The Hidden Cost of
The Hidden Cost of
Gastric Banding
Gastric Banding
Wai Kuen Chow
Physician Advanced Trainee
Concord Repatriation Hospital
Introduction
Introduction
Laparoscopic Gastric Banding
Laparoscopic Gastric Banding
Preferred weight loss surgery for morbid obesity
Preferred weight loss surgery for morbid obesity
Simple, safe with low peri
Simple, safe with low peri
-
-
operative complication
operative complication
risks
risks
Banding of the proximal stomach creates a small
Banding of the proximal stomach creates a small
pouch to trap ingested food
pouch to trap ingested food
“
“
satiety
satiety
”
”
Some patients may have vomiting related to eating
Some patients may have vomiting related to eating
Associated long term respiratory complications are
Associated long term respiratory complications are
poorly recognised
poorly recognised
Case 1
Case 1
–
–
36 year old woman
36 year old woman
Presentation
Presentation
Left pleuritic chest pain
Left pleuritic chest pain
and dyspnoea
and dyspnoea
Multiple medical reviews
Multiple medical reviews
2-2-3 year history of 3 year history of
intermittent night sweats, intermittent night sweats, fevers and rigors
fevers and rigors
Gastric reflux symptomsGastric reflux symptoms
Prescribed multiple courses Prescribed multiple courses
of antibiotics, which briefly of antibiotics, which briefly improved her symptoms improved her symptoms
Past Medical History
Past Medical History
Laparoscopic Gastric Banding Laparoscopic Gastric Banding
2003 2003
Lost 30kgLost 30kg
Frequent regurgitation of Frequent regurgitation of
masticated foods for years masticated foods for years
Mild asthma (stable)Mild asthma (stable)
Not on regular medicationsNot on regular medications
Polycystic Ovarian SyndromePolycystic Ovarian Syndrome
Iron deficiency anaemiaIron deficiency anaemia
Endometriosis Endometriosis
Case 1
Case 1
-
-
Findings
Findings
Clinical Examination
Clinical Examination
T 37.6
T 37.6
ooC,
C,
PR 100, BP 110/70
PR 100, BP 110/70
RR 20, SaO2 99% (RA)
RR 20, SaO2 99% (RA)
Chest clear
Chest clear
No heart murmurs
No heart murmurs
No lymphadenopathy
No lymphadenopathy
CT Chest
CT Chest
Management
Management
FNAB under CT guidance
FNAB under CT guidance
Haemopurulent fluid aspirated
Haemopurulent fluid aspirated
Cultured Cultured Streptococcus milleriStreptococcus milleri
Diagnosis
Diagnosis
Lung abscess secondary to aspiration pneumonia
Lung abscess secondary to aspiration pneumonia
Related to laparoscopic gastric banding (dilated, filled oesophagus) Related to laparoscopic gastric banding (dilated, filled oesophagus)
Treatment (6 weeks)
Treatment (6 weeks)
IV Benzylpenicillin and Metronidazole
IV Benzylpenicillin and Metronidazole
Gastric band deflated
Gastric band deflated
improvement of regurgitation
improvement of regurgitation
Outcome
Outcome
Case 2
Case 2
–
–
44 year old woman
44 year old woman
Presentation
Presentation
2 months of dry cough,
2 months of dry cough,
malaise and fevers
malaise and fevers
Intermittent cough with
Intermittent cough with
yellow
yellow
-
-
green sputum
green sputum
Temporary improvement
Temporary improvement
with several courses of
with several courses of
antibiotics
antibiotics
Non
Non
-
-
smoker (with no
smoker (with no
history of lung disease)
history of lung disease)
Past Medical History
Past Medical History
Laparoscopic Gastric
Laparoscopic Gastric
Banding 2004
Banding 2004
Tightened 2008Tightened 2008
Gastro
Gastro
-
-
oesophageal
oesophageal
reflux disease
reflux disease
Omeprazole 40mg dailyOmeprazole 40mg daily
Case 2
Case 2
-
-
Findings
Findings
Clinical Examination
Clinical Examination
Afebrile, Looked well
Afebrile, Looked well
PR 80
PR 80
Chest clear
Chest clear
No heart murmurs
No heart murmurs
Normal Chest X
Normal Chest X
-
-
ray
ray
Micro-nodular infiltrates in
both lower lobes
CT Chest
CT Chest
Management
Management
Bronchoscopy
Bronchoscopy
Cultured alpha haemolytic streptococcus from bronchial washingsCultured alpha haemolytic streptococcus from bronchial washings
No other organisms (including mycobacteria) isolatedNo other organisms (including mycobacteria) isolated
Diagnosis
Diagnosis
Chronic cough secondary to recurrent aspiration Chronic cough secondary to recurrent aspiration
Related to oesophageal dilatation secondary to LAGBRelated to oesophageal dilatation secondary to LAGB
Treatment
Treatment
Clindamycin (4 weeks)Clindamycin (4 weeks)
Deflation of gastric bandDeflation of gastric band
Outcome
Outcome
Case 3
Case 3
–
–
28 year old woman
28 year old woman
Presentation
Presentation
Transferred from Psychiatric Transferred from Psychiatric
hospital hospital
Cough and right pleuritic chest Cough and right pleuritic chest
pains pains
Fevers, sweats, rigors and Fevers, sweats, rigors and
myalgias myalgias
Vomiting and regurgitationVomiting and regurgitation
NonNon--smoker (with no history smoker (with no history
of lung disease) of lung disease)
Past Medical History
Past Medical History
Laparoscopic Gastric Banding Laparoscopic Gastric Banding
2005 2005
Post natal depressionPost natal depression
Post traumatic stress disorderPost traumatic stress disorder
PancreatitisPancreatitis
Case 3
Case 3
-
-
Findings
Findings
Clinical Examination
Clinical Examination
T 38.4
T 38.4
ooC,
C,
PR 106, BP 115/70
PR 106, BP 115/70
RR 20, SaO2 97% (RA)
RR 20, SaO2 97% (RA)
No heart murmurs
No heart murmurs
Chest clear
Chest clear
No lymphadenopathy
No lymphadenopathy
Management
Management
Diagnosis
Diagnosis
Right lower lobe pneumonia
Right lower lobe pneumonia
Presumed aspiration
Presumed aspiration
Treatment
Treatment
IV Cefotaxime and Metronidazole
IV Cefotaxime and Metronidazole
Outcome
Outcome
Clinical improvement
Clinical improvement
Discharged to Psychiatric Hospital
Discharged to Psychiatric Hospital
Case 4
Case 4
–
–
69 year old man
69 year old man
Presentation
Presentation
Productive cough and Productive cough and
increasing dyspnoea increasing dyspnoea
Significant reflux symptoms, Significant reflux symptoms,
regurgitation of masticated regurgitation of masticated food (nocturnal)
food (nocturnal)
4 hospital admissions in 12 4 hospital admissions in 12
months for LRTI months for LRTI’’ss
Frequent use of oral antibiotics Frequent use of oral antibiotics
for bronchitis (outpatient) for bronchitis (outpatient)
Past Medical History
Past Medical History
Laparoscopic gastric banding (2001)Laparoscopic gastric banding (2001)
Nissen fundoplication (2008) Nissen fundoplication (2008)
COPD with PHTCOPD with PHT
Obstructive sleep apnoea (CPAP)Obstructive sleep apnoea (CPAP)
Type 2 diabetesType 2 diabetes
Diabetic nephropathy (CRF)Diabetic nephropathy (CRF)
Heart Failure, AF, HPTHeart Failure, AF, HPT
Stroke, recurrent TIA’Stroke, recurrent TIA’ss
Case 4
Case 4
-
-
Findings
Findings
Clinical Examination
Clinical Examination
T 36.4
T 36.4
ooC,
C,
PR 81 irregular, BP 160/80
PR 81 irregular, BP 160/80
RR 16, SaO2 93% (RA)
RR 16, SaO2 93% (RA)
No clubbing
No clubbing
Chest : Coarse crackles
Chest : Coarse crackles
bilaterally
bilaterally
No heart murmurs
No heart murmurs
No peripheral oedema
No peripheral oedema
CT Chest
CT Chest
Dilated, fluid filled oesophagus
Ground Glass Changes in Right
Lower Lobe (Posterior)
Management
Management
Diagnosis
Diagnosis
Bilateral pneumonia
Bilateral pneumonia
Likely aspiration
Likely aspiration
Related to dilated oesophagus due to LAGB
Related to dilated oesophagus due to LAGB
Treatment
Treatment
IV Cefotaxime and Azithromycin (stat Gentamicin)
IV Cefotaxime and Azithromycin (stat Gentamicin)
Outcome
Outcome
Returned to baseline function
Returned to baseline function
–
–
ambulating 100
ambulating 100
metres
metres
Summary
Summary
Lower respiratory tract infections
Lower respiratory tract infections
Lung abscess
Lung abscess
Micronodular infiltrates
Micronodular infiltrates
Pneumonic consolidation
Pneumonic consolidation
All cases had previous laparoscopic gastric
All cases had previous laparoscopic gastric
banding for obesity
banding for obesity
Dilated, fluid
Dilated, fluid
-
-
filled oesophagus
filled oesophagus
The body weight perception
Obesity
Obesity
Major public health problem
Major public health problem
Obesity in Australia
Obesity in Australia
Body mass index > 30 kg/m
Body mass index > 30 kg/m
2
2
Bariatric Surgery
Bariatric Surgery
Increasingly used treatment modality for morbid
Increasingly used treatment modality for morbid
obesity (BMI > 35kg/m
obesity (BMI > 35kg/m
22)
)
Which Is The Preferred Procedure ?
Which Is The Preferred Procedure ?
No. of cases
LAGB = 90%
RYGB = 10%
The Key Attributes
The Key Attributes
Percentage of Excess Weight Loss
Percentage of Excess Weight Loss
Gradual weight loss
at 2 years
Stable weight loss
(50%)Reported Complications of LAGB
Reported Complications of LAGB
Early Complications
Early Complications
Acute stomal obstruction
Acute stomal obstruction
(6%)
(6%)
Band infection (0.3
Band infection (0.3
-
-
9%)
9%)
Gastric perforation
Gastric perforation
Haemorrhage
Haemorrhage
Bronchopneumonia
Bronchopneumonia
(post
(post
-
-
op)
op)
Deep vein thrombosis
Deep vein thrombosis
Late Complications
Late Complications
Band Erosions (7%)
Band Erosions (7%)
Band Slippage or Prolapse
Band Slippage or Prolapse
(2
(2
-
-
14%)
14%)
Port or tubing malfunction
Port or tubing malfunction
or leakage (0.4
or leakage (0.4
-
-
7%)
7%)
Oesophageal dilatation
Oesophageal dilatation
(10%)
(10%)
Oesophagitis
Oesophagitis
An average of 13
Long Term Pulmonary
Long Term Pulmonary
Complications
Complications
NOT frequently reported in literature review
NOT frequently reported in literature review
Many studies focused on weight loss outcomes, surgical
Many studies focused on weight loss outcomes, surgical
and mechanical complications
and mechanical complications
Rare peri
Rare peri
-
-
operative pulmonary complications (early)
operative pulmonary complications (early)
Pulmonary aspiration from difficult airway managementPulmonary aspiration from difficult airway management
Acute respiratory distress syndromeAcute respiratory distress syndrome
Post-Post-op pneumoniaop pneumonia
Pulmonary oedemaPulmonary oedema
Pulmonary embolusPulmonary embolus
Published Case Reports
Published Case Reports
Antibiotics
Pt was lost to follow-up Untraceable surgeon CT chest: Dense LLL consolidation, migration of catheter in lung parenchyma 1 mo persistent
nocturnal cough, left pleuritic chest pain, low grade fevers 35 yo woman LAGB 2003 IV antibiotics Gastric band deflation CXR : bilateral lower zone pneumonic consolidations 2 yr recurrent chest infections (antibiotics) Fevers, cough Vomiting, unable to tolerate small quantities of food 44 yo woman LAGB 2004 Hofer et al Obesity Surg 2007;17:565-567 (Austria) IV antibiotics Gastric band deflation CT chest: Patchy air space consolidation of RUL (post), dilated fluid filled
oesophagus 2 mo noturnal cough
and acid reflux Sx Malodorous sputum 26 yo woman LAGB 2004 Asthma (mild) Alamoudi Obesity Surg 2006;16:1685-1688 (Saudi Arabia) IV antibiotics Gastric banding deflation
CT chest: LUL lung abscess, dilated fluid filled oesophagus 5d Fevers, cough, SOB
3 yrs food regurgitation and vomiting 50 yo woman LAGB 2002 NIDDM Zimlichman et al IMAJ 2005;7:742-743 (Israel) Treatment Radiology Symptoms Patient Case Reports
Typical Scenario
Typical Scenario
Protracted respiratory symptoms
Protracted respiratory symptoms
History of regurgitation and vomiting
History of regurgitation and vomiting
Respiratory tract infections secondary to
Respiratory tract infections secondary to
aspiration
aspiration
Linked with dilated fluid filled oesophagus
Linked with dilated fluid filled oesophagus
Oesophageal Dilatation in LAGB
Oesophageal Dilatation in LAGB
Related to mechanical overload in distal oesophagus
Related to mechanical overload in distal oesophagus
Intentional delayed gastric emptying
Intentional delayed gastric emptying
Abnormal peristalsis of oesophagus (role not known)
Abnormal peristalsis of oesophagus (role not known)
Increased gastro
Increased gastro
-
-
oesophageal reflux symptoms and
oesophageal reflux symptoms and
dysphagia
dysphagia
Frequently tolerated
Frequently tolerated
Assumed to be
Assumed to be
‘
‘
normal
normal
’
’
by patients
by patients
Can be
Can be
reversible
reversible
when gastric band is deflated (presumed)
when gastric band is deflated (presumed)
Empirical evidence scant
Empirical evidence scant
Respiratory Complications of LAGB
Respiratory Complications of LAGB
(Postulated Assumption)
(Postulated Assumption)
Related to Oesophageal dilatation
Related to Oesophageal dilatation
Aspiration of
Aspiration of
oesophageal
oesophageal
contents
contents
Incidence not known
Incidence not known
Aspiration can lead to:
Aspiration can lead to:
Pneumonia
Pneumonia
Lung abscess
Lung abscess
Conclusions
Conclusions
Obesity
Obesity
–
–
“
“
Growing
Growing
”
”
epidemic
epidemic
Need urgent solution
Need urgent solution
Laparoscopic gastric banding
Laparoscopic gastric banding
Safe and effective bariatric surgery
Safe and effective bariatric surgery
Tampered normal anatomy and physiology
Tampered normal anatomy and physiology
Delayed pulmonary complications
Delayed pulmonary complications
Poorly recognised
Poorly recognised
Possible increase in incidence due to increase use of bariatric
Possible increase in incidence due to increase use of bariatric
surgery
Take Home Messages
Take Home Messages
Be alert for long term respiratory complications
Be alert for long term respiratory complications
Enquire about fever, respiratory symptoms and
Enquire about fever, respiratory symptoms and
regurgitation/vomiting of foods
regurgitation/vomiting of foods
Chest X
Chest X
-
-
ray is mandatory
ray is mandatory
CT Chest often will detect dilated oesophagus
CT Chest often will detect dilated oesophagus
Treat respiratory infections
Treat respiratory infections
Acknowledgments
Acknowledgments
Dr Elizabeth Veitch
Dr Elizabeth Veitch
Dr Niri Tillekeratne
Dr Niri Tillekeratne
References
References
1.
1. O. Alamoudi, Long Term Pulmonary Complications after Laparoscopic O. Alamoudi, Long Term Pulmonary Complications after Laparoscopic
Adjustable Gastric Banding.
Adjustable Gastric Banding. Obesity Surgery 2006 (16) pg 1685-Obesity Surgery 2006 (16) pg 1685-16881688
2.
2. M. Hofer et al, Recurrent Aspiration Pneumonia after Laparoscopic M. Hofer et al, Recurrent Aspiration Pneumonia after Laparoscopic
Adjustable Gastric Banding.
Adjustable Gastric Banding. Obesity Surgery 2007 (17) pg 565-Obesity Surgery 2007 (17) pg 565-567567
3.
3. P. O’P. O’Brien et al, Brien et al, Obesity, Weight Loss and Bariatric Surgery.Obesity, Weight Loss and Bariatric Surgery. Medical Journal Medical Journal
of Australia 2005; 183:6 pg 310
of Australia 2005; 183:6 pg 310--314314
4.
4. P.O’P.O’Brien et al, Brien et al, Laparoscopic Adjustable Gastric Banding in the Treatment Laparoscopic Adjustable Gastric Banding in the Treatment
of Morbid Obesity.
of Morbid Obesity. Arch Surg 2003;138 pg 376-Arch Surg 2003;138 pg 376-382382
5.
5. E. Zimlichman et al, Lung Abscess: An Unusual Complication of Gastric E. Zimlichman et al, Lung Abscess: An Unusual Complication of Gastric
Banding
The Gastric Band
The Gastric Band
Laparoscopic adjustable gastric band
Laparoscopic adjustable gastric band
Indications for LAGB
Indications for LAGB
The right balance ?
The right balance ?
Medicare Benefits Schedule
Medicare Benefits Schedule