ±13.02 kg. The average age of women was 35.02 ±11.6 years and of men 36.18 ±10.5 years. RESULTS: Among 152 patients after LAGB due to morbid obesity, in 7 (4.6%) migration of the band to the stomach lumen was observed, in 4 port wound purulence occurred, in 3 stomach mucosa ulceration was diagnosed in the band pressure area, 3 reported heartburn and hyperacidity, and 4 suffered from emesis. In all aforementioned patients, body mass loss stopped and they reported lack of restriction after last band regulation. CONCLUSIONS: Surgical or endoscopic treatment in patients with a migrated band is an individual matter depending on the type and size of band dislocation, its clinical symptoms and the general state of the patient, but also on the experience of the operating team and the quality of the equipment.

An unusual case of a completely eroded gastric band and port tubing removed via endoscopy alone.

Bariatric surgery is an established intervention providing significant health benefits to patients with obesity. As a result, the National Institute for Health and Care Excellence now recommends bariatric surgery for those that fulfil the eligibility criteria, while emphasising the need for multidisciplinary care before and after surgery. The UK National Bariatric Surgery Registry shows gastric band procedures to be the second most common bariatric procedure performed in the UK. Gastric band erosion is a known potential complication treated primarily by laparoscopic removal of band and repair of stomach. To our knowledge, we present the first case of a partially eroded gastric band with separate gastric fistulation of the port tubing. The band was removed via endoscopy without the need for a cutaneous exploration as the port had previously been removed at incisional hernia surgery. Owing to the fact that the tubing and band were both evident within the lumen of the stomach, complete band erosion was inferred and therefore endoscopic removal thought to be indicated. In actual fact, there was separate erosion of the band and tubing; more specifically, the gastric band clasp had not eroded fully and while endoscopic removal was still possible, it was challenging and required the band to be divided. This case highlights the importance of careful patient selection, involvement of multidisciplinary care prior and after surgery and close follow-up to facilitate timely identification and management of complications.

Chronic hypokalemia due to gastric exclusion after bariatric surgery.

Hypokalemia is a common complication of repeated vomiting or prolonged gastric suction. In the case we observed, a patient presented with chronic hypokalemia due to gastric dilatation and the development of a superior mesenteric artery syndrome several years after gastric banding. This paper presents pre-operative and post-operative illustrations of a rare but potentially serious entity.

Weight Loss and Late Complications after Silastic Ring Vertical Gastroplasty. A 10 Year Follow-up.

BACKGROUND AND AIM: Severe obesity is a public health care system challenge that requires bariatric surgery. Among the plethora of bariatric surgery techniques silastic ring vertical gastroplasty (SRVG) is a safe and efficient restrictive method that has been successfully used previously. However, it's performance by open approach has been abandoned and replaced by other methods using the laparoscopic method. The aim of the present study was to investigate patients with severe obesity submitted to open SRVG and to report our results over a period of 10 years in terms of weight loss, late complications and surgical re-interventions. MATERIAL AND METHODS: 112 severely obese patients submitted to open SRVG between years 2008- 2009 were investigated retrospectively for body mass index (BMI), percent excess BMI loss (%EBMIL), late surgical complications and reoperations. 41.96% of the patients were followed up 10 years after SRVG. Results: The initial mean BMI was 47.38 +- 7.59 kg/m2 and dropped statistically significant (p 0.001) to 31.05 +- 6.54 kg/m2 by the first year after SRVG. The mean BMI was rather stable along the first 5 years after SRVG when it started to increase gradually, reaching 35.93 +- 7.20 kg/m2 by the 10th year of follow-up when it remained still significantly lower (p 0.001) as compared to the mean baseline value. The %EBMIL was 79% at one year after surgery and reached 51% by the 10th year of follow-up. The most frequent late complications after SRVG were stoma stenosis (8.92%), enlargement of the stoma (8.03%) and incisional hernia (3.36%). As a consequence of stoma stenosis the ring has been removed in all cases. In 2 cases, after the ring removal, the patients underwent gastric bypass. CONCLUSION: SRVG is a safe and efficient restrictive technique of bariatric surgery open to many options to be revised, leading to a successful sustained long term weight loss and maintenance. Stoma stenosis, enlargement of the stoma and incisional hernia are the most frequent late complications after SRVG requesting reoperations.