TECHNICAL REPORT
Reinstating Weight Loss After Leakage From Gastric Bands: A Simple Pull-through Technique to Replace the Broken Band William J. Hawkins, MBChB and Paul Super, MBBS
Purpose: Gastric bands are mechanical devices and are susceptible to mechanical failure. Leakage from the silicone balloon represents a permanent failure of the device that inevitably leads to further surgery. We have developed a simple solution to this problem. Materials and Methods: We describe a straightforward, railroad technique to replace a leaking but otherwise successful gastric band. We identified patients from our prospectively collected database who had undergone this procedure to record weight change before and after band replacement, along with complications up to 2 years postoperatively. Results: Eight patients with complete records were identified. The mean percentage excess weight loss before band leakage was 39.7% over a mean 38 months. The mean weight regain resulting from band failure was 5.6% before band replacement. After replacement, the mean excess weight loss stands at 46.1% from time of the original gastric banding. No complications or readmissions to hospital have been recorded. Conclusions: Our small series demonstrates this to be a safe technique to replace a damaged gastric band and results in continued weight loss. We therefore propose it to be the procedure of choice for this group of patients. Key Words: leaking gastric band, gastric band replacement, revisional bariatric surgery
(Surg Laparosc Endosc Percutan Tech 2014;24:e85–e87)
W
hatever their design, all gastric bands are mechanical devices and are therefore prone to mechanical failure. Leakage from the inflatable portion of a gastric band was first described in 19991 and represents a permanent failure of the device that can only be rectified by further surgery. Technology has improved over the years, but leak rates of between 4.4% and 8.1% were reported in some early series.2–5 Increasing numbers of patients are turning to bariatric or metabolic surgery as the solution to their morbid obesity and related problems with gastric bands being ever popular. In the first report of the UK’s National Bariatric Surgery Registry, one third of the 6537 registered operations were gastric band insertions,6 although the true market share in the United Kingdom is probably higher than this. Even with a more modest leak rate of around 2% (as reported in a more recent study7) the increasing number of gastric bands being Received for publication November 25, 2012; accepted February 1, 2013. From the Heart of England NHS Foundation Trust, Birmingham, UK. The authors declare no conflicts of interest. Reprints: William J. Hawkins, MBChB, Department of Surgery, St Richards Hospital, Spitalfield Lane, Chichester, West Sussex, PO19 6SE, UK (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
inserted will inevitably result in this complication becoming more commonly encountered by bariatric surgeons. For a majority of these patients, the band would have been otherwise successfully aiding their weight loss. Leakage and the subsequent loss of restriction ultimately results in weight gain for most patients. The purpose of any further intervention is to reverse this process. Some surgeons would resort to taking down the entire gastrogastric wrap or tunnel to replace the defective band. Others may even recommend conversion to a gastric bypass or a sleeve gastrectomy. However, we view this as an overly radical approach to the problem if the gastric band has otherwise been functioning well. In this situation, we have adopted an alternative strategy of replacing the band with a “railroad” technique, by attaching a new device onto the old one and pulling it through the preexisting gastrogastric tunnel. We have found that the Soft Gastric Band (AMI, Feldkirch, Austria) works well for this procedure due to its compliance. We have described the technique previously8–9 but is summarized in Figure 1. It is a quick, laparoscopic technique that requires minimal dissection and blood loss. It can usually be performed with the patient discharged on the day of surgery using the same protocols used for the original gastric band insertion. This current study aimed to demonstrate that replacing the defective band in this way is a safe technique that results in continued weight loss for our patients.
MATERIALS AND METHODS Patients who had undergone gastric banding and subsequent band exchange due to a leak in our unit between 2006 and 2010 were identified from our prospectively collected database. Patients were only included if complete preoperative and postoperative data for both operations was obtainable. Data were collected for patient demographics, time to band leakage, weight loss before band failure, change in weight as a result of band failure, and weight loss after band exchange. We also looked for evidence of any postoperative complications after band exchange. Follow-up data were available for up to 2 years after the replacement surgery.
RESULTS Eight patients with complete data were identified. This included patients with 4 different models of gastric band [3 Swedish Adjustable Gastric Band (Ethicon Endosurgery, Cincinnati, OH), 2 Obtech Realize 2200-X (Ethicon Endosurgery), 1 LAP-BAND Vanguard (Allergan, Irvine, CA), and 2 LAP-BAND AP (Allergan)]. All patients were female with a mean age of 43 (range, 32 to 64) and mean body mass index of 50.2 (range,
Volume 24, Number 3, June 2014
www.surgical-laparoscopy.com |
e85
Hawkins and Super
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
FIGURE 1. Steps in the simple pull-through technique to replace the broken band.
43.4 to 58.0) at time of initial band insertion. Chart 1 demonstrates the patterns of weight loss identified in these patients after gastric band insertion, leakage, and replacement. Before band failure, the mean percentage excess weight loss (%EWL) was 39.7% (range, 22.2 to 74.1) over a mean of 38 months (range, 12 to 59). Weight loss was seen to cease in 7 patients after leakage occurred from their gastric band, with 4 of these gaining weight. The mean change in %EWL seen between band failure and subsequent band replacement was + 5.6% (range, 3.8 to + 16.8). After band replacement, this trend reversed. One patient who had gained 12 kg when the original band failed had only lost half of this excess weight after a further 12month follow-up. Up to their most recent follow-up, all other patients have achieved at least the level of weight loss seen before band leakage but most (75%) have exceeded this. From the time of their original gastric band insertion, the overall mean %EWL to date is 46.1% (range, 32.3 to 74.1).
CHART 1. Excess weight loss of patients before and after band replacement (each line representing a separate patient).
e86 | www.surgical-laparoscopy.com
No complications or readmissions to hospital were reported after the replacement procedures.
DISCUSSION Surgery for morbid obesity is now an established surgical specialty. The use of gastric bands to achieve weight loss has been proven to be effective and remains a popular option among patients and surgeons alike. Leaks from the band can occur early or late. Early leaks are usually as a consequence of surgeon error during the operation, whereas late leaks are commonly due to a mechanical failure of the silicone balloon. The first generation of the Swedish Adjustable Gastric Band has been documented to be particularly prone to rupture.2–5 This seems to be due to the silicone stretching and kinking when inserted, causing 4 potential points of weakness10—a problem since addressed by the manufacturer. Technology has certainly moved on since the early days of laparoscopic gastric banding, but the risk of mechanical failure can never be completely removed and this complication has been recorded in other brands of gastric band.7 It is therefore important to have a strategy to deal with this sort of complication as and when it occurs. We routinely use fluoroscopic screening during band fills, usually allowing us to recognize this complication early. We were therefore able to operate on most patients before they had developed significant weight regain. However, even this technique may miss up to 42% of small leaks and 99 mTc-colloid scintigraphy can be a more reliable technique in those with a clinically suspected band leakage.4 Redosurgery after any abdominal surgery can often be associated with significant morbidity and risk of failure. It is up to the surgeon to identify techniques that will minimize this risk. We have introduced a technique that is quick and simple. It does not have any of the inherent risks (such r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
as hemorrhage or perforation) that may be associated with completely deconstructing the preexisting gastrogastric tunnel, which would be required with other techniques of replacing the band or converting to an alternative bariatric procedure. If the band is replaced by taking down and placing new gastrogastric sutures, it would also risk failure of the new device due to suboptimal positioning. Our results, albeit on a relatively small number of patients, demonstrate that the technique that we have adopted is safe and is effective at reinstating weight loss after mechanical failure of a gastric band. We therefore propose it to be the procedure of choice for this group of patients.
4. 5.
6. 7. 8.
REFERENCES 1. Ponson AE, Janssen IMC, Klinkenbijl JHG. Leakage of adjustable gastric bands. Obes Surg. 1999;9:258–260. 2. Mittermair RP, Obermu¨ller S, Perathoner A, et al. Results and complications after Swedish adjustable gastric banding—10 years experience. Obes Surg. 2009;19:1636–1641. 3. Tolonen P, Victorzon M, Ma¨kela¨ J. 11-year experience with laparoscopic adjustable gastric banding for morbid obesity—
r
2014 Lippincott Williams & Wilkins
9. 10.
Gastric Band Replacement
what happened to the first 123 patients? Obes Surg. 2008;18:251–255. Mittermair RP, Weiss HG, Nehoda H, et al. Band leakage after laparoscopic adjustable gastric banding. Obes Surg. 2003;13:913–917. Balsiger BM, Ernst D, Giachino D, et al. Prospective evaluation and 7-year follow-up of Swedish adjustable gastric banding in adults with extreme obesity. J Gastrointest Surg. 2007;11:1470–1477. Welbourn R, Fiennes A, Kinsman R, et al. The National Bariatric Surgery Registry: First Registry Report to March 2010. Henley-on-Thames: Dendrite Clinical Systems; 2011. Launay-Savary MV, Slim K, Bruge`re C, et al. Band and portrelated morbidity after bariatric surgery: an underestimated problem. Obes Surg. 2008;18:1406–1410. Hawkins W, Super P. A simple laparoscopic, pull through technique to replace a leaking gastric band. DVD presentation at the Association of Laparoscopic Surgeons of Great Britain and Ireland Annual Conference, Nottingham, November 2010. Hawkins W, Super P. A simple laparoscopic, pull through technique to replace a leaking gastric band. ALSGBI Conference News. 2010. Reijnen MMPJ, Naus JH, Janssen IMC. Mechanical evaluation of a ruptured Swedish adjustable gastric band. Obes Surg. 2004;14:253–255.
www.surgical-laparoscopy.com |
e87
Reinstating Weight Loss After Leakage From Gastric Bands: A Simple Pull-through Technique to Replace the Broken Band William J. Hawkins, MBChB and Paul Super, MBBS
Purpose: Gastric bands are mechanical devices and are susceptible to mechanical failure. Leakage from the silicone balloon represents a permanent failure of the device that inevitably leads to further surgery. We have developed a simple solution to this problem. Materials and Methods: We describe a straightforward, railroad technique to replace a leaking but otherwise successful gastric band. We identified patients from our prospectively collected database who had undergone this procedure to record weight change before and after band replacement, along with complications up to 2 years postoperatively. Results: Eight patients with complete records were identified. The mean percentage excess weight loss before band leakage was 39.7% over a mean 38 months. The mean weight regain resulting from band failure was 5.6% before band replacement. After replacement, the mean excess weight loss stands at 46.1% from time of the original gastric banding. No complications or readmissions to hospital have been recorded. Conclusions: Our small series demonstrates this to be a safe technique to replace a damaged gastric band and results in continued weight loss. We therefore propose it to be the procedure of choice for this group of patients. Key Words: leaking gastric band, gastric band replacement, revisional bariatric surgery
(Surg Laparosc Endosc Percutan Tech 2014;24:e85–e87)
W
hatever their design, all gastric bands are mechanical devices and are therefore prone to mechanical failure. Leakage from the inflatable portion of a gastric band was first described in 19991 and represents a permanent failure of the device that can only be rectified by further surgery. Technology has improved over the years, but leak rates of between 4.4% and 8.1% were reported in some early series.2–5 Increasing numbers of patients are turning to bariatric or metabolic surgery as the solution to their morbid obesity and related problems with gastric bands being ever popular. In the first report of the UK’s National Bariatric Surgery Registry, one third of the 6537 registered operations were gastric band insertions,6 although the true market share in the United Kingdom is probably higher than this. Even with a more modest leak rate of around 2% (as reported in a more recent study7) the increasing number of gastric bands being Received for publication November 25, 2012; accepted February 1, 2013. From the Heart of England NHS Foundation Trust, Birmingham, UK. The authors declare no conflicts of interest. Reprints: William J. Hawkins, MBChB, Department of Surgery, St Richards Hospital, Spitalfield Lane, Chichester, West Sussex, PO19 6SE, UK (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
inserted will inevitably result in this complication becoming more commonly encountered by bariatric surgeons. For a majority of these patients, the band would have been otherwise successfully aiding their weight loss. Leakage and the subsequent loss of restriction ultimately results in weight gain for most patients. The purpose of any further intervention is to reverse this process. Some surgeons would resort to taking down the entire gastrogastric wrap or tunnel to replace the defective band. Others may even recommend conversion to a gastric bypass or a sleeve gastrectomy. However, we view this as an overly radical approach to the problem if the gastric band has otherwise been functioning well. In this situation, we have adopted an alternative strategy of replacing the band with a “railroad” technique, by attaching a new device onto the old one and pulling it through the preexisting gastrogastric tunnel. We have found that the Soft Gastric Band (AMI, Feldkirch, Austria) works well for this procedure due to its compliance. We have described the technique previously8–9 but is summarized in Figure 1. It is a quick, laparoscopic technique that requires minimal dissection and blood loss. It can usually be performed with the patient discharged on the day of surgery using the same protocols used for the original gastric band insertion. This current study aimed to demonstrate that replacing the defective band in this way is a safe technique that results in continued weight loss for our patients.
MATERIALS AND METHODS Patients who had undergone gastric banding and subsequent band exchange due to a leak in our unit between 2006 and 2010 were identified from our prospectively collected database. Patients were only included if complete preoperative and postoperative data for both operations was obtainable. Data were collected for patient demographics, time to band leakage, weight loss before band failure, change in weight as a result of band failure, and weight loss after band exchange. We also looked for evidence of any postoperative complications after band exchange. Follow-up data were available for up to 2 years after the replacement surgery.
RESULTS Eight patients with complete data were identified. This included patients with 4 different models of gastric band [3 Swedish Adjustable Gastric Band (Ethicon Endosurgery, Cincinnati, OH), 2 Obtech Realize 2200-X (Ethicon Endosurgery), 1 LAP-BAND Vanguard (Allergan, Irvine, CA), and 2 LAP-BAND AP (Allergan)]. All patients were female with a mean age of 43 (range, 32 to 64) and mean body mass index of 50.2 (range,
Volume 24, Number 3, June 2014
www.surgical-laparoscopy.com |
e85
Hawkins and Super
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
FIGURE 1. Steps in the simple pull-through technique to replace the broken band.
43.4 to 58.0) at time of initial band insertion. Chart 1 demonstrates the patterns of weight loss identified in these patients after gastric band insertion, leakage, and replacement. Before band failure, the mean percentage excess weight loss (%EWL) was 39.7% (range, 22.2 to 74.1) over a mean of 38 months (range, 12 to 59). Weight loss was seen to cease in 7 patients after leakage occurred from their gastric band, with 4 of these gaining weight. The mean change in %EWL seen between band failure and subsequent band replacement was + 5.6% (range, 3.8 to + 16.8). After band replacement, this trend reversed. One patient who had gained 12 kg when the original band failed had only lost half of this excess weight after a further 12month follow-up. Up to their most recent follow-up, all other patients have achieved at least the level of weight loss seen before band leakage but most (75%) have exceeded this. From the time of their original gastric band insertion, the overall mean %EWL to date is 46.1% (range, 32.3 to 74.1).
CHART 1. Excess weight loss of patients before and after band replacement (each line representing a separate patient).
e86 | www.surgical-laparoscopy.com
No complications or readmissions to hospital were reported after the replacement procedures.
DISCUSSION Surgery for morbid obesity is now an established surgical specialty. The use of gastric bands to achieve weight loss has been proven to be effective and remains a popular option among patients and surgeons alike. Leaks from the band can occur early or late. Early leaks are usually as a consequence of surgeon error during the operation, whereas late leaks are commonly due to a mechanical failure of the silicone balloon. The first generation of the Swedish Adjustable Gastric Band has been documented to be particularly prone to rupture.2–5 This seems to be due to the silicone stretching and kinking when inserted, causing 4 potential points of weakness10—a problem since addressed by the manufacturer. Technology has certainly moved on since the early days of laparoscopic gastric banding, but the risk of mechanical failure can never be completely removed and this complication has been recorded in other brands of gastric band.7 It is therefore important to have a strategy to deal with this sort of complication as and when it occurs. We routinely use fluoroscopic screening during band fills, usually allowing us to recognize this complication early. We were therefore able to operate on most patients before they had developed significant weight regain. However, even this technique may miss up to 42% of small leaks and 99 mTc-colloid scintigraphy can be a more reliable technique in those with a clinically suspected band leakage.4 Redosurgery after any abdominal surgery can often be associated with significant morbidity and risk of failure. It is up to the surgeon to identify techniques that will minimize this risk. We have introduced a technique that is quick and simple. It does not have any of the inherent risks (such r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
as hemorrhage or perforation) that may be associated with completely deconstructing the preexisting gastrogastric tunnel, which would be required with other techniques of replacing the band or converting to an alternative bariatric procedure. If the band is replaced by taking down and placing new gastrogastric sutures, it would also risk failure of the new device due to suboptimal positioning. Our results, albeit on a relatively small number of patients, demonstrate that the technique that we have adopted is safe and is effective at reinstating weight loss after mechanical failure of a gastric band. We therefore propose it to be the procedure of choice for this group of patients.
4. 5.
6. 7. 8.
REFERENCES 1. Ponson AE, Janssen IMC, Klinkenbijl JHG. Leakage of adjustable gastric bands. Obes Surg. 1999;9:258–260. 2. Mittermair RP, Obermu¨ller S, Perathoner A, et al. Results and complications after Swedish adjustable gastric banding—10 years experience. Obes Surg. 2009;19:1636–1641. 3. Tolonen P, Victorzon M, Ma¨kela¨ J. 11-year experience with laparoscopic adjustable gastric banding for morbid obesity—
r
2014 Lippincott Williams & Wilkins
9. 10.
Gastric Band Replacement
what happened to the first 123 patients? Obes Surg. 2008;18:251–255. Mittermair RP, Weiss HG, Nehoda H, et al. Band leakage after laparoscopic adjustable gastric banding. Obes Surg. 2003;13:913–917. Balsiger BM, Ernst D, Giachino D, et al. Prospective evaluation and 7-year follow-up of Swedish adjustable gastric banding in adults with extreme obesity. J Gastrointest Surg. 2007;11:1470–1477. Welbourn R, Fiennes A, Kinsman R, et al. The National Bariatric Surgery Registry: First Registry Report to March 2010. Henley-on-Thames: Dendrite Clinical Systems; 2011. Launay-Savary MV, Slim K, Bruge`re C, et al. Band and portrelated morbidity after bariatric surgery: an underestimated problem. Obes Surg. 2008;18:1406–1410. Hawkins W, Super P. A simple laparoscopic, pull through technique to replace a leaking gastric band. DVD presentation at the Association of Laparoscopic Surgeons of Great Britain and Ireland Annual Conference, Nottingham, November 2010. Hawkins W, Super P. A simple laparoscopic, pull through technique to replace a leaking gastric band. ALSGBI Conference News. 2010. Reijnen MMPJ, Naus JH, Janssen IMC. Mechanical evaluation of a ruptured Swedish adjustable gastric band. Obes Surg. 2004;14:253–255.
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