Anterior versus posterior slippage: two different types of eccentric pouch dilatation in patients with adjustable laparoscopic gastric banding.

PURPOSE: To describe two different types of band dislocation that may occur in morbidly obese patients following adjustable laparoscopic gastric banding (ALGB) with the LAP-BAND. MATERIALS AND METHODS: 170 morbidly obese patients were treated with an LAP-BAND at our institution. In the first 20 patients the band was positioned transbursally, which means that the lesser sac is penetrated during laparoscopic band implantation. In the following 150 patients the operation technique was changed to suprabursal band positioning where the lesser sac is not penetrated. Plain radiographs and single contrast studies of all patients who developed band instability in the follow-up were analyzed retrospectively and compared to the clinical and intraoperative findings and to the operation technique used. RESULTS: Over a time period of 3.5 years 'posterior slippage' occurred in all 20 patients with transbursal band placement, but it never occurred after suprabursal band placement. Never- theless 4 patients with suprabursal band placement presented with an eccentric pouch dilatation, secondary to 'anterior slippage' after the seromuscular stitches had burst on the anterior and superior surface of the band. All these patients presented with food intolerance and all of them had to be reoperated. The radiographic findings were pathognomonic for each type of band dislocation. CONCLUSION: Band dislocation is a known major complication that may occur following ALGB and it may present in two different forms. While 'posterior slippage' can be avoided if the band is placed suprabursally, 'anterior slippage' may still occur. It is important to be familiar with both types of band dislocation since they require early detection and surgical band replacement or band refixation.

Retroperitoneal endoscopically assisted minilaparotomy for anterior lumbar interbody fusion: technical feasibility and complications.

STUDY DESIGN: Description of a novel less invasive technique and prospective evaluation of associated morbidity and potential complications. OBJECTIVE: To investigate the feasibility of a novel endoscope-assisted retroperitoneal approach (REAM) for anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: Minimally and less invasive approaches are currently favored to perform ALIF. However, the present endoscopic techniques have not found widespread acceptance, because they are technically demanding, and microsurgical techniques are not time effective when two separate approaches are needed for L5-S1 (transperitoneal) and L4-L5 (retroperitoneal). METHODS: The authors have developed the technique of REAM, which consists of three stages: 1) endoscopic retroperitoneal mobilization of the peritoneal sac, 2) midline minilaparotomy (4-6 cm), and 3) standard open anterior lumbar interbody fusion. Twenty patients were prospectively enrolled in this study and perioperative data (i.e., blood loss, operative time, intra- and postoperative complications) were collected to assess the feasibility of this approach. RESULTS: Six single-level and 14 two-level ALIFs from L3-L4 to L5-S1 were performed with a mean operative time of 108 minutes (range, 85-150) and an average estimated blood loss of 200 mL (range, 50-500). The follow-up (range, 12-29 months) on 20 patients showed that there were no perioperative or postoperative complications related directly to this approach. CONCLUSION: Anterior lumbar interbody fusion by REAM can be performed without additional hazard to the patient and appears to be a reasonable alternative to existing less invasive procedures.

Laparoscopic reoperation for failed antireflux procedures.

BACKGROUND: Laparoscopic fundoplication has become the criterion standard for the surgical treatment of gastroesophageal reflux disease. Recently, several patients were referred with recurrent symptoms of gastroesophageal reflux disease or severe dysphagia following previous antireflux surgery for possible laparoscopic reoperation. HYPOTHESIS: To determine the safety and efficacy of this procedure. DESIGN: Case series, consecutive sample. SETTING: University-affiliated and community tertiary care hospitals. PATIENTS: Prospective study of 27 consecutive patients undergoing attempted laparoscopic reoperation for symptoms of recurrent gastroesophageal reflux disease or intractable dysphagia following antireflux surgery. Patients were available for follow-up for 1 to 60 months postoperatively. INTERVENTIONS: All patients underwent preoperative workup and attempted laparoscopic reoperation for treatment of symptoms. MAIN OUTCOME MEASURES: Data were collected on preoperative symptoms and evaluation, operative time, blood loss, time to regular diet, length of hospitalization, morbidity, mortality, and long-term results. RESULTS: Twenty-six patients underwent successful laparoscopic operations, with no mortality and minimal morbidity. One patient underwent conversion to open laparotomy and then developed a proximal gastric leak, which was treated conservatively. Twenty-four patients began a liquid diet by postoperative day 1, and most were discharged from the hospital by postoperative day 3. One patient required dilation for postoperative dysphagia. The remaining patients are doing well and none have required treatment with acid-reducing medication. CONCLUSIONS: Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with excellent results. In the hands of experienced endoscopic surgeons, patients who have undergone unsuccessful antireflux surgery should be offered laparoscopic reoperation.