Of the three main operations for weight loss in the US, the Adjustable Gastric Band (AGB) has the highest failure rate. Commonly, this is because there is no degree of adjustment that results in significant weight loss without also producing unpleasant symptoms. These symptoms include vomiting, intolerance of any solid food, chest pain, coughing, heartburn and other symptoms of reflux (e.g. regurgitation of fluid or food when lying flat). In these cases the patient lacks a “therapeutic window”, to use a surgeon’s term. Of course there are less common complications that make the band ineffective or even require its removal – band slippage or prolapsed, pouch dilatation, erosion, ineffective esophageal motility, hiatal hernia, etc. Any of these problems might require surgical correction with or without removal of the band. Recurrent problems, such as repeat prolapse, probably mean that gastric banding should be abandoned as a weight loss option.
For those patients who have failed the AGB, or who have had success prior to a complication, the good news is that the banding operation does not change the anatomy of the stomach very much. This means that the other surgeries are still an option. It must be understood, however, that a repeat operation does carry some additional risk compared to one where there has been no surgery on the stomach. In general, there is some increased risk of significant bleeding, post-operative leak, and conversion to an open operation from a laparoscopic one for both the Gastric Sleeve and the Gastric Bypass procedures. The quantification of this risk is difficult; however, it should be minimized if done by an experienced laparoscopic bariatric surgeon who routinely performs all three operations.
Currently, for those patients who have failed the AGB and still desire a surgical solution to their excess weight, I recommend conversion of the AGB to a Laparoscopic Sleeve Gastrectomy(LSG), also known as the Gastric Sleeve Operation. This can almost always be completed using the laparoscopic technique in less than 1 ½ hours. Five small incisions are made to allow the scope, instruments and a liver retractor to be placed into the abdominal space. The AGB must be removed – including the subcutaneous port – and the fundus of the stomach must be disconnected from the small pouch. Once this is done a sizing device called a bougie is passed from the mouth down into the stomach, and positioned along the lesser curve (the side of the stomach closer to the patient’s midline). With the bougie in place a surgical stapler is used to divide the stomach from the distal end to up near where the esophagus enters it. This creates a narrow tube of stomach (slightly bigger around than the bougie). The lateral part of the stomach is removed through the incision where the AGB port used to be.
After the operation the patient is helped to get up and walk 2 hours later, and a clear liquid diet is also started at this time. The patient is kept overnight to monitor for bleeding or signs of a leak. Occasionally, depending on circumstances during the surgery a contrast x-ray study may be done. Most patients will go home the following morning. The remainder of the post-operative period should proceed as it would for a person who was having a primary operation (please see “After Gastric Sleeve Surgery” from the After Surgery menu).
In our patients who have undergone conversion we have seen an immediate resumption in weight loss. Patients relate that the biggest difference is the lack of hunger after Gastric Sleeve when compared to AGB. This could be due to decreased Ghrelin levels because of the portion of stomach removed (see “How does a gastric Sleeve Work” in the Operations menu). It is my opinion that the Gastric Sleeve is an excellent choice for a salvage operation after failed AGB.