HOLLYWOOD, FLA. — Undiagnosed hiatal hernias or large hiatal crural defects account for many failed laparoscopic adjustable gastric banding procedures, and correcting these defects can obviate band removal, George A. Fielding, M.B., reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.
In one series of 2,450 patients who underwent laparoscopic adjustable gastric banding (LAGB), 5% experienced symptomatic failure.
Most of these failures were a result of reflux or dysphagia, and many of the patients were found to have a hiatal hernia or large hiatal crural defect, Dr. Fielding wrote in the “poster of distinction” that he presented at the society meeting.
Such patients are now offered repair of the hernia or crural defect. Of those who presented with severe reflux at a mean of 44 months following LAGB, all were on proton pump inhibitor therapy, nine were considering band removal, four had severe dysphagia, nine had hiatal hernia/concentric dilatation, and six had slipped bands.
At an average of 15 visits, the mean band fill was only 1 cc; nine of the patients had empty bands.
A total of 23 patients underwent repairs: 13 had crural defect repair alone, the 4 with severe dysphagia also had a change to an 11-cm band, and the 6 with slipped bands also had repair of the slips, wrote Dr. Fielding of New York University Medical Center, New York.
At a mean follow-up of 13 months, patients had a mean of four postoperative visits and a mean band fill of 2 cc in the standard bands.
All patients were no longer taking proton pump inhibitors and were asymptomatic and reported being satisfied with the bands.
In the 14 months since LAGB, symptomatic patients have been offered defect repair as an alternative to band removal, no bands have been removed, compared with removal of a mean of 10 per year in previous years, Dr. Fielding reported.
The repair of hiatal hernias and large hiatal crural defects will cure reflux symptoms and greatly reduce the need for band removal in LAGB patients with persistent reflux symptoms, allowing band tightening as appropriate, he concluded. Dr. Fielding also noted that surgeons should look for and repair such defects at the time of the original LAGB surgery.