1. Jeff W. Allen MD, FACS Norton Surgical Specialists Louisville, KY

2. Complications Common Anterior prolapse Concentric dilation Port Problems Uncommon Posterior Prolapse Erosion Removals Management / failure

3. Posterior Gastric Prolapse Seen almost exclusively with perigastric approach Trial/patients from foreign medical centers Unusual condition where perigastric technique is used (n=4 for my experience) May be seen in pars flaccida technique, especially if a very generous retrogastric dissection is performed

4. Posterior Gastric Prolapse

6. Management of Posterior Prolapse Take down plication Transect band (unless band designed to be opened) New pars flaccida tunnel New Band

7. Unusual Band Complications 54 year old woman with an initial bmi of 48 kg/m 2 Excellent weight loss over 2 years to a BMI of 29 kg/m 2 Develops latent port infection 6 weeks after an outpatient band adjustment EGD performed by surgeon- no erosion Good visualization of band in retroflexed position

8. Unusual Band Complications No response to antibiotics Port removed ? Laparoscopy at time of port removal ? Repeat endoscopy ?UGI

9. Tubing Erosion Unless in proximal jejunum, may not be seen on endoscopy Generally requires laparoscopy to identify Management= band removal +/- staged band replacement Etiology puzzling and unclear

10. “Ascending Erosion” Common dogma that an infected port is the harbinger of an eroded band Provost first identified the possibility that a port infection can cause total band infection/abscess and eventual erosion Diagnosis made by laparoscopy after EGD negative

11. Latent port infection Treat with anbiotics initially Remove port/EGD If negative, consider eroded tubing, contaminated adjustment, additional septic source (infected hernia mesh) and “ascending erosion” Laparoscopy to diagnose

12. Explants Subhepatic abscesses Subphrenic Obstructions Dilations Prolapses Erosion Excessive weight loss HIV conversion Perforated ulcer 6 months after placement Inadequate weight loss- patient choice

13. Port Complications: Leakage 6 patients Inadequate weight loss No aspirate on port access All at the port/tubing interface No diagnostic studies performed, only operative intervention

14. Port Complications: Pain 3 patients Injections offered temporary relief in all Operative replacement relieved pain in all three

15. Should I take the band out? Other intra-abdominal problems such as appendicitis, diverticulitis, ovarian torsion Decided on a case by case basis

16. O.P.I.E O: Overall health of the patient 30 year old now with a BMI of 22 and no co-morbidities 66 year old lost 18 pounds with band, BMI 55 kg/m2 and NIDDM and COPD P: Proximity to the band Non-ruptured appendicitis Perforated ulcer I: Infectious agent Transverse colon flora from perforation Skin flora (from a stab wound) E: Exposure 6 days after failed conservative management of diverticulitis 6 hours after diagnosis of ovarian torsion

17. Managing the plateau patient Make sure it is the patient with the problem – Ensure a closed system – No leaks – Adjuster is hitting the port Patient understands program No undiagnosed psychopathology/sabotage Identify what may have changed when the plateau began – Less exercise – New medications, especially anti- depressants

18. Band Problems Leak in the system At the port At the band In the tubing Slow leak Erosion Erroneous placement of the band initially Unbuckling of the band

19. Leak in the System? Fill the band half full with certainty  Use fluoro if necessary Re-check in 1-2 weeks  All fluid should still be there  If all- not a leak  If none-need surgical repair  If significantly decreased  Measurement error or  Slow leak

20. Repairing a Leak Localize vs Non-Localize To localize use x-ray and a small amount of dilute gastrograffin OR methylene blue I prefer not to localize  Can be misleading  Still need an operation  Use general anesthesia anyway  Commonly a needle stick or kink in tubing

22. Worried about band-no leak Video Esophagram- with pre and post-injection shots EGD to evaluate for erosion Laparoscopy to check for unbuckling, erroneous placement (use calibration tube)

23. Video 54 year old woman, initial BMI 44 kg/m2 Excellent initial weight loss Plateau 6 months out All fluid (9/10 cc) still in band No erosion No indentation on EGD or UGI with 9 cc in

25. Vitamin Deficiencies after Band Vitamin D Protein deficiency Vitamin C Vitamin B12 All are usually a combination of maladaptive eating and lack of supplements