Overview
Definition:
Band removal and conversion to sleeve gastrectomy is a surgical procedure undertaken when a laparoscopic adjustable gastric band (LAGB) has failed, caused complications, or is no longer desired by the patient
It involves the complete explantation of the gastric band and subsequent creation of a vertical sleeve gastrectomy.
Epidemiology:
While gastric banding was once a popular bariatric procedure, its declining use means fewer primary band placements
However, a significant number of patients who had banding in the past are now presenting for revision surgery due to insufficient weight loss, band-related complications (slippage, erosion, obstruction), or patient preference for a more effective procedure
Conversion rates from band to sleeve vary but are substantial among revision bariatric surgeries.
Clinical Significance:
This conversion is critical for managing patients who have not achieved satisfactory outcomes or have suffered complications from gastric banding
It offers a pathway to improved weight loss and resolution of comorbidities, while addressing the sequelae of the failed band
Understanding the indications, surgical technique, and potential complications is vital for bariatric surgeons preparing for DNB and NEET SS examinations, as this represents a common and complex revision scenario.
Indications
Insufficient Weight Loss:
Failure to achieve or maintain at least 50% excess weight loss after 18-24 months
Persistent obesity-related comorbidities despite significant weight loss.
Complications Of LAGB:
Gastric band slippage, erosion into the gastric lumen, pouch distension or dilation, esophageal dilation or stasis, port infection or extrusion, band intolerance, or mechanical failure of the device.
Patient Preference:
Patient dissatisfaction with the quality of life post-LAGB, desire for a more definitive weight loss procedure, or resolution of psychological distress associated with the band.
Radiological Findings:
Evidence of band malposition, significant pouch dilatation, or obstruction on barium swallow or CT scan.
Preoperative Preparation
Detailed Patient History:
Thorough review of previous bariatric history, band adjustments, complications, and weight loss trajectory
Assess for comorbid conditions and current medications.
Nutritional Assessment:
Evaluate for potential nutritional deficiencies common after prolonged band use, such as iron or vitamin B12 deficiency
Initiate supplementation as needed.
Endoscopy:
Upper gastrointestinal endoscopy is crucial to assess the integrity of the stomach, rule out band erosion, pouch dilatation, stasis, or other intrinsic gastric pathology prior to band removal and conversion.
Imaging:
Barium swallow may be performed to evaluate gastric anatomy, esophageal function, and identify any issues not apparent on endoscopy
CT scan can be useful for port assessment and overall abdominal anatomy.
Informed Consent:
Comprehensive discussion with the patient regarding the risks, benefits, alternatives, and expected outcomes of band removal and sleeve conversion, including potential new complications.
Surgical Technique
Laparoscopic Approach:
The conversion is typically performed laparoscopically, allowing for minimally invasive surgery with reduced recovery time
The procedure is usually performed in a single operative setting.
Band Explantation:
Careful dissection around the gastric band is performed to mobilize and remove the device
The stomach wall, particularly where the band is in close proximity, must be meticulously inspected for any signs of erosion or fibrosis.
Ports And Drainage:
Placement of standard laparoscopic ports
Consider placement of a drain in the area of the excised band if significant inflammation or fibrosis is present.
Sleeve Gastrectomy Creation:
Following band removal, the greater curvature of the stomach is dissected free from the omentum
A calibrated bougie (e.g., 36-40 Fr) is inserted into the stomach lumen
The stomach is then transected along the greater curvature using an endoscopic stapler, creating the sleeve.
Staple Line Reinforcement:
Consider reinforcement of the staple line with sutures or buttressing material to reduce the risk of staple line leak, especially in patients with prior gastric surgery or significant fibrosis.
Postoperative Care
Pain Management:
Adequate analgesia, typically with IV opioids initially, transitioning to oral pain medication
Epidural analgesia may be considered in some cases.
Fluid Management:
Intravenous fluids are maintained
Oral fluid intake is gradually advanced as tolerated, starting with clear liquids and progressing to full liquids, pureed, and soft diets over several weeks.
Mobilization:
Early ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
Patients are typically mobilized within 24 hours of surgery.
Monitoring For Complications:
Close monitoring for signs of staple line leak (tachycardia, fever, abdominal pain, elevated white blood cell count), bleeding, or infection
Routine vital sign monitoring and abdominal examination.
Dietary Progression:
A structured post-operative diet plan is followed, emphasizing small, frequent meals, adequate protein intake, and avoidance of carbonated beverages, high-fat foods, and refined sugars.
Complications
Early Complications:
Staple line leak is the most feared complication, often requiring reoperation and intervention
Bleeding from the staple line or port sites
Injury to adjacent organs (spleen, esophagus, stomach)
Pulmonary embolism
Port site infection or hernia.
Late Complications:
Stricture formation at the staple line, gastroesophageal reflux disease (GERD) which can be new or worsen existing symptoms
Nutritional deficiencies (e.g., vitamin B12, iron, calcium, vitamin D)
Gallstone formation
Weight regain
Gastric fistula or abscess formation.
Specific To Conversion:
Persistent dysphagia if esophageal stasis was present pre-operatively and not adequately addressed
Adhesions from previous surgery can make dissection more challenging and increase risk of visceral injury
Difficulty completely removing the band if heavily fibrosed or embedded.
Key Points
Exam Focus:
Understand the indications for conversion, the importance of preoperative endoscopy, and the common complications of both LAGB and sleeve gastrectomy
Differentiate between primary sleeve and converted sleeve in terms of technical challenges and outcomes.
Clinical Pearls:
Thorough preoperative assessment, especially endoscopy, is paramount
Be prepared for potential intraoperative difficulties due to adhesions or fibrosis from the previous band
Staple line reinforcement is often beneficial in revision cases
Meticulous inspection of the stomach wall for band erosion is critical.
Common Mistakes:
Underestimating the risk of staple line leak in revision bariatric surgery
Inadequate preoperative evaluation leading to missed contraindications or unidentified pathology
Insufficient post-operative dietary guidance
Failing to address pre-existing GERD effectively.