Comments on: Management of slipped adjustable gastric bands

Abstract

Eating slowly and eating a small amount at each meal, about the amount of food to fill half a glass, are arguably the 2 most important responsibilities of the laparoscopic adjustable gastric banding (LAGB) patient. Eating too big a volume of food at a meal or eating quickly will inevitably stretch the pouch above the band. Doing this repeatedly will lead to one or the other of the forms of proximal enlargement. This is the most common error a LAGB patient can make, and it brings into prominence the greatest area of vulnerability of the band. The upward and outward force created by rapid or large-volume eating demonstrates the weakest link of the ring of band stabilization. In the era of the perigastric approach to LAGB placement, the posterior wall was the most mobile, and posterior slippage was common. With the change to the pars flaccida approach [1], the weakest link became the medial and lateral aspects of the anterior fixation, and a series of anterior slips became prominent. More recently, better fixation all around has meant that fewer “slips” are occurring, and we are now seeing symmetric enlargement of the stomach above the band. This primarily reflects the daily pressure of bad eating behaviors, but it can also bring to light the occult hiatal hernia, in which too much stomach was left above the band at the initial placement. Manganiello et al. [2] have described their experience with this range of problems in a consecutive series of 660 LAGB patients. Revisional surgery was needed in 34 patients (5%). This is a commendable level, well below the level we have been able to achieve [3]. Because they always used the pars flaccida approach, they missed the era of the posterior slip. They describe all the enlargements as anterior slips. Attention to completion of the anterior fixation, plus careful and repeated advice to the patients regarding the eating pattern required should allow an additional lowering of this complication. A most important technical message from this report is the inadvisability of the gastric reduction procedure. Of the 16 patients who underwent simple reduction of the slip, 11 came back for an additional revisional procedure. However, none of those who underwent removal and replacement of the band required additional revision. Because the latter procedure is, in fact, technically easier and, now, with an LAGB that can be readily opened at revision (Lap-Band, Allergan, Irvine, CA), I fully support their recommendation that this should be the first option at revisional surgery. In addition, we recommend dissection of the hiatus and distal esophagus to exclude or treat a hiatal hernia and dissection of the thickening over the esophagogastric junction to enable restoration of the satiety induction that is so critical to successful weight loss with the LAGB [4]. Any procedure we perform as a long-term solution for our bariatric patients is going to have maintenance needs for optimal effect. The need for revision of the LAGB is being reduced. This report is helpful in both identifying what could be regarded as an “acceptable” incidence and a way to approach the repair.