1. Unbuckling the Band Recycling the Band and Rehabilitating the Patient Terry Simpson MD, FACS – Virginia Mason 1991

2. Classic Band Slip 2 yrs post Lap Band with Complete Obstruction

3. The Lap Band 500,000 bands placed in US since introduction in 2001 Most weight loss surgeons placed bands in their practice Direct to Consumer Marketing made it the most asked for weight loss operation Responsible for the Rise in Gastric Sleeve Operations Difficulty with instructions and follow up had increased rate of band failure compared to band dedicated practices

4. What Won’t Work Instructing patients that the band will make them “feel full” or “feel satisfied” leads to poor results This leads to eating fast, loading the stomach pouch above the band and leads to slips The patient presented chronically ate fast and noticed reflux and heartburn for the previous two months. GI placed on Nexium

5. Increased pressure in upper pouch leads to pouch dilation as well as a slip of stomach coming up through the band. Either from people eating too fast, or stuffing the upper pouch with food to feel “full.” This leads to reflux, heartburn and what is called an “early” band slip.

6. Classic Band Slip

7. Most patient can be treated by removing fluid from the band and placing them on a liquid diet. About 85% improve with this regimen. However, some present with complete obstruction

8. Problems with Traditional Repair Standard revision leaves thinned out pouch that can later perforate Removal of band solves the issue but leads to weight regain Conversion to other bariatric procedures has a high rate of complications

10. Lap Band Slip 3876 patients banded, 411 (11%) had band revised for pouch related problems. 2% had band removed. 3% converted to another procedure Most often treated by removing fluid from the band and placing patients on a liquid diet If not satisfactory then patient will require surgery

11. Surgical Treatment Morbidity and Mortality of conversion to gastric sleeve includes 5.5% rate of “leak” Conversion to RNY has leak rate of 3% Removal of band solves issue but loss of weight loss tool leads to increased weight gain The plan is removing the pressure from the stomach- hence, why not unbuckle – a new procedure

12. Classic Band Slip

13. Unbuckling the band there was a large amount of scar tissue beneath that would not even admit a 32 French (10 mm) gastric tube. After lysis easily admits 90 French balloon (30 mm). Immediate relief in the post operative recovery room, able to drink fluids without reflux or heartburn

14. Two Months Later 2 months later- band buckled – op time 12 minutes Patient able to eat and drink without difficulty now 4 years out

15. Unbuckling the Band 63 cases of unbuckling and re-buckling the band done since 2010 Most re-buckled in two months- some re-buckled as long as two years later No mortality 5 cases needed to be repositioned after two months or more of unbuckling 3 patients had recurrence of slips- all from maladaptive eating behavior Allowed patients to “keep” their band Done acutely and allowed patients to be discharged that day or done as an outpatient procedure

16. Re-buckling the Band It is a second procedure Takes less than 20 minutes of operating room time Allows patient to keep their tool and to be rehabilitated in their eating behavior Less morbidity and mortality than conversion to other procedures In two cases new bands were placed as the bands were damaged in the revision

17. New Procedure Unbuckling and re-buckling the band is a new procedure that has promise It involves careful dissection with the scar around the stomach – hence that procedure is called the “Ryan” procedure