Journal of Minimally Invasive Surgery Vol. 15. No. 1, 2012
□ Case Report □
Simultaneous Laparoscopic Band Removal and Sleeve Gastrectomy: Case Report and Review of Literature Yoon Young Choi, M.D., Yong Jin Kim, M.D., Ph.D., Kyung Yul Hur, M.D., Ph.D. Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea More attention has been paid to bariatric surgery due to an increase in the obese population in Korea. Laparoscopic adjustable gastric banding (LAGB) is the most popular procedure for weight-loss but the complication rate may increase with time. Revision surgery is needed if there are complications or the weight is regained after LAGB, and a laparoscopic sleeve
INTRODUCTION Laparoscopic adjustable gastric banding (LAGB) is one of the most common procedures for patients who are morbidly obese. However, the complication rates of LAGB increase over 1 time, and sometimes patients need revisional surgery. The type of procedure that is appropriate in the case of revisional surgery is still controversial; however, there have been several reports that laparoscopic sleeve gastrectomy (LSG) is feasible for failed 2,3 LAGB. Recently, bariatric surgery has garnered attention in Korea, because the obese population has increased. We successfully performed band removal and LSG simultaneously in the case of failed LAGB.
CASE REPORT A 44-year-woman who underwent laparoscopic adjustable gastric banding (LAGB) at an outside institution one year prior visited our hospital because of unsatisfactory weight loss, chest discomfort, and dysphagia during eating. Since there was no band related problem (Fig. 1A, B), we removed the saline (9.5 ml), and the patient consulted a psychologist and nutritionist to maintain a suitable diet for two months. However, after such efforts, the patient still regained weight (nearly returning to her 2 original weight of 90 kg, 35.6 kg/m ). The patient was not
Received January 6, 2011, Revised 1st, June 13, 2011; 2nd, October 4, 2011, Accepted October 17, 2011 ※ Corresponding author：Yong Jin Kim Department of Surgery, Soonchunhyang University Hospital, Hannamdong, Yongsan-gu, Seoul 140-743, Korea Tel：+82-2-709-9479, Fax: +82-2-795-1687 E-mail：
[email protected]
gastrectomy could be performed in the case of band failure. Successful band removal and sleeve gastrectomy wereperformed simultaneously without complications. Key words: Sleeve gastrectomy, Morbid obesity, Laparoscopic adjustable gastric banding
tolerable for sounds of gulp while she is eating, so she refused the regular filling, and consequently had an arthritis symptom because of obesity. Finally, we decided to perform simultaneous removal of the band and laparoscopic sleeve gastrectomy (LSG). After identifying the gastric band, we dissected the peri-buckle area and mobilized the band using 5 trocar technique (Fig. 2A∼ D). After band removal, we performed LSG (Fig. 2E) using the 4 same method that we previously reported. After clearly identifying that the previous gastro-gastric suturing had been removed and the pseudomembrane that was located around the band. Once the band was successfully removed and the angle of His identified, LSG was performed with careful dissection of that area to avoid esophageal injury. The upper gastrointestinal series, which was performed with water absorbable contrast (Gastrographin), on the first postoperative day (POD) showed no signs of leakage. The patient’s diet was advanced, and she was discharged on POD 2 without any complications. At her six-month follow up visit, the patient was doing well, with 15 kg reduction in her weight.
DISCUSSION As the rate of global obesity has accelerated, the spotlight on bariatric surgery has expanded to countries worldwide, including Korea. According to Buchwald and Oien’s report,1 LAGB is one of the most commonly (42.3%) performed procedures for morbid obesity, and its rate in the Asia/Pacific area is 80%. Those statistics are understandable, because LAGB is safe and easy to perform, with very low morbidity and 5 almost nonexistent mortality. However, LAGB is also known as a procedure with failure and complication rates that increase 5 with time, so sometimes revision is required. The most
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
24 Journal of Minimally Invasive Surgery Vol. 15. No. 1, 2012
Fig. 1. Well placed Swedish band on CT scan (A) and upper gastrointestinal series (B).
Fig. 2. Operative findings and postoperative upper gastrointestinal series. (A) Trocar placement and subcutaneous port was removed through umbilical port site (white arrow). (B) Swedish band was placed in correct position. (C) Swedish band was removed from the stomach after cut the buckle. (D) Gastro-gastro suture site for band fixation was released. (E) Sleeve gastrectomy with staple line reinforcement was done as usual. (F) Postoperative upper gastrointestinal series showed well tabularized structure and no leakage.
common cause of revision is failure of weight loss,6 and the type of procedure for revisional surgery varies. It is still controversial what type of operation is suitable for failed LAGB. If the cause of revision has been failure of weight loss,
malabsorptional surgery such as Rouxen-Y gastric bypass may be more suitable. However, if the cause is maladjustment, as in this case, LSG could be a treatment choice. LSG was originally considered to be a bridge procedure for
Yoon Young Choi et al.: Sleeve Gastrectomy as a Revisional Procedure
biliopancreatic diversion or duodenal switch. However, its early outcomes were acceptable,7 and since LSG is one of the easiest and quickest of all bariatric procedures to perform, it has become a stand alone bariatric procedure. Basically, LSG is a restrictive surgery, but it also works by other, hormonal mechanisms, such as a decrease in the plasma levels of ghrelin, 8 which regulates the feeling of hunger. While revisional surgery is technically more difficult and associated with higher morbidity and mortality compared to a 1 primary procedure because of altered anatomy and scar tissue, there have been several reports on LSG as a revisional surgery 3,8,9 Although they contained only short term for failed LAGB. follow up outcomes, LSG was shown to be a safe and effective 2,3 procedure to revise failed LAGB. There is still controversy surrounding the performance of an interval LSG versus doing LSG with band removal simultaneously, and there have been no clear data comparing the 1 procedures. One author had an interval before performing 3 2 LSG ; another performed it simultaneously with band removal. 10 Abu-Abeid et al. reported that if there is no serious infection, it is feasible and safe to do laparoscopic band removal and replacement simultaneously. However, the most common site of leak after LSG is the esophagogastric junction, and that site is also the location where the band was originally positioned. Hence, if there is inflammation or infection, delaying LSG after band removal and until inflammation has subsided might be a better choice than performing LSG with band removal simultaneously. In our case, the patient had no band complications and no inflammation, so it was possible to successfully perform band removal and LSG at the same time. To our knowledge, this is the first report of simultaneous band removal and LSG performed in Korea. Although more studies are needed to figure out its feasibility in the long term, LSG is a suitable revisional procedure for failed LAGB.
25
REFERENCES 1) Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2008. Obes Surg 2009;19:1605-1611. 2) Iannelli A, Dainese R, Piche T, Facchiano E, Gugenheim J. Laparoscopic sleeve gastrectomy for morbid obesity. World J Gastroenterol 2008;14:821-827. 3) Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ. Safety and short term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg 2009;19:1612-1616. 4) No JH, Kim ZS, Kim YJ, Cho SW, Choi DH, Hur KY, et al. Initial experience of laparoscopic sleeve gastrectomy in morbidly obese patients. J Korean Surg Soc 2010;79:460-466. 5) Suter M, Calmes JM, Paroz A, Giusti V. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates. Obes Surg 2006;16: 829-835. 6) Patel S, Eckstein J, Acholonu E, Abu-Jaish W, Szomstein S, Rosenthal RJ. Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis 2010;6:391-398. 7) Menenakos E, Stamou KM, Albanopoulos K, Papailiou J, Theodorou D, Leandros E. Laparoscopic sleeve gastrectomy performed with intent to treat morbid obesity: a prospective single-center study of 261 patients with a median follow-up of 1 year. Obes Surg 2010;20:276-282. 8) Iannelli A, Schneck AS, Ragot E, Liagre A, Anduze Y, Msika S, et al. Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty. Obes Surg 2009;19:1216-1220. 9) Frezza EE, Jaramillo-de la Torre EJ, Calleja Enriquez C, Gee L, Wachtel MS, Lopez Corvala JA. Laparoscopic sleeve gastrectomy after gastric banding removal: a feasibility study. Surgical Innovation 2009;16:68-72. 10) Abu-Abeid S, Zohar DB, Sagie B, Klausner J. Treatment of intra-gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replacement. Obes Surg 2005;15:849-852.
