Intragastric migration of a laparoscopic band

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Intragastric   migration   of   a   laparoscopic   band

Authors
JM Zimmermann, D Fölscher
Mots-clés
operation,morbid obesity,gastric band,laparoscopy
Type de vidéo
Durée
15'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1117e.htm

Intragastric   migration   of   a   laparoscopic   band

1. Case presentation 00'13''
This is a 28-year-old man who had a gastroplasty performed 2 years ago according to the original technique with the Megan band. The postoperative course was complicated by an absence of weight loss despite maximal band adjustment. The patient then left the country to Germany and was lost to follow-up for some period. He returned after diagnosis of band migration through the anterior wall of the stomach was made in Germany. This was illustrated radiologically by the passage of contrast between the gastric wall and the band, suggesting that the anterior portion of the band was intragastric. During flexible endoscopy, the band is visible inside the lumen of the stomach entering through the gastric wall. Currently, the patient has a BMI of 35 compared to a BMI of 52 at the initial surgery. Therefore, we will only remove the band and not perform any other procedure at this stage. If needed, further obesity surgery can be considered in 2 to 3 months’ time. We begin by placing the ports in the same position as previously using an open technique. One port is placed left laterally in the same position and I’ll put another one here for the grasper on the right. We’ll see it later if we do need a liver retractor after inspection of the peritoneal cavity. Adhesions around the liver may make a retractor unnecessary. I think we’ll put a liver retractor in this case. I’ve now seen the anterior wall of the stomach. I know the band is here because I see the adhesions. We will free this part of the stomach to open it here but we need a bit of space first. There was a question if there are more or less adhesions than previous operations I did for migration. This is less here. I think it may depend on how much of a leak occurs during the actual migration. During the dissection, I’ll try and describe the typical clinical presentation of a band migration. Typically, these patients return to the hospital after full inflation of the band but they are still or again able to eat a full meal and they do not lose any weight. Thereafter, the radiological investigation will confirm the suspicion as in this case. If the radiologists do not see the migration on normal anteroposterior views, ask for oblique pictures, which show the band position and the contrast passing below the band. Therefore, the patients who can again eat a full meal after band adjustment need complete radiological investigation. We do flexible endoscopy only after the radiology and with low air inflation pressure so as not to open up the adhesions around the perforation. This allows us to confirm that the band is indeed visible inside the gastric lumen. I will now cut the catheter. It is important to remember to cut below this wider part as the easy communication of the gastric lumen and one does not want to enlarge the hole already present by pulling through this big part. One tries not to dissect all these adhesions as they will be useful later or rather I’ll attempt to find the band inside the stomach. The band is here and I will therefore open the stomach just below the band position. Why does one not perform more dissection higher up? Yes, I feel the band in the stomach, although it’s not in there completely, the posterior part not, but this is what I will do; For part of the band to be in the stomach, there are 2 holes in the gastric wall. They are fragile but at present they are sealed. If one frees all the adhesions, one will end up with 2 holes in the gastric wall but if one pulls out the band carefully through an incision in the stomach wall, the perforations will seal off and 2 or 3 days from now, all will be normal. In the worst case, the patient can have an abscess. If I free all these adhesions, I will definitely have to close 2 holes in the stomach wall, which can be difficult in this tissue, which is often fragile and inflamed. There is a question if I open the stomach just below the band, that’s it. I go at this site but not too low, then it’s again difficult to catch the band inside the lumen of the stomach. There’s something here. It’s difficult to decide if it’s the nasogastric tube or the band. Yes, here’s the band coming through the posterior wall of the stomach and it will now need to be cut. Here’s the band visible. I try both sides to see which way is the easiest and the smoothest to remove the band. It is a bit stuck by adhesions. We can now see it going through the gastric wall. This is a good instrument to grip the ring with. The gastrotomy is about the length of an open forceps. It’s not very big at all. This forceps is about 1.5cm when open so the gastrotomy is about 2 maximum 3cm. Not very big but it allows adequate maneuvering inside the gastric lumen. If you agree, we will now do a methylene blue test to check that there is no leak. Methylene blue is injected. It looks good. I can see no leak. We are now going to remove the catheter at the same time as the reservoir but we obviously have to ensure that this tube is free to remove it easily and smoothly. There is a question if I’m happy if there’s no leak. Yes, I am very happy. Not a problem at all. So just to recap: I think this can be a troublesome procedure. For me, the removal of a migrated gastric band is an extremely difficult procedure and it worries me when I go to conferences and hear people saying it’s easy. You just do it so and so. Migration and removal can be easy in 4 out of 5% of cases but be careful, it can be a very difficult procedure to dissect and free the band when there’s dilatation of the gastric pouch. If you have to completely dissect the stomach away from the liver, it can be difficult as there’s no easy plane of cleavage between the stomach and the liver. Therefore, when one sees the thin stomach wall after band inflation, it’s very easy to enter the stomach with only one cut of the scissors. Therefore, for me re-intervention is a very difficult procedure.