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Side Effects Laparoscopic Adjustable Gastric Banding

 

 
 

Conditions and benefits :

Abstract Literature data concerning the effect of laparo-scopic adjustable gastric banding (LAGS) on esophageal motility are conflicting. Achalasia-like disorder involving the absence of esophageal peristalsis and impaired esophago-gastric junction (EG)) is probably under-estimated and can result in failure and band removal. The aim of our study was to focus on cases of achalasia-like disorder and study its evolution after band deflating or removal. LAGS patients with food intolerance and whose esophageal manometry confirmed dysmotility were selected from our database. Achalasia-like disorder was defined as the absence of esophageal peristalsis (< 20% contraction waves) with impairment of E01 relaxation. Manometric control was performed after removal or band deflating; functional results were assessed. Eleven patients among 20 (55%) with esophageal motility disorders (EMD) fitted the manometric criteria of achalasia-like disorder with a mean £01 resting pressure of 32.1 cmH20 and a E01 relaxation pressure of 24.2. Nine patients out of II under¬went band removal which resulted in the resolution of their
symptoms. The other two underwent band deflation. Man-ometric control after band removal showed both a decrease in resting and relaxation EGJ pressures (mean of 9.5 and 6.5 cmH20) and a recovery of wave contractions in 87.5% of cases. Four patients underwent revision surgery due to weight regain with a successful outcome. Achalasia-like disorder is a manometric diagnosis and accounts for a sig-nificant part of symptomatic EMD after LAGB. It often results in band removal, allowing some reversibility of the disorders.


Fly2india4Health - Side Effects Adjustable Gastric BandingIntroduction

Obesity has now become a real public health problem in most western countries, affecting 90 million Americans and nearly 14% of French. At the same time, surgical management of obesity has considerably increased with laparoseopic adjustable gastric banding (LAGS) which is the most commonly performed procedure in the world. Several studies have demonstrated its efficiency in terms of weight loss with the advantage of being reversible and of having a low morbi•monality rate.

However, dysphagia and severe vomiting are among its complications and can reveal esophageal motility disorders (EMD). Conflicting data can be found in the literature concerning the effect of LAGS on esophageal motility, making It difficult to assess and classify these second-ary motility disorders. Achalasia•like disorder is the most severe of these disorders: the diagnosis made on the basis of the symptoms is confirmed by the esophageal manometry

showing the absence of peristalsis associated with impaired esophago-gastric junction (ECU) relaxation. Al ¬though it is considered rare (1.9% of LAGB in the literature), achalasia-like disorder is probably under-estimated and must not be overlooked since it generally results in failure and removal of the band.


The purpose of our study was to assess the prevalence of achalasialike disorder among EMD, to study the evolution of this motility disorder after deflating or removal of the band and to assess the other surgical options for these patients who were still obese after band failure.

Patients and Methods
Population

SIDE-EFFECTS-ADJUSTABLE-GASTRIC-BANDING-VomitingWe conducted a retrospective review of our collected data on obese patients with a LAGB who suffered from food intoler¬ance (dysphagia, vomiting) and whose esophageal manometry confirmed the presence of EMD. Between January 2000 and October 2008, 359 patients benefited from a LAGB in our came. Twenty patients suffered from food intolerance with EMI) at manometry: 18 females and two malts operated on either in our centre or referred secondarily to us for failure or band intolerance. The bands were placed using pars flaccida technique and were fixed. The mean age was 38.2 years (range 19-55). and the mean preoperative body mass index (BM!) was 34.5 kg/m2 (range 33.6-54.7).

Diagnosis
All the patients underwent esophageal manometry after LAGS, which confirmed the presence of EMD. The diag-nosis of achalasia-like disorder was made when there was less than 20% of contraction waves propagated in the esoph-ageal body, more or less associated with impaired relaxation of the esophagolastric junction (EGJ resting pressure >40 cmH20, residual pressure >7 cmH20) VOL
Diagnosis was made with conventional waterperfused manometry (catheter with five pressure recording sites; Medtronic, Stockholm, Suede) in 11 out of 20 patients or with high-resolution manometry (HRM; Manoseanni, Given Imaging, Los Angeles, CA, USA) in the nine other patients. Studies were performed in the fasting state. The manometric probe was inserted transnasally in a supine patient and positioned to record from the hypopharynx to the proximal stomach. ECU resting and relaxation pressures were evaluated. Eat consisted of LES and crural diaphragm. In some patients, aural diaphragm and band were superimposed; consequently, it was not possible to differentiate pressure due to the aural diaphragm from pressure due to the band in these patients.

A gastrografin esophagram was systematically performed to ensure correct band placement, absence of complications (to rule out slippage, pouch dilatation) and assess the repercussions on the esophagus (dilatation, stasis). The esophagus was considered as dilated when its diameter was more than 35 mm according to Dargent and Naef. Dargent's radiological classification was used: stage I characterised moderate dilatation with delayed emptying, stage II for hypercontracting esophagus, stage III for significant dilatation and stage IV for major achlasia-like dilatation or megaesophagus Gastroscopy was also per-formed to detect any sign of esophagitis, ulcer or

     
 
 
 

Gastric Sleeve (Obesity Surgery) Patient

 
 
Elizabeth, Dallas
 

brachyesophagus.

Management and Follow-up
A manometric control was performed at 2 months after
deflating or removal of the band. The outcome was assessed
in terms of weight loss and requirement for revision surgery.

Results
Clinical Signs and Manometric Findings After LAGB
Eleven patients out of 20 (55%) fitted the manometric criteria of achalasia-like disorder with less than 20% of contraction waves propagated in the esophageal body. The other motility disorders were impaired EGJ relaxa¬tion with more than 20% of oesophageal contractions (n=6) and normal EGJ relaxation associated with hypo-peristalsis (n=3).
Among the 11 patients with achalasia-like disorder (ten females, one male), the mean age was 37.5 years at time of LAGB (range: 19-55) and the mean preoperative BMI was 43.7 kg/m2 (range 33.6-54.7). Nine patients out of 11(82%) had several band inflatings, two patients (3 and 9) had no band inflating because of early food intolerance (at 5 months and at I month) associated with a significant weight loss (-33 and -57 kg). The mean weight loss was 39.5 kg (median 38.5, range 13-62). Patient details are summarized in Table I.

The mean length of time prior to the onset of food intolerance was 36.5 months (median 19.5, range 1-96): there was 68.5% of dysphasia, 85% of regurgitation and/ or vomiting and 31.5% of heartburn. Diagnostic manometry was performed postoperatively in a mean interval of 51 months (range 5-96), that is. 14.5 months on average after the onset of symptoms. Among the II patients, seven had HRM. Crural diaphragm and band were superimposed in four of these patients and two high pressure zones (corresponding to crural diaphragm and band respectively) were identified in the three remaining patients.

Risks

Gastric Bypass is a major operation, and carries with it hazards of major surgery in general. These risks are usually increased in the obese patient.

Before deciding whether to have surgery it is important for you to know that the potential complications include:

     
Wound infection   2%
     
Leaks or perforations causing internal infection
  Less than 1%
     
Opening later proves to be too small or too large
  Less than 1%
     
Death   0.3%
 
 
 

 

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Side Effects Adjustable Gastric Banding