The new Lap-bands from Allergan (AP Standard and AP Large) have a redesigned buckle that makes them easy to unbuckle laparoscopically. This provides a unique opportunity for surgeons to salvage a device in a patient with an acute Lap-band slip or pouch dilation or both. A patient has a chronically dilated pouch, or a pouch that seems to get dilated easily, with a Lap-band that is in the horizontal position. Conservative measures – removing the fluid from the device and placing the patient on a full liquid diet for one to two weeks can resolve this issue 80% of the time. However, sometimes it recurs.
These patients are ideal to undergo an unbuckling of their Lap-band. This takes the pressure off the upper pouch and allows the chronically dilated pouch to return to its normal size. In one to two months returning to the operating room the device will be in perfect position (no need to make a new retrogastric tunnel) and be able to be rebuckled as an outpatient.
A patient comes in with an acute obstruction. The history is typically progressive difficulty eating solid foods, ignoring this and eating more soft foods, progressing to only drinking, and now unable to keep liquids down. Removing fluid can sometimes reverse this, but often the area is too swollen for this. Taking the patient to the operating room and unbuckling the Lap-band provides immediate relief without the danger of removing the device from a thinned out stomach. The patient is able to drink again and in two months is able to have the device rebuckled.
The new unbuckling Lap-band lets patients with slips avoid having it removed
Prior to unbuckling the device the only two options for these patients with slips were removing the device – with later replacing with a new Lap-band or another weight loss operation. The other was to reposition the device in a new retrogastric tunnel. The dangers of this include the pressure on the thinned out new upper pouch could cause perforation in the early postoperative period.
Typically when a Lap-band slips it is placed in a new retrogastric position with the diverticulum of dilated pouch sutured above it to drain. This presents two issues: (a) The thinned out upper pouch may perforate from the thin wall several days after the device is repositioned – from the pressure placed by even an unfilled Lap-band in a dilated upper pouch (b) The reposition may itself be impossible to do, leading to removal of the device.
Unbuckling was done in six consecutive patients who had chronic slips with either acute exacerbations or chronically dilated pouches that were resistant to conservative measures (removing fluid, placing on a liquid diet).
These patients all did well, and returned to the operating room for a simple out-patient buckling of the device and resumed weight loss easily.