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Endoscopic removal of eroded bands in vertical banded gastroplasty: a novel use of endoscopic scissors (with video)
Endoscopic removal of eroded bands in vertical banded gastroplasty: a novel use of endoscopic scissors (with video) John A. Evans, MD, Noel N. Williams, MD, FRCS, Erick P. Chan, MD, Michael L. Kochman, MD, FACP Philadelphia, Pennsylvania, USA
Background: Vertical banded gastroplasty (VBG) as a surgical therapy for morbid obesity was first described in 1982. VBG involves partitioning the stomach with a vertical staple line and restricting the outlet pouch with a Gortex band. Complications of VBG include partial and total erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Band erosion occurs after surgery in 1% to 3% of patients, and patients may present with symptoms of obstruction, weight gain, nausea, pain, and bleeding. Unless a band has freely eroded from the stomach wall, allowing spontaneous elimination or simple endoscopic retrieval, surgical removal has been required heretofore. Previous attempts at endoscopic removal of eroded bands have included the use of neodymium-yttrium aluminum garnet laser ablation and other electrosurgical devices. Endoscopic scissors transection to remove an eroded laparoscopic band has been described in Europe but has not been performed in the United States. Objective: In this series, we describe the endoscopic removal of partially eroded bands embedded in the gastric wall by using flexible endoscopic scissors to sever and subsequently withdraw the bands endoscopically through the mouth. Conclusions: Eroded gastric bands have been safely removed endoscopically in 2 ambulatory outpatients. Design: Case series. Setting: Tertiary-care academic center. Main Outcome Measurements: Efficacy and safety. Limitations: Highly selected motivated patient population.
Vertical banded gastroplasty (VBG) as a surgical therapy for morbid obesity was first described in 1982.1 VBG involves partitioning the stomach with a vertical staple line and restricting the outlet pouch with a Gortex band (W. L. Gore Inc, Elkton, Md). Complications of VBG include partial and total erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Band erosion occurs after surgery in 1% to 3% of patients2 and may present with symptoms of obstruction, weight gain, nausea, pain, and bleeding.3 Unless a band has freely eroded from the stomach wall, allowing spontaneous elimination or simple endoscopic retrieval, surgical removal has been required heretofore. Previous attempts at endoscopic removal of eroded bands have included the use of neodymium-yttrium aluminum garnet (Nd:YAG) laser ablation4 and other electrosurgical devices.5 Endoscopic-scissors transection to remove an eroded laparoscopic band has been described in Europe6 but has not been performed in the United States. In this series, we describe the endoscopic Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.04.036
removal of partially eroded bands embedded in the gastric wall by using flexible endoscopic scissors to sever and subsequently withdraw the bands endoscopically through the mouth. We felt that a 2-step procedure for the removal of the eroded band and then an interval gastric bypass reconstruction would be a more rational alternative to the common 1-step combined surgical approach. It was felt that the stepwise approach would allow for an improvement in the surgical field and, subsequently, a better outcome. Moreover, the patient would be able to make an interval decision regarding further surgical therapy, while not experiencing significant symptoms from the eroded band. In 2001, 2 sisters (ages 55 and 60) underwent VBG for morbid obesity within 1 week of each other. Four years after surgery, each patient began experiencing weight gain accompanied by nausea, and each underwent endoscopy, which demonstrated erosion of the band through the lesser curvature into the stomach pouch. The bands had not freely eroded into the stomach lumen but remained partially embedded within and outside of the gastric wall. Individual and multidisciplinary discussions were held with each patient and the bariatric surgeon, and were offered an initial attempt to remove the bands endoscopically as an alternative to surgical removal required at
www.giejournal.org
Volume 64, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY 801
A novel use of endoscopic scissors
Evans et al
Capsule Summary What is already known on this topic d
d
Complications of VBG include erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Unless a band has eroded free of the stomach wall and allowed spontaneous elimination or simple endoscopic retrieval, removal of the band is performed surgically or endoscopically by using laser ablation.
What this study adds to our knowledge d
Figure 1. A, Endoscope position during band removal in case 1. B, Eroded band as best visualized in a retroflexed position (case 1).
In 2 ambulatory outpatients, partially eroded bands embedded in the gastric wall were removed endoscopically by using flexible endoscopic scissors to sever and withdraw the bands.
alligator forceps (GF-49L-1; Olympus) in the 3.8-mm channel, the gastric band tag was grasped firmly adjacent to the closure wing and stabilized. The endoscopic scissors (36B-315; Olympus) were advanced through the 3.2-mm instrument channel, where the band was sequentially transected in a piecemeal fashion. The scissors were used on the opposite side of the grasping forceps. The band was severed, pulled from the stomach wall, and removed in 1 piece upon withdrawal of the endoscope. The endoscope was reinserted, and inspection of the resection site revealed mucosal oozing but no active bleeding or evidence of complication. The total length of the procedure from endoscopic intubation to final withdrawal was 45 minutes. The patient was monitored for 4 hours, reported no abdominal pain or nausea, and was discharged to home. On subsequent follow-up in the bariatric clinic, she was doing well and contemplating a gastric-bypass procedure.
Case 2
With the patient under monitored anesthesia care (MAC) sedation with propofol, an Olympus double-channel endoscope (GIF 2T100; Olympus America, Center Valley, Pa) with 3.2-mm and 3.8-mm instrument channels was introduced by mouth and was advanced into the gastric pouch. Optimal exposure to the gastric band was obtained with the endoscope retroflexed in the antrum (Fig. 1A and B). By using
With the patient under MAC sedation with propofol, a double-channel endoscope (GIF 2T100; Olympus) again was advanced to the gastric pouch. The eroded band was readily visualized, with optimal exposure of the endoscope in an en face position. (Fig. 2A and B) By using the alligator forceps passed through the 3.2-mm instrument channel, the band was grasped and held firmly adjacent to the closure wing. The forceps were pulled into the instrument channel, thus applying tension along the band length. Endoscopic scissors were passed through the 3.8-mm instrument channel, which allowed scissors access to the thinnest portion of the band in a perpendicular manner (Fig. 3). The band was then transected, with sequential scissors closure across the band. After complete transection, the band was pulled free from the gastric wall. By holding the band tightly with the forceps, the endoscope was withdrawn and the band was removed (Fig. 4, Video 1, available online at www.giejournal.org). Endoscopic reinspection of the site
802 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 5 : 2006
www.giejournal.org
the time of gastric bypass reconstruction. Informed consent included the possibility of a free perforation complicating their condition, but each individually opted for the endoscopic attempt to avoid the more complex operative intervention.
PATIENTS AND METHODS Case 1
Evans et al
A novel use of endoscopic scissors
Figure 3. Scissors (left) cutting through band with alligator forceps (right) holding band (case 2).
Figure 2. A, Endoscope position during band removal in case 2. B, En face view of eroded band from the gastric pouch (case 2).
demonstrated no obvious complications. The band had eroded transmurally and was replaced by inflammatory tissue (Fig. 5). The duration of the procedure from initial intubation to final withdrawal of the endoscope was 7 minutes. The patient was monitored for 4 hours, reported no abdominal pain or nausea, and was discharged to home. At a 3-month follow-up, the patient’s nausea had dissipated and she was contemplating gastric bypass surgery.
Figure 4. Band after removal, demonstrating straight and controlled cut (case 2).
Endoscopic scissors are an important tool in interventional GI endoscopy. Their use was described in the endoscopic palliation of refractory esophageal strictures7 and EMRs.8 Jess and Fonnest6 reported the first use of endoscopic scissors in the removal of an eroded vascular prosthesis placed during gastric surgery. Their report differs from this series, however, in that an electrosurgical device was required to facilitate the extraction of the eroded band.
A considerable difference in duration of our 2 procedures is evident. This difference was because of the favorable location of the eroded band in case 2. An en face position allowed precise endoscopic tip control and optimal delivery of the instruments. The alligator forceps grasped the band, and applied tension allowed it to be transected by fewer scissors applications in a perpendicular fashion. Delivery of the instruments in a retroflexed position, as required in case 1, was much more difficult. Control of the instruments was more complex and necessitated significant torque of the endoscope. The grasping forceps could not apply sufficient tension across the band to maintain an optimal taut condition of the band. Rather than
www.giejournal.org
Volume 64, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY 803
DISCUSSION
A novel use of endoscopic scissors
Evans et al
the management of other patients. Strategies to predict and manage this and other bariatric complications should be developed in a multidisciplinary fashion by working closely with bariatric surgeons.
ACKNOWLEDGMENTS The authors thank Adele K. Evans, MD, for providing illustrations. DISCLOSURE
Figure 5. Site of transmural band erosion, with overlying inflammatory tissue immediately after band removal (case 2).
a true perpendicular cut, the scissors cut on an oblique angle along the band, functionally increasing the effective length of the cut and increasing the number of applications of the scissors and the duration of the procedure. Other devices or means are potentially available to sever an eroded band. Nd:YAG laser ablation of a gastric band has been described; but in this initial description, the vaporization of the band was incomplete and required further therapy for removal.4 A failed attempt at using argon plasma coagulation (APC) to transect a gastric band has been reported.5 While seemingly attractive, the ablative abilities of APC are limited to the conduction properties of the material to which it is applied. Gastric bands are often made of Gortex or other synthetic materials that are not electrically conductive and, therefore, would not be amenable to removal via APC or other electrosurgical techniques. Alternatively, grasping the band with a stabilizing device (eg, forceps, snare) and applying mechanical force to pry the band free could cause significant trauma by disruption of the gastrogastric fistula and, subsequently, harm the patient. Not surprisingly, there are no published reports concerning this approach. We demonstrated the ability to endoscopically remove eroded gastric bands in ambulatory outpatients with apparent safety. Larger, prospective studies should further address the safety of this procedure. As the volume of bariatric surgery increases in the United States, the gastroenterology community will be continuously faced with managing complications of surgery in a minimally invasive fashion, and an awareness of this technique may benefit
804 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 5 : 2006
The University of Pennsylvania does not require institutional review board approval for the description of cases series that were not accumulated for the purpose of data collection. The endoscopic scissors used in this series are a prototype donated by Olympus America, Center Valley, Pa. Dr Kochman has received prior research support from Olympus Medical Systems.
REFERENCES 1. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982;117: 701-6. 2. Moreno P, Alastrue A, Rull M, et al. Band erosion in patients who have undergone vertical banded gastroplasty: incidence and technical solutions. Arch Surg 1998;133:189-93. 3. Fobi M, Lee H, Igwe D, et al. Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg 2001;11:699-707. 4. Lunde OC. Endoscopic laser therapy for band penetration of the gastric wall after gastric banding for morbid obesity. Endoscopy 1991;23:100-1. 5. Meyenberger C, Gubler C, Hengstler PM. Endoscopic management of a penetrated gastric band. Gastrointest Endosc 2004;60:480-1. 6. Jess P, Fonnest G. Gastroscopic treatment of a gastric band penetrating the gastric wall. Dan Med Bull 1999;46:428. 7. Beilstein MC, Kochman ML. Endoscopic incision of a refractory esophageal stricture: novel management with an endoscopic scissors. Gastrointest Endosc 2005;61:623-5. 8. Miyashita M, Tajiri T, Maruyama H, et al. Endoscopic mucosal resection scissors for the treatment of early gastric cancer. Endoscopy 2003;35: 611-2.
Received February 13, 2006. Accepted April 27, 2006. Current affiliations: Gastroenterology Division, Department of Medicine (Drs Evans, Chan, and Kochman), Gastrointestinal Surgery Division, Department of Surgery (Dr Williams), University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, Gastroenterology Division, University of Pennsylvania Health System, 3 Ravdin, 3400 Spruce St, Philadelphia, PA 19104.
www.giejournal.org
Background: Vertical banded gastroplasty (VBG) as a surgical therapy for morbid obesity was first described in 1982. VBG involves partitioning the stomach with a vertical staple line and restricting the outlet pouch with a Gortex band. Complications of VBG include partial and total erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Band erosion occurs after surgery in 1% to 3% of patients, and patients may present with symptoms of obstruction, weight gain, nausea, pain, and bleeding. Unless a band has freely eroded from the stomach wall, allowing spontaneous elimination or simple endoscopic retrieval, surgical removal has been required heretofore. Previous attempts at endoscopic removal of eroded bands have included the use of neodymium-yttrium aluminum garnet laser ablation and other electrosurgical devices. Endoscopic scissors transection to remove an eroded laparoscopic band has been described in Europe but has not been performed in the United States. Objective: In this series, we describe the endoscopic removal of partially eroded bands embedded in the gastric wall by using flexible endoscopic scissors to sever and subsequently withdraw the bands endoscopically through the mouth. Conclusions: Eroded gastric bands have been safely removed endoscopically in 2 ambulatory outpatients. Design: Case series. Setting: Tertiary-care academic center. Main Outcome Measurements: Efficacy and safety. Limitations: Highly selected motivated patient population.
Vertical banded gastroplasty (VBG) as a surgical therapy for morbid obesity was first described in 1982.1 VBG involves partitioning the stomach with a vertical staple line and restricting the outlet pouch with a Gortex band (W. L. Gore Inc, Elkton, Md). Complications of VBG include partial and total erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Band erosion occurs after surgery in 1% to 3% of patients2 and may present with symptoms of obstruction, weight gain, nausea, pain, and bleeding.3 Unless a band has freely eroded from the stomach wall, allowing spontaneous elimination or simple endoscopic retrieval, surgical removal has been required heretofore. Previous attempts at endoscopic removal of eroded bands have included the use of neodymium-yttrium aluminum garnet (Nd:YAG) laser ablation4 and other electrosurgical devices.5 Endoscopic-scissors transection to remove an eroded laparoscopic band has been described in Europe6 but has not been performed in the United States. In this series, we describe the endoscopic Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.04.036
removal of partially eroded bands embedded in the gastric wall by using flexible endoscopic scissors to sever and subsequently withdraw the bands endoscopically through the mouth. We felt that a 2-step procedure for the removal of the eroded band and then an interval gastric bypass reconstruction would be a more rational alternative to the common 1-step combined surgical approach. It was felt that the stepwise approach would allow for an improvement in the surgical field and, subsequently, a better outcome. Moreover, the patient would be able to make an interval decision regarding further surgical therapy, while not experiencing significant symptoms from the eroded band. In 2001, 2 sisters (ages 55 and 60) underwent VBG for morbid obesity within 1 week of each other. Four years after surgery, each patient began experiencing weight gain accompanied by nausea, and each underwent endoscopy, which demonstrated erosion of the band through the lesser curvature into the stomach pouch. The bands had not freely eroded into the stomach lumen but remained partially embedded within and outside of the gastric wall. Individual and multidisciplinary discussions were held with each patient and the bariatric surgeon, and were offered an initial attempt to remove the bands endoscopically as an alternative to surgical removal required at
www.giejournal.org
Volume 64, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY 801
A novel use of endoscopic scissors
Evans et al
Capsule Summary What is already known on this topic d
d
Complications of VBG include erosion of the band through the vertical staple line or through the lesser curvature into the gastric pouch. Unless a band has eroded free of the stomach wall and allowed spontaneous elimination or simple endoscopic retrieval, removal of the band is performed surgically or endoscopically by using laser ablation.
What this study adds to our knowledge d
Figure 1. A, Endoscope position during band removal in case 1. B, Eroded band as best visualized in a retroflexed position (case 1).
In 2 ambulatory outpatients, partially eroded bands embedded in the gastric wall were removed endoscopically by using flexible endoscopic scissors to sever and withdraw the bands.
alligator forceps (GF-49L-1; Olympus) in the 3.8-mm channel, the gastric band tag was grasped firmly adjacent to the closure wing and stabilized. The endoscopic scissors (36B-315; Olympus) were advanced through the 3.2-mm instrument channel, where the band was sequentially transected in a piecemeal fashion. The scissors were used on the opposite side of the grasping forceps. The band was severed, pulled from the stomach wall, and removed in 1 piece upon withdrawal of the endoscope. The endoscope was reinserted, and inspection of the resection site revealed mucosal oozing but no active bleeding or evidence of complication. The total length of the procedure from endoscopic intubation to final withdrawal was 45 minutes. The patient was monitored for 4 hours, reported no abdominal pain or nausea, and was discharged to home. On subsequent follow-up in the bariatric clinic, she was doing well and contemplating a gastric-bypass procedure.
Case 2
With the patient under monitored anesthesia care (MAC) sedation with propofol, an Olympus double-channel endoscope (GIF 2T100; Olympus America, Center Valley, Pa) with 3.2-mm and 3.8-mm instrument channels was introduced by mouth and was advanced into the gastric pouch. Optimal exposure to the gastric band was obtained with the endoscope retroflexed in the antrum (Fig. 1A and B). By using
With the patient under MAC sedation with propofol, a double-channel endoscope (GIF 2T100; Olympus) again was advanced to the gastric pouch. The eroded band was readily visualized, with optimal exposure of the endoscope in an en face position. (Fig. 2A and B) By using the alligator forceps passed through the 3.2-mm instrument channel, the band was grasped and held firmly adjacent to the closure wing. The forceps were pulled into the instrument channel, thus applying tension along the band length. Endoscopic scissors were passed through the 3.8-mm instrument channel, which allowed scissors access to the thinnest portion of the band in a perpendicular manner (Fig. 3). The band was then transected, with sequential scissors closure across the band. After complete transection, the band was pulled free from the gastric wall. By holding the band tightly with the forceps, the endoscope was withdrawn and the band was removed (Fig. 4, Video 1, available online at www.giejournal.org). Endoscopic reinspection of the site
802 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 5 : 2006
www.giejournal.org
the time of gastric bypass reconstruction. Informed consent included the possibility of a free perforation complicating their condition, but each individually opted for the endoscopic attempt to avoid the more complex operative intervention.
PATIENTS AND METHODS Case 1
Evans et al
A novel use of endoscopic scissors
Figure 3. Scissors (left) cutting through band with alligator forceps (right) holding band (case 2).
Figure 2. A, Endoscope position during band removal in case 2. B, En face view of eroded band from the gastric pouch (case 2).
demonstrated no obvious complications. The band had eroded transmurally and was replaced by inflammatory tissue (Fig. 5). The duration of the procedure from initial intubation to final withdrawal of the endoscope was 7 minutes. The patient was monitored for 4 hours, reported no abdominal pain or nausea, and was discharged to home. At a 3-month follow-up, the patient’s nausea had dissipated and she was contemplating gastric bypass surgery.
Figure 4. Band after removal, demonstrating straight and controlled cut (case 2).
Endoscopic scissors are an important tool in interventional GI endoscopy. Their use was described in the endoscopic palliation of refractory esophageal strictures7 and EMRs.8 Jess and Fonnest6 reported the first use of endoscopic scissors in the removal of an eroded vascular prosthesis placed during gastric surgery. Their report differs from this series, however, in that an electrosurgical device was required to facilitate the extraction of the eroded band.
A considerable difference in duration of our 2 procedures is evident. This difference was because of the favorable location of the eroded band in case 2. An en face position allowed precise endoscopic tip control and optimal delivery of the instruments. The alligator forceps grasped the band, and applied tension allowed it to be transected by fewer scissors applications in a perpendicular fashion. Delivery of the instruments in a retroflexed position, as required in case 1, was much more difficult. Control of the instruments was more complex and necessitated significant torque of the endoscope. The grasping forceps could not apply sufficient tension across the band to maintain an optimal taut condition of the band. Rather than
www.giejournal.org
Volume 64, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY 803
DISCUSSION
A novel use of endoscopic scissors
Evans et al
the management of other patients. Strategies to predict and manage this and other bariatric complications should be developed in a multidisciplinary fashion by working closely with bariatric surgeons.
ACKNOWLEDGMENTS The authors thank Adele K. Evans, MD, for providing illustrations. DISCLOSURE
Figure 5. Site of transmural band erosion, with overlying inflammatory tissue immediately after band removal (case 2).
a true perpendicular cut, the scissors cut on an oblique angle along the band, functionally increasing the effective length of the cut and increasing the number of applications of the scissors and the duration of the procedure. Other devices or means are potentially available to sever an eroded band. Nd:YAG laser ablation of a gastric band has been described; but in this initial description, the vaporization of the band was incomplete and required further therapy for removal.4 A failed attempt at using argon plasma coagulation (APC) to transect a gastric band has been reported.5 While seemingly attractive, the ablative abilities of APC are limited to the conduction properties of the material to which it is applied. Gastric bands are often made of Gortex or other synthetic materials that are not electrically conductive and, therefore, would not be amenable to removal via APC or other electrosurgical techniques. Alternatively, grasping the band with a stabilizing device (eg, forceps, snare) and applying mechanical force to pry the band free could cause significant trauma by disruption of the gastrogastric fistula and, subsequently, harm the patient. Not surprisingly, there are no published reports concerning this approach. We demonstrated the ability to endoscopically remove eroded gastric bands in ambulatory outpatients with apparent safety. Larger, prospective studies should further address the safety of this procedure. As the volume of bariatric surgery increases in the United States, the gastroenterology community will be continuously faced with managing complications of surgery in a minimally invasive fashion, and an awareness of this technique may benefit
804 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 5 : 2006
The University of Pennsylvania does not require institutional review board approval for the description of cases series that were not accumulated for the purpose of data collection. The endoscopic scissors used in this series are a prototype donated by Olympus America, Center Valley, Pa. Dr Kochman has received prior research support from Olympus Medical Systems.
REFERENCES 1. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg 1982;117: 701-6. 2. Moreno P, Alastrue A, Rull M, et al. Band erosion in patients who have undergone vertical banded gastroplasty: incidence and technical solutions. Arch Surg 1998;133:189-93. 3. Fobi M, Lee H, Igwe D, et al. Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg 2001;11:699-707. 4. Lunde OC. Endoscopic laser therapy for band penetration of the gastric wall after gastric banding for morbid obesity. Endoscopy 1991;23:100-1. 5. Meyenberger C, Gubler C, Hengstler PM. Endoscopic management of a penetrated gastric band. Gastrointest Endosc 2004;60:480-1. 6. Jess P, Fonnest G. Gastroscopic treatment of a gastric band penetrating the gastric wall. Dan Med Bull 1999;46:428. 7. Beilstein MC, Kochman ML. Endoscopic incision of a refractory esophageal stricture: novel management with an endoscopic scissors. Gastrointest Endosc 2005;61:623-5. 8. Miyashita M, Tajiri T, Maruyama H, et al. Endoscopic mucosal resection scissors for the treatment of early gastric cancer. Endoscopy 2003;35: 611-2.
Received February 13, 2006. Accepted April 27, 2006. Current affiliations: Gastroenterology Division, Department of Medicine (Drs Evans, Chan, and Kochman), Gastrointestinal Surgery Division, Department of Surgery (Dr Williams), University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. Reprint requests: Michael L. Kochman, MD, Gastroenterology Division, University of Pennsylvania Health System, 3 Ravdin, 3400 Spruce St, Philadelphia, PA 19104.
www.giejournal.org