Lap band complications

Background

• Laparoscopic adjustable gastric banding
• Band placed at gastroesophageal junction and inflated to limit food passage
• Band constriction adjustable via reservoir
• Subcutaneous reservoir (~5ml port site) allows adjustment without invasive intervention
• Postoperative complications near 10% over lifetime of patient
• Patients typically discharged same day or POD #1

Clinical Features

• Abdominal, chest or neck/throat pain
• Nausea/vomiting, food intolerance
• Sepsis, abnormal vitals

Differential Diagnosis

Early

At or near time of banding or adjustment of band

• Acute gastroesophageal obstruction - postop edema at application site forces proximal movement of the band, get KUB
• Intra-abdominal bleeding
• Perforated viscus
  • Esophageal pouch dilation – pain, vomiting, nausea

Late

Weeks to years after adjustment or application

• Chronic Slippage
  • herniation of stomach through band
  • can occur long after surgery
  • may progress to gastric necrosis and perforation
• Gastric Erosion
  • Band can erode through the full thickness of the gastric wall 
  • can present as a port site infection, gastrocutaneous fistula or intra-abdominal sepsis
• Port Complications
  • primary overlying skin infection may represent extension of intra-abdominal process
  • need antibiotic coverage for intra-abdominal and skin flora
• Tubing Dislodgement
• Port Ulceration

Evaluation

• Lab workup dictated by presentation
• Obtain an upright KUB to assess band position & slippage
  • Phi (φ) angle- Angle between a vertical line oriented through the spine and a second line running on the long axis of the lap band
  • Normal is 4-58 degrees
• Swallow Study under fluoroscopy to assess for gastro-esophageal obstruction
• CT Abd/Pelvis to assess for perforation (contained or free), abscess, intra-abdominal fluid or bleeding
• Endoscopy – visualize inner lumen of esophagus and stomach for partial or full erosion

Management

• Early surgical consultation key for all patients suspected of having complications
• Intra-abdominal sepsis management (fluids, antibiotics)
• Remember to dose antibiotics for morbid obesity if necessary
• Consider deflating band via port site if impending gastric necrosis due to edema/recent band inflation

Disposition

• Admit for:
  • Band slippage with obstruction or inability to tolerate liquids
  • Band erosion (requires surgical removal)
  • Peritonitis or signs of perforation
  • Severe dehydration from prolonged vomiting
• Discharge with surgical follow-up for:
  • Mild port-site complications
  • Resolved obstructive symptoms after band adjustment
  • Mild reflux symptoms

See Also

• Bariatric surgery complications
• Medical device complications