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Tag: stricture

Long Term Complications of Adjustable Gastric Banding

October 17, 2017 6:35 am

It is interesting to encounter patients who are still being recommended for Lap Band placement to treat morbid obesity. There is a vast body of scientific evidence supporting that Lap Band not only does not result in a sustained weight loss for majority of the patients, but that it results in significant long term complications for some.

One of the complications is a significant stricture (narrowing) where the band is located even when it is completely empty. This is cause by:

1- either scarring of the tissue around that band causing a “belt” effect around the stomach, or

Long Term Complications of Adjustable Gastric Banding
Stricture of a deflated AP-10cc band 2-Slipped band.
Long Term Complications of Adjustable Gastric Banding
Partially slipped band

There are numerous other complications that are associated with Adjustable Gastric Bands that encompass a wide range of areas that are not discussed in this blog. This recent article (yes another one) outlines the dismal long term outcome of the Adjustable Gastric banding- Buyer Beware.

https://www.dsfacts.com/pdf/agb-long-term-results-1506834076.pdf

Shared Success- Samantha had a Sleeve to Duodenal Switch Revision

July 14, 2017 9:30 am

After struggling with obesity for most of my life I was finally fed up. I had heard about weight loss surgeries before but was always under the common misconception that it was for people who wanted the “easy” way out of a hard situation. I had been working out and reducing calories and tried every popular diet and trainer you could think of. I was still huge and each time I would stop one of these extreme programs I would only end up larger than I was before.

My husband’s cousin had the sleeve surgery and she raved about it. Watching her success is what started to open my mind to surgery, but I was only considering the sleeve gastrectomy. I went to a center in another state that offers Duodenal switch, lapband, RNY and the sleeve. The surgeon I met with strongly suggested RNY to me, but I was stuck on the sleeve. I didn’t want my intestines touched period. I had the sleeve surgery on October 9, 2013.

My high weight was 402 lbs and I weighed 343 on the day of my sleeve surgery. I actually did well with the sleeve and was able to get down to 218 as my lowest. However it was still much like dieting. It was so stressful. After a while my body wouldn’t drop the weight regardless of how little I ate and exercised. I was eating 800-1200 calories a day and low fat meals and working out and kept slowly gaining weight. I was frustrated  and honestly I gave up. My reflux wouldn’t go away so I visited a bariatric surgeon in my area who suggested that we essentially re-do the sleeve surgery to make my sleeve small again so that I would eat less and lose weight again. I got a second opinion and that surgeon suggested I revise to RNY. I went to obesity help’s website to explain my situation and a lot of people with much more experience than me HIGHLY urged me to see Dr Keshishian before making a decision. He was said to be an expert in revision weight loss surgery. I almost cancelled my appointment and didn’t have hope with this doctor either, but since I was in a dead end I went anyway. Dr Keshishian told me it wasn’t my fault. WHAT!? I had never heard that before. I usually get the shame from doctors who assume I must not be trying or that I am secretly eating something wrong. He ordered tests and told me it was “simply science” and I just LOVED him! I had a stricture in my Sleeve that needed to be repaired so since I needed surgery anyway I decided to go ahead and revise to a surgery that has the highest success rate, Duodenal Switch.

Before Sleeve to Duodenal Switch revision
Before Sleeve to Duodenal Switch revision
after Sleeve to Duodenal Switch revision
after Sleeve to Duodenal Switch revision

I was so scared of my intestines being cut and Dr. Keshishian eased my fears. I wish I had went that route the first time but then I might not appreciate it like I do now. Duodenal switch is the ONLY surgery I would recommend to anyone. As Dr K says it’s simple numbers. It’s the surgery with the highest percent of excess weight lost and kept off. I was 252 before my revision from Sleeve to Duodenal Switch and I am just at a year out and today I weigh in the low 190’s and I am still losing. Dr K’s goal for me was about 180. My goal is about 175.  I eat more fat now than I ever did even when I was 400 lbs. I enjoy what I eat and I enjoy exercising and most of all I get to enjoy seeing results from my hard work. Food no longer causes me stress and anxiety. I know with 100% certainty that I made the right decision. Thank you Dr. K for your great skill and I don’t mean just with the knife but with the way you are able to make a high anxiety situation seem like no big deal.

 

After Sleeve to Duodenal Switch Mud Run
After Sleeve to Duodenal Switch Mud Run
After Duodenal Switch Mud Run
After Duodenal Switch Mud Run

Ulcer and Stricture

August 29, 2016 5:21 am

A patient was referred to us for second opinion who was experiencing nausea, vomiting, GERD.  The patient had Duodenal Switch procedure many years ago but more recently had developed significant nausea, worsening reflux and solid intolerance. The patient had an endoscopy a few months ago and was only found to have a stricture within the Duodenum, no definitive treatment was offered at the time to the patient. On second examination of this patient with a second EGD the result was development of diffuse Duodenal ulcers  and stricture.

First EGD of Duodenal Stricture
First EGD of Duodenal Stricture
Second EGD with Duodenal Stricture and Ulceration
Second EGD with Duodenal Stricture and Ulceration

Note that these images are nearly identical positioning showing the stricture at 9 position. The image on the right also shows patchy ulcers.

Any changes in GERD, nausea, vomiting, gastric pain or discomfort after weight loss surgery should always be evaluated, treated, and followed. In a previous blog, the effects of GERD have been described.

Stricture after Sleeve Gastrectomy Duodenal Switch

May 01, 2016 9:45 pm

According to the American Society of Metabolic and Bariatric Surgery sleeve gastrectomy has become the most commonly performed operations in 2012.  Sleeve gastrectomy became popular because of the high failure rate of the adjustable gastric banding and the issues with RNY pouch. The Sleeve Gastrectomy was performed many years prior to 2012 as a part of the Duodenal Switch procedure. Stricture is a complication occurring post Sleeve Gastrectomy and Duodenal Switch.

Stricture:

Sleeve gastrectomy may appear to be a simple procedure under the surface; however, it is fraught with very unique and challenging complications. These may include, but are not limited to, staple line failure resulting in leak,  injury to the spleen,  stricture,  and even a rare and under diagnosed portal vein thrombosis.  Technique is important in avoiding short and long-term complications. Strictures can be caused by making the sleeve stomach too narrow or by stapling in a fashion where the corkscrew stomach.

Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction.   This can result in significant GERD in patient with  no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention.  Balloon dilation by an endoscopy method is frequently unsuccessful.  The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair.   Strictures are usually a short narrow segment of the stomach.  The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of  the staples line that is present on one side of the  tube of the stomach that cannot be stretched.

Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch

Some surgeons create a very narrow sleeved stomach in an attempt to maximize weight loss by increasing restriction.   This can result in significant GERD in patient with  no long-term benefit. Re-sleeving is another incidence were strictures can become an issue. These strictures are debilitating and almost all the time require surgical intervention.  Balloon dilation by an endoscopy method is frequently unsuccessful.  The patient who has a stricture should seek the attention of an experienced revision surgeon for surgical repair.   Strictures are usually a short narrow segment of the stomach.  The reason why sleeve gastrectomy strictures do not respond well to balloon dilatation is because of  the staples line that is present on one side of the  tube of the stomach that cannot be stretched.

Stricture after Sleeve Gastrectomy Duodenal Switch
Stricture after Sleeve Gastrectomy Duodenal Switch

An increasingly more complicated problem is when the stricture  is caused by a spiraling of the staple line.  This is quite frequently seen where the stapling of the stomach was started on the  greater curvature of the stomach and rotated anteriorly causing a corkscrew effect of the stomach.  A long segment stricture of the stomach cannot be corrected by balloon angioplasty and would require surgical intervention.

I have been involved with numerous repairs of strictures on sleeve gastrectomies and Duodenal Switch  stomach from other institutions.  In  my opinion, repeated endoscopy and balloon dilatation only complicate  further care  by compromising the tenuous tissue of a strictured stomach due to scaring and blood supply.   As above-stated earlier it is critical that a patient who is experiencing significant reflux, changes in nausea and vomiting, suspected stricture or narrowing, or has a corkscrew stomach to be seen by an experienced surgeon for surgical repair.  See the following Blog for health issues that can occur or progress with strictures.

Sleeve Gastrectomy specimen picture.

Failure of Anti-Reflux Procedures

September 28, 2015 7:13 am

A recent study Published in JAMA Surgery,  quoted rate of 10-20% of patients who have had anti-reflux surgical procedures will have recurrence of his symptoms  within the research data.  There are numerous studies that  have identified predictive factors leading to  return of the symptoms after surgical intervention. Some of these predictive factors are improper diagnosis, inadequate work up and technical issues.

Due to the significant rise of sleeve gastrectomy as well as a high failure rate of the lap band, we have seen several patients presenting with significant reflux disease after weight loss surgery.  There is a little scientific data regarding the failure of anti-reflux procedures in patients who have had previous weight loss surgical operations. In our practice, however,  we have  extensive experience with anti-reflux operations in patient who have had previous weight loss surgeries including Gastric Bypass,  Adjustable Gastric Banding, Sleeve Gastrectomy and Duodenal Switch operation.

Improper diagnosis, inadequate work up, and technical issues have been cited as possible causes for recurrence of symptoms in patients  who have not had weight loss surgery. One could assume that those variables are still a factor in addition to other factors resulting from a previous weight loss surgery. The complications of a previous weight loss surgery can not be under-estimated; an example would be a patient with significant esophageal motility issues directly related to an Adjustable Gastric Band. Other situations that exacerbate symptoms of reflux are an hour glass shaped sleeve or a stricture mid stomach post Sleeve Gastrectomy or Duodenal Switch.

Screen-Shot-2015-08-26-at-7.51
Screen-Shot-2015-09-26-at-9.14

In our experience, some patients have responded well with anti-reflux surgical procedures and mesh placement if indicated after a compete work up with has included and upper endoscopy, upper GI series, manometry and Ph studies.  Any patient with symptoms of reflux after weight loss surgery, should be evaluated, and a complete work up should be performed to  establish the proper treatment options. It is not wise to have patients be treated with proton pump inhibitors as a default treatment without a complete work up for any patient with reflux. These class of medications have significant side effects associated with them. Furthermore, prolonged reflux is a factor in development of Barret’s Esophagus, a pre-cancerous condition.