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(1)

The Hidden Cost of

The Hidden Cost of

Gastric Banding

Gastric Banding

Wai Kuen Chow

Physician Advanced Trainee

Concord Repatriation Hospital

(2)

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

(3)

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

(4)

Case 1

Case 1

-

-

Findings

Findings

Clinical Examination

Clinical Examination

T 37.6

T 37.6

oo

C,

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

(5)

CT Chest

CT Chest

(6)

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

(7)

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

(8)

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

(9)

CT Chest

CT Chest

(10)

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

(11)

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

(12)

Case 3

Case 3

-

-

Findings

Findings

Clinical Examination

Clinical Examination

T 38.4

T 38.4

oo

C,

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

(13)

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

(14)

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

(15)

Case 4

Case 4

-

-

Findings

Findings

Clinical Examination

Clinical Examination

T 36.4

T 36.4

oo

C,

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

(16)

CT Chest

CT Chest

Dilated, fluid filled oesophagus

Ground Glass Changes in Right

Lower Lobe (Posterior)

(17)

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

(18)

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

(19)
(20)

The body weight perception

(21)

Obesity

Obesity

Major public health problem

Major public health problem

(22)

Obesity in Australia

Obesity in Australia

Body mass index > 30 kg/m

Body mass index > 30 kg/m

2

2

(23)

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

)

)

(24)

Which Is The Preferred Procedure ?

Which Is The Preferred Procedure ?

No. of cases

LAGB = 90%

RYGB = 10%

(25)

The Key Attributes

The Key Attributes

(26)

Percentage of Excess Weight Loss

Percentage of Excess Weight Loss

Gradual weight loss

at 2 years

Stable weight loss

(50%)
(27)

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

(28)

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

(29)

Published Case Reports

Published Case Reports

(30)

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

(31)

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

(32)

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

(33)

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

(34)

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

(35)

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

(36)

Acknowledgments

Acknowledgments

Dr Elizabeth Veitch

Dr Elizabeth Veitch

Dr Niri Tillekeratne

Dr Niri Tillekeratne

(37)

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

(38)
(39)
(40)

The Gastric Band

The Gastric Band

(41)

Laparoscopic adjustable gastric band

Laparoscopic adjustable gastric band

(42)

Indications for LAGB

Indications for LAGB

(43)

The right balance ?

The right balance ?

(44)

Medicare Benefits Schedule

Medicare Benefits Schedule

References

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