Banded RYGB Ring Slippage Endoscopic Removal with Self-expandable Stents: a Comparative Study Between Metallic and Plastic One

PURPOSE

Banded Roux-en-Y gastric bypass (RYGB) was a common bariatric procedure in the 2000s, and the ring slippage is one of its late adverse events. Both plastic and metallic stents have been reported as adjunct methods to induce erosion and facilitate endoscopic removal of the ring.

OBJECTIVE

To compare the safety and effectiveness of self-expanding metallic stents (SEMS) and plastic stents (SEPS) to treat ring slippage.

MATERIALS AND METHODS

We conducted a retrospective longitudinal study analyzing consecutive patients with ring dysfunction treated with stents plus endoscopic removal.

RESULTS

Ninety patients were enrolled (36 SEMS vs. 54 SEPS). The mean age was 48.56 ± 13.07 and 45.6 ± 12.1 in the SEMS and SEPS groups, respectively. All patients had band slippage, but 24 from SEMS group and 23 from SEPS group had further complications. There were more complications in metallic stent concerning mean absolute number of therapy-related adverse events (1.33 ± 0.48 vs. 1.72 ± 0.5, p > 0.05) and time until erosion (14.9 ± 1.6 vs. 13.8 ± 1.4 days, p > 0.05). Female sex and age > 41 years old correlated with longer time to band erosion and higher incidence of adverse events in SEMS patients. In SEPS group, only female sex was a risk factor for adverse events.

CONCLUSION

Both procedures were efficient at inducing band erosion with similar safety profiles. Older and female patients are at a higher risk of treatment-related adverse events, especially those receiving SEMS.

Endoscopic removal of eroded laparoscopic adjustable gastric bands: a preferred approach

BACKGROUND

Complications related to laparoscopic adjustable gastric banding (LAGB) have led to an increased number of removals. An uncommon but potentially devastating complication is gastric band erosion into the gastric lumen, which can be managed by open surgical, laparoscopic, and endoscopic approaches.

OBJECTIVE

A wide array of management techniques has been reported for removal of LAGB that have eroded into the stomach. We describe the preferred method for successful endoscopic band removal at our institution.

SETTING

Community tertiary-care referral hospital accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

METHODS

A single-center, retrospective review of a prospectively maintained database was used to identify patients who underwent LAGB removal from 2009 to 2019. We identified the subset of patients with band erosion. We analyzed patient characteristics, presenting symptoms, diagnostic modalities, and method of band extraction.

RESULTS

A total of 132 patients underwent LAGB removal, among whom 22 (16.7%) patients were diagnosed with erosion. Seven (32%) patients underwent laparoscopic removal, 14 (64%) patients underwent endoscopic removal, and 1 patient (4%) underwent combined laparoscopic and endoscopic approach. These latter patients had variable amounts of erosion and buckle visibility, but all underwent endoscopic retrieval. We found that using an endoscopic retrograde cholangiopancreatography guidewire with an endoscopic retrograde cholangiopancreatography mechanical lithotriptor for band transection and snare for retrieval have been effective.

CONCLUSIONS

A standardized, multidisciplinary, and minimally invasive endoscopic approach for LAGB erosion has been found to be successful without the need for further surgical intervention and may be offered to patients upon discovery of erosion.

Eroded Gastric Band: Where to Next? An Analysis of the Largest Contemporary Series

PURPOSE

Erosion of a laparoscopic adjustable gastric band (LAGB) is a devastating problem. There is no clear evidence in literature to guide the choice of revisional procedure following an eroded LAGB. The purpose of this study is to analyse the largest series of erosions following LAGB published to-date with an aim to share our experience with this rare complication and how we managed this cohort of patients following explantation of their LAGB.

MATERIALS AND METHODS

This is a retrospective cohort study. Patient data is maintained prospectively in a surgical database. The study period was from January 1996 to January 2019. The outcomes of patients who underwent an erosion of LAGB were studied.

RESULTS

Gastric band erosion was encountered in 4.7% of patients. Sixty patients opted for a revisional procedure which included 37 repeat LAGBs, 6 laparoscopic sleeve gastrectomies (LSG), 7 Roux-en-Y gastric bypasses (RYGB), 1 intragastric balloon, and 9 failed revisional procedures. Re-erosions were noted in 27% of patients who underwent a repeat gastric banding. Median %TWL at a 1-year follow-up was significantly higher in LSG and RYGB groups compared with that in LAGB (P < 0.008 and P < 0.000, respectively). There was no significant difference between the LSG and RYGB groups.

CONCLUSION

The risk of re-erosion is increased in patients who undergo repeat AGB following a previous episode of erosion. Repeat LAGB should not be offered after a previous erosion. LSG and RYGB should be considered as appropriate revisional procedures in a patient who experience weight regain following explantation of an eroded LAGB.

A case report of an adjustable gastric band erosion and migration into the jejunum resulting in biliary obstruction

•

LAGB can rarely erode into the stomach and migrate into the small bowel.

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Migration of the LAGB can result in bowel and biliary obstruction.

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Band erosion should be managed by removal of the LAGB.

Introduction

Laparoscopic adjustable gastric band is a bariatric operation which has lost popularity due to its high rate of reoperation and complications such as band erosion. Erosion may be partial or complete with intragastric migration of the band. Once in the stomach lumen, the band has the potential to migrate into the small bowel.

Presentation of case

A 43-year-old male with history of morbid obesity and laparoscopic adjustable gastric band placement presented with abdominal pain secondary to biliary obstruction. Endoscopic retrograde cholangiopancreatography revealed eroded gastric band tubing into the lumen of the stomach and duodenum with resultant distortion of the ampulla. Upon surgical exploration, the band was found to have migrated into the jejunum and was removed through an enterotomy. The patient did well and was discharged home on postoperative day 8.

Discussion

Once completely eroded into the gastric lumen, a gastric band can migrate into the small bowel with the distance traveled being limited by the length of the connecting tube. The stretched tubing can result in distortion of the ampulla leading to biliary obstruction. Band erosion should be managed with band removal which can be completed using endoscopic, laparoscopic, or open approach.

Conclusion

Band migration should be suspected in patients with a history of gastric band placement presenting with bowel or biliary obstruction. Its management depends on the location of the band as well as the expertise of the surgical team.

Endoscopic management of erosion after banded bariatric procedures

BACKGROUND

Prosthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes.

OBJECTIVES

We will describe our methods and experience with endoscopic management of intraluminal gastric band erosions after bariatric procedures.

SETTING

University hospital in the United States.

METHODS

A retrospective review of our bariatric surgery database identified patients undergoing removal of gastric bands. A chart review was then undertaken to confirm erosion of prosthetic material into the gastrointestinal tract. Baseline characteristics, operative reports, and follow-up data were analyzed.

RESULTS

Sixteen patients were identified with an eroded gastric band: 11 after banded gastric bypass, 3 after laparoscopic adjustable gastric band (LAGB), and 2 after vertical banded gastroplasty. All patients were successfully treated with endoscopic removal of the prosthetic materials using either endoscopic scissors or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a postoperative gastrointestinal bleed requiring repeat endoscopy, 1 patient with asymptomatic pneumoperitoneum requiring observation, and 1 with seroma at the site of LAGB port removal.

CONCLUSIONS

Endoscopic management of intraluminal prosthetic erosion after gastric banded bariatric procedures can be safe and effective and should be considered when treating this complication. Erosion of the prosthetic materials inside the gastric lumen allows for potential endoscopic removal without free intraabdominal perforation. Endoscopic devices designed for dividing eroded LAGBs may help standardize and increase utilization of this approach.

Endoscopic Management of Eroded Bands Following Banded-Gastric Bypass (with Video)

BACKGROUND

Banded-gastric bypass is a highly effective bariatric procedure, yet the possibility of band erosion remains a significant drawback. Surgical removal of eroded bands may be associated with significant morbidity. In this study, we assess the efficacy and safety of a solely peroral endoscopic approach for the management of eroded bands in patients with a banded-gastric bypass.

MATERIALS AND METHODS

Starting January 2012, all patients with banded-gastric bypass and an eroded band were subjected to an attempt at peroral endoscopic removal using endoscopic scissors and/or argon plasma coagulation (APC), regardless of the circumference of band eroding inside the lumen.

RESULTS

Sixteen patients presented with eroded bands, 2 were deemed not amenable to endoscopic removal as only part of the thickness was eroded. Of the 14 patients where endoscopic attempts were performed, 12 (86%) were completely removed successfully, while 2 (14%) were cut but could not be extracted and only the intraluminal portion was trimmed. Complete resolution of symptoms occurred in 13 (93%) while in 1 patient (7%) there was partial improvement. Only one endoscopic session was performed per patient with a median time of 37.5 min per session (22-55 min). No complications were encountered.

CONCLUSION

Endoscopic removal of eroded gastric bands in patients with banded-gastric bypass is effective and safe in the majority of patients. When bands are adherent to the gastric wall, removal of the intraluminal portion of the band may lead to full or partial improvement of symptoms. Endoscopic band removal can be attempted even when a small part of band circumference has eroded.

Management of laparoscopic adjustable gastric band erosion

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) was a popular procedure in the USA and Europe in the past decade. However, its use has currently declined. Band erosion (BE) is a rare complication after LAGB with a reported incidence rate of 1.46 %. Controversies exist regarding the management, approach and timing for the band removal. The aim of this study is to describe the rate, clinical presentation and perioperative outcomes of BEs at our institution and provide overall recommendations regarding the diagnosis and management of BE.

MATERIALS AND METHODS

This study is a single-center, retrospective review of a prospectively maintained database. Data were collected from all consecutive patients who underwent a LAGB and band revisional surgeries at the University of Illinois Hospital and Health Sciences System from December 2008 to September 2015. We identified patients who underwent gastric band removal due to a BE and analyzed their outcomes.

RESULTS

A total of 576 LAGBs were performed at our institution. Nine patients underwent surgery for BE at our hospital. The average time between the primary surgery and the removal of the band was 68.5 (42.9) months. Abdominal pain, nausea and/or vomiting were the most frequently mentioned symptoms. In all patients, a minimally invasive approach was used to remove the band. The mean length of hospitalization was 2.6 (1.1) days. The only complication was a pneumonia (n = 1).

CONCLUSIONS

BE is one of the most severe complications of LAGB. The minimally invasive approach provided us with the opportunity to repair the fistula, and it was associated with a prompt recovery with very little morbidity. In general, it is recommended that the band be removed at the time of the diagnosis of the BE. Endoscopic band removal can be utilized with patients who have a more advanced BE and migration into the gastric lumen.

Asymptomatic Gastric Band Erosion Detected during Routine Gastroduodenoscopy

The incidence of gastric band erosion has decreased to 1%. Gastric band erosion can manifest with various clinical symptoms, although some patients remain asymptomatic. We present a case of a mostly asymptomatic patient who was diagnosed with gastric band erosion during a routine health check-up. A 32-year-old man without any underlying diseases except for non-alcoholic fatty liver underwent laparoscopic adjustable gastric band surgery in 2010. He had no significant complications postoperatively. He underwent routine health check-ups with near-normal gastroduodenoscopic findings through 2014. However, in 2015, routine gastroduodenoscopy showed that the gastric band had eroded into the stomach. His gastric band was removed laparoscopically, and the remaining gastric ulcer perforation was repaired using an omental patch. Due to the early diagnosis, the infection was not serious. The patient was discharged on postoperative day 3 with oral antibiotics. This patient was fortunately diagnosed early by virtue of a routine health check-up; thus, eliminating the possibility of serious complications.

Acute Abdominal Pain in the Bariatric Surgery Patient

Obesity is present in epidemic proportions in the United States, and bariatric surgery has become more common. Thus, emergency physicians will undoubtedly encounter many patients who have undergone one of these procedures. Knowledge of the anatomic changes specific to these procedures aids the clinician in understanding potential complications and devising an organized differential diagnosis. This article reviews common bariatric surgery procedures, their complications, and the approach to acute abdominal pain in these patients.

[Gastric band erosion: Alternative management]

BACKGROUND

Obesity is a public health problem, for which the prevalence has increased worldwide at an alarming rate, affecting 1.7 billion people in the world.

OBJECTIVE

To describe the technique employed in incomplete penetration of gastric band where endoscopic management and/or primary closure is not feasible.

MATERIAL AND METHODS

Laparoscopic removal of gastric band was performed in five patients with incomplete penetrance using Foley catheterization in the perforation site that could lead to the development of a gastro-cutaneous fistula.

CLINICAL CASES

The cases presented include a leak that required surgical lavage with satisfactory outcome, and one patient developed stenosis 3 years after surgical management, which was resolved endoscopically. In all cases, the penetration site closed spontaneously.

DISCUSSION

Gastric band erosion has been reported in 3.4% of cases. The reason for inserting a catheter is to create a controlled gastro-cutaneous fistula, allowing spontaneous closure.

CONCLUSIONS

Various techniques have been described: the totally endoscopic, hybrid techniques (endoscopic/laparoscopic) and completely laparoscopic. A technique is described here that is useful and successful in cases where the above-described treatments are not viable.

Connecting tube colonic erosion and gastrocolic fistula formation following late gastric band erosion

Band erosion is a rare complication of laparoscopic adjustable gastric banding (LAGB) with a reported prevalence varying from 0.3% to 14%. Intraluminal colonic erosion of the connecting tube is very rare, as only isolated cases have been described. Consequently, simultaneous gastric band erosion and connecting tube colonic erosion is an extremely rare event. Herein, we present a case of a woman with morbid obesity, who submitted to LABG 4 years ago. The patient presented with symptoms and signs of right lower quadrant peritonitis. Computed tomography (CT) demonstrated migration of the band into the gastric lumen, inflammation around the intra-abdominal course of the connecting tube and an inflammatory mass surrounding the tube at the right lower quadrant. Laparotomy revealed the eroded band, the eroded transverse colon from the connecting tube, a gastrocolic fistula along the course of the tube and a right lower quadrant phlegmon. The connecting tube was mobilized from the surrounding adherent tissues, the gastric band removed, the stomach and colon walls closed, and the gastrocolic fistula excised. To our knowledge this is the second case of concurrent band erosion and connecting tube colonic erosion along with gastrocolic fistula formation in a patient with morbid obesity treated with LAGB.

Early experience with diagnosis and management of eroded gastric bands

PURPOSE

Band erosion is a well-known complication of laparoscopic adjustable gastric band placement. We gained experience with laparoscopic removal of an eroded gastric band.

METHODS

We retrospectively reviewed the operative log of our obesity surgery unit to identify all operations performed for band erosion from March 2009 to May 2011.

RESULTS

During the study period, a total of six of 96 patients (6.3%), five females and one male, were diagnosed with band erosion and underwent surgical removal of the band system. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 8.5 months (range, 7 to 22 months), with most band erosion occurring within the first year (5/6, 83%). The median body mass index at band removal was 28.4 kg/m(2). Upper abdominal pain was the most common symptom (5/6, 83%), and other signs and symptoms were port site infection (3/6, 50%) and loss of restriction and weight regain (1/6, 17%). All eroded bands were removed using laparoscopy. Further complications after laparoscopic removal of the band system were observed in three cases. One patient showed multiple intra-abdominal abscesses requiring insertion of a pigtail catheter for drainage. The other two patients experienced sepsis with localized peritonitis, eventually requiring laparoscopic washout and drainage.

CONCLUSION

Gastric band erosion requires the removal of the gastric band. Laparoscopic removal is technically achievable in the majority of patients with eroded gastric band. The method can be challenging, has potential postoperative complications (fistula, abscess), and should be attempted only by experienced surgeons.