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Category: Lap Band Removal

Revision from failed AGB to Duodenal Switch

January 10, 2018 2:10 pm

A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.

Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.

Long-term_AGB_outcome-791x1024

What is also interesting that more patients underwent revision from failed AGB to the duodenal switch than the sleeve gastrectomy (Fig 1.). This is what I also recommend.

More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.

Complication’s were broad and frequent (Table 3.)

Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here.

Rebanding- A Bad Idea In My Opinion

May 12, 2015 3:42 pm

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There is a wide discrepancy of outcomes for patients who have decided to have weight loss surgery and are experiencing different weight loss, regain and complications primary related to their choice of the procedure. In our practice we see quite a few revisions cases on weekly basis.  More recently there have been a few “Rebanding” patients seeking revision to the Duodenal Switch.

The typical scenario is of a  patient who had an adjustable gastric band placed, and after the initial weight loss (mostly because of the persistent nausea and vomiting) the weight stabilized. The weight loss was never  close to a healthy weight and in most cases their co-morbidities did not resolve but now have added  complications of reflux and abdominal pain  developed. These patients were then recommended to have the band  repositioned to resolve a slipped band causing the above complications.

The scientific evidence for rebranding is not justifiable. I think there continues to be an element of denial that the adjustable gastric banding procedures do not work for the vast majority of the people. In fact, AGB in the  long term will result in some complications that may not be revisable.   The scientific literature shows that there is no benefit to rebranding when it comes to weight loss.

In my opinion when a patient encounters problem with the adjustable gastric band,  Duodenal Switch operation represent the best option because it has the best long term outcome of all weight loss surgical procedures.

Screen-Shot-2015-05-12-at-4.39

Erosion of Gastric Band

November 30, 2014 5:03 pm

Gastric bands are restrictive rings placed around the top part of the stomach, close to the junction of the esophagus. Their mechanism of action is to create a small tight band to restrict the flow of the food into the stomach. The theory has been that the band will decrease the time food travels down past the narrowing thereby eating less with the end result of weight loss. One of the many complications from the band is erosion of the band into the lumen of the stomach. This results in the patient presenting with nausea, vomiting and some patients develop abdominal accesses. This may present itself with symptoms of abdominal pain, fever, and redness at the port site under the skin.

ring-Errosion
ring-Errosion

The treatment for this is urgent removal of the band and repair of the erosion/ulceration. Patients who are contemplating a revision to another weight loss surgical procedure are best advised to stage the procedure because of the potential for leak from the repair site. Almost all of these procedures can be done laparoscopically.

Adjustable Gastric Band Easily Reversible?

November 24, 2014 3:25 pm

The Adjustable Gastric Band  (AGB) procedures have been advertised as “easily reversible” minimally invasive procedures. A point of interest is why doesn’t anyone ask the question, “Why would a successful device and/or procedure need to be revised or removed?”

The long term success data shows that the AGB procedure is the most inferior of all bariatric  procedures. It is important, that when looking at the published data,  special attention is given to the definitions in that particular study. An example would be that if a study defines “successful outcomes as weight loss for 30 days!” then all procedure will be successful.

The following is an example of a patient who had the Lap Band (R) a several years ago in another institution. She was seen for surgical follow up with minimal weight loss over a short period of time. She then developed the typical complications of the band, namely the upper abdominal pain, reflux, inability to swallow solids, persistent nausea and vomiting. Her symptoms were all “worked up” and  was told that all the studies were normal.  All of her  symptoms were contributed to her eating habits, even though they persisted after the Lap Band (R) was completely empty.

The patient then presented n our office for a second opinion. After being seen in our office and having a full work up, she had the Lap Band removed and was revised to a Laparoscopic Sleeve Gastrectomy. She had complete resolution of all of her prior presenting symptoms.

Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
Pictured is the LapBand being dissected. There is significant scarring that has to be dissected to expose the band.
Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
With the band removed a very thick band of scar tissue is exposed. This is a typical outcome- and it explains why most patients continue to experience the same symptoms even with the band completely empty.
Adjustable Gastric Band Easily Reversible?
Adjustable Gastric Band Easily Reversible?
The thick scar tissue must be dissected and removed to allow for the underlying tissue to return to near normal anatomy. The scar tissue act like a restrictive band. If this scar tissue is not removed the patient will continue to have problem after the band is removed.
Hopefully this will reassure patients who are having problems with the band after it’s reservoir is emptied. Scar tissue formation under the band is most likely the contributing factor to the continued and significant symptoms of abdominal pain, nausea, vomiting, and reflux.  If you are having continued symptoms after your band has been deflated seek other surgical opinions.

“Normal” Lap Band placement!

April 23, 2013 9:39 pm

One of the most common problems that we see are patients who have been told that their band is in correct placement, and yet they are still having nausea, vomiting, reflux etc. These patients are frequently blamed for their symptoms as if properly placed band completely eliminates the problems being associated with the band.

The image above is an upper GI of a patient with no band in place.
The image above shows the esophagus of a patient with band placed, with no dilation of the esophagus.
The above image, shows the properly placed band with a grossly dilated esophagus above it.
This patient presented with daily nausea and vomiting and severe reflux, not even tolerating liquids even-thought the study was reported as “normal location and position” for Lap band.

Slipped Band

November 02, 2012 10:40 pm

“Slipped band” is actually a misnomer. It suggests that the band “slips” over part of the stomach, which is actually incorrect. In most cases, the band itself is scarred down to the surrounding tissue, as the stomach above and below the band is what migrates. This results in the stomach being partially trapped above or below the band, which causes nausea, vomiting, and abdominal pain. If it is not urgently treated, it may cause erosion and perforation of the trapped stomach tissue.
The treatment may be as simple as completely removing the fluid in the band, which may allow the stomach to return to its proper place. Though in my experience, the majority of the cases require a surgical intervention and removal of the band.

Revision or Reversal of the Duodenal Switch

September 08, 2012 7:00 pm

A significant portion of my practice involves the revision of the Gastric bypass and Adjustable Gastric Banding procedures to the Duodenal Switch operation. The re-operations are necessary to correct the complications that have been caused by these procedures. There are also instances of required revisions due to inadequate weight loss or weight regain. Our website contains detailed information regarding reasons for revision and the reversal of weight loss surgical procedures. I think it is important to mention that these complications are very common and almost never have anything to do with the patient’s behavior.

Duodenal switch operations may also require reversal or revision. The general reasons for a revision or reversal of the Duodenal Switch is the same as for all weight loss surgical procedures and include a variety of reasons. The reversal or revision of the Duodenal Switch operation is one of the simplest revision surgeries that I perform.

Let’s review a few facts about Duodenal switch.

Reversal of Duodenal Switch
Duodenal Switch anatomy

The Duodenal Switch procedures has two components:

1.) The sleeve gastrectomy

2.) The separation of the biliopancreatic secretions from the food to limit its absorptions.

Clearly, the portion of the stomach that has been removed cannot be reintroduced to the abdominal cavity. The second part of the operation can, however, be easily “undone.

The assumption is that the bowel needs to be divided again and re-anastomosed to reconstitute its continuity. This revision or reversal of the Duodenal Switch operation is done by simply creating a new connection between a new anastomosis, located between the biliopancreatic limb, and the alimentary limb.

If a complete reversal is needed, then the connection is made just distal to the ligament of Treitz. Ligament of Treitz is the transition point between the duodenum and Jejunum. This single anastomosis is safe and simple to perform and does not involve removing the previous staple lines.

If a partial revision is needed, or the common channel needs to be lengthened, then the anastomosis is made further proximal to the junction of both the alimentary limb and the biliopancreatic limb, but distal to the ligament of Treitz to allow for increased absorption of the calories and nutrientsIn my opinion, the revision and reversal of the Duodenal Switch operation is, from a technical perspective, the simplest of all revisional weight loss surgical procedures.

In my opinion, the revision and reversal of the Duodenal Switch operation is, from a technical perspective, the simplest of all revisional weight loss surgical procedures.

Obesityhelp.com revision Forum information

November 08, 2009 9:00 am

I am not sure what has happened over the past two weeks or so, but I have received a number of inquiries from patients who have had questions about the revision of RNY or Lap Band® for weight regain, inadequate weight loss, or other complications. I finally had to ask one of the patients where he got his information and heard about our practice. His source of information was the obesityhelp.com website.

I have spent some time looking over and responding to several postings on the forum sites. I have referred to a number of publications in some of my postings on obsityhelp.com.

Nishie et.al. (Obesity Surgery, 17, 2007 1183-1188) reported:
“Pouch size area, measured by routine UGI on the first postoperative day does not influence short term postoperative weight loss. “

Cottam et.al. (Obesity Surgery 2009, 19:13-17) concluded:
“The level of restriction or the presence of stenosis achieved by different stapler sizes does not have a significant role in weight loss.”

O’Connor et.al. (Surgery for Obesity and Related Dis. 4(2008) 399-403) summarizes:
“With construction of divided, vertical, lesser curvature based small-volume (less than or equal to  20 cm gastric pouches, the actual size of the gastric pouch did not correlate with the %EWL at 1 year laparoscopic GB.”

I am a firm believer that the best patient is the most knowledgeable patient. It is always safer to spend as much time as needed to ask questions and investigate all options. If I can provide any information, please contact us at contact@dssurgery.com