Systematic Removal of More Than 50% of Fluid in Patients With Clinically Significant Reflux Or Slippage-like Complications of Adjustable Gastric Banding Is an Effective Treatment Option

Andrea S Bedrosian, MD, Nabeel R Obeid, MD, Bradley F Schwack, MD, Heekoung Youn, RN MA, Christine J Ren Fielding, MD, George A Fielding, MD, Marina S Kurian, MD. New York University Langone Medical Center

Introduction
As the patient population with laparoscopic adjustable gastric banding (LAGB) becomes more prevalent, and with it several known clinical complications, we investigated whether systematic loosening for specific band-related problems can prevent re-operation. We hypothesized that removing all fluid in patients with documented band slip, esophageal dilatation, pouch dilatation, or clinically significant reflux may be a sufficient therapeutic intervention, thereby avoiding the risks and cost associated with surgical revision of the band.

Methods and Procedures
We conducted a single-institution restrospective review of 273 patients who had LAGB with Allergan AP-Standard bands performed between June 2006 and July 2011, were at least 120 days from initial surgery with ≥5 mL of fluid in the band, and had ≥50% fluid removed for various reasons. Justification for fluid removal was divided into band-related clinical complications ( documented slip, esophageal dilatation, pouch dilatation, or reflux) and non-band related issues (e.g., pre-procedure fluid removal, patient request, etc.), and the percent of fluid removed was largely provider-dependent. We analyzed rate of re-operation for band-related complications, as well as categorization of documented resolution for those not undergoing surgical revision. Data points studied included demographic information, time from band loosening to re-operation, number of adjustments following band loosening, and weight change.

Results
113 of the original 273 patients had a band-related clinical complication justifying fluid removal of ≥50%: 34.5% had slippage, 28.3% reflux, 23.9% pouch dilatation, and 13.3% esophageal dilatation. Of these, 71.7% had documented resolution of the complication without surgery following fluid removal of ≥50%, while 25.7% underwent re-operation. Resolution was defined as complete alleviation of symptoms or normal follow-up imaging studies, such that the band could be refilled. Overall, 51.7% of patients with band slips had resolution without surgical revision, compared to 81.5% of patients with pouch dilatation, 81.3% with reflux, and 86.7% with esophageal dilatation. Three adjustment groups of fluid removal were selected: 50%, 51-75%, and ≥76%. Of the 10 patients who had 50% of fluid removed, none required band revision. For the 31 patients with 51-75% of fluid removed, 22.6% required band revision. For the 72 patients with >75% of fluid removed, 25% required band revision. In each adjustment group in those not requiring re-operation, an average of 4 adjustments was needed to reach the band’s original fill volume. Patients not requiring surgical revision saw an average of +7.6% change in weight, and weight gain was similar across all adjustment groups.

Conclusions
We found that simple fluid removal of ≥50% in LAGB patients is a good therapeutic option with >71% overall success. Over 80% of patients presenting with pouch dilatation, esophageal dilatation, or reflux had resolution without surgical re-intervention. Even in those with esophagram-proven slips, over 50% did not require re-operation. The small number of office visits to refill the band and <8% weight gain are acceptable when compared to additional surgery.
 

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