Abstract
Background
Symmetrical pouch dilatation has become the most common problem following laparoscopic adjustable gastric banding (LAGB). Although, in a significant number of symptomatic patients, no explanation for the underlying problem is identified with a contrast swallow. There is a need for a better understanding of the pathophysiology of LAGBs and more sensitive diagnostic tests.
Methods
LAGB patients with adverse symptoms or poor weight loss (symptomatic patients), in whom a contrast swallow had not shown an abnormality, underwent high-resolution video manometry. This incorporated a semi-solid, stress barium, swallow protocol. Outcomes were categorized based on anatomical appearance, transit through the LAGB, and esophageal motility. Cohorts of successful (>50% excess weight loss with no adverse symptoms) and pre-operative patients were used as controls.
Results
One hundred twenty-three symptomatic patients participated along with 30 successful and 56 pre-operative patients. Five pathophysiological patterns were defined: transhiatal enlargement (n = 40), sub-diaphragmatic enlargement (n = 39), no abnormality (n = 30), aperistaltic esophagus (n = 7), and intermittent gastric prolapse (n = 3). Esophageal motility disorders were more common in symptomatic and pre-operative patients than in successful patients (p = 0.01). Differences between successful and symptomatic patients were identified in terms of the length of the high-pressure zone above the LAGB (p < 0.005), peristaltic velocity (p < 0.005), frequency of previous surgery(p = 0.01), and lower esophageal sphincter tone (p = 0.05).
Conclusions
Video manometry identified abnormalities in three quarters of symptomatic patients where conventional contrast swallow had not been diagnostic. Five primary patterns of pathophysiology were defined. These were used to develop a seven category, clinical, classification system based on the anatomical appearance at stress barium. This system stratifies the spectrum of symmetrical pouch dilatation and can be used to logically guide treatment.
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References
O'Brien PE, Dixon JB, Brown W. Obesity is a surgical disease: overview of obesity and bariatric surgery. ANZ J Surg. 2004;74:200–4.
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;12:652–60.
O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med. 2006;144:625–33.
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;86:113–8.
Brown W, Burton P, Anderson M, et al. Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management. Obes Surg. 2008;18:1104–8.
O'Brien PE, Dixon JB, Laurie C, et al. A prospective randomized trial of placement of the laparoscopic adjustable gastric band: comparison of the perigastric and pars flaccida pathways. Obes Surg. 2005;15:820–6.
Gamagaris Z, Patterson C, Schaye V, et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268–72.
Iovino P, Angrisani L, Tremolaterra F, et al. Abnormal esophageal acid exposure is common in morbidly obese patients and improves after a successful Lap-band system implantation. Surg Endosc. 2002;16:1631–5.
Korenkov M, Kohler L, Yucel N, et al. Esophageal motility and reflux symptoms before and after bariatric surgery. Obes Surg. 2002;12:72–6.
Fox MR, Bredenoord AJ. Oesophageal high-resolution manometry: moving from research into clinical practice. Gut. 2008;57:405–23.
Burton PR, Brown WA, Laurie C, et al. The effect of laparoscopic adjustable gastric bands on esophageal motility and the gastroesophageal junction; analysis using high resolution video manometry. Obes Surg. 2009;19(7):905–14.
Kahrilas PJ, Ghosh SK, Pandolfino JE. Esophageal motility disorders in terms of pressure topography: the Chicago Classification. J Clin Gastroenterol. 2008;42:627–35.
Grubel C, Hiscock R, Hebbard G. Value of spatiotemporal representation of manometric data. Clin Gastroenterol Hepatol. 2008;6:525–30.
Gulkarov I, Wetterau M, Ren CJ, et al. Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc. 2008;22:1035–41.
Koppman JS, Poggi L, Szomstein S, et al. Esophageal motility disorders in the morbidly obese population. Surg Endosc. 2007;21:761–4.
Jaffin BW, Knoepflmacher P, Greenstein R. High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients. Obes Surg. 1999;9:390–5.
Grande L, Lacima G, Ros E, et al. Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication. J Clin Gastroenterol. 1991;13:11–6.
Foletto M, Bernante P, Busetto L, et al. Laparoscopic gastric rebanding for slippage with pouch dilation: results on 29 consecutive patients. Obes Surg. 2008;18:1099–103.
Dixon AF, Dixon JB, O'Brien PE. Laparoscopic adjustable gastric banding induces prolonged satiety: a randomized blind crossover study. J Clin Endocrinol Metab. 2005;90:813–9.
Gumbs AA, Pomp A, Gagner M. Revisional bariatric surgery for inadequate weight loss. Obes Surg. 2007;17:1137–45.
O'Brien P, Brown W, Dixon J. Revisional surgery for morbid obesity—conversion to the Lap-Band system. Obes Surg. 2000;10:557–63.
Naslund E, Kral JG. Patient selection and the physiology of gastrointestinal antiobesity operations. Surg Clin North Am. 2005;85:725–40. vi.
Colquitt JL, Picot J, Loveman E, et al. Surgery for obesity. Cochrane Database Syst Rev. 2009:CD003641.
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Burton, P.R., Brown, W.A., Laurie, C. et al. Pathophysiology of Laparoscopic Adjustable Gastric Bands: Analysis and Classification Using High-Resolution Video Manometry and a Stress Barium Protocol. OBES SURG 20, 19–29 (2010). https://doi.org/10.1007/s11695-009-9970-z
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DOI: https://doi.org/10.1007/s11695-009-9970-z