Endoscopic Removal of Eroded Gastric Band Using Standard Endoscopy Equipment

by Peter M. Bertin, DO, and Marc L. Costa, MD

Drs. Bertin and Costa are from Excela Health Westmoreland Hospital in Greensburg, Pennsylvania.FUNDING: No funding was provided.

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

Bariatric Times. 2012;9(10):20–22

ABSTRACT
Several case series have reported successful removal of eroded adjustable gastric bands endoscopically using a specialized band cutter, not presently available for use in the United States. This report demonstrates that readily available endoscopic equipment and skills can be used to achieve this result. Endoscopic removal has several potential advantages compared to open or laparoscopic methods.

Introduction
Laparoscopic adjustable gastric banding is a commonly performed restrictive bariatric surgery. Erosion of the prosthesis through the wall of the stomach is an uncommon late complication of the procedure. The estimated prevalence varies between published series but is likely 1 to 4 percent with the current prostheses and the pars flaccida technique of placement.[1,4,5] The etiologic factors may include injury to the viscera at the time of implantation, overfilling of the band postoperatively, or an abnormal foreign body reaction. The most common clinical sign is weight regain. Patients may also present with complaints of lost restriction, late port-site infection, or even obstruction.2 Erosion can at times be seen on upper gastrointestinal (GI) contrast studies but is best evaluated with endoscopy if suspected. Once erosion occurs, the band should be removed. Laparoscopic and endoscopic techniques for removal have been described. Presently described endoscopic techniques have used a specialized gastric band cutter (Agency of Medical Inovations, Gotzis, Switzerland) not available in the United States due to lack of United States Food and Drug Administration (FDA) approval.[4] A mechanical lithotriptor, which is intended to crush biliary stones in endoscopic retrograde cholangiopancreatography (ERCP), was adapted for the off-label use of endoscopic band cutting using a guidewire as a seton. This report provides further support as to the safety of endoscopic removal, highlights its advantages compared to laparoscopic removal, and demonstrates the feasibility of endoscopic removal with commonly available endoscopic equipment and skills.

Case Presentation and Management
A 58-year-old man came to us to request replacement of his adjustable gastric band port and continued follow up. His band (LapBand® AP standard, Allergan Inc., Irvine, California) was placed nearly four years prior at another institution. At that time he was 5’8” and weighed 283 pounds. His body mass index (BMI) was 43kg/m2. In one year, he lost 53 pounds for a 42-percent excess weight loss (EWL). He lost some additional weight but then returned for follow up about a year and a half after surgery complaining of some weight regain. He was four pounds heavier than his last visit. He experienced a lack of restriction even after multiple band fills with up to 9mL of saline in the 10mL-capacity band.

An upper GI contrast study was performed at two years postoperative (Figure 1). The written report stated that that the band was in good position without evidence of complication. The images show oral contrast encircling a portion of the band. This indicates that a portion of the band communicates with the lumen of the stomach.
The patient had ulcerative colitis, and a dysplastic polyp was found on screening colonoscopy. He had a laparoscopic-converted-to-open proctocolectomy with ileorectal anastamosis two months after the upper GI study was performed. His postoperative course was complicated by anastamotic leak and multiple reoperations. He developed a necrotizing abdominal wall infection, and the band port was removed. The surgical team felt that the band itself was in good position and, therefore, left it alone.

On presentation to our bariatric center, the patient complained of epigastric discomfort and reflux in the morning in addition to the weight regain. He jokingly referred to the symptoms as morning sickness. His weight was 271 pounds. An abdominal film showed that the band was no longer near the gastroesophageal (GE) junctionFigure 2A). Computed tomography (CT) confirmed the band was in an intragastric position (Figure 2B). The patient’s upper GI two months prior to the colectomy showed that erosion had commenced prior to his episode of intra-abdominal sepsis.

The patient was consented for attempted endoscopic removal. The plan was to perform the removal with laparoscopic monitoring for safety and to address the band tubing. It was not clear from operative reports how the band tubing was addressed at the prior surgery.

Methods and Results
The patient was placed under general anesthesia. Endoscopy was performed with a standard diagnostic gastroscope. Band tubing was seen entering the cardia of the stomach. Retained material was evacuated and the band was seen impacted within the pylorous (Figure 3A).

The band was grasped well with alligator forceps (rotatable Rat Tooth Alligator Jaw grasping forceps, Olympus Endoscopy, San Jose, California) and dislodged by sustained gentle traction. A gastric-length overtube (Guardus®, US Endoscopy, Mentor, Ohio) was placed to protect the esophagus from potential repeated instrumentation. A 0.035 inch guide wire (Tracer Metro® Direct™, Wilson-Cook Medical Inc., Winston Salem, North Carolina) was looped about the band. A silk suture was tied to the guidewire and grasped by the alligator forceps to direct the wire though the band. It was then regrasped and brought out through the patient’s mouth. This technique was chosen to avoid a guidewire exchange. The two ends of the wire were placed through the cable of a mechanical lithotriptor (Soehendra® Lithotriptor, Wilson-Cook Medical Inc.) and attached to the crank of the device. The guidewire cut through the band easily by progressively tightening it about the band (Figure 3B). The band was grasped by a polypectomy snare (Sensation™ Short Throw Snare, Boston Scientific, Natick, Massachusetts).Laparoscopy was then performed. Access was attained with an open cutdown technique near the epigastrium. Working space was limited and significant lysis of adhesions was performed to identify the band tubing. There were significant inflammation and adhesions noted in the region of the upper stomach. The distal tubing was excised by cutting the tubing and foreign body reaction with scissors and withdrawing it with laparoscopic graspers. The band was then removed endoscopically. We were unable to remove it through the overtube, which has a 16.7mm inner diameter. The closed buckle makes the band too wide. The overtube was removed, and the band was retrieved with gentle traction. Repeat endoscopy showed very minor evidence of trauma. It was very similar to that expected from percutaneous gastrostomy tube placement. This process was viewed laparoscopically, and a leak test under saline was performed. No air leak was identified at the location where the foreign body reaction encircled the band tubing. The operative time for the endoscopic component of the procedure was approximately 45 minutes. It was extended by the time needed to evacuate gastric contents and what would normally be expected as part of a learning curve. The patient was observed postoperatively and discharged home the next day. His recovery was uneventful.

Photo of Explanted Band

Discussion
There have been three relatively large case series of endoscopic band removal as well as some smaller series.[3–8] In a series from Brazil by Neto et al,3 endoscopic removal was performed successfully in 78 out of 82 (92%) patients. Nineteen patients did need a second endoscopic procedure to successfully remove the band. Chisholm et al[4] in Australia were successful in 46 of 50 (80%) cases. Mozzi et al[5] from Italy removed 16 bands in 20 attempts endoscopically.

The procedures in these series used a specialized band cutter. Five cases of pneumoperitoneum occurred in the series performed by Neto et al.[3] One patient required suture repair of the gastric wall laparoscopically. The others were managed conservatively. Chisholm et al[4] noted that one patient developed asymptomatic pneumoperitioneum, whereas Mozzi et al[5] did not report this occurrence. In Chrisholm et al, before endoscopic removal was introduced, four patients had laparoscopic removal. One patient developed an esophageal leak and another developed a left subphrenic abscess.

In a series of 49 patients undergoing laparoscopic removal,[9] one patient (2%) experienced a postoperative leak. The patient was managed with drainage and parenteral nutrition.

We elected to perform laparoscopy at the time of the procedure. The operative notes from the colorectal procedure did not mention what was done with the band tubing. We felt that viewing the procedure under laparoscopic vision would add a level of safety. The band tubing was found to be enveloped in a foreign body reaction and unattached to structures within the abdomen or abdominal wall. In this case, we found the foreign body reaction and inflammation effectively sealed the site of erosion. Laparoscopy confirmed this process but did create a risk of injury from entry and lysis of adhesions.

Research suggests that intra-abdominal sepsis can precipitate band erosion, such as erosion found at the time of an episode of diverticulitis.10 In our case, we had the benefit of an upper GI, which demonstrated that the process of erosion had already commenced.

It is important to note that the foreign body reaction to the gastric band may envelope it with time and prevent direct contamination from other sources within the abdomen.

Endoscopic removal of eroded gastric bands is a feasible and safe alternative to laparoscopic removal. It can be performed with readily available equipment and techniques as shown in this case report. It provides the advantages of minimal access and avoids technical difficulties that may be associated with laparoscopy on the reoperative abdomen. A major risk of band removal is leak. Endoscopic removal may limit this risk to a degree since the foreign body and inflammatory reaction in the region of the band is left undisturbed and can continue to seal off the area. The greater the degree of erosion that is present, the more amendable endoscopic removal may be.[3–7] Chisholm et al[4] suggest that it is best for the band buckle be visible within the lumen. This makes it more likely the band will be able to be retrieved into the lumen of the stomach. A majority of patients with an eroded band will not have significant symptoms or associated intra-abdominal pathology, such as abscess, that would necessitate urgent treatment or laparoscopic/open removal.[5,7] In uncomplicated cases, it may be prudent to permit the natural history of the erosion to progress sufficiently prior to endoscopic removal.[4,5] Complete erosion, however may lead to distal migration and obstruction.[7,11]

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9.    Regusci L, Groebli Y, Meyer JL, et al. Gastroscopic removal of an adjustable gastric band after partial intragastric migration. Obes Surg. 2003;13(2):281–284.
10.    Naim HJ, Gorecki P, Wise L. Early Lap-Band erosion associated with colonic inflammation: A case report and literature review. JSLS. 2005;9(1):102–104.
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Category: Case Report, Past Articles