Obesity Surgery, 13, 435-438

11-cm Lap-Band System Placement after History of Intragastric Migration

M. Vertruyen, MD1; G. Paul, MD2
Deptartment of Laparoscopic GI Tract Surgery; 2Deptartment of Gastroenterology, Europe StMichel Clinic, Brussels, Belgium
1

Background: Intragastric migration (erosion) of the band after laparoscopic adjustable silicone gastric banding (LAGB) is a serious late complication. It requires removal of the entire system. Subsequent recurrence of obesity can be treated by laparoscopic placement of a larger band: the 11-cm Lap-Band System. Methods: In 727 laparoscopic gastric bandings using the 9.75 Lap-Band, 10 cases presented with intragastric migration of the band. The same complication was encountered in an additional 4 patients who had previously been implanted with an Obtech band in another hospital. Laparoscopic removal of the band was performed in all cases. In 9 cases, after a delay of 6 months, a new gastric band was placed using the 11-cm Lap-Band, because of uncontrollable recurrence of obesity. Results: No complication was observed during the laparoscopic removal of the system. The placement of a new band required conversion to laparotomy in 1 patient who had previously received an Obtech band which had been placed using the pars flaccida technique. After a mean follow-up of 21 months, no intragastric migration of the new bands was noted. Conclusions: Laparoscopic placement of an 11-cm Lap-Band in patients with a history of intragastric migration is a safe procedure. It allows effective control of recurrent obesity. The laparoscopic procedure was easier in patients initially operated using the perigastric technique. Key words: Morbid obesity, intragastric migration, erosion, gastric banding, laparoscopy, bariatric surgery

The etiology of this complication remains obscure. Its occurrence, sometimes 3 years after the initial placement of the band, cannot be only explained as a technical problem encountered perioperatively.5 Several theoretical hypotheses have been proposed: gastric perforation due to a gastric peptic ulcer or due to gastric wall ischemia, too tight adjustment, or the implantation of an initially infected device.2,6-8 In most cases, the only symptom is sudden and unexplained infection of the port. Gastroscopy confirms the intragastric migration of the band. The most reasonable treatment is the laparoscopic removal of the system and the closure of the perforation in the same way as a perforated ulcer is treated.2,3 Removal of the band through gastroscopy has been suggested but required an almost total intragastric migration.6 The reversibility of LAGB allows postoperative care without complications but cannot prevent subsequent recurrence of obesity. The laparoscopic placement of a new band can be proposed as an interesting alternative to control the obesity trend. This band placed at a correct level will surround a thickened gastric wall. Therefore, a larger band (11cm Lap-Band System) has been chosen to prevent postoperative dysphagia.

Materials and Methods Introduction

Laparoscopic adjustable gastric banding (LAGB) has reportedly been associated with a 1% incidence of intragastric migration (erosion) of the band.1-4
Reprint requests to: Marc Vertruyen, MD, 255, rue de la Station, 6210 Rves, Belgium. Fax: 00 32 2 737 84 05; e-mail : marcvertruyen@belgacom.net FD-Communications Inc.

Patients
Between October 1993 and May 2002, 727 patients (657 female and 70 male) underwent LAGB using the Lap-Band System 9.75 (INAMED Health, Santa Barbara, CA, USA). They had mean age 41 years (17-65) and mean body weight 118 kg (92262) corresponding to mean BMI of 45 kg/m2 (35Obesity Surgery, 13, 2003

435

Vertruyen and Paul

69). All patients had been operated using the perigastric dissection. No systematic screening for band erosion was performed in this series. Patients with a previous history of vertical banded gastroplasty with staple disruption were excluded from this study. Band erosion with partial intragastric migration was encountered in 14 cases: 10 cases (1.4 %) with a previous Lap-Band System and 4 cases with an Obtech band placed in another hospital by the pars flaccida technique. The only clinical feature was the sudden and unexplained occurrence of a port infection with local tenderness and tumefaction. No other sign such as fever, dysphagia, hematemesis or epigastric pain was observed. A Gastrografin swallow demonstrated no leakage, fistulas or proximal pouch dilatation. Gastroscopy allowed us to confirm the intragastric migration of the band. An immediate laparoscopic removal of the entire system was performed in all cases. The acute pain and abscess permitted us no delay in the surgical treatment. The placement of a new band was proposed in 9 patients (7 with a previous Lap-Band System and 2 with a previous Obtech band) due to uncontrollable recurrence of overweight. A postoperative delay of 6 months was required to secure the healing of the sutures and to expect a softening of the adhesions. A larger band (11-cm Lap-Band System) was chosen, to avoid postoperative dysphagia because of potential thickening of the gastric wall.

closed with 2 stitches of 2-0 silk. An omentoplasty covering the suture was performed and peritoneal lavage with saline ended the laparoscopic procedure. The entire system was removed from the abdomen through the scar above the port, and the infected capsule around the port was excised. An external drainage in front of the sutures was maintained for 2 days. Nasogastric aspiration and intravenous antibiotics were applied for 5 days. Laparoscopic LapBand Placement of the 11-cm

Surgical Technique
Laparoscopic Removal of the Band for Intragastric Migration Five trocars were necessary for the laparoscopic removal of the bands (2 of 10 mm and 3 of 5 mm). The scar from the initial procedure were used for the reoperation. All the cases first required an adhesiolysis between the left liver lobe and the anterior part of the stomach. The inflammatory capsule surrounding the catheter and the locking system were incised in the direction of the band. A part of the inflatable portion of the band was freed and transsected. The removal of the band through its tunnel demonstrated the gastric wall perforation. This was
436
Obesity Surgery, 13, 2003

Five trocars (2 of 10 mm and 3 of 5 mm) were also necessary for the laparoscopic placement of the 11cm Lap-Band System. The same scars used for the removal procedure were used for the redo. All cases first required an important adhesiolysis between the left liver lobe and the anterior part of the stomach. A proximal pouch was then calibrated with 15 cc of saline. The pars flaccida was used in patients who had had a previous band placement using the perigastric technique. In these cases, the lesser sac was free of adhesions. A classical pars flaccida dissection close to the diaphragmatic pillars was performed in order to reach the angle of His. Patients who had had a previous Obtech band placement using the pars flaccida technique presented a lot of scar tissue on the posterior part of the esophagogastric junction. A careful dissection was necessary to create a channel at the right level. The 11-cm LapBand System was pulled through the channel and stabilized in good position with 4 sero-serous sutures placed between the proximal pouch and the distal part of the stomach. The procedure ended with the fixation of the port on the anterior sheath of the left rectus abdominis muscle below the costal margin.

Results
Fourteen patients required a laparoscopic removal of the band for intragastric migration: 10 Lap-Band Systems of a total series of 727 patients and 4 Obtech bands placed previously in another hospital. Intragastric migration occurred after a mean delay of 27 months (range 17-39) for the Lap-Band System and 15 months (12-21) for the Obtech

Lap-Band Intragastric Migration

bands. The level of the erosion was the lesser curvature in 9 cases and the posterior gastric wall in 5 cases. The erosion led to a gastric fistula progressing along the catheter to the port. The infection was covered with omentum, and no signs of peritonitis were observed during the procedure. No particular intra- or postoperative complications were observed for this procedure. The mean operative time was 35 minutes (20-45). No conversions to laparotomy were necessary. All the patients were able to be discharged from the hospital after 5 days. A gastroscopy at 1 month postoperatively confirmed the good healing of the perforation. After a follow-up of 6 months, 5 patients (35.7 %) succeeded in stabilizing their BMI near its pre-erosion level and did not require an additional bariatric procedure. In 9 patients (64.2%) (7 previous Lap-Band and 2 previous Obtech), recurrence of morbid obesity was noted with a mean preoperative BMI of 34 kg/m2 at the time of the band erosion, reaching 43 kg/m2 6 months later. These cases benefited from the placement of an 11-cm Lap-Band. The mean operative time was 70 minutes (30-120). Liver laceration was observed in 3 cases (33.3%) and treated by spray coagulation. Conversion to laparotomy was necessary in one case (11.1%) whose initial band placement used the pars flaccida technique; the laparoscopic approach did not allow a safe dissection through the scar tissue in the posterior esophagogastric region, so a hand-assisted dissection allowed the creation of the retrogastric tunnel. Deep venous thrombosis was observed in one patient (11.1%), who required a laparotomy. No complaints of postoperative dysphagia were noted in this series. A Gastrografin swallow at Day 1 confirmed good positioning of the band and good passage through the stoma. The mean hospital stay was 1.2 days (1-3). The same postoperative diet as after the initial procedure was prescribed. After a mean follow-up of 21 months (6-45), there was no recurrence of intragastric migration and no late proximal pouch dilatation has occurred in these 9 cases. Connecting tube disruption was observed in one case (11.1 %) and required reconnection under local anesthesia. Review of these 9 patients confirmed the return of the initial postprandial satiety sense. A mean BMI of 33 kg/m2 was obtained after a mean follow-up of 21 months.

Discussion
Intragastric migration of an LAGB is a serious late complication, because it leads to the removal of the entire system and results in a high rate of obesity recurrence. It is not, however, a dangerous complication because no signs of peritonitis were observed during the removal procedure. Moreover, in this series, no technical difficulties or particular complications were encountered from removal. The lesser curvature and the posterior gastric wall were the most affected areas. Laparoscopic placement of a new band in cases with a history of intragastric migration is a safe, effective and reproductible procedure. No particular complications were observed during this procedure. Moderate liver laceration was due to the adhesiolysis and was easily controlled by spray electrocoagulation. Previous band placement by the perigastric technique permitted a safer posterior dissection because of the untouched resection plane at the right crus and behind the esophagus after opening the pars flaccida. Previous band placement by the pars flaccida technique, generating a lot of adhesions, required conversion to an open procedure in 50% of the cases. This may be an additional argument for initial perigastric placement of the band. The use of a band with a larger stoma (11-cm LapBand) has probably prevented postoperative dysphagia. After a mean follow-up of 21 months, a noticeable and durable decrease in BMI was observed and there was no recurrence of intragastric migration of the band. A larger band inducing less pressure against the gastric wall and the presence of scar tissue can be considered as protective factors. No difference in postprandial satiety sense was noted between the 9.75 and 11-cm Lap-Band. In this series, no relationship was observed between band erosion and proximal pouch dilatation.

References
1. Vertruyen M. Experience with Lap-Band System up to 7 years. Obes Surg 2002; 12: 569-72.
Obesity Surgery, 13, 2003

437

Vertruyen and Paul 2. Niville E, Dams A, Vlasselaers J. Lap-Band erosion: Incidence and treatment. Obes Surg 2001; 11: 744-7. 3. Meir E, Van Vaden M. Adjustable silicone gastric banding and band erosion: personal experience and hypotheses. Obes Surg 1999; 9: 191-3. 4. Chelala E, Cadire GB, Favretti F. Conversions and complications in 185 laparoscopic adjustable gastric banding cases. Surg Endosc 1997; 11: 268-71. 5. Abu-Abeid S, Szold A. Laparoscopic management of Lap-Band erosion. Obes Surg 2001; 11: 87-9. 6. Weiss H, Nehoda H, Labeck B. Gastroscopic band removal after intragastric migration of adjustable gastric band: a new minimal invasive technique. Obes Surg 2000; 10: 167-70. 7. Silecchia G, Restuccia A, Elmore U. Laparoscopic Adjustable Silicone Gastric Banding: prospective evaluation of intragastric migration of the LapBand . Surg Laparosc Endosc Percutan Tech 2001; 11: 229-34. 8. De Jonge ICDYM, Gie Tan K, Oostenbroek R. Adjustable silicone gastric banding: a series with three cases of band erosion. Obes Surg 2000; 10: 2632. (Received August 31, 2002; accepted December 2, 2002)

438

Obesity Surgery, 13, 2003