CASE REPORT
JMBSJournal of Metabolic and Bariatric Surgery J Metab Bariatr Surg 2015;4(1):25-28
Received: January 6, 2015, Revised: January 23, 2015, Accepted: January 30, 2015
Corresponding author: Sang-Moon Han, 566 Nonhyun-ro, Gangnam-gu, Seoul 135-913, Korea
Department of Surgery, Gangnam CHA Medical Center, School of Medicine, CHA University Tel: 82-2-3468-3369, Fax: 82-2-3468-3507, E-mail: [email protected]
Copyright © 2015, The Korean Society for Metabolic and Bariatric Surgery
Conversion Sleeve Gastrectomy for Pouch Dilatation and Band Scar Stenosis: 1 Case
Department of Surgery, Gangnam CHA Medical Center, School of Medicine, CHA University, Seoul, Korea
Ji-Sun Hong, Sang-Moon Han
Esophageal and gastric pouch dilatations are common complications that occur after laparoscopic adjustable gastric banding, often performed to treat morbid obesity. Most cases are treated by a gastric band deflation or a removal of band. Nevertheless, additional surgical procedures are rarely ever needed to treat persistent dysphagia and pouch dilatation.
We report here, the case of a 38-year-old woman with constant vomiting and severe persistent epigastric pain despite the gastric band deflation, and a band scar stenosis, treated via laparoscopic conversion sleeve gastrectomy. Surgical band scar revision, or revision sleeve gastrectomy, may be considered if gastric pouch dilation and dysphagia are not treated by gastric band deflation.
Key Words: Laparoscopic adjustable gastric banding, Pouch dilatation, Scar stenosis, Reflux esophagitis
INTRODUCTION
Laparoscopic adjustable gastric banding (LAGB) is a restrictive surgical procedure which has low morbidity and mortality rate in the immediate postoperative period along with a good weight loss [1-3]. Nevertheless, we occasionally meet long-term complications such as gastric band slippage, band erosion, and gastric pouch dilatation. Most of the esophageal and gastric pouch dilatations are treated by gastric band deflation or removal. However, if it is not treated by band deflation, additional surgical procedure is taken into consideration in order to treat the esophageal or pouch dilatation after LAGB. In this case study, we report a patient with persistent dysphagia and pouch dilatation with reflux esophagitis after band deflation, which was surgically managed.
CASE REPORT
A 38-year-old female was presented to our outpatient clinic with a history of epigastric pain, dysphagia, vomiting, and ongoing weight loss after band deflation.
This patient had undergone LAGB (LAP-BANDTM) procedure for severe obesity at a local clinic in March 2010. At the time of LAGB, her initial weight was 90 kg with a body mass index (BMI) of 35.6 kg/m2. In the postoperative period, her recorded weight was 55 kg with a BMI of 21.0 kg/m2 in May 2011, and she began experiencing repeated over-filling during this period. Because of the persistent epigastric pain and vomiting, she had undergone deflation of the band.
However, persistent dysphagia and epigastric pain were not improved, and her weight decreased to 47 kg with a BMI of 18.8 kg/m2 in April 2013. She was diagnosed with severe reflux esophagitis with pouch dilatation confirmed
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Fig. 1. The upper gastrointestinal series showing severe dilatation of the proximal gastric pouch.
Fig. 2. The gastroscopy showing severe reflux esophagitis.
Fig. 4. Postoperative upper gastrointestinal series after laparoscopic conversion sleeve gastrectomy.
Fig. 3. Fibrous band scar (white arrow).
by the upper gastrointestinal series (UGIS) and a gastroscopy (Figs. 1, 2). At that time, her general condition was normal and vital signs were stable. Laboratory tests also proved to be normal. We recommended the band removal with band scar revision. However, the patient did not agree on this treatment plan and wished to have a conversion sleeve gastrectomy instead, due to the fear of regaining the weight after the band removal. After many consultations with the patient and her husband, the laparoscopic gastric band removal with fibrous scar
revision and sleeve gastrectomy were performed in June 2013. An incision was made at the previous trocar site in the supra-umbilicus, and the tubing was disconnected. A laparoscopic procedure was performed showing a dense peri-gastric fibrosis with close adhesion to a voluminous left liver lobe. The surrounding adhesions were dissected with a hook cautery. The buckle of the band was identified and cut, and band was removed. Through the intra-operative laparoscopy, we were able to identify the stenotic area corresponding to the former gastric band (Fig.
3), and the fibrous stenotic scar was completely removed.
A 36-French bougie was used to create a long gastric tube.
A point on the greater curvature approximately 4 cm proximal to the pylorus was identified as the distal extent of the resection. The UGIS showed a significant reduction of
Ji-Sun Hong, Sang-Moon Han Conversion Sleeve Gastrectomy for Pouch Dilatation and Band Scar Stenosis: 1 Case
Journal of Metabolic and Bariatric Surgery 27
the pouch diameter on postoperative day 2 (Fig. 4). There was no morbidity in the postoperative period. Proton pump inhibitors were continued for 3 months postoperatively. Twelve months later (June 2014), her weight was 46 kg with a BMI of 18.5 kg/m2. A regular follow-up laboratory test and gastroscopy was performed 12 months later. Her results showed that an iron deficiency was not detected; the level of total protein and albumin was normal; calcium and magnesium remained within normal limits postoperatively; folate and vitamin B12 showed no deficiency. She complained of an intermittent burning sensation around the epigastric area. Mild reflux esophagitis was indicated based on the results of the gastroscopy.
DISCUSSION
The number of LAGB cases has sharply decreased due to long-term complications of the band itself (port and tubing system problems, gastric pouch dilatation, gastric band slippage and band erosion) and high re-operation rate [4-7]. However, the LAGB was a leading procedure in Korea because of the low morbidity and mortality rate to those who are considered morbidly obese [8].
Although a pouch dilatation and an esophageal dilatation after LAGB are common [9], obstruction or fibrous stenosis of the band is rare. Deflation or, no band filling was indicated for obstruction, severe intolerance to solid foods, and night aspiration. In case of esophageal dilatation or pouch dilatation, the band should be deflated to prevent esophageal dysmotility disorders or band slippage.
Especially, when dysphagia is present after the deflation of band, a band removal with or without conversion to another bariatric procedure such as a sleeve gastrectomy or gastric bypass is considered.
Kuzmak et al. [10] reported 10 serosal fibrosis and 4 serosal fibrosis with pathy fibrous replacement of the muscularis propria at the banding site in 16 cases full thickness gastric wall biopsies. During the conversion bariatric procedure because of band fibrous stenosis, serosal fibrosis at banding site has to be completely removed to recover the esophageal motility [9] and decrease the risk of a gastric leak [11,12]. In our case, the
fibrous scar was completely removed, and then a conversion sleeve gastrectomy was performed to avoid weight regain following removal of the band. If the additional bariatric procedure was not performed after the band removal, most patients reported to have weight regained [13]. Aarts et al.
[13] published that it is highly discouraged to only remove the gastric band without performing an additional bariatric procedure if it is feasible and safe. Therefore, if a patient wants to have additional procedures despite of normal weight, the patient and doctor must have frequent and sufficient conversations about further treatment options.
Naef et al. [9] published that majority of patients (68.8%) who undergo LAGB reported to have suffered from esophageal or pouch dilatation during the long-term follow-up. Especially, esophageal dilatation with stage III or IV was 25.5%. Esophageal dysmotility disorders due to an esophageal or pouch dilatation after LAGB are frequent, poorly appreciated complications [9]. In case of stage III or IV dilatation, a prompt deflation of band is needed to recover the motility of the esophagus. Furthermore, if dysphagia persists after deflation of the band, additional surgical procedure is followed by a recovery of pouch dilatation or esophageal motility.
With the increasing number of LAGB procedures being performed in Korea, the surgeon has to cope with potential complications including esophageal or pouch dilatation with fibrous stenosis. In the case of fibrous stenosis at the banding site, the bariatric surgeon should perform additional surgical procedures.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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