A 13-year journey of a gastric band - ultimate destination terminal jejunum: a case report.

BACKGROUND: Laparoscopic adjustable gastric banding has been the gold standard for surgical management of obesity over the last decades in USA and Europe. However, significant complications have been documented due to foreign body placement, including band erosions. Our treatment approach for erosions is rather observant with regular follow-up until the band has sufficiently perforated the gastric wall which facilitates endoscopic removal. Consequences of a not followed-up band erosion may present even after a long time following initial diagnosis with more severe complications. CASE PRESENTATION: A 51-year-old Caucasian woman presented to our out-patients' clinic with a 2-week history of worsening abdominal pain in her left upper quadrant, exacerbated by abdominal flexion and extension maneuvers. Here we describe a case involving gastric penetration and subsequent downward migration of a band into distal jejunum causing small bowel obstruction, which occurred more than 10 years following initial diagnosis of erosion. The perforation was missed due to cessation of endoscopic follow-up. CONCLUSION: Prospective and long-term follow-up is mandatory in those with partial band erosion to avoid further complications.

Piggyback or Cava Replacement: Which Implantation Technique Protects Liver Recipients From Acute Kidney Injury and Complications?

The cava-preserving piggyback (PB) technique requires only partial cava clamping during the anhepatic phase in liver transplantation (LT) and, therefore, maintains venous return and may hemodynamically stabilize the recipient. Hence, it is an ongoing debate whether PB implantation is more protective from acute kidney injury (AKI) after LT when compared with a classic cava replacement (CR) technique. The aim of this study was to assess the rate of AKI and other complications after LT comparing both transplant techniques without the use of venovenous bypass. We retrospectively analyzed the adult donation after brain death LT cohort between 2008 and 2016 at our center. Liver and kidney function and general outcomes including complications were assessed. Overall 378 transplantations were analyzed, of which 177 (46.8%) were performed as PB and 201 (53.2%) as CR technique. AKI occurred equally often in both groups. Transient renal replacement therapy was required in 22.6% and 22.4% comparing the PB and CR techniques (P = 0.81). Further outcome parameters including the complication rate were similar in both cohorts. Five-year graft and patient survival were comparable between the groups with 81% and 85%, respectively (P = 0.48; P = 0.58). In conclusion, both liver implantation techniques are equal in terms of kidney function and overall complications following LT.

Hand-assisted living-donor nephrectomy: a retrospective comparison of two techniques.

BACKGROUND: Living-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function. METHOD: Retrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients. RESULTS: There was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function. CONCLUSIONS: Both techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

Long-term outcomes of gastric band removal without additional bariatric surgery.

OBJECTIVE: The outcomes of patients undergoing band removal alone without an additional bariatric procedure after laparoscopic gastric banding are not well reported. We seek to close this gap in the literature. SETTING: Cantonal Hospital & University Teaching Hospital, Switzerland METHODS: In this retrospective study, we investigated 21 patients who underwent band removal with a mean follow-up of 63 months. Weight regain, co-morbidities, and quality of life were assessed. RESULTS: The laparoscopic gastric bandings were implanted at a mean initial body mass index (BMI) of 44.6 kg/m2. The bands remained in situ for an average of 87.7 months (range: 14-185 mo). The reasons for band removal included band slippage in 9 cases (42.9%), band penetration in 6 cases (28.6%), leakage, port infection, and patient request in 2 cases (9.5% each). The average BMI at the time of band removal was 34.9 kg/m2. At 62.9 months after band removal, patients regained an average of 17.3 kg and attained a mean BMI of 41.0 kg/m2. Co-morbidities such as type 2 diabetes, arterial hypertension, obstructive sleep apnea, and psychiatric disorders worsened during the follow-up period. Thirteen of 21 patients rated their quality of life as bad, 5 as mediocre, and only 3 as good. Only 2 patients said they would undergo a gastric banding procedure again. The patients achieved an average of-.6 points on the Moorehead-Ardelt quality of life score, which indicates a fair quality of life. CONCLUSION: This study finds that reversal of gastric banding procedures with removal of the banding system alone leads to weight regain, deterioration of physical and psychiatric co-morbidities, and low quality of life scores.

How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery.

OBJECTIVE: Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed. METHODS: This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references. RESULTS: The patients in the study group were significantly heavier than those in the reference group (165 vs. 127 kg, p < 0.001), with 79 % having a BMI >50 kg/m(2). The patients lost a median of 11 kg after 2 months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m(2). All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034). CONCLUSION: The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10 % excess weight reduction before accepting superobese patients (BMI >50 kg/m(2)) for surgery at our hospital.

Long-Term Follow-Up of Gastric Banding 10 Years and Beyond.

BACKGROUND: This investigation assessed the long-term outcome of patients with gastric banding implanted more than 10 years ago. METHODS: A total of 73 patients undergoing laparoscopic gastric banding between 1997 and 2003 were identified. Patients who had their band removed were converted to a laparoscopic gastric bypass procedure. RESULTS: The mean preoperative body mass index (BMI) was 44.4 (SD 5.3). The mean follow-up was 11.6 (SD 2.1) years. The reasons for reoperation were leakage (N = 16, 21.9 %), slipping (N = 15, 20.5 %), and insufficient weight loss (N = 9, 12.3 %). The band was left in situ in 33 patients (45.2 %). The 5- and 10-year survival rates for the banding were 82.2 % (95 %CI 73.9-91.5 %) and 53.4 % (95 %CI 43.1-66.2 %). Best results were observed in male patients (10-year survival rate 76.5 %, 95 %CI 58.7-99.5 %, HR = 0.44, P = 0.043) and patients older than 50 years (10-year survival rate 63.8 %, 95 %CI 51.5-79.2 %, HR = 0.41, P = 0.006). Overall, the BMI was 31.0 (SD 6.3) at follow-up, excess weight loss was 68.1 % (SD 26.4), and the score for the Moorehead-Ardelt Questionnaire was 1.6 (SD 1.0). Similar results were obtained for patients with and without banding failure. CONCLUSION: The present investigation provides evidence that gastric banding remains effective after more than 10 years in less than 50 % of initially operated patients. Older (>50 years) and male patients seemed to maintain the banding as long-time carriers with good results, and these patients subjectively profited from this method. Good results can be achieved if patients are followed thoroughly, and alternative surgical options for patients who fail may be offered with longstanding success.