Postoperative complications:
Pouch complications
Pouch dilatations (Enlargement of the pouch)
- Fig. 10: Concentric pouch dilatation
There are several different forms; namely early and late stage, and acute and chronic pouch enlargements. An early dilatation may occur a few weeks after surgery; this is usually caused by an incorrectly positioned band. The main effect of this is creation of a pouch that is too large. The late-stage form manifests itself after weeks, often even after a year, and is usually caused by abnormal eating habits like meal sizes that are too large (possibly even pre-operative binge-eating), or a gastrostoma that is too constricted. This may also include sliding hiatal hernia (diaphragmatic hernias with an upwards-shifting stomach entrance) in front of an otherwise well-positioned band. Radiological visualisation will show a concentric pouch. If left untreated, the dilatation may progress into real "slipping," including upwards-shifting of the stomach wall below the band.
Slippage
- Fig. 11: Dorsal Slipping
Shifting upwards of the rear (dorsal slipping) or front (anterior slipping) stomach wall through the band. This is a typical post-stomach-band operation complication, mainly caused by operational circumstances. As described in international literature, it is nowadays reduced to below 1%. Upon introducing a contrast medium, the pouch will look excentric on x-rays. Mechanism: Due to the enlargement of the pouch, a valve-like mechanism occurs, in which passage to the main stomach is progressively obstructed by parts of the stomach wall (partial to complete stoma occlusion). Passage in reverse order is still possible though (reflux from the main stomach to the pouch or the oesophagus).
- Fig. 12: Anterior Slipping
Ailments and symptoms
There are acute (suddenly occurring) and chronic ailments, which occur similarly in both forms of pouch complications. While pouch dilatation initially causes meal sizes to become larger followed by vomiting, subsequently, as the pouch gets increasingly larger, a similar situation as with slippage can occur, in which parts of the stomach wall can cause a shift of the gastrostoma or other inflammations progressively obstruct the passage. This is reflected in intolerance towards solid foods and then to liquid foods until there is a complete stoppage in passage.
Chronic:
- Increasing passage disorders for solid foods; Repeated vomiting after meals; Regurgitations (back-flow of food-remains, burping), occurring at night also.
- Progressively increasing capacity limitations even for liquids; Drinking only possible in little sips; solid foods not tolerated anymore at all.
- Excessive weight-loss, reflux symptoms (pain or burning sensation behind the breast bone), general complaints like tiredness, deficient nutrition
- Any chronic form can escalate into an acute form.
Acute:
- Complete halt of passage (total food intolerance)
- Consequences of untreated total food intolerance: Dehydration (fluid deficiency), shock condition (reduction in blood volume), electrolyte imbalance (disturbed blood/salinity balance), prerenal failure (kidney failure caused by dehydration), extremely heightened risk of aspiration mostly at night (breathing reflux stomach contents into the airways causing a risk of pneumonia)
Therapy
a) Conservative
If dilatation caused by an overly constricted stomach band occurs in isolation, without any upwards shifting of stomach wall parts, then conservative therapy should be sufficient.
- Completely opening the stomach band (decongest)
- Insertion of a gastric tube to relieve the pouch and avoid aspiration
- Immediate rehydration (administration of fluids), balancing electrolytes via IV (intravenous infusion of saline solution)
- Administration of antacid (e.g. Omeprazol): to protect against or treat mucosal changes within the pouch
- Deficiencies: Substitutive therapy (iron, vitamins, etc.)
- Parenteral nutrition (feeding completely by infusing into a central vein): Seldom; Only in cases of decompensation combined with malnutrition, where enteral nutritional intake is not possible despite decongestion of the band and other measures.
b) Re-operating
Laparoscopic revision is demanding and requires extensive experience in this technique. Most of the time, a replacement of the stomach band or a repositioning using the laparoscopic technique is sufficient.
- Band repositioning:
Repositioning of the band without exchanging it is usually only possible in the early stages of pouch complications; however, it is almost always done using the laparoscopic technique. The part of the stomach that has slipped upwards through the band is pulled back down, and the band is then re-fixated. This requires that there be no extreme concrescences to the band itself and that the pouch not be highly vulnerable due to inflammation. - Band replacement:
If late pouch complications occur (after months or even years), the stomach band will have to be replaced, usually using the laparoscopic technique. When doing so, it is cut close to the seal and pulled out of its connective tissue membrane, and a new band is inserted in the proper position.
Pouch rupture
Rupture of the pouch is a very rare complication (described in the literature by Götzen, 1998) in which, during the course of a pouch dilatation, after excessive consumption of carbonated beverages, the pouch will burst and spill its contents into the abdominal cavity. This may also occur due to complete congestion of the pouch passage to the main stomach because of a pileup of food (band occlusion).
This consists of acute abdominal symptoms (acute abdomen) requiring emergency surgery to remove the band and securely close the stomach due to the stomach rupture.