Gastric Band Erosion into Colon and Stomach: Case Report and Review of the Literature

| July 1, 2015

by Allison M. Barrett, MD, and Jonathan D. Klonsky, MD, FACS

Drs. Allison M. Barrett and Jonathan D. Klonsky are from North Shore-LIJ, Hospital at Syosset, Syosset, New York. They are also Assistant Clinical Professors of Surgery, at Hofstra-North Shore LIJ School of Medicine, Hempstead, New York.

ABSTRACT
Gastric band erosion is a well-known though rare complication of laparoscopic adjustable gastric band placement. Simultaneous erosion into the colon is even less common, with only a few cases reported. Here we present a case of gastric band erosion into the stomach and transverse colon, with a review of the literature.

Bariatric Times. 2015;12(7):8–10.


Introduction
Laparoscopic adjustable gastric banding (LAGB) has been performed in countless patients around the world. Gastric band erosion is a rare, but known complication and usually presents many years following surgery. It is less common for the band to erode into other organs. Here, we present a case of band erosion into the transverse colon and stomach, with a review of the literature.

Case Report
A 37-year-old woman presented to our clinic post-LAGB. She underwent LAGB with the Lap-Band® Adjustable Gastric Banding System 10.0 (Allergan, Irvine, California) in 2004 for a body mass index (BMI) of 42.9kg/m2. She subsequently suffered a gastric prolapse in 2006, for which she underwent surgical revision. During this operation, the prior fundoplication was transected with a linear endoscopic stapler, a new band (The LAP-BAND VG System, Allergan) was placed superior to this, and the fundoplication recreated. The patient’s lowest BMI following LAGB was 31.6kg/m2. She subsequently had three pregnancies, gained weight, and was unable to lose it.

In 2014, the patient presented to our clinic for revision surgery consultation due to insufficient weight loss. Her BMI was 40.5kg/m2. Her medical and surgical history was otherwise unremarkable. She was asymptomatic, and denied reflux, dysphagia, abdominal pain, or altered bowel habits. She elected to undergo revision from LAGB to Roux-en-Y gastric bypass (RYGB) due to insufficient weight loss. Surgery was planned in two stages, and no preoperative endoscopy was performed.

The patient was taken to the operating room for elective LAGB removal. Intraoperatively, the transverse colon was noted to be adherent to the anterior aspect of the gastric band (Figure 1). On further dissection, it became apparent that the band had eroded into the colon at the level of the band/tubing junction with the tubing extending intraluminally in the colon. There was an exit point of the tubing from the colon approximately 10 to 15cm distal to the entry point. Dissection continued until the band could be divided, at which point an anterior gastric erosion was also noted (Figure 2). The procedure was converted to open. Endoscopy was performed, demonstrating an anterior gastric erosion on retroflexion (Figure 3). The gastrotomy was closed in two layers. Given the size of the colotomy, chronic inflammation, and concern regarding fecal spillage, the portion of affected transverse colon was resected and the ends brought out as a colostomy and mucous fistula. Her postoperative course was unremarkable. She has since undergone colostomy reversal and is doing well. The Roux-en-Y gastric bypass was not performed, due to the need for colostomy and reversal.

Discussion
Gastric erosion of LAGB has been well documented in the literature and was initially described as a complication in 1998.[1,2] Contributing factors have been heavily debated, but the etiology of band erosion still remains unclear. Some have hypothesized it to be secondary to intraoperative trauma to the stomach, which may occur by instrumentation, thermal injury, or ischemia, or may be seen with excessive tension of the gastric plication sutures. Postoperatively, over-tightening of the band has been suggested as a mechanism for erosion.[3–5] Some authors have faulted the peri-gastric technique for the lack of fat buffering the band from the lesser curvature of the stomach. With conversion to the pars flaccid approach, the incidence of erosion has subsequently decreased from eight percent to 0.9 percent.[6] Following a systematic review of the literature, Egberts et al[7] found the incidence of erosion ranged from 0.23 to 32.65 percent. Among the 25 studies reviewed, there were 231 reports of erosions in 15,775 patients for an overall incidence of 1.46 percent.[7] Most studies report an incidence of erosion from 0.2 to 3 percent.[8,9]

Gastric band erosion into the colon has been reported in the literature only a few times. Tyrell et al[10] reported a case of band erosion into the stomach and colon four years following LAGB. They theorized that the patient had a subclinical gastric injury at the time of band placement, which resulted in a chronic inflammatory process and eventual erosion. Povoa et al[11] reported a patient who presented with colicky abdominal pain four years following LAGB. Colonoscopy was notable for presence of the gastric band tubing within the colonic lumen. The patient underwent removal of the band, where a gastrocolic fistula was located, divided, and repaired. They theorized that foreign body reaction was the cause of band erosion. Tan et al[12] reported a case of gastric band erosion into the stomach and colon causing simultaneous small bowel obstruction due to the inflammatory process.

In the patient presented here, erosion was asymptomatic and was found incidentally. The etiology of erosion was likely related to chronic irritation along the staple line that was created during band replacement for gastric prolapse.

In patients with band erosion, timing for surgery is dependent on presentation. Given the long time course required for band erosion to occur, there is usually sufficient capsule formation to inhibit free leakage of gastric contents into the peritoneal cavity. Therefore, patients who are asymptomatic can be scheduled for surgery electively.  However, those who present with peritonitis, vomiting, or bowel obstruction require urgent surgical exploration and band removal.

Summary
Band erosion into the stomach and colon simultaneously is a rare complication of LAGB and can be asymptomatic, as in the patient presented here. More common presentations include abdominal pain, port-site erythema and pain, and dysphagia. In the asymptomatic patient, surgery can be performed electively. However, patients presenting with acute bowel obstructions or peritonitis require urgent surgical intervention.

References
1.    Weiner R, Emmerlich V, Wagner D, et al. Management and therapy of postoperative complications after “gastric banding” for morbid obesity. Chirurg. 1998;69(10):1082–1088.
2.    Safety of laparoscopic adjustable gastric banding: an evidence update. Ont Health Technol Assess Ser. 2009;9(Suppl 2): 1–13.
3.    DiLorenzo N, Lorenzo M, Furbetta F, et al. Intragastric gastric band migration and erosion: an analysis of multicenter experience on 177 patients. Surg Endosc. 2013;27:1151–1157.
4.    Ren CH, Weiner M. Favorable early results of gastric banding for morbid obesity: The American experience. Surg Endosc. 2004;18(3);543–546.
5.    Meir E, Van Baden M. Adjustable silicone gastric banding and band erosion: Personal experience and hypotheses. Obes Surg. 1999;9(2):191–193.
6.    Boschi S, Fogli L. Avoiding complications after laparoscopic esophago-gastric banding: experience with 400 consecutive patients. Obes Surg. 2006;16(9):1166–1170.
7.    Egberts K, Brown W, O’Brien P. Systemic review of erosion after laparoscopic adjustable gastric banding. Obes Surg. 2011;21:1272–1279.
8.    Carelli AM, Youn HA, Kurian MS, Ren CJ, Fielding GA. Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence. Surg Endosc. 2010;24(8):1819–1823.
9.    Mittermair RP, Obermuller S, Perathoner A, et al. Results and complications after Swedish Adjustable Gastric Banding: 10 years experience. Obes Surg. 2009;19(12):1636–1641.
10.    Tyrell R, Kukar M, Dring R, Gadaleta D. Simultaneous gastric and colonic erosion of gastric band. Amer Surg. 2014;80(1):E14–E16.
11.    Povoa AA, Soares C, Esteves J, et al. Simultaneous gastric and colic laparoscopic adjustable gastric band migration: complication of bariatric surgery. Obes Surg. 2010;20:796–800.
12.    Tan L, So J, Shabbir A. Connection tubing causing small bowel obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. J Med Case Reports. 2012;6:9.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

 

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Category: Case Report, Past Articles, Review

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