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					The Hidden Cost of
 Gastric Banding
       Wai Kuen Chow
  Physician Advanced Trainee
 Concord Repatriation Hospital
        18th May 2009
               Introduction
Laparoscopic Gastric Banding
  Preferred weight loss surgery for morbid obesity
  Simple, safe with low peri-operative complication
  risks
  Banding of the proximal stomach creates a small
  pouch to trap ingested food “satiety”
    Some patients may have vomiting related to eating
  Associated long term respiratory complications are
  poorly recognised
   Case 1 – 36 year old woman
Presentation                         Past Medical History
  Left pleuritic chest pain             Laparoscopic Gastric Banding
                                        2003
  and dyspnoea
                                            Lost 30kg
                                            Frequent regurgitation of
  Multiple medical reviews                  masticated foods for years
     2-3 year history of                Mild asthma (stable)
     intermittent night sweats,             Not on regular medications
     fevers and rigors                  Polycystic Ovarian Syndrome
     Gastric reflux symptoms            Iron deficiency anaemia
     Prescribed multiple courses        Endometriosis
     of antibiotics, which briefly
                                            Menorrhagia
     improved her symptoms
            Case 1 - Findings
Clinical Examination
  T 37.6oC,
  PR 100, BP 110/70
  RR 20, SaO2 99% (RA)
  Chest clear
  No heart murmurs
  No lymphadenopathy




                         Left mid zone rounded opacity
CT Chest
                    Management
FNAB under CT guidance
  Haemopurulent fluid aspirated
     Cultured Streptococcus milleri
Diagnosis
  Lung abscess secondary to aspiration pneumonia
     Related to laparoscopic gastric banding (dilated, filled oesophagus)
Treatment (6 weeks)
  IV Benzylpenicillin and Metronidazole
  Gastric band deflated improvement of regurgitation
Outcome
  Clinical and radiological improvement
  Case 2 – 44 year old woman
Presentation                 Past Medical History
  2 months of dry cough,       Laparoscopic Gastric
  malaise and fevers           Banding 2004
  Intermittent cough with         Tightened 2008
  yellow-green sputum          Gastro-oesophageal
  Temporary improvement        reflux disease
  with several courses of         Omeprazole 40mg daily
  antibiotics                  Iron deficiency anaemia

  Non-smoker (with no
  history of lung disease)
           Case 2 - Findings
Clinical Examination
  Afebrile, Looked well
  PR 80
  Chest clear
  No heart murmurs
Normal Chest X-ray



                          Micro-nodular infiltrates in
                          both lower lobes
                           CT Chest




Dilated, fluid filled oesophagus
                    Management
Bronchoscopy
   Cultured alpha haemolytic streptococcus from bronchial washings
   No other organisms (including mycobacteria) isolated
Diagnosis
   Chronic cough secondary to recurrent aspiration
   Related to oesophageal dilatation secondary to LAGB
Treatment
   Clindamycin (4 weeks)
   Deflation of gastric band
Outcome
   Symptoms and radiological resolution
   Case 3 – 28 year old woman
Presentation                         Past Medical History
   Transferred from Psychiatric         Laparoscopic Gastric Banding
   hospital                             2005
   Cough and right pleuritic chest      Post natal depression
   pains                                Post traumatic stress disorder
   Fevers, sweats, rigors and           Pancreatitis
   myalgias
                                        Biliary dyskinesia
   Vomiting and regurgitation

   Non-smoker (with no history
   of lung disease)
            Case 3 - Findings
Clinical Examination
  T 38.4oC,
  PR 106, BP 115/70
  RR 20, SaO2 97% (RA)
  No heart murmurs
  Chest clear
  No lymphadenopathy




                         Right lower zone patchy consolidation
              Management
Diagnosis
  Right lower lobe pneumonia
  Presumed aspiration
Treatment
  IV Cefotaxime and Metronidazole
Outcome
  Clinical improvement
  Discharged to Psychiatric Hospital
  Failed to follow-up at Respiratory Clinic
     Case 4 – 69 year old man
Presentation                         Past Medical History
  Productive cough and                 Laparoscopic gastric banding (2001)
  increasing dyspnoea                  Nissen fundoplication (2008)
  Significant reflux symptoms,         COPD with PHT
  regurgitation of masticated
                                       Obstructive sleep apnoea (CPAP)
  food (nocturnal)
                                       Type 2 diabetes
  4 hospital admissions in 12
  months for LRTI’s                        Diabetic nephropathy (CRF)
  Frequent use of oral antibiotics     Heart Failure, AF, HPT
  for bronchitis (outpatient)          Stroke, recurrent TIA’s
                                       Depression
             Case 4 - Findings

Clinical Examination
  T 36.4oC,
  PR 81 irregular, BP 160/80
  RR 16, SaO2 93% (RA)
  No clubbing
  Chest : Coarse crackles
  bilaterally
  No heart murmurs
  No peripheral oedema

                       Bilateral patchy consolidation + cardiomegaly
                                   CT Chest




Dilated, fluid filled oesophagus

Ground Glass Changes in Right
Lower Lobe (Posterior)
              Management
Diagnosis
  Bilateral pneumonia
  Likely aspiration
  Related to dilated oesophagus due to LAGB
Treatment
  IV Cefotaxime and Azithromycin (stat Gentamicin)
Outcome
  Returned to baseline function – ambulating 100
  metres
  Referred to Gastric Surgeon
                 Summary
Lower respiratory tract infections
  Lung abscess
  Micronodular infiltrates
  Pneumonic consolidation
All cases had previous laparoscopic gastric
banding for obesity
Dilated, fluid-filled oesophagus
  All described regurgitation of fluid and food
The body weight perception …
         Obesity
Major public health problem
   Obesity in Australia
Body mass index > 30 kg/m2
          Bariatric Surgery
Increasingly used treatment modality for morbid
obesity (BMI > 35kg/m2)
Which Is The Preferred Procedure ?



                         No. of cases
                         LAGB = 90%
                         RYGB = 10%
The Key Attributes
Percentage of Excess Weight Loss



                      Gradual weight loss
                            at 2 years

                      Stable weight loss (50%)
                             at 6 years
Reported Complications of LAGB
  Early Complications                            Late Complications
       Acute stomal obstruction                       Band Erosions (7%)
       (6%)                                           Band Slippage or Prolapse
       Band infection (0.3-9%)                          (2-14%)
       Gastric perforation                            Port or tubing malfunction
       Haemorrhage                                    or leakage (0.4-7%)
       Bronchopneumonia                               Oesophageal dilatation
       (post-op)                                      (10%)
       Deep vein thrombosis                           Oesophagitis

An average of 13-15 percent of patients will require reoperation for various complications
         Long Term Pulmonary
            Complications

NOT frequently reported in literature review
Many studies focused on weight loss outcomes, surgical
and mechanical complications
Rare peri-operative pulmonary complications (early)
  Pulmonary aspiration from difficult airway management
  Acute respiratory distress syndrome
  Post-op pneumonia
  Pulmonary oedema
  Pulmonary embolus
  Atelactasis
Published Case Reports
Case Reports                     Patient         Symptoms                    Radiology             Treatment
Zimlichman et al                 50 yo woman     5d Fevers, cough, SOB       CT chest: LUL lung    IV antibiotics
IMAJ 2005;7:742-743              LAGB 2002       3 yrs food regurgitation    abscess, dilated      Gastric banding
(Israel)                         NIDDM           and vomiting                fluid filled          deflation
                                                                             oesophagus

Alamoudi                         26 yo woman     2 mo noturnal cough         CT chest: Patchy      IV antibiotics
Obesity Surg 2006;16:1685-1688   LAGB 2004       and acid reflux Sx          air space             Gastric band
(Saudi Arabia)                   Asthma (mild)   Malodorous sputum           consolidation of      deflation
                                                                             RUL (post), dilated
                                                                             fluid filled
                                                                             oesophagus
                                 35 yo woman     1 mo persistent             CT chest: Dense       Antibiotics
                                 LAGB 2003       nocturnal cough, left       LLL consolidation,    Pt was lost to follow-
                                                 pleuritic chest pain, low   migration of          up
                                                 grade fevers                catheter in lung      Untraceable surgeon
                                                                             parenchyma

Hofer et al                      44 yo woman     2 yr recurrent chest        CXR : bilateral       IV antibiotics
Obesity Surg 2007;17:565-567     LAGB 2004       infections (antibiotics)    lower zone            Gastric band
(Austria)                                        Fevers, cough               pneumonic             deflation
                                                 Vomiting, unable to         consolidations
                                                 tolerate small quantities
                                                 of food
          Typical Scenario
Protracted respiratory symptoms
History of regurgitation and vomiting
Respiratory tract infections secondary to
aspiration
Linked with dilated fluid filled oesophagus
Secondary to laparoscopic gastric banding
Oesophageal Dilatation in LAGB
Related to mechanical overload in distal oesophagus

Intentional delayed gastric emptying
   Abnormal peristalsis of oesophagus (role not known)

Increased gastro-oesophageal reflux symptoms and
dysphagia
   Frequently tolerated
   Assumed to be ‘normal’ by patients

Can be reversible when gastric band is deflated (presumed)
  Empirical evidence scant
  Regurgitation symptoms reduced
Respiratory Complications of LAGB
(Postulated Assumption)

  Related to Oesophageal dilatation
  Aspiration of oesophageal contents
    Incidence not known

  Aspiration can lead to:
    Pneumonia
    Lung abscess
    Bronchiectasis
                  Conclusions
Obesity – “Growing” epidemic
  Need urgent solution


Laparoscopic gastric banding
  Safe and effective bariatric surgery
  Tampered normal anatomy and physiology


Delayed pulmonary complications
  Poorly recognised
  Possible increase in incidence due to increase use of bariatric
  surgery
Take Home Messages

 Be alert for long term respiratory complications
 Enquire about fever, respiratory symptoms and
 regurgitation/vomiting of foods
 Chest X-ray is mandatory
   CT Chest often will detect dilated oesophagus
 Treat respiratory infections
 Gastric banding deflation
Acknowledgments


        Dr Elizabeth Veitch
        Dr Niri Tillekeratne
        A/Prof Christine Jenkins
                            References
1.   O. Alamoudi, Long Term Pulmonary Complications after Laparoscopic
     Adjustable Gastric Banding. Obesity Surgery 2006 (16) pg 1685-1688

2.   M. Hofer et al, Recurrent Aspiration Pneumonia after Laparoscopic
     Adjustable Gastric Banding. Obesity Surgery 2007 (17) pg 565-567

3.   P. O’Brien et al, Obesity, Weight Loss and Bariatric Surgery. Medical Journal
     of Australia 2005; 183:6 pg 310-314

4.   P.O’Brien et al, Laparoscopic Adjustable Gastric Banding in the Treatment
     of Morbid Obesity. Arch Surg 2003;138 pg 376-382

5.   E. Zimlichman et al, Lung Abscess: An Unusual Complication of Gastric
     Banding. The Israel Medical Association Journal Nov 2005 (7) pg 742-743
Thank You!
The Gastric Band
Laparoscopic adjustable gastric band
            Indications for LAGB




Source : Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. (Chapter 18)
The right balance ?
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