Surg Endosc (2008) 22:1482–1486 DOI 10.1007/s00464-007-9651-8
Esophageal dilation after laparoscopic adjustable gastric banding L. Milone Æ A. Daud Æ E. Durak Æ L. Olivero-Rivera Æ B. Schrope Æ W. B. Inabnet Æ D. Davis Æ M. Bessler
Received: 18 May 2007 / Accepted: 29 August 2007 / Published online: 20 November 2007 Ó Springer Science+Business Media, LLC 2007
Abstract Background Esophageal dilation can occur after laparoscopic adjustable gastric banding (LAGB). There are few studies in the literature that describe the outcomes of patients with esophageal dilation. The aim of this article is to evaluate weight loss and symptomatic outcome in patients with esophageal dilation after LAGB. Methods We performed a retrospective chart review of all LAGBs performed at Columbia University Medical Center from March 2001 to December 2006. Patients with barium swallow (BaSw) at 1 year after surgery were evaluated for esophageal diameter. A diameter of 35 mm or greater was considered to be dilated. Data collected before surgery and at 6 months and 1, 2 and 3 years after surgery were weight, body mass index (BMI), status of co-morbidities, eating parameters, and esophageal dilation as evaluated by BaSw. Results Of 440 patients, 121 had follow-up with a clinic visit and BaSw performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of 40.9 ± 4.6 mm. There were no significant differences in percent of excess weight lost at any time point; however, GERD symptoms and emesis were more frequent in patients with dilated esophagus than in those without dilation. Intolerance of bread, rice, meat, and pasta was not different at any time during the study.
L. Milone A. Daud E. Durak L. Olivero-Rivera B. Schrope W. B. Inabnet D. Davis M. Bessler (&) Department of Surgery, Minimal Access Surgery Center, Columbia University College of Physician and Surgeons, 630 West 168 Street, New York, New York 10032, USA e-mail:
[email protected]
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Conclusions In our experience the incidence of esophageal dilation at 1 year after LAGB was 14%. The presence of dilation did not affect percent excess weight loss (%EWL). GERD symptoms and emesis are more frequent in patients who develop esophageal dilation. Keywords Morbid obesity Obesity surgery Laparoscopic adjustable gastric banding Esophageal dilation
Laparoscopic adjustable gastric banding (LAGB) is one the most frequently performed surgical procedure to treat obesity both in Europe and in the United States. According to the manufacturers, over 250,000 procedures have been performed. Many complications such as erosion, slippage, leak, and obstruction have been described in the literature [1, 3, 7]. Many of these complications require surgical treatment [5, 8]. Less attention has been paid to esophageal dilation as a problem after LAGB. Patients with a gastric band are more susceptible to esophageal dilation because of the resistance to passage of food after it enters a small gastric pouch. This may be especially true if the band is too tight. Little is known about the risk factors for esophageal dilation, which has been hypothesized to be due to an overly tight band, underlying esophageal motility problems, or both. DeMaria et al. reported 18 of 25 patients (71%) with esophageal dilation after LAGB placed as part of the first trial with Lap-Band in the United States. Of these, 13 (72%) had prominent dysphagia, vomiting, or reflux [4]. Dargent, reporting his series of 1,232 patients undergoing LAGB, describes 8 patients (0.6%) with esophageal dilation; he reports no significant correlation between dilation and insufficient weight loss after 5 years [2].
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The aim of the present study was to evaluate the incidence, weight loss, and symptomatic outcome in patients with esophageal dilation after LAGB.
Methods We performed a retrospective review of patients who underwent LAGB at Columbia University Medical Center from March 2001 to December 2006. A standard 5-trocar pars flaccida technique was used to place the adjustable gastric band, as described previously [6]. The first two follow-ups were scheduled at 2 at 6 weeks and thereafter patients returned monthly for the first year and then every 6 months thereafter. All patients were required to undergo a barium swallow (BaSw) before filling of the band at 6 weeks and again at 6 months, 1, 2, and 3 years to evaluate the status of the band pouch, stoma, and esophagus. Barium swallow was performed using single contrast under fluoroscopy and was interpreted by an attending radiologist. The known measurements of the Lap-Band were used as an internal control for magnification of the images, as accurate measurements are not possible without a known reference. An esophageal diameter of 35 mm or greater was considered dilated. Parameters recorded before surgery and at 6 months, 1, 2, and 3 years after surgery were weight, body mass index (BMI), percent of excess weight lost (%EWL), status of comorbidities, gastrointestinal complaints, and BaSw results as captured in the radiology reports. Eating behavior as volume of food consumed at each meal, frequency of meals, food intolerance, as well as volume of fluid in the band and adjustments made at each visit were recorded. Adjustments were performed at the bedside without fluoroscopy and were tailored to achieve early satiety without frequent emesis or GERD symptoms. GERD-like symptoms and emesis were indications for decreasing fill volume, as was esophageal dilation seen on BaSw. T-test and chi-square were used to evaluate the statistical significance of continuous and discrete variables, respectively, using Stat-View software.
Results A total of 440 patient records were reviewed; 121 had a BaSw available at 1 year and were included in the study. Of these, 17 (14%: 10 women and 7 men), were found to have esophageal dilation, with an average esophageal diameter of 40.9 ± 4.6 mm (Figs. 1 and 2). Demographics of the dilated and non-dilated group were similar, except for higher weight and a trend toward higher BMI in the dilated group (Table 1).
1483 Table 1 Patient demographics Dilated
Not dilated
p Value NS
Age
43.7 ± 14.1
43.0 ± 11.8
Gender, % female
58.8
72.1
NS
Initial weight
338.6 ± 107.3
295.6 ± 61.5
\0.02
Initial body mass index (BMI)
52.1 ± 13.3
47.2 ± 7.5
\0.056
In this series, 112 patients had a 10-cm Lap-Band implant, and 9 had a VG band. Table 2 shows the incidence of dilation at 6 months as well as 2 and 3 years for the 17 patients found to be dilated at 1 year. Figure 3 shows the average esophageal diameter of the dilated group at baseline 1, 2, and 3 years. There was no difference at any time point in %EWL between the 2 groups; p = 0.40 at 3 years (Fig. 4). The average fill volume of the band at 6, 12, 24, and 36 months was similar for patients with 10-cm bands in the two groups (Fig. 5) Patients with VG bands were not included in this volume analysis, because the VG band has a greater volume capacity and there were too few VG band patients to evaluate separately. The incidence of reported GERD-like symptoms and emesis are shown in Figures 6 and 7; patients with esophageal dilation were significantly more likely to report such symptoms. Of patients with dilation 29% were asymptomatic. Three was no difference between groups in food intolerance at any time points.
Discussion Laparoscopic adjustable gastric banding procedures are being performed in increasing numbers in the United States and continue to be performed in large numbers in the rest of the world. The length and content of follow-up after patients have reached a stable weight and fill volume has not been well defined. A significant minority of patients, 14% in this study, have been demonstrated to develop esophageal dilation in the year after having LAGB. While some patients are symptomatic and may present for evaluation, many are asymptomatic and may not be discovered without routine radiographic evaluation. In fact five (29%) Table 2 Incidence of dilation at 6 months, 1, 2 and 3 years Dilated (%)
Not dilated (%)
6M
14 (11.6)
1Y
17 (14)
76 (62.8)
2Y
14 (11.6)
59 (48.8)
3Y
7 (5.8)
26 (21.5)
104 (85.9)
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Fig. 1 Normal esophagus
of our patients with esophageal dilation were completely asymptomatic. Even in practices where adjustments are done with fluoroscopic guidance, dilation may not be discovered if patients are asymptomatic with good weight loss, and therefore are not adjusted. Routine BaSw to evaluate for esophageal dilation would seem prudent. The questions remain, however, for how long should this be followed and what are the consequences of unrecognized and therefore untreated esophageal dilation in the LABG population? The concern, of course, is that, left untreated, progressive dilation will occur and eventually, as in achalasia, the esophagus will become aperistaltic. This is by no means a certainty, as the primary defect in achalasia is neural dysfunction, which leads to aperistalsis, and the dilation is secondary to the consequent lack of lower esophageal sphincter relaxation. It is possible and even likely that normal esophageal function would be regained after band emptying or removal, even in the presence of significant dilation. Evaluation of esophageal function in patients with dilation would be an interesting and valuable study. What is the best definition of esophageal dilation? Dargent discusses stages in the progression of dilation based on peristalsis and resolution with band emptying but does not give size criteria [2]. Change over baseline by
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Fig. 2 Dilated esophagus
Fig. 3 Average of esophageal diameter of dilated group at baseline, 1, 2, and 3 years
30% was the measure used in the report by DeMaria et al. [4]. While this definition has the advantage of not requiring a known internal reference for control of magnification, it also requires that a baseline study be available. In addition, it is unclear what level of increase over baseline would represent dilation. Normal esophageal diameter has not been well defined in the literature, so we chose an upper limit of normal at 34 mm based on discussion with the radiologists at our institution. We recognize that this is a
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Fig. 7 Percent of patients with emesis (p \ 0.05 at 2 and 3 years) Fig. 4 Percent EWL between dilated and not dilated patients (p = 0.40)
Table 3 Meal volume and frequency Dilated
Not dilated
6M
8.1/3.8
8.4/3.6
1Y
8.9/3.8
9.1/4.2
2Y
8.8/4.1
8.5/3.8
3Y
10.3/3.9
11/2.7
Fig. 5 Filling volume of the band at 6 m, 1, 2, and 3 years
Fig. 8 Percent of patients with food intolerance
Fig. 6 Percent of patients with GERD (p \ 0.05, at 1 and 3 years)
relatively arbitrary definition. Interestingly, the average percent increase from baseline was 43% in our group of patients with esophageal dilation, which is similar to the definition chosen by DeMaria et al. [4]. It was our hypothesis entering this study that esophageal dilation would not only be associated with GERD-like symptoms but also with lower %EWL (Fig. 6). This hypothesis was based on the theory that the dilated esophagus would act as a reservoir and defeat the restriction associated with a small pouch. In addition, because the treatment for dilation is to remove fluid from the band,
patients with dilation might not continue to have the same restriction. This hypothesis is not supported by the results of this study. In fact %EWL was similar, as were meal volume and frequency (Table 3). Our data stand in contrast to those reported by Wiesner et al., who found poor weight loss in patients with esophageal dilation with lower esophageal sphincter (LES) insufficiency [9]. Emesis and GERD-like symptoms were more common in the dilated group, perhaps as a consequence of the large esophageal reservoir (Figs. 6 and 7). Food intolerance was more prevalent in the dilated group at 6 months, perhaps indicating a too tight band or poor eating behavior at that time, and the lack of statistical significance may be related to low power (Fig. 8). This food intolerance resolved by one year, which may be due to the dilation itself, improved eating behavior, or loosening of the band in symptomatic patients.
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In conclusion, esophageal dilation is not an infrequent occurrence after LAGB and is associated with increased GERD symptoms and emesis, although some patients remain asymptomatic. Esophageal dilation in the first year after LAGB responds to conservative treatment with dietary education and band deflation, and it does not appear to have a negative impact on weight loss.
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Surg Endosc (2008) 22:1482–1486 4. DeMaria EJ, Sugerman HJ, Meador JG, Doty JM, Kellum J, Wolfe L, Szucs RA, Turner MA (2001) High failure rate after Laparoscopic Adjustable silicone gastric banding for treatment of morbid obesity. Ann Surg 233;908–818 5. Fan FC, Hong D, Pereira N, Patterson EF (2005) Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: A single-institution comparison study of early results. J Gastrointest Surg 9:30–41 6. Lew JI, Daud A, DiGorgi L, Olivero-Rivera L, Davis DG, Bessler M (2006) Preoperative esophageal manometry and outcome of laparoscopic adjustable silicone gastric banding. Surg Endosc 20:1242–1247 7. Rao AD, Ramalingam G. (2006) Abstract exsanguinating hemorrhage following gastric erosion after laparoscopic adjustable gastric banding. Obes Surg 16:1675–1678 8. Sarker S, Herold K, Creech S, Shayani V (2004) Early and late complications following laparoscopic adjustable gastric banding. The Am Surg 70:146–150 9. Wiesner W, Hauser M, Schob O, Weber M, Hauser RS (2001) Pseudo-achalasia following laparoscopically placed adjustable gastric banding. Obes Surg 11:513–18
