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When is revision of adjustable gastric banding (AGB) to another adjustable gastric banding (Lap-Band® Realize®) indicated?

Posted On : January 07, 2012

Band to band revision is never a good idea, in my opinion. Please let me explain. There are many reasons why an adjustable gastric banding (AGB) revision may be needed, which include but not limited to complications of the surgery, inadequate weight loss or both. These complications are a lot more common than publicized. (i)

Over time the incidence of band failure, as defined to EBWL (Excess body weight loss) <25% or band removal increases from 13.2% at 18 months (the best mark) to 36.9% at 7 years(ii).The source that this date comes from has lowered the EBWL to 25% and although it’s been lowered, the success rate is still not impressive.

If the patient has had complications such as slippage, erosion, ulceration or perforation and the adjustable gastric banding needs to be removed, the procedure should then be revised to an alternative such as a Sleeve Gastrectomy or the Duodenal Switch operation. Revising to either of the two procedures, in my opinion, serve as better alternatives than to revise to a Gastric Bypass.

If the patient has developed physiologic and functional complication of the adjustable gastric banding, such as reflux, difficulty with swallowing or esophageal dysfunction, then removing and replacing the band will not solve the underlying problem. I would argue that the band itself would likely be the cause of the complication(s).

If the patient has an infection of the injection port side, then the port will needs to be removed and replaced in a subsequent operation.

The only time that I can possibly think that a revision of a band to band is an option is if the band was one an earlier model placed many years ago. You may question why this would be important. The value behind this is that it will not only determine what type of band was used for placement but also were it has been placed.

So the only question of importance would be: when was the adjustable gastric banding placed? This question is only significant if the AGB was placed at a time prior to the recommendation of a “pars flaccida” dissection. The first technique recommended for adjustable gastric banding placement was the “perigastric” technique. This meant that the band was placed sitting right on the stomach. In order to perform this, all the tissue around the stomach specifically on the medial aspect was dissected and the band was wrapped around the tissue of the stomach itself. This provided a tighter grip of the stomach. However, it became evident that this also resulted also in a high erosion rate because there was no tissue protecting the stomach from the foreign body wrapped around it. A second problem with this technique was that the top part of the stomach, again on the medial aspect, had a near straight extension line to the distal esophagus and thus resulted in a higher slippage rate. Additionally, the design of the band itself evolved during the same time frame, as the techniques were refined. So, if a patient has complications that a surgeon can directly contribute to the older “model” or the early technique of the placements of the AGB, one can argue revising and AGB to AGB.

I would like to raise the following question that all patients need to ask themselves; If some of the overwhelming reasons for choosing the AGB was its perceived “least invasive” nature, and the “low complication rate” as it is advertised so much, then wouldn’t the need for a revision itself prove both of those fact to be incorrect. The data demonstrates that the complications of the AGB are much more prevalent than initially thought, or reported.

It is my opinion that the AGB should not be the default procedure of choice and that there should be very good indications as to why a patient cannot have any of the other procedures.

 

(i) Long-Term Results of a Prospective Study of Laparoscopic Adjustable Gastric Banding for Morbid Obesity – Y. Nieuwenhove et.al. Obesity Surgery-21 (5), 2011, 582-587

(ii)A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long-Term Complication and Failure Rates – M. Suter et.al. Obesity Surgery, 16, 2006, 829-835

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