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Endoscopic management of erosion after banded bariatric procedures
Author’s Accepted Manuscript Endoscopic Management of Erosion after Banded Bariatric Procedures Matthew D. Spann, Chetan V. Aher, Wayne J. English, D. Brandon Williams www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30352-0 http://dx.doi.org/10.1016/j.soard.2017.07.025 SOARD3083
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Matthew D. Spann, Chetan V. Aher, Wayne J. English and D. Brandon Williams, Endoscopic Management of Erosion after Banded Bariatric P r o c e d u r e s , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.07.025 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Endoscopic Management of Erosion after Banded Bariatric Procedures
Matthew D. Spann, M.D. Chetan V. Aher, M.D. Wayne J. English, M.D. D. Brandon Williams, M.D.
Vanderbilt Center for Surgical Weight Loss Vanderbilt University Medical Center
Corresponding Author: Matthew D. Spann, M.D. 1161 Medical Center Drive MCN D-5203 Nashville, TN 37232-2577 Phone: 615-322-7555 Fax: 615-343-9485
Endoscopic Management of Band Erosion
Endoscopic Management of Erosion after Banded Bariatric Procedures
Abstract 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 non-adjustable 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
Endoscopic Management of Band Erosion
or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a post-op GI bleed requiring repeat endoscopy, one patient with asymptomatic pneumoperitoneum requiring observation, and one with seroma at the site of her 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. Keywords band erosion; laparoscopic adjustable gastric band; Lap-Band; vertical banded gastroplasty; VBG; banded gastric bypass; endoscopic management, Roux-en-Y gastric bypass; RYGB
Endoscopic Management of Band Erosion
Introduction Morbid obesity remains a pandemic and one of the greatest public health risks all countries will face in the coming years. The healthcare community has long struggled with effective ways of preventing and treating morbid obesity. Bariatric surgery was introduced as a treatment for morbid obesity over 60 years ago and remains the most effective treatment for this disease and its associated comorbidities.(1) The principles of bariatric surgery have focused heavily on restriction, malabsorption, or a combination of these mechanisms. Gastric restriction is a fundamental component of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass(RYGB), and failure of restriction was thought to be responsible for inadequate weight maintenance.(2,2) Bariatric procedures frequently included prosthetic materials placed around the stomach to ensure persisting restraint. (3) By definition, the VBG included banding the stomach with a silastic ring, heavyweight mesh, or other prosthetic material at the distal aspect of the gastroplasty to limit outflow from the gastric pouch. With RYGB, silastic bands were also frequently placed around the gastric pouch outlet. The practice of gastric restriction with prostheses became especially popular with the laparoscopic adjustable gastric band (LAGB). While observers noted weight loss success with these procedures, a known complication was intraluminal erosion of the prosthetic material.(4) While successful management of this complication can obviously be accomplished through laparotomy or laparoscopy, advances in minimally invasive techniques have allowed clinicians to manage gastric band erosion endoscopically, providing improved patient outcomes.(5) We report our experience as a tertiary referral center of gastric band erosions managed endoscopically by bariatric surgeons.
Endoscopic Management of Band Erosion
Methods We retrospectively reviewed our institutional bariatric surgery database, which was approved by our Institutional Review Board. Patients with eroded gastric bands were identified by searching Current Procedures Terminology code for removal of gastric band (43774) and upper gastrointestinal endoscopy with foreign body removal (43247). A chart review of potential patients was undertaken, and those patients with endoscopic confirmation of gastric band erosion were included for analysis. Patients with no documentation of gastric band erosion were excluded. No patients underwent removal of a partially eroded gastric band at the time of another bariatric procedure, as our practice is to manage band erosions prior to revisional surgery. Demographic data, case history, and operative details were reviewed. We collected the following variables for reporting: original procedure, time to erosion, symptom presentation and resolution, details of removal procedure, weight loss, postoperative complications, and risk factors for ulcer disease, including smoking and use of non-steroidal anti-inflammatory drugs (NSAIDs). At the time of this review, the FDA had not approved any device for the specific purpose of removing eroded gastric banding material. As such, the techniques we describe involve off-label use of devices, not recommended by the device manufacturers. Our technique predominately utilized a 9.9mm diameter single channel gastroscope, with only occasional use of the dual channel gastroscope. We first attempted to divide the eroded silastic or mesh banding material using dual action endoscopic scissors. If we could not cut through the banding material with the scissors, we passed a 450cm biliary guidewire (Boston Scientific Hydra Jagwire ST) around the eroded material. We passed the wire through a mechanical lithotripter (Olympus BML-110A-1), and tightening the wire through this device caused the wire to sever the eroded band material. We then removed the band using either a snare or large endoscopic forceps. Removal of the band material was considered complete when no visible prosthetic
Endoscopic Management of Band Erosion
material was observed within the gastric wall or lumen and there were no apparent missing portions of the ring when examined ex vivo. No attempt was made to close the resulting mucosal defect. For further details of this procedure, please see the additional media for a video description of our lithotripter technique. Results From November 1, 2014 through December 31, 2016, 60 patients underwent removal of a gastric band prosthesis originally placed for weight loss as part of a primary procedure. Sixteen patients were identified with erosion of gastric banding material. Endoscopic images were reviewed, and in all cases the band material was partially eroded, with a portion of the prosthetic material visible inside the lumen of the stomach and a portion outside of the lumen, presumably within the gastric wall or peritoneal cavity. All patients with documented evidence of band erosion were managed endoscopically. Baseline characteristics are displayed in Table 1. All patients were female. Most patients were overweight or suffered from class 1 obesity at the time of band removal. Historical weight data was available on 9 patients, with an average excess body weight loss of 47.6% (0 - 84). The predominant indications for removal were epigastric abdominal pain (62.5%) or chronic nausea and emesis (31.3%). One patient was asymptomatic, and removal was indicated in preparation for a revisional bariatric procedure. Of the 16 patients, 11 had history of an open, banded Roux-en-Y gastric bypass (BGB). Three patients had LAGB erosion, all with the band buckle clearly visible in the lumen. Two patients had a VBG erosion. Average time to identification of erosion was shortest with LAGB (5.2 years) and longest for VBG (27 years). The banding material used in patients with BGB was a silastic tube placed over a permanent, monofilament suture. Heavyweight polypropylene mesh was used in both patients with a
Endoscopic Management of Band Erosion
VBG. A majority of patients reported no tobacco use (75%), and half of patients reported no use of NSAIDs. Complete endoscopic removal of all the eroded band material was accomplished in 14 of 16 patients (87.5%). In one patient with prior BGB, a small amount of imbedded monofilament suture was unable to be removed endoscopically. In one patient with prior VBG, the heavyweight mesh had become incorporated in the gastric wall, but nearly all the intraluminal mesh was successfully removed. No patients required laparoscopic or open interventions. Operative characteristics are detailed in Table 2. We used dual action scissors to divide and remove 6 of the 11 (54.5%) silastic BGB bands. The remaining bands (5 BGB bands, 3 LAGBs, and 2 VBGs) required use of the mechanical lithotripter for division and removal. Thus, overall, dual action scissors successfully divided the eroded band material in 6 of 16 patients (37.5%). The average procedure time was shorter when dual action scissors were successful (29 minutes), compared with use of the mechanical lithotripter (78.1 minutes). Fifteen patients (94%) were discharged on the day of the procedure after tolerating a liquid diet. Short term follow-up data was available in 15 of 16 patients. Of those patients, all experienced resolution of nausea, vomiting, and epigastric pain. Of note, both patients with partial removal of the eroded material had a complete resolution of symptoms. Complications occurred in three patients, with two after LAGB removal. One patient had a seroma at the port site that resolved without intervention. Another patient had pneumoperitoneum seen on postoperative chest x-ray; this patient underwent fluoroscopic contrast evaluation which revealed no evidence of gastric leak. The patient was observed overnight and discharged without sequelae. The third patient required readmission after removal of a silastic band for a post-op GI bleed, leading to a repeat endoscopy which showed no residual hemorrhage. It was later determined this patient had unreported use of antiplatelet therapy.
Endoscopic Management of Band Erosion
Discussion Erosion of prosthesis used in bariatric surgery has been well described. While the true incidence of erosion is difficult to obtain, the reported rates for this long-term complication are between 1 and 10%.(4, 6) Symptoms of erosion vary but often include dysphagia. Early approaches to manage erosion of mesh or silastic rings after VBG and BGB included laparotomy and major revision. While effective, open techniques required an inpatient hospitalization and carried higher perioperative morbidity. Endoscopic removal often could not be accomplished in patients due to limitations of instruments and endoscopic technique.(4, 7) However, advances in endosurgical techniques have allowed removal of eroded VBG and BGB prostheses to become increasingly successful through use of argon beam, YAG laser, and endoscopic scissors.(5, 7, 8) We experienced similar success by removing all visible prosthetic material from 11 of our 13 VBG and BGB patients, leaving behind only a small amount of monofilament suture in one BGB patient and a small amount of heavyweight mesh in one VBG patient, both of whom still had a complete resolution of symptoms. Almost half of patients with eroded silastic bands were successfully managed with endoscopic scissors (45.4%). The dual channel endoscope was required in some cases to apply countertraction when tension on the band was inadequate for division with the endoscopic scissors. VBG and BGB patients were all discharged on the day of the procedure. The only complication in this group was a self-limited postoperative intraluminal hemorrhage occurring in one patient. Two patients with prior VBG had heavyweight mesh used to create the gastric band. With heavyweight mesh, tissue ingrowth to the prosthesis will likely make complete removal difficult. However, one patient did have a successful endoscopic removal of the entire mesh prosthetic, perhaps because it was almost entirely eroded into the gastric lumen. Once the mesh was divided, the remaining portion pulled easily into the stomach and was subsequently removed using a snare. If tissue ingrowth
Endoscopic Management of Band Erosion
does not allow for complete retrieval of mesh prosthesis, the band will need to be sectioned in two places. In patients with prior banded gastric bypass, over half were found to have gastrogastric fistulae at the time of band removal. The exact cause of the fistulae is unknown, but thought to be due to nondivided gastric staple lines, although operative details were not readily available for all our patients. The presence of the gastric prosthesis may be related to formation of the gastrogastric fistulae. While management of the gastrogastric fistula was discussed with each patient, most elected to wait for recurrence of symptoms due to the risks associated with the revisional bariatric surgery. The first reported LAGB erosion occurred in 1998, and early erosions were treated through a laparoscopic or open approach.(6, 9, 10) While effective, these approaches often required extended hospitalization, with average length of stay for laparoscopic removal of LAGB after erosion being up to 4 days.(6) Endoscopic management of LAGB erosions requires additional technology and is accomplished by various methods of ligation, including band cutters, mechanical lithotripters, and endosurgical devices.(5, 11-13) Our series included three patients with eroded LAGBs, all of whom had a clearly visible intraluminal erosion of the band buckle, which is a critical finding on initial endoscopy for planning endoscopic management. We would not attempt to manage a LAGB erosion with a purely endoscopic method if the band buckle was not visible and would consider a hybrid method, combining the endoscopic and laparoscopic approaches. Erosion of the buckle is important because it is the thickest portion of the band, and bringing it inside the lumen, if not already eroded, would be technically difficult and potentially cause trauma to the gastric wall and adjacent organs. Endoscopic management of LAGB erosion is somewhat challenging in the United States due to a lack of tools dedicated to endoscopic band ligation. Thus, off-label use of products is required. We chose to use the mechanical lithotripter for band ligation in our patients. Care must be taken to avoid snaring a portion of mucosa when using this
Endoscopic Management of Band Erosion
device. Other operative options include hybrid approaches, using transgastric ports and laparoscopic instruments to divide the LAGB.(12, 14) The required approach to LAGB erosion will not be known until the time of the procedure; thus, we recommend management in the operating room, ideally directed by a bariatric surgeon with advanced endoscopy experience, or through a multidisciplinary approach between a bariatric surgeon and endoscopist. Management of the remaining gastric mucosal defect after endoscopic removal of eroded bands is somewhat controversial. For non-adjustable gastric bands, the thick perigastric capsule formed due to the band should still be intact after endoscopic removal and prevent gastric leaks. However, removal of LAGB endoscopically when the buckle has eroded leaves behind a defect in the gastric mucosa the diameter of the band or larger. Many available series regarding endoscopic management of LAGB erosions do not describe any management directed at this mucosal defect without report of leak despite early refeeding. (11, 15) Our practice is to avoid routine closure of the mucosal defect unless there is a concern for hemostasis. Patients are observed for several hours after starting clear liquids. If a patient experiences abdominal pain, or pain beyond what is expected from port removal after LAGB, we recommend abdominal imaging to rule out gastric leak. Patients are routinely discharged on the day of the procedure after tolerating liquids and instructed to return with abdominal pain or fever. Patient proximity and support system must be considered with plans for same day discharge. Erosion of the gastric prosthetics can be used for patient benefit is rare situations. Forced erosion is a concept that involves placing a covered stent across a stenosis created by a non-adjustable gastric band. Over the weeks following stent placement, pressure necrosis of the gastric wall between the stent and band results in forced erosion of the gastric band and allows subsequent removal at the time of stent retrieval. The potential for forced erosion of gastric bands to treat intractable vomiting from chronic band-related strictures has been successful in patients with outlet stenosis, avoiding major
Endoscopic Management of Band Erosion
revisional bariatric surgery.(16-18) Forced endoscopic erosions should be considered in VBG and BGB patients that are not suitable candidates for revisional surgery. Thankfully, attempting forced erosion is unlikely to alter other surgical options if erosion is unsuccessful. The decision for operative intervention and timing will vary from patient to patient. Urgent intervention should be considered in any patient presenting with gastrointestinal hemorrhage due to band erosion. For patients presenting with pain, symptoms may be managed similar to peptic ulcer symptoms, using acid suppression and sucralfate until the band removal. We also prefer acid suppression for 4 weeks following an endoscopic band removal due to the friable tissue often seen at the base of the mucosal defect. For high-risk patients that have minimal symptoms, or if erosion is found incidentally, conservative management with observation has been described. (10) Prosthetic materials have also been used around the distal esophagus and stomach for the treatment of gastroesophageal reflux disease and paraesophageal hernias. In the 1980s, a silicon ring, the Angelchik device, was used to augment the lower esophageal sphincter to aid in gastroesophageal reflux control. (19) Erosion was one of many reasons this device was abandoned. We have also seen a rise in the use of prosthetics during paraesophageal hernia repairs in effort to decrease early recurrence. However, erosion of hiatal prosthesis can be as high as 60%.(20-22) The latest mainstream use of a prosthetic includes a magnetic ring placed at the gastroesophageal junction, serving as an artificial sphincter. While the efficacy the device is good, there are reports of transmural migration. (23, 24) Erosion may be an underreported risk for prosthetics, as it is often a long-term complication, occurring years after the prosthetic is placed. In our current era of medical innovation, we must consider the history of prosthetics that are placed near the gastrointestinal tract and avoid revisiting lessons already learned. Our study is limited due to a small sample size and the retrospective nature of the review. Future investigations into the incidence and safety of endoscopic management of band erosion would
Endoscopic Management of Band Erosion
be aided greatly by including this variable into the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry.
Conclusion The complication of gastric band prosthetic erosion will be a problem bariatric surgeons face for many years to come due to its delayed presentation. Open and laparoscopic management of band erosions are safe and effective. Recent advances in endoscopic techniques have allowed endoluminal division of the eroded prosthetics, facilitating endoscopic removal in many cases and avoiding the need to approach a potentially hostile reoperative foregut. Endoscopic management of erosion from VBG, BGB, and LAGB can be safe and effective and should be considered by bariatric surgeons managing this feared complication. The ultimate approach to management should be the one safest for the patient and will vary from case to case based on the characteristics of the erosion and individual surgeon’s experience. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
Endoscopic Management of Band Erosion
References
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Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366(17):1567-76. Mason EE, Printen KJ, Hartford CE, et al. Optimizing results of gastric bypass. Ann Surg 1975; 182(4):405-14. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982; 117(5):701-6. Fobi M, Lee H, Igwe D, et al. Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg 2001; 11(6):699-707. Chisholm J, Kitan N, Toouli J, et al. Gastric band erosion in 63 cases: endoscopic removal and rebanding evaluated. Obes Surg 2011; 21(11):1676-81. Kohn GP, Hansen CA, Gilhome RW, et al. Laparoscopic management of gastric band erosions: a 10-year series of 49 cases. Surg Endosc 2012; 26(2):541-5. Evans JA, Williams NN, Chan EP, et al. Endoscopic removal of eroded bands in vertical banded gastroplasty: a novel use of endoscopic scissors (with video). Gastrointest Endosc 2006; 64(5):801-4. Karmali S, Snyder B, Wilson EB, et al. Endoscopic management of eroded prosthesis in vertical banded gastroplasty patients. Surg Endosc 2010; 24(1):98-102. Carbajo Caballero MA, Martin del Olmo JC, Blanco Alvarez JI, et al. Intragastric migration of laparoscopic adjustable gastric band (Lap-Band) for morbid obesity. J Laparoendosc Adv Surg Tech A 1998; 8(4):241-4. Di Lorenzo N, Lorenzo M, Furbetta F, et al. Intragastric gastric band migration: erosion: an analysis of multicenter experience on 177 patients. Surg Endosc 2013; 27(4):1151-7. Neto MP, Ramos AC, Campos JM, et al. Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases. Surg Obes Relat Dis 2010; 6(4):423-7. Prathanvanich P, Chand B. Complete endoscopic/transgastric retrieval of eroded gastric band: a novel technique. Gastrointest Endosc 2013; 78(6):816. Shehab H, Gawdat K. Endoscopic Management of Eroded Bands Following BandedGastric Bypass (with Video). Obes Surg 2017. El-Hayek K, Timratana P, Brethauer SA, et al. Complete endoscopic/transgastric retrieval of eroded gastric band: description of a novel technique and review of the literature. Surg Endosc 2013; 27(8):2974-9. Lattuada E, Zappa MA, Mozzi E, et al. Band erosion following gastric banding: how to treat it. Obes Surg 2007; 17(3):329-33. Wilson TD, Miller N, Brown N, et al. Stent induced gastric wall erosion and endoscopic retrieval of nonadjustable gastric band: a new technique. Surg Endosc 2013; 27(5):161721. Dugan J, Bajwa K, Singhal S. Endoscopic removal of gastric band by use of a stentinduced erosion technique. Gastrointest Endosc 2016; 83(3):654-5. Marins Campos J, Moon RC, Magalhaes Neto GE, et al. Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent. Endoscopy 2016; 48(6):516-20.
Endoscopic Management of Band Erosion
19. 20. 21.
22. 23. 24.
Carbonell AM, Maher JW. Laparoscopic transgastric removal of an eroded Angelchik prosthesis. Am Surg 2006; 72(8):724-6; discussion 727. Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23(6):1219-26. Kepenekci I, Turkcapar AG. Mesh erosion as a complication of laparoscopic fundoplication with prosthetic hiatal closure: report of a case. Surg Laparosc Endosc Percutan Tech 2009; 19(2):e51-4. Soricelli E, Basso N, Genco A, et al. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Surg Endosc 2009; 23(11):2499-504. Bauer M, Meining A, Kranzfelder M, et al. Endoluminal perforation of a magnetic antireflux device. Surg Endosc 2015; 29(12):3806-10. Asti E, Siboni S, Lazzari V, et al. Removal of the Magnetic Sphincter Augmentation Device: Surgical Technique and Results of a Single-Center Cohort Study. Ann Surg 2016.
Table 1. Baseline Characteristics of Patients with Gastric Band Erosion Sex Female 100% (16) Race White 75% (12) Black 25% (4) Age at removal 57.3 (33-71) BMI at removal 37.8 (25.4 - 53.4) Initial procedure type BGB 68.8% (11) LAGB 18.7% (3) VBG 12.5% (2) Years since initial procedure BGB LAGB VBG Banding material (other than LAGB) Heavyweight mesh Silastic band with monofilament suture Tobacco use since banding procedure Yes No Unknown Non-steroidal anti-inflammatory drug use Yes No
15.5 (10-22) 5.2 (3-6.5) 27 (20-34)
12.5% (2) 68.8%(11) 18.8% (3) 75% (12) 6.2% (1) 43.8% (7) 50% (8)
Endoscopic Management of Band Erosion
Unknown
6.2% (1)
Legend: BGB: banded gastric bypass, LAGB: laparoscopic adjustable gastric band, VBG: vertical banded gastroplasty
Table 2. Operative Details of Patients Undergoing Endoscopic Band Removal Indication for removal Epigastric pain 62.5% (10) Nausea, emesis, or dysphagia 31.3% (5) Asymptomatic 6.2% (1) Complete retrieval Yes 87.5% (14) No 12.5% (2) Operative technique Dual action scissors (DAS) 37.5% (6) Mechanical lithotriptor (ML) 62.5% (10) Operative length (minutes) DAS ML Resolution of symptoms Yes Unknown Gastrogastric fistula (BGB patients) Yes No
29 (13-64) 78.1 (49 - 120) 80% (12) 20% (3) 55% (6) 45% (5)
Legend: BGB: banded gastric bypass
Endoscopic Management of Band Erosion
PII: DOI: Reference:
S1550-7289(17)30352-0 http://dx.doi.org/10.1016/j.soard.2017.07.025 SOARD3083
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Matthew D. Spann, Chetan V. Aher, Wayne J. English and D. Brandon Williams, Endoscopic Management of Erosion after Banded Bariatric P r o c e d u r e s , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.07.025 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Endoscopic Management of Erosion after Banded Bariatric Procedures
Matthew D. Spann, M.D. Chetan V. Aher, M.D. Wayne J. English, M.D. D. Brandon Williams, M.D.
Vanderbilt Center for Surgical Weight Loss Vanderbilt University Medical Center
Corresponding Author: Matthew D. Spann, M.D. 1161 Medical Center Drive MCN D-5203 Nashville, TN 37232-2577 Phone: 615-322-7555 Fax: 615-343-9485
Endoscopic Management of Band Erosion
Endoscopic Management of Erosion after Banded Bariatric Procedures
Abstract 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 non-adjustable 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
Endoscopic Management of Band Erosion
or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a post-op GI bleed requiring repeat endoscopy, one patient with asymptomatic pneumoperitoneum requiring observation, and one with seroma at the site of her 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. Keywords band erosion; laparoscopic adjustable gastric band; Lap-Band; vertical banded gastroplasty; VBG; banded gastric bypass; endoscopic management, Roux-en-Y gastric bypass; RYGB
Endoscopic Management of Band Erosion
Introduction Morbid obesity remains a pandemic and one of the greatest public health risks all countries will face in the coming years. The healthcare community has long struggled with effective ways of preventing and treating morbid obesity. Bariatric surgery was introduced as a treatment for morbid obesity over 60 years ago and remains the most effective treatment for this disease and its associated comorbidities.(1) The principles of bariatric surgery have focused heavily on restriction, malabsorption, or a combination of these mechanisms. Gastric restriction is a fundamental component of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass(RYGB), and failure of restriction was thought to be responsible for inadequate weight maintenance.(2,2) Bariatric procedures frequently included prosthetic materials placed around the stomach to ensure persisting restraint. (3) By definition, the VBG included banding the stomach with a silastic ring, heavyweight mesh, or other prosthetic material at the distal aspect of the gastroplasty to limit outflow from the gastric pouch. With RYGB, silastic bands were also frequently placed around the gastric pouch outlet. The practice of gastric restriction with prostheses became especially popular with the laparoscopic adjustable gastric band (LAGB). While observers noted weight loss success with these procedures, a known complication was intraluminal erosion of the prosthetic material.(4) While successful management of this complication can obviously be accomplished through laparotomy or laparoscopy, advances in minimally invasive techniques have allowed clinicians to manage gastric band erosion endoscopically, providing improved patient outcomes.(5) We report our experience as a tertiary referral center of gastric band erosions managed endoscopically by bariatric surgeons.
Endoscopic Management of Band Erosion
Methods We retrospectively reviewed our institutional bariatric surgery database, which was approved by our Institutional Review Board. Patients with eroded gastric bands were identified by searching Current Procedures Terminology code for removal of gastric band (43774) and upper gastrointestinal endoscopy with foreign body removal (43247). A chart review of potential patients was undertaken, and those patients with endoscopic confirmation of gastric band erosion were included for analysis. Patients with no documentation of gastric band erosion were excluded. No patients underwent removal of a partially eroded gastric band at the time of another bariatric procedure, as our practice is to manage band erosions prior to revisional surgery. Demographic data, case history, and operative details were reviewed. We collected the following variables for reporting: original procedure, time to erosion, symptom presentation and resolution, details of removal procedure, weight loss, postoperative complications, and risk factors for ulcer disease, including smoking and use of non-steroidal anti-inflammatory drugs (NSAIDs). At the time of this review, the FDA had not approved any device for the specific purpose of removing eroded gastric banding material. As such, the techniques we describe involve off-label use of devices, not recommended by the device manufacturers. Our technique predominately utilized a 9.9mm diameter single channel gastroscope, with only occasional use of the dual channel gastroscope. We first attempted to divide the eroded silastic or mesh banding material using dual action endoscopic scissors. If we could not cut through the banding material with the scissors, we passed a 450cm biliary guidewire (Boston Scientific Hydra Jagwire ST) around the eroded material. We passed the wire through a mechanical lithotripter (Olympus BML-110A-1), and tightening the wire through this device caused the wire to sever the eroded band material. We then removed the band using either a snare or large endoscopic forceps. Removal of the band material was considered complete when no visible prosthetic
Endoscopic Management of Band Erosion
material was observed within the gastric wall or lumen and there were no apparent missing portions of the ring when examined ex vivo. No attempt was made to close the resulting mucosal defect. For further details of this procedure, please see the additional media for a video description of our lithotripter technique. Results From November 1, 2014 through December 31, 2016, 60 patients underwent removal of a gastric band prosthesis originally placed for weight loss as part of a primary procedure. Sixteen patients were identified with erosion of gastric banding material. Endoscopic images were reviewed, and in all cases the band material was partially eroded, with a portion of the prosthetic material visible inside the lumen of the stomach and a portion outside of the lumen, presumably within the gastric wall or peritoneal cavity. All patients with documented evidence of band erosion were managed endoscopically. Baseline characteristics are displayed in Table 1. All patients were female. Most patients were overweight or suffered from class 1 obesity at the time of band removal. Historical weight data was available on 9 patients, with an average excess body weight loss of 47.6% (0 - 84). The predominant indications for removal were epigastric abdominal pain (62.5%) or chronic nausea and emesis (31.3%). One patient was asymptomatic, and removal was indicated in preparation for a revisional bariatric procedure. Of the 16 patients, 11 had history of an open, banded Roux-en-Y gastric bypass (BGB). Three patients had LAGB erosion, all with the band buckle clearly visible in the lumen. Two patients had a VBG erosion. Average time to identification of erosion was shortest with LAGB (5.2 years) and longest for VBG (27 years). The banding material used in patients with BGB was a silastic tube placed over a permanent, monofilament suture. Heavyweight polypropylene mesh was used in both patients with a
Endoscopic Management of Band Erosion
VBG. A majority of patients reported no tobacco use (75%), and half of patients reported no use of NSAIDs. Complete endoscopic removal of all the eroded band material was accomplished in 14 of 16 patients (87.5%). In one patient with prior BGB, a small amount of imbedded monofilament suture was unable to be removed endoscopically. In one patient with prior VBG, the heavyweight mesh had become incorporated in the gastric wall, but nearly all the intraluminal mesh was successfully removed. No patients required laparoscopic or open interventions. Operative characteristics are detailed in Table 2. We used dual action scissors to divide and remove 6 of the 11 (54.5%) silastic BGB bands. The remaining bands (5 BGB bands, 3 LAGBs, and 2 VBGs) required use of the mechanical lithotripter for division and removal. Thus, overall, dual action scissors successfully divided the eroded band material in 6 of 16 patients (37.5%). The average procedure time was shorter when dual action scissors were successful (29 minutes), compared with use of the mechanical lithotripter (78.1 minutes). Fifteen patients (94%) were discharged on the day of the procedure after tolerating a liquid diet. Short term follow-up data was available in 15 of 16 patients. Of those patients, all experienced resolution of nausea, vomiting, and epigastric pain. Of note, both patients with partial removal of the eroded material had a complete resolution of symptoms. Complications occurred in three patients, with two after LAGB removal. One patient had a seroma at the port site that resolved without intervention. Another patient had pneumoperitoneum seen on postoperative chest x-ray; this patient underwent fluoroscopic contrast evaluation which revealed no evidence of gastric leak. The patient was observed overnight and discharged without sequelae. The third patient required readmission after removal of a silastic band for a post-op GI bleed, leading to a repeat endoscopy which showed no residual hemorrhage. It was later determined this patient had unreported use of antiplatelet therapy.
Endoscopic Management of Band Erosion
Discussion Erosion of prosthesis used in bariatric surgery has been well described. While the true incidence of erosion is difficult to obtain, the reported rates for this long-term complication are between 1 and 10%.(4, 6) Symptoms of erosion vary but often include dysphagia. Early approaches to manage erosion of mesh or silastic rings after VBG and BGB included laparotomy and major revision. While effective, open techniques required an inpatient hospitalization and carried higher perioperative morbidity. Endoscopic removal often could not be accomplished in patients due to limitations of instruments and endoscopic technique.(4, 7) However, advances in endosurgical techniques have allowed removal of eroded VBG and BGB prostheses to become increasingly successful through use of argon beam, YAG laser, and endoscopic scissors.(5, 7, 8) We experienced similar success by removing all visible prosthetic material from 11 of our 13 VBG and BGB patients, leaving behind only a small amount of monofilament suture in one BGB patient and a small amount of heavyweight mesh in one VBG patient, both of whom still had a complete resolution of symptoms. Almost half of patients with eroded silastic bands were successfully managed with endoscopic scissors (45.4%). The dual channel endoscope was required in some cases to apply countertraction when tension on the band was inadequate for division with the endoscopic scissors. VBG and BGB patients were all discharged on the day of the procedure. The only complication in this group was a self-limited postoperative intraluminal hemorrhage occurring in one patient. Two patients with prior VBG had heavyweight mesh used to create the gastric band. With heavyweight mesh, tissue ingrowth to the prosthesis will likely make complete removal difficult. However, one patient did have a successful endoscopic removal of the entire mesh prosthetic, perhaps because it was almost entirely eroded into the gastric lumen. Once the mesh was divided, the remaining portion pulled easily into the stomach and was subsequently removed using a snare. If tissue ingrowth
Endoscopic Management of Band Erosion
does not allow for complete retrieval of mesh prosthesis, the band will need to be sectioned in two places. In patients with prior banded gastric bypass, over half were found to have gastrogastric fistulae at the time of band removal. The exact cause of the fistulae is unknown, but thought to be due to nondivided gastric staple lines, although operative details were not readily available for all our patients. The presence of the gastric prosthesis may be related to formation of the gastrogastric fistulae. While management of the gastrogastric fistula was discussed with each patient, most elected to wait for recurrence of symptoms due to the risks associated with the revisional bariatric surgery. The first reported LAGB erosion occurred in 1998, and early erosions were treated through a laparoscopic or open approach.(6, 9, 10) While effective, these approaches often required extended hospitalization, with average length of stay for laparoscopic removal of LAGB after erosion being up to 4 days.(6) Endoscopic management of LAGB erosions requires additional technology and is accomplished by various methods of ligation, including band cutters, mechanical lithotripters, and endosurgical devices.(5, 11-13) Our series included three patients with eroded LAGBs, all of whom had a clearly visible intraluminal erosion of the band buckle, which is a critical finding on initial endoscopy for planning endoscopic management. We would not attempt to manage a LAGB erosion with a purely endoscopic method if the band buckle was not visible and would consider a hybrid method, combining the endoscopic and laparoscopic approaches. Erosion of the buckle is important because it is the thickest portion of the band, and bringing it inside the lumen, if not already eroded, would be technically difficult and potentially cause trauma to the gastric wall and adjacent organs. Endoscopic management of LAGB erosion is somewhat challenging in the United States due to a lack of tools dedicated to endoscopic band ligation. Thus, off-label use of products is required. We chose to use the mechanical lithotripter for band ligation in our patients. Care must be taken to avoid snaring a portion of mucosa when using this
Endoscopic Management of Band Erosion
device. Other operative options include hybrid approaches, using transgastric ports and laparoscopic instruments to divide the LAGB.(12, 14) The required approach to LAGB erosion will not be known until the time of the procedure; thus, we recommend management in the operating room, ideally directed by a bariatric surgeon with advanced endoscopy experience, or through a multidisciplinary approach between a bariatric surgeon and endoscopist. Management of the remaining gastric mucosal defect after endoscopic removal of eroded bands is somewhat controversial. For non-adjustable gastric bands, the thick perigastric capsule formed due to the band should still be intact after endoscopic removal and prevent gastric leaks. However, removal of LAGB endoscopically when the buckle has eroded leaves behind a defect in the gastric mucosa the diameter of the band or larger. Many available series regarding endoscopic management of LAGB erosions do not describe any management directed at this mucosal defect without report of leak despite early refeeding. (11, 15) Our practice is to avoid routine closure of the mucosal defect unless there is a concern for hemostasis. Patients are observed for several hours after starting clear liquids. If a patient experiences abdominal pain, or pain beyond what is expected from port removal after LAGB, we recommend abdominal imaging to rule out gastric leak. Patients are routinely discharged on the day of the procedure after tolerating liquids and instructed to return with abdominal pain or fever. Patient proximity and support system must be considered with plans for same day discharge. Erosion of the gastric prosthetics can be used for patient benefit is rare situations. Forced erosion is a concept that involves placing a covered stent across a stenosis created by a non-adjustable gastric band. Over the weeks following stent placement, pressure necrosis of the gastric wall between the stent and band results in forced erosion of the gastric band and allows subsequent removal at the time of stent retrieval. The potential for forced erosion of gastric bands to treat intractable vomiting from chronic band-related strictures has been successful in patients with outlet stenosis, avoiding major
Endoscopic Management of Band Erosion
revisional bariatric surgery.(16-18) Forced endoscopic erosions should be considered in VBG and BGB patients that are not suitable candidates for revisional surgery. Thankfully, attempting forced erosion is unlikely to alter other surgical options if erosion is unsuccessful. The decision for operative intervention and timing will vary from patient to patient. Urgent intervention should be considered in any patient presenting with gastrointestinal hemorrhage due to band erosion. For patients presenting with pain, symptoms may be managed similar to peptic ulcer symptoms, using acid suppression and sucralfate until the band removal. We also prefer acid suppression for 4 weeks following an endoscopic band removal due to the friable tissue often seen at the base of the mucosal defect. For high-risk patients that have minimal symptoms, or if erosion is found incidentally, conservative management with observation has been described. (10) Prosthetic materials have also been used around the distal esophagus and stomach for the treatment of gastroesophageal reflux disease and paraesophageal hernias. In the 1980s, a silicon ring, the Angelchik device, was used to augment the lower esophageal sphincter to aid in gastroesophageal reflux control. (19) Erosion was one of many reasons this device was abandoned. We have also seen a rise in the use of prosthetics during paraesophageal hernia repairs in effort to decrease early recurrence. However, erosion of hiatal prosthesis can be as high as 60%.(20-22) The latest mainstream use of a prosthetic includes a magnetic ring placed at the gastroesophageal junction, serving as an artificial sphincter. While the efficacy the device is good, there are reports of transmural migration. (23, 24) Erosion may be an underreported risk for prosthetics, as it is often a long-term complication, occurring years after the prosthetic is placed. In our current era of medical innovation, we must consider the history of prosthetics that are placed near the gastrointestinal tract and avoid revisiting lessons already learned. Our study is limited due to a small sample size and the retrospective nature of the review. Future investigations into the incidence and safety of endoscopic management of band erosion would
Endoscopic Management of Band Erosion
be aided greatly by including this variable into the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry.
Conclusion The complication of gastric band prosthetic erosion will be a problem bariatric surgeons face for many years to come due to its delayed presentation. Open and laparoscopic management of band erosions are safe and effective. Recent advances in endoscopic techniques have allowed endoluminal division of the eroded prosthetics, facilitating endoscopic removal in many cases and avoiding the need to approach a potentially hostile reoperative foregut. Endoscopic management of erosion from VBG, BGB, and LAGB can be safe and effective and should be considered by bariatric surgeons managing this feared complication. The ultimate approach to management should be the one safest for the patient and will vary from case to case based on the characteristics of the erosion and individual surgeon’s experience. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
Endoscopic Management of Band Erosion
References
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Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366(17):1567-76. Mason EE, Printen KJ, Hartford CE, et al. Optimizing results of gastric bypass. Ann Surg 1975; 182(4):405-14. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982; 117(5):701-6. Fobi M, Lee H, Igwe D, et al. Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg 2001; 11(6):699-707. Chisholm J, Kitan N, Toouli J, et al. Gastric band erosion in 63 cases: endoscopic removal and rebanding evaluated. Obes Surg 2011; 21(11):1676-81. Kohn GP, Hansen CA, Gilhome RW, et al. Laparoscopic management of gastric band erosions: a 10-year series of 49 cases. Surg Endosc 2012; 26(2):541-5. Evans JA, Williams NN, Chan EP, et al. Endoscopic removal of eroded bands in vertical banded gastroplasty: a novel use of endoscopic scissors (with video). Gastrointest Endosc 2006; 64(5):801-4. Karmali S, Snyder B, Wilson EB, et al. Endoscopic management of eroded prosthesis in vertical banded gastroplasty patients. Surg Endosc 2010; 24(1):98-102. Carbajo Caballero MA, Martin del Olmo JC, Blanco Alvarez JI, et al. Intragastric migration of laparoscopic adjustable gastric band (Lap-Band) for morbid obesity. J Laparoendosc Adv Surg Tech A 1998; 8(4):241-4. Di Lorenzo N, Lorenzo M, Furbetta F, et al. Intragastric gastric band migration: erosion: an analysis of multicenter experience on 177 patients. Surg Endosc 2013; 27(4):1151-7. Neto MP, Ramos AC, Campos JM, et al. Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases. Surg Obes Relat Dis 2010; 6(4):423-7. Prathanvanich P, Chand B. Complete endoscopic/transgastric retrieval of eroded gastric band: a novel technique. Gastrointest Endosc 2013; 78(6):816. Shehab H, Gawdat K. Endoscopic Management of Eroded Bands Following BandedGastric Bypass (with Video). Obes Surg 2017. El-Hayek K, Timratana P, Brethauer SA, et al. Complete endoscopic/transgastric retrieval of eroded gastric band: description of a novel technique and review of the literature. Surg Endosc 2013; 27(8):2974-9. Lattuada E, Zappa MA, Mozzi E, et al. Band erosion following gastric banding: how to treat it. Obes Surg 2007; 17(3):329-33. Wilson TD, Miller N, Brown N, et al. Stent induced gastric wall erosion and endoscopic retrieval of nonadjustable gastric band: a new technique. Surg Endosc 2013; 27(5):161721. Dugan J, Bajwa K, Singhal S. Endoscopic removal of gastric band by use of a stentinduced erosion technique. Gastrointest Endosc 2016; 83(3):654-5. Marins Campos J, Moon RC, Magalhaes Neto GE, et al. Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent. Endoscopy 2016; 48(6):516-20.
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Carbonell AM, Maher JW. Laparoscopic transgastric removal of an eroded Angelchik prosthesis. Am Surg 2006; 72(8):724-6; discussion 727. Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23(6):1219-26. Kepenekci I, Turkcapar AG. Mesh erosion as a complication of laparoscopic fundoplication with prosthetic hiatal closure: report of a case. Surg Laparosc Endosc Percutan Tech 2009; 19(2):e51-4. Soricelli E, Basso N, Genco A, et al. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Surg Endosc 2009; 23(11):2499-504. Bauer M, Meining A, Kranzfelder M, et al. Endoluminal perforation of a magnetic antireflux device. Surg Endosc 2015; 29(12):3806-10. Asti E, Siboni S, Lazzari V, et al. Removal of the Magnetic Sphincter Augmentation Device: Surgical Technique and Results of a Single-Center Cohort Study. Ann Surg 2016.
Table 1. Baseline Characteristics of Patients with Gastric Band Erosion Sex Female 100% (16) Race White 75% (12) Black 25% (4) Age at removal 57.3 (33-71) BMI at removal 37.8 (25.4 - 53.4) Initial procedure type BGB 68.8% (11) LAGB 18.7% (3) VBG 12.5% (2) Years since initial procedure BGB LAGB VBG Banding material (other than LAGB) Heavyweight mesh Silastic band with monofilament suture Tobacco use since banding procedure Yes No Unknown Non-steroidal anti-inflammatory drug use Yes No
15.5 (10-22) 5.2 (3-6.5) 27 (20-34)
12.5% (2) 68.8%(11) 18.8% (3) 75% (12) 6.2% (1) 43.8% (7) 50% (8)
Endoscopic Management of Band Erosion
Unknown
6.2% (1)
Legend: BGB: banded gastric bypass, LAGB: laparoscopic adjustable gastric band, VBG: vertical banded gastroplasty
Table 2. Operative Details of Patients Undergoing Endoscopic Band Removal Indication for removal Epigastric pain 62.5% (10) Nausea, emesis, or dysphagia 31.3% (5) Asymptomatic 6.2% (1) Complete retrieval Yes 87.5% (14) No 12.5% (2) Operative technique Dual action scissors (DAS) 37.5% (6) Mechanical lithotriptor (ML) 62.5% (10) Operative length (minutes) DAS ML Resolution of symptoms Yes Unknown Gastrogastric fistula (BGB patients) Yes No
29 (13-64) 78.1 (49 - 120) 80% (12) 20% (3) 55% (6) 45% (5)
Legend: BGB: banded gastric bypass
Endoscopic Management of Band Erosion