Lap band complications: Difference between revisions

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==Background==
=== This page contains the following errors: ===
*Laparoscopic adjustable gastric banding
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*Band placed at gastroesophageal junction and inflated to limit food passage
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*Band constriction adjustable via reservoir
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*Subcutaneous reservoir (~5ml port site) allows adjustment without invasive intervention
'''Complications of Lap Band Surgery'''
*Postoperative complications near 10% over lifetime of patient
*Patients typically discharged same day or POD #1


<u>'''1. Background <br/>'''</u>
==Clinical Features==
*[[abdominal pain|Abdominal]], [[chest pain|chest]] or [[neck pain|neck]]/[[sore throat|throat pain]]
*[[Nausea/vomiting]], food intolerance
*[[Sepsis]], abnormal vitals


<u>'''2. Presentation <br/>'''</u>
==Differential Diagnosis==
 
===Early===
<u>'''3. Complications - early and late<br/>'''</u>
''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  
<u>'''&nbsp;4. Workup <br/>'''</u>
 
<u>'''5. Disposition'''</u
 
'''1. Background<br/>'''
 
- laparoscopic adjustable gastric banding
 
- band placed at GE 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
 
<br/>'''2. Presentation'''
 
- abdominal, chest or neck/throat pain
 
- nausea, vomiting, food intolerance
 
- sepsis, abdnormal vitals
 
'''3. Complications'''
 
a. 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  
*Intra-abdominal bleeding  
*Perforated viscus Esophageal pouch dilation – pain, vomiting, nausea
*Perforated viscus  
**Esophageal pouch dilation – pain, vomiting, nausea


b. Late  
===Late===
 
''Weeks to years after adjustment or application''
*Chronic Slippage - weeks to years after adjustment or application
*Chronic Slippage
 
**herniation of stomach through band  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - herniation of stomach through band
**can occur long after surgery  
 
**may progress to gastric necrosis and perforation  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - can occur long after surgery  
*Gastric Erosion  
 
**Band can erode through the full thickness of the gastric wall&nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - may progress to gastric necrosis and perforation
**can present as a port site infection, gastrocutaneous fistula or intra-abdominal sepsis  
 
*Port Complications  
*Gastric Erosion - band can erode through the full thickness of the gastric wall&nbsp;
**primary overlying skin infection may represent extension of intra-abdominal process
 
**need antibiotic coverage for intra-abdominal and skin flora  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - can present as a port site infection, gastrocutaneous fistula or intra-abdominal sepsis
*Tubing Dislodgement
 
*Port Complications - primary overlying skin infection may represent extension of intra-abdominal process
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - need abx coverage for intra-abd and skin flora
 
*Tubing Dislodgement&nbsp;
*Port Ulceration
*Port Ulceration


'''4. Workup'''
==Evaluation==
 
*Lab workup dictated by presentation  
Lab w/u 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
KUB-upright to assess band position & slippage
**Normal is 4-58 degrees
 
*Swallow Study under fluoroscopy to assess for gastro-esophageal obstruction  
&nbsp; &nbsp; &nbsp; &nbsp; - nl 30-45 deg to the horizontal (~2 o'clock)
*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
Swallow Study under fluoroscopy to assess for gastro-esophageal obstruction  
 
CT AP 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  
 
'''5. Treatment <br/>'''
 
- early surgical consultation key for all patients suspected of having complications
 
- intra-abdominal sepsis EGDT, antibiotics
 
- remember to dose antibiotics for morbidly obese as neccesary
 
- if impending gastric necrosis due to edema/recent band inflation
 
can deflate band via port site,&nbsp;otherwise wait for surgeon
 


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


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==See Also==
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*[[Bariatric surgery complications]]
''Ann Emerg Med. 2006;47:160-166., Tintinalli''
*[[Medical device complications]]


==References==
<references/>


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[[Category:GI]]
[[Category:Surgery]]

Latest revision as of 15:15, 24 April 2022

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

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

See Also

References

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