Insights into Proximal Pouch Dilatation Following Adjustable Gastric Banding—a Form of Inattentional Blindness?

ratio of 2.3 (95 % CI, 1.4–3.8, p<0.001). Exploration and repair rates increased throughout the series from 27 to 60 % and 90 % in consecutive groups of 1,000 patients, on the expectation that this additional step would reduce the risk of a significant hiatal defect being missed, with the concern that an oversight may increase the risk of subsequent surgical revision [2]. We examined the revision rate for PPD during the first 36 months for all patients who had completed at least 3 years follow-up after band placement. This analysis demonstrated a significant and sustained reduction in the incidence of PPD with time, but this was not related to greater rate of crural repair. The increased risk of subsequent revision with exploration and repair was most prominent early in the series, but at no stage did exploration and repair reduce risk. The staff in the surgical practice now believe that the reduced incidence of PPD is more likely related to a better understanding of the mechanism of action of the band over time by both staff and patients. There is now a focus on band adjustments for satiety and satisfaction rather than restriction. The practice of repairing significant hiatal hernia and careful exploration in patients with significant gastrooesophageal reflux symptoms appears reasonable, but exploration of a normal esophageal hiatal area in an asymptomatic patient is not supported by this large carefully documented series. A second clinically important observation was that women and lower age were independently associated with an increased risk of PPD requiring revision [3]. Exploring the data proved interesting as the age effect was restricted to women with younger women at a higher risk, and men and post menopausal women at much lower risk. As all cases of PPD were classified by barium study into symmetrical and asymmetrical dilatations, we examined for any influence on type of dilatation. Asymmetrical dilatations, found to occur earlier with more acute symptoms, dominated in younger