jeff w. allen md, facs norton surgical specialists louisville, ky
TRANSCRIPT
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Jeff W. Allen MD, FACSNorton Surgical Specialists
Louisville, KY
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ComplicationsCommon
Anterior prolapseConcentric dilation
Port Problems
Uncommon
Posterior Prolapse
ErosionRemovalsManagement / failure
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Posterior Gastric ProlapseSeen almost exclusively with perigastric approachTrial/patients from foreign medical centersUnusual condition where perigastric technique is used (n=4 for my experience)
May be seen in pars flaccida technique, especially if a very generous retrogastric dissection is performed
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Posterior Gastric Prolapse
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Posterior Gastric Prolapse
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Management of Posterior ProlapseTake down plication
Transect band (unless band designed to be opened)
New pars flaccida tunnel
New Band
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Unusual Band Complications54 year old woman with an initial bmi of 48 kg/m2
Excellent weight loss over 2 years to a BMI of 29 kg/m2
Develops latent port infection 6 weeks after an outpatient band adjustment
EGD performed by surgeon- no erosion Good visualization of band in retroflexed position
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Unusual Band ComplicationsNo response to antibiotics
Port removed
? Laparoscopy at time of port removal? Repeat endoscopy?UGI
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Tubing ErosionUnless in proximal jejunum, may not be seen on endoscopy
Generally requires laparoscopy to identify
Management= band removal +/- staged band replacement
Etiology puzzling and unclear
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“Ascending Erosion”Common dogma that an infected port is the harbinger of an eroded band
Provost first identified the possibility that a port infection can cause total band infection/abscess and eventual erosion
Diagnosis made by laparoscopy after EGD negative
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Latent port infectionTreat with anbiotics initiallyRemove port/EGDIf negative, consider eroded tubing, contaminated adjustment, additional septic source (infected hernia mesh) and “ascending erosion”
Laparoscopy to diagnose
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Explants Subhepatic abscessesSubphrenic ObstructionsDilationsProlapses ErosionExcessive weight loss HIV conversionPerforated ulcer 6 months after placement
Inadequate weight loss- patient choice
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Port Complications: Leakage6 patients
Inadequate weight lossNo aspirate on port access
All at the port/tubing interface
No diagnostic studies performed, only operative intervention
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Port Complications: Pain3 patients
Injections offered temporary relief in all
Operative replacement relieved pain in all three
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Should I take the band out?Other intra-abdominal problems such as appendicitis, diverticulitis, ovarian torsion
Decided on a case by case basis
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O.P.I.EO: Overall health of the patient
30 year old now with a BMI of 22 and no co-morbidities 66 year old lost 18 pounds with band, BMI 55 kg/m2 and
NIDDM and COPD
P: Proximity to the band Non-ruptured appendicitis Perforated ulcer
I: Infectious agent Transverse colon flora from perforation Skin flora (from a stab wound)
E: Exposure 6 days after failed conservative management of diverticulitis
6 hours after diagnosis of ovarian torsion
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Managing the plateau patient
• Make sure it is the patient with the problem– Ensure a closed system– No leaks– Adjuster is hitting the port
• Patient understands program• No undiagnosed psychopathology/sabotage• Identify what may have changed when the plateau began– Less exercise– New medications, especially anti- depressants
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Band ProblemsLeak in the system
At the portAt the bandIn the tubingSlow leak
ErosionErroneous placement of the band initiallyUnbuckling of the band
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Leak in the System?Fill the band half full with certainty
Use fluoro if necessaryRe-check in 1-2 weeks
All fluid should still be thereIf all- not a leakIf none-need surgical repairIf significantly decreased
Measurement error or Slow leak
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Repairing a LeakLocalize vs Non-LocalizeTo localize use x-ray and a small amount of dilute gastrograffin OR methylene blue
I prefer not to localize Can be misleading Still need an operation Use general anesthesia anyway Commonly a needle stick or kink in tubing
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Worried about band-no leakVideo Esophagram- with pre and post-injection shots
EGD to evaluate for erosion
Laparoscopy to check for unbuckling, erroneous placement (use calibration tube)
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Video54 year old woman, initial BMI 44 kg/m2
Excellent initial weight loss
Plateau 6 months outAll fluid (9/10 cc) still in bandNo erosionNo indentation on EGD or UGI with 9 cc in
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Vitamin Deficiencies after BandVitamin DProtein deficiencyVitamin CVitamin B12
All are usually a combination of maladaptive eating and lack of supplements