Abstract

Bariatric surgical procedures are being performed at an exponential rate. Gastric banding is a commonly performed Bariatric surgical procedure with band erosion being a known complication. Until recently eroded Gastric Bands have undergone surgical removal. Recent reports have described endoscopic removal using a biliary guide-wire and biliary mechanical lithotripter.

Aim: To determine the safety and feasibility of endoscopic removal of eroded gastric bands using lithotripsy devices following Bariatric surgery.

Methods: Thirteen patients (9w, 3m), age 33–59 (mean 45) presented with a diagnosis of eroded gastric band. These include 9 adjustable lap bands. Presenting symptoms included pain 10/13, N/V 7/13, fever/port infection 1/13. All patients had confirmation of gastric band erosion with endoscopy and CT scan 13/13.

Results: All patients with non-adjustable gastric bands were removed successfully, endoscopically. Of the patients with Adjustable Lap Bands, endoscopic removal was successful in 8/9 patients. The failed attempt was in a patient whose Band had significant fibrotic component and non-visualization of the buckle. This patient required laparoscopic removal. All patients underwent post-op contrast upper GI imaging to exclude gastric leak.

Conclusion: Patients with Gastric Band erosion present most often with abdominal pain, followed by nausea and vomiting. Diagnosis is established by endoscopy and CT imaging. Endoscopic removal is highly but not universally successful and requires coordination with a Bariatric Surgeon for the removal of the adjustable port and removal of the band in the setting of endoscopic failure. The endoscopist needs to familiarize him with Bariatric Surgical procedures and their inherent complications and eventually assist in their care when called upon.

Introduction

Obesity is defined as abnormal or excessive fat accumulation that presents as a risk to health [1]. Despite obesity being a well identified and acknowledged problem, it continues to grow as a global epidemic [2]. Obesity has emerged as a major problem, the primary reason being an imbalance between the consumption and expenditure of calories. Since 1975, the number of obese people has increased by three times across the globe. According to the 2016 World Health Organization statistics, 650 million people (13%) 18 years and above have been identified as obese [3]. 36.5% of the total population of United States is Obese [4]. Obese people can have a significantly negative impact on the quality of their lives in terms of an increased risk of having diabetes mellitus type 2, infertility, cardiovascular diseases, respiratory disorders, malignancies, as well as social and functional limitations [5].

Bariatric care has expanded over the period to be identified as a growing field for consideration as a treatment option for obesity [6,7]. Bariatric procedures cause weight loss by limiting the amount of food the stomach can hold or malabsorption of nutrients or a combination of both. The commonly performed bariatric procedures include Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, Adjustable Gastric Band, and Biliopancreatic Diversion with Duodenal Switch [8].

In the United States, trends have been shifting towards Laparoscopic Gastric bands as means of attaining weight loss [9]. Where lap bands have proven as an effective alternative to the conventional weight loss methods, they come with a cost of complications ranging from mild to serious [10].

The pathophysiology of gastric band erosion has yet to be understood [11]. The established understanding of gastric band erosion reveals that acute and chronic tissue damage could be a potential trigger to initiate band erosion [12]. Undiagnosed gastric perforations that may occur during band placements and early infections can serve as the possible causes of early erosions. Late erosions are caused by gastric band induced high pressure leading to chronic ischemia [13,14]. This prolonged ischemia gives way to band erosion through the mucosal layer and hence a perception of pain.

Gastric band erosion has been identified as a common complication with its incidence varying from 0.23% to 32.65% [15]. Symptoms of gastric band erosion include abdominal pain, excessive vomiting, weight loss cessation or unexplained weight regain and the inability to regulate the stoma [16]. Endoscopic removal of eroded gastric bands has been identified as a potent and safe technique to address this complication [17].

We report a unique approach towards the removal of eroded gastric bands using a biliary guided wire and biliary mechanical lithotripter. This method was applied in 19 patients with eroded gastric bands and represents one of the largest case series in this respect. Literature review reveals that our technique is one of its kinds and can potentially contribute to determining the safety and feasibility of endoscopic removal of eroded gastric bands following Bariatric Surgery.

Materials and Methods

Thirteen patients (9w, 3m), age 33–59 (mean 45) presented to the University of Texas, and Memorial Hermann Hospital with symptoms leading to a diagnosis of eroded gastric lap band. This included 4 non-adjustable and 9 adjustable (attached injection port) lap bands. Presenting symptoms included; pain 10/13, nausea/vomiting 7/13, fever/port infection 1/13. Patients presented 5–24 weeks from start of symptoms (mean 16 weeks). All patients had confirmation of gastric band erosion with upper endoscopy and CT scan imaging.

Procedure technique; a flexible biliary hydrophilic guide-wire with flexible tip (0.025 in x 450cm) is advanced through the band while the endoscope is withdrawn (Figure 1). The endoscope is re-advanced alongside the wire and the distal tip is captured with forceps and withdrawn through the mouth (Figure 2). With the two ends of the wire now outside the patient’s mouth a flexible lithotripter cable, the Emergency Lithotripter System BML-110A-1 (Olympus America) (Figure 3) is advanced over the two ends of the wire until the tip rests against the gastric band (Figure 4). The lithotripter handle is then attached to the cable and progressively ratcheted down until the wire cuts across the band (Figure 5). The surgeon detaches and removes the port in those with adjustable bands while the endoscopist removes the cut band with a stiff, braided snare (Figure 6).

Figure 1. Guide-wire across the eroded lap band.

Figure 2. Guide-wire across the eroded lap band and both ends outside the mouth.

Figure 3. Emergency Lithotripter System.

Figure 4. Lithotripter advanced through the guide-wire now rests against the eroded lap band.

Figure 5.Wire cutting across the band.

Figure 6. Removed eroded lap band.

Results

All patients with non-adjustable gastric bands were removed successfully, endoscopically using the above technique. Of the patients with Adjustable Lap Bands, endoscopic removal was successful in 8/9 patients. The failed attempt was in a patient whose Band had significant fibrotic component and non-visualization of the buckle. This patient required laparoscopic removal at the same time as port removal. Procedure time recorded ranged from 18 minutes to 32 minutes (mean 24 minutes). All patients underwent post-op contrast upper GI imaging using dilute barium to exclude gastric leak within 12 hours of band removal. No leaks or perforations were identified. Minor bleeding occurred in one patient which resolved spontaneously. Patients were discharged 1–4 days post-op (mean 1.4 days). One patient with port infection required prolonged hospitalization for IV antibiotics and fever resolution.

Discussion

Obesity has been recognized as an important contributive factor towards premature deaths [18]. Laparoscopic gastric banding has evolved as an effective strategy for weight loss that has been proven to decrease total body weight by up to 20% [19]. Where gastric bands are now recognized widely as an effective tool for weight loss and significant contributions towards comorbidities of obesity, its complications like port or tubing malfunction, band slippage, and obstruction of the stoma, band erosion, pouch dilation, and infection cannot be ignored [20].

Where a definite cause of gastric band erosion has yet to be established, it is imperative to apply certain techniques at the time of insertion of gastric band to minimize the risk of gastric band erosion [12,21]. External as well as internal pressure applied to the gastric wall has been hypothesized as a key etiologic factor of band erosion [22]. External pressure may be induced by band over-filling, band rapid filling or band infection [23,24]. Binge eating after the band placement surgery is a contributive factor towards internal pressure [25,20]. One of the important pathophysiologic causes of band erosion stems from the recognition of gastric band as a foreign body by the immune system [26–28]. This results in the formation of an encapsulating fibrotic shell around the eroded lap band that leads to tissue contraction. This shrinked tissue protects the integrity of the fistulous tract [29]. As lap band erosion through the stomach wall occurs over a period of several years, gastric perforation is a rare occurrence [30]. This pathophysiology reflects that active perforation is absent in eroded lap bands. Endoscopic removal of lap bands is therefore a safe yet effective procedure for the removal of eroded lap bands [31–36].

While patients with gastric band erosions can be completely asymptomatic, symptoms if present include repeated port infections, bowel obstruction, abdominal pain and rarely as serious as sepsis with peritonitis [37]. These being mentioned, band erosions can also lead to serious consequences like massive GI hemorrhage and circulatory collapse [38,39], pyelophlebitis of the portal vein [40] and intra-abdominal abscess [41]. Therefore, it is crucial to remove the eroded gastric band [8].

Various techniques have evolved over the course of time for the removal of eroded gastric bands. Unfortunately, literature review is lacking with respect to the comparison of different techniques used for the retrieval of eroded gastric bands [42]. However, the efficacy and design specific model of each technique varies from case to case. For instance, the hybrid technique considers the simultaneous use of laparoscopic and endoscopic methods to complement and facilitate each other [3]. Where some studies advocate the safety of removal of eroded gastric bands using a Single Incision Laparoscopic Surgery (SILS) [43], others urge on the use of standard endoscopy equipment for the removal of eroded gastric bands [44]. A study by Kohn GP explains the superiority of laparoscopic removal in terms of time duration from band erosion to band removal [45]. Nevertheless, physicians have yet to establish certain set guidelines identifying the superiority of one technique over the other in different situations. Due to the limitations of endoscopic and laparoscopic procedures in this regard, the role of a Bariatric surgeon becomes crucial. In certain cases, laparoscopic and endoscopic techniques may both fail in removing the gastric band in which case the role of bariatric surgeon emerges as one of utmost importance [46–48].

In our series band removal was successfully performed using our technique in 12/13 patients. CT scan and endoscopy was performed to confirm the diagnosis. We had 4 patients with adjustable gastric bands and 9 patients with non-adjustable gastric bands. Contrast upper Gastrointestinal imaging was performed in all patients after the procedure to exclude gastric leaks. Success rate with our technique was 92%. We had a failed attempt in a single patient. In this case the band had undergone significant fibrosis obscuring the buckle. In this patient laparoscopic removal was performed.

Conclusion

Abdominal pains followed by nausea and vomiting are the most common symptoms of gastric band erosion. CAT scan and endoscopy are used as the primary tools for establishment of a diagnosis. Bariatric surgeons and endoscopists should work in a closely coordinated team to address the complications of gastric band removal. Lithotripsy devices can be effectively and safely used in the retrieval of eroded gastric bands.

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