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Other potential postoperative complications

a) Bleeding

In the abdominal cavity: Very rare
Abdominal wall, subcutaneously (subcutaneous tissue): Relevant hematomas requiring surgical treatment are very rare

b) Infections

With the relative hyper-perfusion of fat tissues (e.g. in comparison to muscles) and the resulting impaired accessibility for the immune system, theoretically, infections should occur at higher rates. This has not yet been proven though. No early infections have been recorded so far. Regardless, antibiotic protection (e.g. 2nd-generation cephalosporins as used in our clinic) is applied considering that foreign matter is being implanted into the body.

Abscess formation (encapsulated accumulations of pus) not related to the implant (gastric band) may be left untreated under certain circumstances. If the gastric band is part of the process or the origin of the infection is in doubt, the whole system, including the port, must be removed immediately while applying antibiotic protection. The infection may be caused primarily (by bacterial invasion during implantation using non-sterile instruments or materials) or secondarily (by infection of the band through progressive infection of the port and small undetected injuries to the abdominal wall). It is rather easy to determine the type by examining the bacterial spectrum (skin bacteria or contamination bacteria as opposed to bacteria only found in the gastro-intestinal tract.

c) Incisional hernias

Abdominal wall hernias (breakthroughs), so-called port-site-hernias in the area of the trocar insertions, are known to occur after laparoscopies. In our experience, these are rarely symptomatic and usually small in morbidly obese patients; therefore, their rate of occurrence is unknown. They occur comparatively frequently after open surgery and cause serious complaints due to their size.

d) Port system complications

Infections (<1%):

This requires immediate removal of the port to prevent the infection from progressing to the band and into the abdominal cavity along the catheter. The port can be replaced after recovery. Secondary infections of the port due to gastric fistulas are even rarer. If this occurs, the whole gastric band system must be removed.

Broken catheters:

After an initial increase in the occurrence of fatigue fractures at typical weak points close to the port as well as at the adapter piece during increasing weight-loss, the implantation method was adjusted and the manufacturer made appropriate modifications (to avoid snap-off). This type of complication is no longer being reported.

Port-pains:

Complaints in the area of the port or along the catheter are rare (1 – 2%). Typically though ports are perceived as being disturbing or there are even twinge-type pains within the first 4 – 6 weeks following surgery, especially in ports positioned over the costal arch. The advantage of this "oncological" placement is that the port may be punctuated much more easily without having to use an x-ray image amplifier. Thus, females who may not know they are in the early stages of pregnancy will not be subjected to radiation. Port pains remaining over a longer period of time require a transplant operation of the port, which should be removed and exchanged for a smaller model if it involves an older implant.

e) Stoma occlusion

Unchewed chunks of food (meat pieces, fondue, oysters, etc.) may cause a shifting gastrostoma with subsequent complete halt of food and liquid passage. Thus, it is of utmost importance to chew very consciously. Certain foods may have to be avoided completely under certain circumstances, especially with repeated vomiting (long-grained vegetables, legumes, coarse-grained meats, pasta).

Initially an attempt is made to remove the congestion by opening the band and drinking fluids. If this is unsuccessful, a gastroscopy is almost always sufficient. If congested for more than 6 hours the band should remain open for approx. one week, and acid reducing treatment should be implemented to treat inflammation and swelling of the mucous membrane.

If the time needed to restore passage through the band exceeds 6 hours, then there is a risk of acute pouch extension with stomach rupture. In this case, emergency intervention with partial stomach removal will be necessary.

f) Gastric band erosion

An erosion of the stomach or penetration of the stomach wall by the band occurs very rarely (<1%). It normally occurs more than one year after the surgery. The causes of this are still being discussed but may include: primary occult (undiscovered) stomach wall injuries, pressure-related stomach wall necrosis caused by strong filling of the band or a secondary infection along the band system. There may be a complete lack of symptoms or the only sign may be stagnation of weight progress – or there may be complaints related to an infection of the upper abdomen, bleeding, etc. Diagnosis is made after decongesting the band by means of a gastroscopy, which enables viewing of the whole band and not only the constricted part at the stomach entrance.

Treatment consists of removal of the band and securely closing the stomach wall. If the stomach wall was penetrated completely, the band may be salvaged endoscopically after severing the catheter.

g) Oesophageal deviations

Severe deviations in the function (dysfunctional movement, motility) and anatomy of the oesophagus after stomach-restrictive surgery using gastric bands have indeed come to be viewed with some importance after their severity was initially rather underestimated. How often and how long after surgery they appear, under optimal conditions and operative techniques, is unclear so far.

Oesophageal dysfunctions are usually indicated by discomfort. They may either result from continuing increased pressure on the oesophagus, or by the effects of exposure to stomach acids with the corresponding inflammatory reactions of the mucous membrane. Should these dysfunctions manifest themselves, they may be visualised radiologically, endoscopically and by corresponding pressure and acid measurements. This allows for diagnostic differentiation and determination of further treatments. Proactive scrutinisation of symptoms during after-care is imperative in order to ensure a timely response. In addition, non-symptomatic diseases of the oesophagus should be ruled out using a gastroscopy.

If the oesophageal diseases cannot be controlled over a longer period of time by adjusting the band, eating habits, or drugs, removal of the gastric band must be considered. Unfortunately, the weight-loss achieved cannot usually then be maintained and no further weight reduction is possible. Thus, in this case, performing an alternative adiposity surgery may become necessary (e.g. transformation surgery to create a stomach bypass).

h) Gallstone development

The quicker weight is lost, the more often gallstone development is observed. If there are pre-existing gallstones before a gastric band insertion, the normal procedure at our clinic is to perform a gallbladder removal.