Colleen Smith RTR & Shantell Hayes MSN, APRN, FNP-C
Laparoscopic Adjustable Gastric Banding (LAGB) is a medical device used to assist in weight loss, which in turn, reduces the comorbidities associated with obesity. The LAGB is placed around the upper part of the stomach, just below the gastroesophageal junction, creating a pouch that is approximately 50-80 mL in size. The placement of the band is usually at a 45 degree angle pointing toward the left shoulder. The purpose of this surgery is to restrict the amount of food and caloric intake, helping patients to feel full quicker and therefore consume fewer calories. However, the LAGB can present with unique complications that require early identification.
Pouch dilation is the enlargement of the gastric pouch above the band. This can present with or without a change in the position of the band. Some causes of a pouch dilation are over-inflation of a fill adjustment, overeating, and consuming carbonated beverages. Symptoms commonly experienced with a pouch dilation include lack of satiety, heartburn, night coughs, regurgitation, and infrequent chest or upper back pain. We use a barium swallow study to screen for and diagnose this condition. If diagnosed, the initial step is a total band deflation for 4-6 weeks, accompanied with portion control of food and beverages. If left untreated, pouch dilation increases risk for aspiration pneumonia. The reflux associated with dilation and positional changes of the band also creates a risk for esophageal erosion, which could ultimately lead to cancer of the esophagus. We have discovered patients with the most success of recovering from a pouch dilation were those who addressed the situation promptly and followed the treatment protocol as directed. This is why we recommend an annual visit to evaluate your band by a healthcare professional.
A prolapse, also referred to as a “slip” occurs as a result of the stomach wall migrating up through the band, causing the pouch to enlarge and the band to slip below the diaphragm. This may or may not affect the angle of the band. If too much pressure from food is placed on the band, it can cause the band to flip completely, which obstructs the passage of food into the stomach and leaves patients unable to swallow any food and a limited amount of fluids. The most common reason a prolapse/slip may occur is due to an acute illness or incident causing vomiting. A patient will usually present with an inability to swallow food and/or water. He or she may also experience night coughs, and infrequent chest or back pain. A diagnosis may be obtained either by a barium swallow study or a CT study with gastrografin. Complications of a prolapse or slip include gastric perforation, necrosis or erosion of the gastric mucosa, bleeding of gastrointestinal tract, and aspiration pneumonia. Depending on the findings, initially we completely de-fill the band and put the patient on a 4-6 week “band vacations” accompanied with portion control for food and beverages. We do this to evaluate if the band will return to the proper position and to determine if we can slowly begin filling patient’s band to a level which provides adequate restriction of food. If an erosion if discovered, the patient needs to have the band removed surgically due to the potential complications which may occur.
Band erosion is a rare, potential long-term complication which occurs when the gastric band gradually grows into the stomach wall and gastric lumen. Most patients are asymptomatic; however, when symptomatic, the initial signs of band erosion are increased hunger, nonspecific abdominal pain, and weight gain. Gastric band erosion can be caused by a tight band, binge eating, and/or vomiting. Band erosion creates a risk for gastric wall ischemia, which is decreased tissue perfusion to the area. This causes necrosis and death of the effected tissue. When symptoms of erosion occur, the diagnosis is confirmed by an endoscopy, a procedure where a scope is inserted through the mouth into the esophagus and stomach to allow direct visualization of the area. Treatment for band erosion is removal of the band. Band erosion can also cause port-site infections, as the erosion causes ascending infection into the port-site. If left untreated, this can develop into intra-abdominal sepsis and be potentially life-threatening (Eid, Birch, Sharma, Sherman, & Karmali, 2011).
Port-site infections manifest with signs of swelling, pain, and redness surrounding the port. This can occur early during the postoperative period or later. When caught in the early stages, the infection can be treated with oral antibiotics. If there is not an adequate response to oral antibiotics, intravenous antibiotics may be necessary. If the infection continues, the port will need to be removed until the infection resolves and then a new port can be placed.
When there is leakage in the tubing extending from the band to the port, it is referred to as port tubing leak or breakage. At My Bariatric Solutions we use Huber needles to access patient’s ports under fluoroscopy to reduce risk for this complication. Typically, port breakage manifests as a slow leak, as the fluid in the tubing for the band steadily seeps into the surrounding tissue. This is essentially harmless, however patients will not have the expected restriction and the volume aspirated from the port-site will not be equivalent to the documented amount. To diagnose this compilation, we aspirate all the fluid from the band to evaluate if this is equivalent to the documented volume of fluid. For example, if we expect to aspirate 7 cc of fluid, but can only remove 2 cc, we strongly suspect a leak. We then schedule the patient for an injection of isovue into the port and use the fluoroscopy machine to watch the isovue travel along the tubing. When a leak is present, we will be able to see the isovue leak out into the abdominal cavity instead of traveling all the way to the band site. Port, tubing, or band replacement is the treatment for this complication.
Laparoscopic adjustable gastric banding is an effective and safe way to lose weight, reduce comorbidities linked to obesity, and improve overall health. However, it requires close follow up with qualified, educated health care providers to recognize small issues before they result in large complications and to achieve good patient outcomes. We recommend annual evaluation to optimize your results and reduce complications with your lap band.
Eid, I., Birch, D. W., Sharma, A. M., Sherman, V., & Karmali, S. (2011). Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guides. Canadian journal of surgery. Journal canadien de chirurgie, 54(1), 61–66. doi:10.1503/cjs.015709