Staged Repair of Laparoscopic Gastric Band Slippage

Sebastian R Eid, MD, Christopher W Finnell, MD, Amit Trivedi, MD, Hans J Schmidt, MD, Shomaf Nakhjo, DO, Douglas R Ewing, MD. Hackensack University Medical Center, Department of Surgery, Divison of Bariatric Surgery

Introduction
Laparoscopic gastric band slippage is a known complication that requires re operation following laparoscopic adjustable gastric banding (LAGB). Inflammation distorts the normal anatomy and can make revision or replacement exceedingly difficult. The surgeon’s options include removing or revising the band, or converting to an alternative bariatric operation. We propose a fourth alternative that salvages the LAGB and allows for the inflammatory process to subside prior to definitive repair. We propose a 2 stage procedure with the first stage consisting of simply unbuckling the band and reducing the slippage followed by a definitive revision at a later date. We assess whether this is a feasible alternative for treating LAGB slippage.
Methods
Between January 2006 and August 2010, 1548 patients underwent LAGB at our institution. We retrospectively reviewed all operative records for treatment of LAGB slippage. We identified 12 patients (75% female, mean age 32.17 ± 8.23 years) who underwent a staged repair of their LAGB due to band slippage. Data were collected retrospectively and included age, gender, BMI at primary operation, BMI at time of unbuckling (time of slippage), BMI at final revision and operative time and length of stay (LOS) at the time of unbuckling and at final revision. Additionally, the time period between primary operation and first stage of the repair and between the first and second stage of the repair were analyzed.
Results
Of 12 patients, all 12 underwent a laparoscopic reduction of their slipped lap band and unbuckling of the band while leaving the band in place. All patients’ dysphagia and food intolerance resolved following unbuckling. 11 patients had their bands revised and one pt was lost to follow up. There were no morbidities or mortalities following re operations. The operative times for unbuckling and final revision were 31.27 ± 18.57 minutes, (Range 13-73 minutes, Median 25 Minutes) and 61.18 ± 20.40 minutes (Range 38-109 minutes, Median 60 minutes) respectively. The LOS for the unbuckling and final revision was 1.18± 1.33 days (Range 0-4, Median 1) and 0.36 ±0.50 days (Range 0-1, Median 0 days) respectively. The average BMI at the primary operation was 45.45 ± 7.29 kg/m² and at band slippage (unbuckling) 27.54 ± 4.39 kg/m². The average time to band slippage was 28.45 ± 15.20 months (range 6-58, Median 23 months) from the primary LAGB placement. Time to definitive repair or rebuckling of the slipped band was 20.45 ± 18.06 weeks (range 6-60, median 11 weeks). BMI at time of final stage of the revision was 33.45 ± 6.01 kg/m² an increase of 20.14% (p-value <0.0001) from the time of unbuckling.
Conclusions
Staged repair of a LAGB slippage is a safe and feasible alternative for treating gastric slippage while salvaging the band. Time period between first and second stages of repair leads to significant weight gain, however more follow-up is needed to determine whether these patients lose their excess weight after final repair. It is imperative to perform the final revision in a timely manner to decrease the weight gain during this time period.

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