Removal of Peri-Gastric Fat Prevents Acute Obstruction after Lap-Band Surgery

Transcription

1 Obesity Surgery, 14, Removal of Peri-Gastric Fat Prevents Acute Obstruction after Lap-Band Surgery Roy Shen, MD; Christine J. Ren, MD Department of Surgery, NYU School of Delivered Medicine, by New Ingenta York, tony, USA IP: Background: Acute postoperative gastroesophageal obstruction is a potential complication after laparoscopic adjustable gastric banding (LAGB). Utilizing the pars flaccida technique may increase the incidence due to the incorporation of perigastric fat, particularly in patients with greater visceral obesity. Removal of peri-gastric fat pads may be necessary to avoid postoperative obstruction. We present our experience of 267 LAGB operations using the Lap- Band System and the incidence of postoperative obstruction, before and after incorporating routine removal of peri-gastric fat pads. Methods: A retrospective review of a prospective database of 267 consecutive Lap-Band placements between July 2001 and November 2002 was conducted. Results: All operations were completed laparoscopically using the pars flaccida technique, and all patients underwent esophagogram the morning after surgery. From July 2001 to May 2002, 143 Lap-Band placements were performed, with 11 patients (8%) having abnormal postoperative esophagograms. There were 43 males/100 females with mean BMI 48.3 (range 35 to 78.9). Complete esophageal obstruction was seen in 5 of these patients, all of whom underwent laparoscopic revision. Significantly delayed emptying was seen in the 6 remaining patients, who were managed conservatively with intravenous fluids from 2-7 days. In these 11 patients, there were 6 males/5 females with mean BMI 47.1 (range ). Subsequently, removal of peri-gastric fat pads was routinely performed during Lap-Band placement. From June 2002 to November 2002, there were 43 males/81 females with mean BMI 48 (range 35-79); these 124 Lap-Band placements were performed with no abnormal postoperative esophagograms. Conclusion: Routine removal of peri-gastric fat pads when using the pars flaccida technique for Lap- Reprint requests to: Christine J. Ren, MD, Director, Surgical Weight Loss Program, 530 First Avenue, Suite 10S, New York, NY 10016, USA. Christine.Ren@med.nyu.edu Band surgery appears to prevent postoperative esophageal obstruction. Key words: Morbid obesity, bariatric surgery, complication, obstruction, esophagogram, gastric banding, laparoscopy Introduction Laparoscopic adjustable gastric banding (LAGB) has been used as a surgical treatment option for morbid obesity since the early 1990s. 1-4 Availability in the U.S. occurred with FDA approval of the first LAGB specifically the Lap-Band System (Inamed Health, Santa Barbara, CA) in Initial surgical technique for placing the band circumferentially around the proximal stomach concentrated on perigastric dissection to create a tunnelnextto the stomach wall. Significant rates of gastric prolapse (band slippage) led to modifications of this technique, with transition to the pars flaccida approach. Although the pars flaccida technique is a simpler, more reproducible technique, it has been associated with higher rates of acute postoperative esophageal (or stomal) obstruction at the level of the band. 9 This may be a consequence of incorporating visceral perigastric fat within the band, causing excessive external compression on the stomach. We reviewed our experience of over 200 consecutive LAGB procedures performed at a single institution, before and after the practice of perigastric fat removal was routinely incorporated, and the incidence of postoperative obstruction. 224 Obesity Surgery, 14, 2004 FD-Communications Inc.

2 Materials and Methods Prospective data was collected on all consecutive patients undergoing bariatric surgery at NYU Medical Center between July 2001 through November 2002 and entered anonymously into a secured computerized database (Microsoft Access ). All patients who had undergone LAGB obstruction, as well as to document band position were retrospectively reviewed. Indications for surgery were based on the National Institutes of Health Delivered by and Ingenta pouch tosize (Figure 2). Patients were then discharged on a liquid diet for 2 weeks, which pro- recommendations for bariatric surgery. 5 All IP: patients had a body mass index (BMI) 40 kg/mdate: 2 gressed to puree and then solid food over the course,or> of 6 weeks. kg/m 2 in association with a recognized co-morbidity. Patients were educated and screened with preoperative psychological, nutritional, and medical evaluation. Patients did not undergo formal screening for eating behavior (ie. sweet eaters vs volume eaters), but were assessed for motivation and commitment to long-term follow-up. Preoperative esophagograms were performed to document presence of hiatal hernia, esophageal dysmotility or achalasia. All operations were performed by one fellowshiptrained laparoscopic bariatric surgeon at a teaching hospital utilizing a comprehensive bariatric program. Training for the Lap-Band included attending a 2-day workshop and subsequent on-site proctoring of the initial 5 operations by an expert surgeon. The placement of the device was performed laparoscopically utilizing the pars flaccida technique, as described by Fielding and Allen. 6 Briefly, the pars flaccida technique is a method to gain access to the posterior aspect of the gastroesophageal junction via the right crus, in order to encircle the upper stomach circumferentially. This technique requires minimal gastric dissection, maintains normal gastric anatomy and avoids disruption of the lesser sac. Since no dissection is performed along the gastric serosa, visceral fat deposits on the stomach wall are incorporated within the band. These fat deposits, or fat pads, lie consistently in several locations: anterolaterally, posterolaterally at the angle of His, medially at the lesser curve and posteromedially between the right crus and the gastroesophageal junction (Figure 1 A-D). These fat pads were consistently removed during the latter half of our experience. The band is not filled initially with saline, and is secured in place with anterior gastro-gastric sutures. The tubing leading to the band is connected to an access port that is secured to the anterior rectus sheath in a mid-abdominal location. The 9.75-cm Lap-Band was used in females with BMI <50 kg/m 2 ; heavier females and all males received the 10-cm Lap-Band device. Routine contrast esophagogram was performed the morning after surgery to check for perforation or The time periods before and after technique modification were compared on the complication rates using Fisher s exact test. SAS statistical software was used to analyze the data. A P-value 0.05 was considered statistically significant. Results Removal of Peri-Gastric Fat From July 2001 through November 2002, 267 consecutive patients underwent LAGB using the Lap- Band. In the first 11 months (July 2001 through May 2002), 143 patients underwent LAGB as the primary operation for morbid obesity. There were 43 males and 100 females with mean BMI 48.3 kg/m 2 (range 35 to 78.9). Mean length of stay was 1 day, ranging from 0 to 10 days. Of the 143 patients, 11 patients (8%) had abnormal postoperative esophagograms: 5 complete obstruction and 6 significantly delaying emptying. In these 11 patients, there were 6 males and 5 females with mean BMI 47.1 kg/m 2 (range ). Mean weight was 140 kg (range kg), mean age was 42.4 years (range years) and mean Waist/Hip ratio was 0.94 ±0.05 SD. Five patients were diabetic. Complete esophageal obstruction at the level of the band was observed in 5 of 11 patients (3.5%) (Figure 3). Mean BMI was 46.2 kg/m 2 ( ) and mean weight was 133 kg ( kg). There were 2 males and 3 females, and one patient was diabetic. These patients typically developed symptoms of retching, regurgitation of saliva, or chest pain several hours after surgery. Anti-inflammatory medication (ie. ketorolac [Toradol ], steroids) were utilized without effect. Nasogastric decompression Obesity Surgery, 14,

3 Shen and Ren Figure 1. PERI-GASTRIC FAT PADS. A Delivered by Ingenta to IP: A. Anterior epiphrenic fat pad. C. Antero-medial fat pad. C B B. Angle of His fat pad. D. Postero-medial fat pad (medial to the caudate lobe). D Figure 2. Normal esophagram (Lap-Band postop day 1). Figure 3. Complete stomal obstruction. 226 Obesity Surgery, 14, 2004

4 Removal of Peri-Gastric Fat enced immediate resolution of obstruction and were discharged the day after surgical revision. All underwent laparoscopic revision between the first and sixth postoperative day. Two patients were re-operated on post-operative day 1, two on postoperative day 4, and one on postoperative day 8. Significantly delayed esophageal emptying was seen in 6 of 11 patients (4.5%). Esophageal dilatation with a bird s beak pattern of emptying through the band was observed (Figure 4). Of these 6 patients, mean BMI was 47.8 kg/m 2 ( ) and mean weight was 145 kg ( kg). There were 4 males and 2 females, 4 diabetics and 2 nondiabetics. These patients typically did not experience intolerance to saliva, but were unable to drink clear liquids. Treatment involved intravenous hydra- provided symptom relief but was poorly tolerated tion, nothing by mouth, and non-steroidal inflammatory due to nasopharyngeal discomfort. Time of re-operation agents. These patients were managed con- was dependent on whether the patient was able servatively and experienced complete resolution to tolerate a nasogastric tube and/or symptoms. All after 2-7 days. Four patients were treated for 2 days, re-operations were performed laparoscopically and one patient for 4 days, and one for 7 days. involved taking down the anterior gastro-gastric Subsequently, change in surgical technique was sutures, excision of peri-gastric fat within the band incorporated to include routine removal of peri-gastric lumen until the band moved easily around the stomach, fat pads during Lap-Band placement. From and re-securing of the gastro-gastric sutures. June 2002 to November 2002, 124 Lap-Band Confirmation of adequate lumen diameter Delivered was by placements Ingenta to were performed. There were 43 males obtained by passing an orogastric tube Ms Nichols easily (cid and ) 81 females with mean BMI 48 kg/m 2 (range 35- through the band after revision. All patients IP: experi ), and mean weight 145 kg (range kg). Mean Waist/Hip ratio was 0.83±0.11 SD, which was not significantly different than the ratio for those patients who experienced postoperative obstruction (P=NS). There were no abnormal postoperative esophagograms in any of this cohort. All patients, except for one, were discharged the day after surgery. That patient experienced pulmonarycomplications requiring 10 days of hospitalization, but had a normal esophagogram. The change in technique resulted in a significantly lower postoperative esophageal obstruction rate. The complication rate before the technique change was 7.7% (n=11 of 143). This rate was reduced to 0% (n=0 of 124) after the change (chi-square test statistic=9.95, n=267, df=1, P=0.001). Discussion Figure 4. Partial stomal obstruction with delayed esophageal empyting. Laparoscopic placement of adjustable gastric bands using the Lap-Band System has been performed for over 10 years. Several operative techniques can be utilized in placing the gastric band circumferentially around the proximal stomach. Initial experience internationally utilized the peri-gastric technique, 7-9 where a tunnel was made with dissection posterior to the stomach, along the gastric serosa. This ensured that only stomach was incorporated within the band. Because of the increased rate of gastric prolapse (slippage), the technique was changed to the pars flaccida technique. The approach involves minimal dissection around the stomach, and instead involves the landmarks of the right crus and angle of His in order to place the band circumferentially around the stomach. However, this can result in incorporation of peri-gastric fat Obesity Surgery, 14,

5 Shen and Ren within the lumen of the band. Typically, the lumen compression of the stomach may lead to ischemia of the locked band can accommodate the entire and subsequent erosion. Surgical correction, proximal stomach without causing obstruction. although it requires another operation, can be performed Excessive amounts of peri-gastric fat cause external laparoscopically with good result and dis- compression on the stomach, and results in charge the next day. Therefore, it has been the esophageal obstruction. The early U. S. results show authors experience to routinely excise perigastric a higher incidence of postoperative gastroesophageal fat pads. However, if postoperative obstruction obstruction when compared with the occurs, surgical correction should be utilized for European and Australian results, reflecting the difference patients with complete esophageal obstruction, in techniques used. 10 Delivered by while Ingenta conservative to management can be practised on From July 2001 through November 2002, Ms Nichols 267 (cid patients ) with delayed esophageal emptying. patients underwent LAGB with the Lap-Band IP: Of Although not addressed in this series, the two-step the 267 patients, 11 (4.1%) had postoperative esophagograms significant for acute obstruction at the band site. The cohort was then subdivided into two groups as determined by the time of surgical technique change. Before June 2002, no peri-gastric fat pads were removed, and an 8% obstruction rate was observed. After June 2002, routine removal of peri-gastric fat pads was adopted, with no postoperative obstruction observed. There were no differences in the groups regarding gender ratio, mean BMI and range of BMI. The incidence of postoperative obstruction was reduced from 8% to 0% after fat pad resection was routinely practised. This outcome reflects the impact of peri-gastric fat pad excision when using the pars flaccida technique on postoperative obstruction, and supports this practice. The results also show that postoperative obstruction does not necessarily correlate with a higher BMI or weight, but may occur in greater frequency in men and in diabetic patients. This is reflected by the fact that although 30% of the surgical cohort and subgroups were men, they constituted over 50% of the patients who developed postoperative stomal obstruction. Similarly, 50% of the obstructed patients were diabetics. Therefore, the surgeon should keep in mind that these patients will have a potentially higher chance of postoperative obstruction and may require greater attention during surgery to prevent this. Both conservative and surgical treatments can be utilized to treat postoperative stomal obstruction, but each has its advantages and disadvantages. Conservative treatment allows a patient to avoid a general anesthetic and surgery, but does require a prolonged hospital stay with the discomfort of salivary intolerance or a nasogastric tube. It is also unknown whether prolonged excessive external technique is an alternative approach that should be mentioned to manage excessive peri-gastric visceral fat pads. 11 This technique utilizes a combination of pars flaccida and then peri-gastric dissection to exclude the fatty deposits along the lesser curvature, particularly if a replaced left hepatic artery is present. 12 Conclusion Laparoscopic adjustable gastric banding is one option in the surgical treatment of morbid obesity. Although less invasive and safer than other bariatric operations, LAGB is not without its complications. Postoperative stomal obstruction with abnormal esophageal emptying is correlated with the incorporation of visceral peri-gastric fat and can be successfully avoided by routine removal of these fat pads. This detail in surgical technique may contribute to increased peri-operative complications in the surgeon s early experience with a new procedure, as demonstrated by this study. This study was made possible by an unrestricted educational grant by United States Surgical Corporation. References 1. Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for treatment of morbid obesity. Obes Surg 2002; 12: Cadière GB, Himpens J, Vertruyen M et al. Laparoscopic gastroplasty (adjustable silicone gastric 228 Obesity Surgery, 14, 2004

6 banding). Semin Laparosc Surg 2000; 7: Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases. Surg Endosc 1999;13: O Brien PE, Brown WA, Smith A et al. Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 1999; 86: Gastrointestinal Surgery for Severe Obesity. National Institutes of Health Consensus Development Conference Draft Statement. Obes Surg 1991;1: Fielding GA, Allen JW. A step-by-step guide to placement of the Lap-Band adjustable gastric banding system. Am J Surg 2002; 184: 26S-30S. 7. Favretti F, Cadière GB, Segato G et al. Laparoscopic adjustable silicone gastric banding (Lap-Band ): how to avoid complications. Obes Surg 1997; 7: Delivered by Ingenta to IP: Removal of Peri-Gastric Fat 8. O Brien PE, Dixon JB, Brown W et al. The laparoscopic adjustable gastric band (Lap-Band ): a prospective study of medium-term effects on weight, health and quality of life. Obes Surg 2002; 12: Spivak H, Favretti F. Avoiding postoperative complications with the Lap-Band system. Am J Surg 2002; 184: 31S-37S. 10.Ren CJ, Horgan S, Ponce J. US experience with the Lap-Band system. Am J Surg 2002; 184: 46S-50S. 11.Rubin M, Benchetrit S, Lustigman H et al. Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step techniquemay improve outcome. Obes Surg 2001; 11: Nehoda H, Lanthaler M, Labeck B et al. Aberrant left hepatic artery in laparoscopic gastric banding. Obes Surg 2000; 10: (Received August 27, 2003; accepted November 18, 2003) Obesity Surgery, 14,