Laparoscopic adjustable gastric band revisional surgery: a single surgeon series
When considering the success or otherwise of a bariatric procedure, outcomes considered include sustainable excess weight loss (EWL), resolution of obesity‐related co‐morbidities, operative morbidity, incidence of failure requiring revision and improvement in overall survival. Since its inception in the 1970s, restrictive bariatric surgery has evolved from a non‐adjustable, restrictive, polypropylene mesh to the adjustable gastric bands used today. The first use of the laparoscopic adjustable gastric band was reported in 1993 by Belachew et al. in Huy, Belgium.6 Common complications from this early era included difficulty achieving appropriate restriction, emesis due to stenosis of the gastric outlet, band slippage, erosion and oesophagitis.7 Several significant technical advancements define the modern era of bands: laparoscopy, adjustability, low‐pressure bands and the pars flaccida approach.6
Prevention of recognized early gastric band complications, including acute band obstruction, gastric perforation, bleeding and infection rely on meticulous surgical technique.9 Occasionally, surgical intervention in the early post‐operative period is required for adjustment or replacement of the device.10 Proximal pouch enlargements above the band including anterior, posterior and symmetrical dilatation, band erosion and access port or tubing failure are complications that may occur later.11 The introduction of the pars flaccida approach has significantly reduced the rates of gastric band slippage.12 A review by Egan et al., however, highlighted the considerable variation in the literature regarding band slippage rates, ranging from less than 1% to over 20%.13
Enlargement of the gastric pouch may occur as a result of symmetrical pouch dilatation (SPD) or band slippage. These two entities pose different diagnostic and management dilemmas. Band slippage can represent an acute issue requiring surgical correction, due to the risk of gastric ischaemia. The patient may have a noticeable change in food tolerance, associated with a nocturnal cough, reflux, epigastric pain, the sensation of food getting ‘stuck’ and excessively rapid weight loss. SPD is a diverse entity describing chronic proximal pouch dilatation above a satisfactorily positioned band, and is likely caused by excessive pressures generated in the proximal gastric pouch. This does not usually represent an acute surgical problem and can be managed with band deflation and reassessment; however, some authors advocate removal and replacement of the band for refractory symptom complexes.14
The literature regarding the ability of revisional surgery to maintain the goals of the primary bariatric operation, such as sustained weight loss and reduction of obesity‐related co‐morbidities, is encouraging. Studies are now emerging to suggest that sustained weight loss may be achieved with selection of an appropriate revision procedure. Gastric band adjustment or replacement, conversion to sleeve gastrectomy or conversion to Roux‐en‐Y gastric bypass (RYGB) are viable options; however, consensus regarding the best approach in a given clinical scenario is lacking. Some authors advocate that conversion to RYGB for a primary band requiring revision should be preferred.16 In contrast, O'Brien et al. found that patients undergoing band revision (usually band replacement) did well, maintaining an acceptable long‐term EWL of approximately 50%, no different to their overall study group.1
A laparoscopic approach to revisional surgery is preferred, and may be performed safely in experienced hands, even after previous open surgery.18 However, when revisional surgery is required, it may be complex and technically difficult. Evidence regarding the optimal approach and potential pitfalls with complex revisional procedures are limited.