Kulvinder S. Bajwa

Past, present, and future: Critical analysis of use of gastric bands in obese patients

Adjustable gastric banding (AGB) is quickly becoming the most popular bariatric operation performed in the United States and Canada. Patients are particularly fond of the simplicity of the tool, the relatively low morbidity of the surgery, the quick recovery, and overall results. The gastric band has evolved over its 35-year history into a very successful adjustable tool used to restrict food consumption and limit caloric intake. The percent of excessive weight loss after banding can range from 30%–60% and depends on the time out from surgery. Along with weight loss, there is good resolution of the co-morbid conditions that are associated with excess weight and improvements in quality of life demonstrated after banding. Nutrition and follow up are extremely important after banding to ensure good compliance and adequate weight loss. Failure to follow the postoperative diet, exercise regiment, or mechanical failure of the band can lead to failure to lose adequate weight. While there are particular early and late complications associated with this surgery, the safety profile of the AGB is very appealing when compared to other bariatric operations. As we continue to reduce the morbidity of the procedure, the simple adjustable band concept has a lot of potential to remain a primary technique of maintaining long term weight loss. In conclusion, AGB has and continues to play an important role in the treatment of morbid obesity. It offers reasonably good weight loss results with very little morbidity, and the future of the adjustable band is bright.

Cytomegalovirus Enteritis Manifesting as Recurrent Bowel Obstruction and Jejunal Perforation in Patient with Acquired Immunodeficiency Syndrome: Rare Report of Survival and Review of the Literature

BACKGROUND Cytomegalovirus (CMV) enteritis presenting with perforation in the setting of acquired immunodeficiency syndrome (AIDS) represents a particularly deadly combination. METHODS Case report and review of the pertinent literature. CASE REPORT The authors report a patient with AIDS and CMV enteritis presenting as recurrent small-bowel obstruction and leading to perforation of the jejunum with subsequent survival. CONCLUSION This is believed to represent the second case in the English-language literature of survival after CMV-induced small intestinal perforation in a patient with AIDS.

A Randomized Trial Comparing Reflux Symptoms in Sleeve Gastrectomy Patients with or without Hiatal Hernia Repair

BACKGROUND The effect of laparoscopic sleeve gastrectomy (SG) on reflux symptoms is unclear. Many surgeons offer SG only to patients with minor or no reflux symptoms, fearing that patients with severe reflux symptoms will experience worsening of their condition after SG. Many also advocate crural repair at the time of SG to prevent de novo or worsening reflux symptoms. These decisions are made without suitable data to form such conclusions. OBJECTIVE To determine the effect of SG with or without hiatal hernia repair on reflux symptoms. SETTING University of Texas Health Sciences Center in Houston. METHODS The Gastrointestinal Symptom Rating Scale (GSRS) was administered to 100 consecutive, preoperative SG patients who were then randomly assigned into a crural repair group or nonrepair group in a parallel design. The patients were subsequently followed-up every 3 months for 1 year. We compared reflux symptoms of the 2 groups on the basis of demographic characteristics, body mass index, weight loss, presence and size of hiatal hernia, and GSRS for 12 months. RESULTS At 1 year, with 78% follow-up, the data demonstrated a significant decrease in the GSRS for both groups (P<.001); however, there was no difference between the groups (P = .35). Age, starting body mass index, percent excessive weight loss, and hiatal hernia size did not correlate with change in the GSRS score. The only variable that affected outcome was the preoperative GSRS. At 12 months, 38% of patients with a preoperative GSRS score less than the median score of the study population experienced worsening of their symptoms compared with only 2% of patients who had a preoperative GSRS score greater than the median. Overall, 19% experienced worsening reflux (5% de novo), 14% had no change, and 66% reported an improvement in symptoms. CONCLUSION These data suggest that a crural repair at the time of SG does not significantly reduce reflux symptoms compared with SG alone. Preoperative patients with significant reflux symptoms experienced a more significant improvement in symptoms after surgery compared with those who did not report significant reflux symptoms before surgery. The high incidence of reflux after SG observed in the current literature may be a result of a specific patient subpopulation who undergoes SG because of surgeon bias rather than an inherent property of SG itself or the presence of a hiatal hernia.

Portal vein thrombosis after laparoscopic cholecystectomy

Portal vein thrombosis should be included in the differential diagnosis for abdominal symptoms and/or elevated hepatic function tests after laparoscopic cholecystectomy.

Simultaneous left ventricular assist device placement and laparoscopic sleeve gastrectomy as a bridge to transplant for morbidly obese patients with severe heart failure

From the Department of Surgery, University of Texas Medical School at Houston, Houston, Texas; Division of Critical Care, Pulmonary and Sleep, University of Texas Medical School at Houston, Houston, Texas; Center for Advanced Heart Failure, University of Texas Medical School at Houston, Houston, Texas; and the Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, Texas.

Words of Caution Regarding Adjustable Gastric Band Tubing

Introduction: With the decreasing popularity of adjustable gastric band (AGB) placement and the increase in explants of the devices, for erosion, slips, or inadequate weight loss, in performing revisional surgery, it is of vital importance for surgeons to understand the problems that may arise during removal. This case involved an uncommonly reported complication of fractured band tubing resulting in incomplete removal of the tubing during revisional bariatric surgery, with reoperation necessary for complete removal. In the course of the procedure, a small-bowel tumor was identified. Case Description: We present a 35-year-old woman who underwent conversion of a laparoscopic AGB to a sleeve gastrectomy. Failure to recognize a fracture in the band tubing resulted in retained tubing and readmission secondary to abdominal pain. During reoperation to remove the retained tubing, a small-bowel gastrointestinal stromal tumor (GIST) was incidentally identified and resected. Discussion: This case highlights a rarely reported complication of fractured gastric band tubing, resulting in incomplete removal of the tubing during revisional surgery, with the incidental discovery of a GIST in the small bowel.

Retained Gastric Band Tubing Resulting in Large Bowel Obstruction

Introduction: Complications due to retained gastric band tubing are rarely reported and frequently include disconnections of the tubing requiring operative revision. Obstruction from adjustable gastric band tubing is an infrequently reported event. Case Description: The patient presented to us 1 month after removal of a presumed isolated infected port performed at an outside facility. The wound was left open, but the intra-abdominal tubing and band were left in place. Abdominal distention, pain, and peritonitis developed, and the patient was taken to the operating room because of concern regarding an acute intra-abdominal process. Intraoperatively, he was noted to have a sigmoid obstruction from the retained gastric band tubing. Discussion: Although obstruction from adjustable gastric band tubing is infrequently reported in the literature, it poses a potentially devastating complication. We review the relevant literature and potential issues when dealing with band-related tubing.

Bouveret syndrome: current management strategies

Bouveret syndrome is a rare complication of cholelithiasis that usually presents with signs and symptoms of gastric outlet obstruction. Given the relative rarity of this condition, there are no standardized guidelines for the management of this condition. In this paper, we review the diagnosis and management options (endoscopic, laparoscopic, and open approaches) of patients with Bouveret syndrome, including a report of one case to illustrate some of the endoscopic and surgical principles of management.

Erosion of Gastric Band Tubing Presenting as Port-Site Cellulitis

Introduction: Long-term outcomes of laparoscopic adjustable gastric band (LAGB) placement have shown suboptimal excess weight loss and higher than expected device-related complications. Case Description: We report a 45-year-old woman in whom the adjustable gastric band tubing eroded into the stomach, causing a port-site infection. Conclusion: Because of the number of LAGB procedures performed previously and the incidence of band-related complications, surgeons must be able to recognize and manage these complications. Erosion of the gastric band or the connection tubing or both should be included in the differential diagnosis for patients presenting with a port-site infection.