Problems after Gastric Banding
Gastric Banding was until recently the most commonly performed bariatric procedure in Australia over the last 20 years. It rose to popularity, marketed as a safe, simple and reversible procedure and was rapidly adopted by many general surgeons without requiring the extensive training and expertise required to perform more complex stomach and intestinal surgery. Time has shown it to be less effective than the other surgical bariatric procedures including sleeve gastrectomy and gastric bypass.
There are no ideal and perfect bariatric procedures and no one fits all approach. Each procedure has its pros and cons including different outcomes, risks and side effects and must be considered taking into account each patient’s individual circumstances.
What problems can arise after gastric banding?
Acid reflux is common following gastric band surgery. Reflux symptoms including heartburn and regurgitation of food or fluid can be a sign that the band is too tight or its position may have changed. In the first instance some fluid should be removed from the band. If reflux persists then further investigations to determine the cause are required and may include an x-ray, contrast study and/or endoscopy. Ultimately it is often necessary to remove the gastric band and consider conversion to another procedure such as sleeve gastrectomy or gastric bypass.
A hiatus hernia can develop after surgery where the junction between the food pipe (oesophagus) and stomach slides up above the diaphragm into the chest. Hiatus hernias decrease the effectiveness of the valve mechanism that protects against reflux. Previous hiatus hernias repaired with simple sutures can recur as tissues weaken again. Subsequent repairs may require reinforcement with mesh like we do for other hernias to reduce further recurrences.
Difficulty swallowing or tolerating solid foods is common after gastric banding especially if the band is overtightened. This can lead to maladaptive dietary choices including high calorie liquids and softer foods which are easy to swallow than the desired healthier food options.
Persistent obstruction caused by the gastric band can cause permanent damage to the valve mechanism above the stomach contributing to ongoing reflux. It can also cause dilatation of the oesophagus further impairing swallowing and becoming a larger reservoir for food leading to increased portion sizes and weight regain.
Over time the small pouch of stomach above the gastric band can stretch (pouch dilatation) which reduces the effectiveness and can also cause reflux and obstructive symptoms.
"Although the band is usually fixed in position using sutures, its position may change (Slippage) which reduces the effectiveness and can also cause reflux and obstructive symptoms. If a large portion of stomach slips through the band, its blood supply may be compromised (Ischaemia) and a portion of the stomach can become gangrenous (Infarction). Although this is uncommon, it is a surgical emergency requiring immediate removal of the band and the compromised portion of stomach may need to be removed."
The gastric band can wear a hole through the wall of the stomach (Erosion) which is another uncommon but potentially very serious problem and could occur at any time including years after the initial surgery. If this happens slowly then a portion of or even the entire band can end up located inside the stomach and may be able to be removed endoscopically. Erosion can also result in a free perforation with leakage of stomach contents into the abdominal cavity much like a ruptured ulcer or a leak following other types of surgery. This is a life-threatening problem requiring emergency surgery, removal of the band and the hole to be closed. Healing is impaired in the presence of infection and an ongoing leak can occur which can be very difficult to manage.
Port and tubing problems are very common and require further surgery to manage. These can include blocking, breaking, disconnection, infection, erosion, flipping and sometimes the bowel can become tangled and obstructed.
"The gastric band, tubing and port are made of silicon plastic and constitutes foreign material in the body. The generates an inflammatory reaction resulting in a thick capsule of scar tissue surrounding the band and components. The band can be removed but the associated changes are not completely reversible and the stomach does not return to completely normal anatomy and function. If the band or components become colonised by bacteria or infected then the band needs to be removed."
The gastric band can damage by compression or even sever the main nerves to the stomach and intestine (Vagus nerves) which can impair gastrointestinal function including impairing stomach emptying (Gastroparesis).
Obesity is a risk factor for Gallstones and Gallbladder disease. Gallstones will often form during periods of significant weight loss. Patients with gallstones often develop pain under the right ribs, around the right side or back and is often exacerbated by eating. Once gallstones start to cause symptoms the gallbladder should be removed, or more serious complications can occur. Gallbladder removal can usually be done by keyhole surgery even after bariatric surgery. It usually requires an overnight stay in hospital.
Vitamin and mineral deficiencies can occur especially if you do not take the recommended daily supplements. The best way to avoid potentially serious problems is to take the recommended supplements every day and to have blood tests performed annually.
Inadequate weight loss and/or weight regain can occur following any bariatric procedure. Gastric banding is the least effective of all the surgical bariatric procedures. 50% of patients will lose less than half of their excess weight. Over time problems can reduce the effectiveness of the gastric band Obesity is a chronic disease process and some patients may require more than one operation during their lifetime to maintain control. Whilst the initial surgery to place a gastric band is relatively safe and straightforward, management of its complications is technically challenging and has increased risks. Although the gastric band can be revised or replaced these options tend to be even less effective than the original surgery.
Diabetes can improve with weight loss after gastric banding but there are more powerful and effective operations such as gastric bypass and SIPS surgery which increases the chance of reversing diabetes without requiring ongoing anti-diabetic medications.
We favour removal of the gastric band, waiting at least 3 months for the associated thick capsule of scar tissue to thin and soften before attempting conversion to another procedure. This approach reduces the associated risks and has better outcomes. Surgical options after gastric banding include conversion to sleeve gastrectomy, gastric bypass or duodenal switch (SIPS surgery). Before undertaking further surgery, it is important to address all issues that may have contributed including not following the recommending dietary and lifestyle changes and underlying psychological issues.
Problems after Gastric Banding
Although the initial insertion of a gastric band can be performed with relatively low risks, there have been many issues recognised over the longer term which can be challenging to manage and have resulted in high rates of removal and/or further revision surgery. Although the gastric band can be removed, it does cause extensive scarring to the stomach and can have adverse effects on the function of the oesophagus and stomach which are not fully “reversible.”
Why Upper GI West?
At Upper GI West all our Surgeons are highly trained and experienced with stomach surgery for a whole range of conditions including obesity, reflux, hiatus hernias and cancer.
We take specific measures during the preparation and with the technical aspects of surgery to reduce the chances of having problems. However sometime issues can still arise.
We have the necessary expertise and skills to diagnose and manage the problems that may occur. If your original surgery has been performed by another surgeon we can provide a second opinion to help resolve ongoing issues.
We are all surgeon endoscopists and are best positioned to perform endoscopy to assess and treat issues related to Bariatric surgery.