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Lap-Band Complications
Acute Surgical Complications
Slippage
Erosion
Esophageal Dilation
Access Port Problems
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Complications occur after all types of surgical procedures. Some are due to the nature of the patient's condition or illness, some due to an error of judgement or technique, and some are linked to randomness or chance. Each patient is built differently and each reacts differently to a given set of circumstances. When a medical device such as a Lap-Band is introduced, there is an additional set of factors. How does the patient's body react to the device, and how well does the patient work with the device to use it properly to prevent problems?

Medicine is as much art as science. The surgeon must use his or her judgment to try to do the best procedure or treatment for a given patient, never knowing all the facts. Likewise the patient must do his or her own best to work with the treatment. In the case of the Lap-Band, the patient must allow the band implantation to heal completely, and then she or he must eat properly. The vast majority of patients do very well after surgery. However, even when both doctor and patient do their best and use generally accepted protocol, complications or death may occur.


Related Medical Journals

A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates.

Suter M, Calmes JM, Paroz A, Giusti V.

Department of Surgery, Hopital du Chablais, Aigle-Monthey, Switzerland.

BACKGROUND: Since its introduction about 10 years ago, and because of its encouraging early results regarding weight loss and morbidity, laparoscopic gastric banding (LGB) has been considered by many as the treatment of choice for morbid obesity. Few long-term studies have been published. We present our results after up to 8 years (mean 74 months) of follow-up. METHODS: Prospective data of patients who had LGB have been collected since 1995, with exclusion of the first 30 patients (learning curve). Major late complications are defined as those requiring band removal (major reoperation), with or without conversion to another procedure. Failure is defined as an excess weight loss (EWL) of <25%, or major reoperation. RESULTS: Between June 1997 and June 2003, LGB was performed in 317 patients, 43 men and 274 women. Mean age was 38 years (19-69), mean weight was 119 kg (79-179), and mean BMI was 43.5 kg/m(2) (34-78). 97.8% of the patients were available for follow-up after 3 years, 88.2% after 5 years, and 81.5% after 7 years. Overall, 105 (33.1%) of the patients developed late complications, including band erosion in 9.5%, pouch dilatation/slippage in 6.3%, and catheter- or port-related problems in 7.6%. Major reoperation was required in 21.7% of the patients. The mean EWL at 5 years was 58.5% in patients with the band still in place. The failure rate increased from 13.2% after 18 months to 23.8% at 3, 31.5% at 5, and 36.9% at 7 years. CONCLUSIONS: LGB appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. Only about 60% of the patients without major complication maintain an acceptable EWL in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.

Obes Surg. 2006 Jul;16(7):829-35.


Management of failed adjustable gastric banding.

Biertho L, Steffen R, Branson R, Potoczna N, Ricklin T, Piec G, Horber FF.
Department of Surgery and Internal Medicine, Hirslanden Clinics, Bern and Zurich, Switzerland.

BACKGROUND: About 100,000 adjustable gastric band placements have been performed worldwide, but more than 10% of patients have needed reoperation for insufficient weight loss or device-related complications. This study investigates the complications following gastric banding, and the outcome using a structured management strategy. METHODS: In the period April 1996 to January 2002, 824 severely obese patients (body mass index 43 +/- 1 kg/m 2 [mean +/- standard error under the mean], age 43 +/- 1 years; 77% women) underwent gastric banding in a single institution and were followed prospectively. Complications, insufficient weight loss, and subsequent management were analyzed. RESULTS: By the fifth treatment year, excess weight loss (EWL) was 54.8 +/- 1.7%; 72.8% of patients lost weight continuously or attained EWL of at least 50%. Insufficient weight loss occurred in 143 patients, and band-related complications occurred in 131 patients, with a mean annual rate of 5.0%. Major reoperation was necessary in 121 patients, and the annual reoperation rate was 4.7%. Following major reoperation, band- and bypass-related complication rates ranged from 6.3% to 11.7% per year. Three deaths occurred, 1 after reoperation and 2 due to preexisting cardiovascular disease. CONCLUSIONS: Applying a structured reoperation algorithm, 5% annual failure after banding was corrected in most patients, and 72.8% of patients attained sufficient weight loss. Reoperation-related mortality was low (.8%), and its annual morbidity was acceptable (4.6%).

Surgery. 2005 Jan;137(1):33-41


Outcome after laparoscopic adjustable gastric banding - 8 years experience.

Weiner R, Blanco-Engert R, Weiner S, Matkowitz R, Schaefer L, Pomhoff I.

Krankhenhaus Sachsenhausen, Frankfurt Center for Minimally Invasive Surgery, Section of Bariatric Surgery, Germany. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has been our choice operation for morbid obesity since 1994. Despite a long list of publications about the LAGB during recent years, the evidence with regard to long-term weight loss after LAGB has been rather sparse. The outcome of the first 100 patients and the total number of 984 LAGB procedures were evaluated. METHODS: 984 consecutive patients (82.5% female) underwent LAGB. Initial body weight was 132.2 +/- 23.9 SD kg and body mass index (BMI) was 46.8 +/- 7.2 kg/m(2). Mean age was 37.9 (18-65). Retrogastric placement was performed in 577 patients up to June 1998. Thereafter, the pars flaccida to perigastric (two-step technique) was used in the following 407 patients. RESULTS: Mortality and conversion rates were 0. Follow-up of the first 100 patients has been 97% and ranges in the following years between 95% and 100% (mean 97.2%). Median follow-up of the first 100 patients who were available for follow-up was 98.9 months (8.24 years). Median follow-up of all patients was 55.5 months (range 99-1). Early complications were 1 gastric perforation after previous hiatal surgery and 1 gastric slippage (band was removed). All complications were seen during the first 100 procedures. Late complications of the first 100 cases included 17 slippages requiring reinterventions during the following years; total rate of slippage decreased later to 3.7%. Mean excess weight loss was 59.3% after 8 years, if patients with band loss are excluded. BMI dropped from 46.8 to 32.3 kg/m(2). 5 patients of the first 100 LAGB had the band removed, followed by weight gain; 3 of the 5 patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) with successful weight loss after the redo-surgery. 14 patients were switched to a "banded" LRYGBP and 2 patients to a LRYGBP during 2001-2002. The quality of life indices were still improved in 82% of the first 100 patients. The percentages of good and excellent results were at the highest level at 2 years after LAGB (92%). CONCLUSIONS: LAGB is safe, with a lower complication rate than other bariatric operations. Reoperations can be performed laparoscopically with low morbidity and short hospitalizations. The LAGB seems to be the basic bariatric procedure, which can be switched laparoscopically to combined bariatric procedures if treatment fails. After the learning curve of the surgeon, results are markedly improved. On the basis of 8 years long-term follow-up, it is an effective procedure.

Obes Surg. 2003 Dec;13(6):965.


Despite the fact that Lap-Band surgery is the least invasive and safest of the various weight loss surgeries, complications occur in every surgeon's experience. Patients often underestimate the likelihood of these unusual events ("It will never happen to me"), and likewise underestimate the potential severity of the consequences. Hence it is essential that each patient be sure that she or he has tried and failed non-surgical approaches and that she or he is ready to work with the medical team if complications occur.

Many surgeons perform an Upper GI X-ray and a blood count the morning after surgery to assure that the band is properly placed, that there is no sign of a perforation or leakage, and that the patient's blood level is stable.

Potential acute complications include but are not limited to the following:

  • Bleeding from laparoscopic instrument insertion sites <1%
  • Bleeding from site where band goes around the stomach <1%
  • Spleen injury causing bleeding and possible removal of spleen <1%
  • Acute post-op obstruction (band too tight) 1%
  • Infection of the infusion port site or instrument introduction sites 2%
  • Perforation of the back wall of the stomach leading to abscess or peritonitis <0.2%
  • Pneumonia <0.02%
  • Heart attack or arrhythmia (irregular heart beat) Rare
  • Conversion to open surgery <1%
  • Return to surgery for treatment of complication <1%
  • Potential prolonged ICU stay to treat complication: Rare
  • Death may occur as a result of bleeding, stomach perforation, blood clot to the lungs (pulmonary embolism), or heart problem 0.01%

 


From time to time the stomach wall can slip up through the band. Slippage causes an hourglass effect with a bulge above the band and extra stomach tissue with in the band.

Slippage may be mild and intermittent, or it may be severe and may not resolve. Symptoms are nausea and vomiting and a decrease in the ability to take foods or liquids.

Slippage requiring reoperation or removal of the band occurs in less than 5 percent of patients when the currently accepted surgical technique known as the pars flacida technique is used to implant the band. Care is taken as well to make the pouch above the band very small.

Normal Location of the Lap-Band®

There is a small amount of stomach above the band. Note the diagonal orientation of the band.

 

 

 

Slip with Dilation

Here the back wall of the stomach has slipped up through the band causing dilation of the pouch above the band. Note how the band is now turned upward.

Slippage and dilation will cause nausea and vomiting. In extreme cases the stomach within or above the band may die and need to be removed.

 

 

Diagnosis

  • Symptoms of acute nausea and vomiting and inability to take liquids or foods
  • Upper GI series X-ray.

Treatment

  • Mild slip: Deflate the band, reinflate in one to two weeks
  • Moderate slip: Deflate the band, operate to reposition band
  • Severe slip: Deflate band and operate to remove band

Prevention

  • Appropriate band placement by surgeon
  • Careful progression of diet by patient. No solids for 4 weeks
  • Wait at least 6 weeks for first adjustment

 


Lap-Band erosion is migration of the band through the stomach wall into the stomach. This complication occurs in less than 2% of patients when surgeons use present day technique (pars flacida technique). It was significantly more common early on when the band was placed tightly against the stomach (peri-gastric technique).

Presentation. When the band erodes into the stomach, bacteria from the stomach enter into the capsule that mutually forms around the band. The infection then travels along the tubing into the pocket around the subcutaneous port. Thus many patients who develop erosion first notice pain, redness, and swelling in the vicinity of the access port. Another way that band migration presents is with loss of the band's restrictive effect. When the band erodes well into the stomach, food can bypass around the band. The patient can eat much more than before.

Diagnosis. Band erosion is best diagnosed with upper GI endoscopy. The endoscopist can actually see the band as it penetrates the stomach wall. IAn eroded band can also occasionally be identified on CT scan.

Treatment. Lap band erosion is usually not an emergency. If the access port site is infected, the port must be removed promptly. The band can then be removed semi- electively. Removal of an eroded band can be a difficult procedure requiring an open approach. Most surgeons simply remove the band and then perform rebanding, a gastric bypass, or duodenal switch as second procedure. Some surgeons have had success removing the band and performing a simultaneous rebanding or gastric bypass.

Image from: www.lap-surgery.com/images/gastric_band_comp05.jpg


Related Medical Journals

Treatment of intra-gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replacement.

Abu-Abeid S, et al.

Department of Surgery B and the Advanced Endoscopic Surgery Service, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

BACKGROUND: Intra-gastric band migration (band erosion) following laparoscopic adjustable gastric banding (LAGB) is a known complication requiring revisional surgery. Management has most often involved band removal and suturing of the stomach wall, followed by delayed replacement at a third operation. We report our experience with simultaneous band removal and replacement. METHODS: Between May 2001 and December 2003, we performed 754 laparoscopic operations using the Lap-Band (R). Patients developing band erosion were treated by laparoscopic band removal and immediate replacement of a new band following gastric wall repair. RESULTS: 16 patients (2.1%) developed band erosion after a mean of 23 months following surgery (range 11-40 months). Patients presented with epigastric pain (6), port-site bulge (3) or were asymptomatic (7), band erosion being suspected during fluoroscopy for band adjustment and confirmed by gastroscopy. Postoperatively, 11 patients developed fever that responded to antibiotics. No patient suffered from intra-abdominal infection, wound infection, pneumonia or pulmonary embolism. Mean hospital stay was 4 days (range 1-8 days). CONCLUSION: Band erosion following LAGB can be treated safely with simultaneous laparoscopic band removal, gastric wall suturing and immediate replacement of the band, thereby preventing weight gain, the appearance of co-morbidities and the need for additional surgery.

Obes Surg. 2005 Jun-Jul;15(6):849-52.


Band erosion after laparoscopic gastric banding: occurrence and results after conversion to Roux-en-Y gastric bypass.

* Suter M, et al.

Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

BACKGROUND: Laparoscopic adjustable gastric banding is a popular bariatric operation. Unfortunately, long-term complications such as slippage, infection, and intragastric migration (erosion) may occur. With erosion, band removal is mandatory. Options to prevent weight regain are delayed implantation of a new band, or conversion to another bariatric procedure such as Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion. We present our experience with band erosion and immediate or delayed conversion to RYGBP. METHODS: With a multidisciplinary team approach and prospective data collection, a comparison was made between patients with and without band erosion. The patients who were converted to RYGBP for band erosion were analyzed. RESULTS: Gastric banding was performed on 347 patients between 1995 and 2002. Median follow-up is 52 months. Band erosion developed in 24 patients (6.8 %).The latter were heavier before gastric banding (BMI 45.9 vs 43.3, P <0,01). No band had ever been overinflated. Band erosion was diagnosed after a mean of 22.5 months (3-51). At time of diagnosis, mean BMI of 33.5 kg/m(2) (22.5-48) and average excess weight loss (EWL) of 52.9% (25-97) did not differ from that of the remaining patients at the respective time interval. The band was removed in all cases. Conversion to RYGBP was performed at the same time in 11, and a few months later in 2 patients. Operative morbidity included 1 leak (reoperation) and 4 wound infections. All but 1 patient lost further weight after reoperation, or at least maintained their weight. At last follow-up, mean EWL in relation to the pre-banding weight was 65.1%, and 69.2% of the patients had an EWL >50%, which compares favorably with the results obtained after primary RYGBP. CONCLUSIONS: In our series with a median follow-up >4 years, band erosion was more common than usually reported. Band removal with immediate or delayed conversion to RYGBP is feasible with an acceptable morbidity, and prevents weight regain in most cases. These results support further use of this approach for band erosion.

Obes Surg. 2004 Mar;14(3):381-6

 


Dilation or stretching of the esophagus is an uncommon complication of adjustable gastric banding. It usually is caused by prolonged presence of an overly tight band. Dilation may be more common in patients with preexisting motility disorders of the esophagus like severe reflux (gerd). One should consider evaluation of esophageal motility in patients with severe gerd before surgery. Treatment of dilation is release or removal of the band. Some patients may need to be converted to gastric bypass.


Related Medical Journals

Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy.

Dargent J.

Polyclinique de Rillieux, Rillieux-la-Pape, France. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has become a method of choice worldwide to treat morbid obesity. Long-term complications such as esophageal dilatation require that a relevant strategy for treatment be defined. Esophageal dysmotility is commonly described in morbidly obese patients. METHODS: 1,232 patients have undergone LAGB over 9 years (1995-2004), and 162 (13.1%) have had a reoperation for complications (excluding access-port problems): slippage (109), erosion (28), intolerance (25). 80 patients (6.4%) had their band removed, and 10 had a switch to another procedure. Esophageal dilatation has been an isolated cause for removal in 2 patients and an associated cause in 6 patients. RESULTS: There was no significant correlation between esophageal dilatation and insufficient excess weight loss (<25%) after 5 years (37/257:14.3%). 4 stages of dilatation were identified, with the relevant treatment for each, the ultimate alternative being conversion to a laparoscopic gastric bypass. We suggest that esophageal dilatation be a separate issue from pouch dilatation and gastric erosion, and that it be classified as a complication only in severe cases requiring band removal. Most cases can be handled through deflation of the band under radiological control. CONCLUSION: LAGB can lead to significant esophageal troubles which must remain under scrutiny but generally respond to "radiological management", which also makes LAGB more demanding than other operations in terms of follow-up.

Obes Surg. 2005 Jun-Jul;15(6):843-8


Prevalent esophageal body motility disorders underlie aggravation of GERD symptoms in morbidly obese patients following adjustable gastric banding.

Klaus A, et al.

Department of General and Transplant Surgery and Radiology, Medical University Innsbruck, Innsbruck, Austria.

HYPOTHESIS: Preexisting gastroesophageal reflux disease (GERD) and esophageal motility disorders may affect the outcome of laparoscopic adjustable gastric banding (AGB). DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Between January 1, 1996, and December 31, 2002, AGB procedures were performed in 587 patients (mean body mass index, 46.7 [calculated as weight in kilograms divided by the square of height in meters]). The study population was composed of patients with preoperative GERD (assessed by a symptom-score questionnaire) and was divided into group 1 (those with preoperative GERD symptoms only) and group 2 (those with preoperative and postoperative GERD symptoms). INTERVENTIONS: Laparoscopic AGB was performed according to the pars-flaccida technique. MAIN OUTCOME MEASURES: All patients underwent preoperative and annual postoperative symptom scoring, endoscopy, esophageal barium swallow tests, esophageal manometry, and 24-hour pH monitoring. RESULTS: Mean follow-up time was 33 months (range, 12-49 months). A total of 164 patients (27.9%) were diagnosed as having preoperative GERD symptoms. In 112 (68.3%) of these patients GERD symptoms vanished postoperatively (group 1), whereas 52 patients (31.7%) remained symptomatic after undergoing laparoscopic AGB implantation (group 2). Preoperatively, group 2 patients showed significantly poorer esophageal body motility compared with group 1 patients (20.8% vs 12.8% defective propagations; P = .007). In group 2 the mean symptom scores for dysphagia (0.4 vs 0.9) and regurgitation (0.6 vs 1.4) deteriorated significantly following laparoscopic AGB implantation, respectively. Eighteen patients (34.6%) in group 2 developed esophageal dilatation. CONCLUSIONS: Adjustable gastric banding provides a sufficient antireflux barrier in most of the obese patients with GERD. However, in patients with preoperatively defective esophageal body motility, AGB may aggravate GERD symptoms and esophageal dilatation. Alternative bariatric surgical procedures should be considered in these patients.

Arch Surg. 2006 Mar;141(3):247-51.

 


The access port is the small disk that is implanted on the abdominal wall under the skin and fatty tissue. Over the years, the design of the port has been improved. Still several problems may occur involving the port. Recent reports indicate that about 5%-13% of patients require reoperation during the first few years due to port related problems.

  • Dislodging or Flipping The access port is sutured in place on the fascia (gristle) and muscle of the abdominal wall. If the sutures pull out of the muscle, the port can become loose or even flip over. The port then becomes difficult to access. Fixing the problems requires a return to the operating room for minor surgery.
  • Tubing leak The tubing will leak if it is punctured during attempts to access the port. Careful technique and appropriate use of fluoroscopy can minimize the chance of puncture. There have been occasional reports of the tubing breaking down at it's junction with the port. The connection has been redesigned to minimize this risk. Fixing tubing or connection problems also required a return to the operating room.
  • Infection There are three ways that the access port can become infected. First, infection can be introduced at the time the port and band are inserted. This type of infection would usually show itself a few days after the surgery. Second, infection could be introduced at the time of band adjustment. Again, this would become apparent several days later in most cases. In either case, the port site would become tender, red, hot, and swollen. Treatment requires temporary removal of the port or use of antibiotic impregnated beads.

    The third cause of infection of the port site is by erosion of band into the stomach. When band erosion occurs, bacteria from the stomach work their way into the capsule that has formed around the band. The capsule actually also extends around the tubing and down around the port. The bacteria gradually migrate along the tubing inside the capsule. Eventually infection develops around the port, and the port site gets swollen, red, hot, and tender. Treatment requires removal of the band and port. If the infection is severe, urgent removal of the port and drainage of the infection may be necessary. Removal of the band itself may be done semi-electively.

Related Medical Journals

Port complications following laparoscopic adjustable gastric banding for morbid obesity.

Keidar A, Carmon E, Szold A, Abu-Abeid S. Department of Surgery B, Sourasky Medical Center, Tel Aviv, Israel.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has gained widespread acceptance. However, the technique has problems intrinsic to the material wear and tear around the port and connecting tubing that can lead to failure. Port complications are considered to be minor; however, few studies have analyzed them, and the optimal technique of port implantation and management has not been elucidated. METHODS: All patients who suffered from complications involving the tubing or access-port were included in this study. Their complaints, imaging studies, operative reports and hospitalization files were retrospectively reviewed. RESULTS: 1,272 of the patients were available for a mean follow-up period of 37 months. During this time, 91 patients (7.1%) experienced port complications that required 103 revisional operations. Of these patients, 62 had system leaks, 19 infectious problems, and 10 miscellaneous problems requiring operative correction. Overall port problems led to band removal in 6 patients, and replacement in 1 patient. CONCLUSION: Access-port complications after the Lap-Band procedure are among the most common and annoying ones, and can render the device susceptible to failure. Careful surgical technique and routine use of radiologic guidance for band adjustments are the keys to avoiding complications.

Obes Surg. 2005 Mar;15(3):366.


Device-related reoperations after laparoscopic adjustable gastric banding.

Lyass S, Cunneen SA, Phillips EH, et al.

Dept. Surgery, Cedars Sinai Medical Center, 8700 Beverly Blvd., Suite 8215, Los Angeles, CA 90048, USA.

Laparoscopic adjustable gastric banding (LAGB) is considered a relatively safe weight loss procedure with low morbidity. When complications occur, obstruction, erosion, and port malfunction require reoperation. We retrospectively reviewed our experience with 270 consecutive patients who underwent LAGB. Device-related reoperations were performed in 26 (10%) patients. Reoperations were related to the band in 13, to port/tubing in 11, and related to both in 2 patients. Of the 15 band-related problems, it was removed in 5 (2%): slippage (3), intra-abdominal abscess (1), and during emergent operation for bleeding duodenal ulcer (1). Revision or immediate replacement was performed in 10 (4%): slippage (5), obstruction (4), and leak from the reservoir (1). Port/tubing problems were the reason for reoperations in 13 (5%): infection (5), crack at tubing-port connection (6), and port rotation (2). Port removal for infection was followed later by port replacement (average 9 months). Overall, slippage occurred in 8 (3%), obstruction in 4 (1.5%), leak from reservoir in 7 (3%), and infection in 5 (2%) patients. Fifteen device-related problems occurred during our first 100 cases and 12 subsequently (P = 0.057). Permanent LapBand loss was only 5 per cent, leading to overall rate of 95 per cent of LapBand preservation as a restrictive device.

Am Surg. 2005 Sep;71(9):738-43.


Access-port complications after laparoscopic gastric banding.

Susmallian S, Ezri T, Elis M, Charuzi I.

Department of Surgery B, Wolfson Medical Center, Holon, affiliated with Sackler School of Medicine, Tel Aviv, Israel. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

BACKGROUND: The aim of this retrospective study was to identify complications related to the access-port, after Lap-Band system placement by laparoscopy. METHODS: The records of 333 morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) were reviewed for the overall surgical complications. Data was further analyzed regarding the complications related to the access-port. RESULTS: From January 1999 to December 2001, the overall complication-rate with the LAGB was 25.8%. 45 complications (13.5%) were related to the access-port in 34 patients following LAGB placement. The 45 access-port complications were distributed as follows: infection 51.1%, tubing disconnection 17.7%, dislodgment of the access-port 15.6%, leak of the reservoir 11.1%, and skin ulceration by the port 4.45%. CONCLUSION: The integrity of the Lap-Band system is essential to achieve the objective of the operation: weight loss. Complications related to the access-port were relatively frequent, but preventable.

Obes Surg. 2003 Feb;13(1):128-31.

 

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