Obesity Surgery, 17, 329-333 Band Erosion Following Gastric Banding: How to Treat It Ezio Lattuada, MD 1 ; Marco Antonio Zappa, MD 1 ; Enrico Mozzi, MD 1,2 ; Giuseppe Fichera, MD 1,2 ; Paola Granelli, MD 1 ; Fausto De Ruberto, MD 2 ; Ilaria Antonini, MD 2 ; Stefano Radaelli, MD 2 ; Giancarlo Roviaro, MD 1,2 1 Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano; 2 Universita degli Studi di Milano, Italy Background: Intragastric band migration is an unusual but major long-term complication of gastric banding: its frequency ranges from 0.5-3.8% and always requires removal of the band. Different laparoscopic, laparotomic or endoscopic methods are currently used for band removal. Methods: 571 morbidly obese patients underwent adjustable gastric banding from February 1998 to July 2006. Band erosion occurred in 3 patients (0.52%). In addition, 6 such patients were referred to our Department from other hospitals. To remove the migrated band, in most patients we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation). Results: In 7 of the 9 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparoscopy. In another case, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 2 patients, we had to remove the band surgically in one case for port-site infection with subphrenic abscess, and in the other case for complete band migration into the jejunum associated with acute pancreatitis, cholelithiasis and choledocholithiasis. Conclusion: The Gastric Band Cutter, when used, was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be the procedure of choice for band erosion, because it allows earlier patient discharge and avoids a surgical operation. It is advisable to perform the endoscopic removal in the operating theater, because of possible complications of the procedure. Correspondence to: Dott. Ezio Lattuada, Ospedale Policlinico, Via F. Sproza, 35, 21124 Milan, Italy. E-mail: e.lattuada@policlinico.mi.it Key words: Obesity surgery, morbid obesity, gastric banding, band erosion, endoscopy Introduction Adjustable gastric banding has rapidly become the restrictive procedure of choice in bariatric surgery in Europe, since its introduction in the early 1990s. 1-3 The reasons for its success are related to the ability to obtain an adequate weight loss without need for gastric resection or modification of the anatomy of the stomach and intestine. The reversibility of the procedure and the ease of operating laparoscopically enable an early discharge and a rapid recovery. In spite of these well-recognized results, some longterm complications may occur, most frequently pouch dilatation, port disconnection, and intragastric band erosion and migration. The latter is a major complication, because the migrated band must always be removed; it is reported with a frequency of 0.5 to 3.8%. Different hypotheses have been suggested to explain this complication: 1) damage of the gastric wall during band implantation; 4 2) infection of the band-site; 5 3) overfilling the band; 6 4) abnormal reaction of the periprosthesic tissue to the presence of the band. 7 Different methods are used to remove the band, with authors preferring a laparoscopic or laparotomic approach. An endoscopic approach has been proposed, especially when the band has nearly completely migrated into the stomach. 8 In our study, we observed 9 migrated bands; 5 of them were removed endoscopically with the aid of special endoscopic instrumentation. FD-Communications Inc. Obesity Surgery, 17, 2007 329
Lattuada et al Materials and Methods From February 1998 to July 2006, 571 morbidly obese patients (129 males, 442 females) underwent laparoscopic adjustable gastric banding (LAGB) in the 1st General Surgery Unit of the Fondazione Policlinico, Mangiagalli e Regina Elena of Milan. Mean BMI was 42.9. The first 115 patients had been operated by the perigastric technique, and the last 456 patients with the pars flaccida technique. The operations were always laparoscopic, except 6 cases of laparotomic conversion for hepatosplenomegaly, intraoperative damage to the gastric wall with the perigastric technique, or adhesions. Band erosion occurred in 3 out of the 571 patients (0.52%), and 6 additional patients with band erosion were referred to our Department from other hospitals. In these 9 patients, the diagnosis of erosion was made at an average time of 22 months after the original operation (range 14-36 months). Mean preoperative BMI of patients with erosion was 44 kg/m 2 ; at the time of diagnosis of erosion, the BMI was 36. In 6 patients, the band had been implanted laparoscopically, and in three laparotomically as a conversion from laparoscopy. Table 1 reports the type of band, the approach to placement, the pressure of inflation, and the presenting symptoms. Most common type of bands are represented. We cannot report the pressure of inflation and the follow-up of the patients coming from other hospitals, because their bands had always been deflated, or the port had already been removed. Most common symptoms were weight regain, epigastric pain and port-site infection. One patient was referred to our hospital for port-site infection with CT evidence of subphrenic abscess. Another patient was admitted for acute pancreatitis related to cholelithiasis and choledocholithiasis; her band had, however, completely migrated and was found in the jejunum. For the diagnosis of band migration, a Gastrografin swallow was not always sufficient, and band filling was not effective in reducing the gastric stoma size (Figure 1). Therefore, after checking that there were no leaks in the connecting tube, a gastroscopy was needed in all cases to visualize the erosion. In 7 out of the 9 cases, we tried to remove the band endoscopically with the aid of an endoscopic device designed to cut the migrated band (AMI Gastric Band Cutter, Agency for Medical Innovation GmbH, Götzis, Austria). The procedure is always done in the operating theater, under sedation. First, the port is removed, and then the cutting wire of the device is introduced into the stomach Table 1. Band implantation: type of band, symptoms, and follow-up Patient Hospital of Band Type Way of Presenting Pressure Inflation and Implantation Insertion Symptoms Follow-up No. 1 Other hospital Laparotomy Port-site and Port removed 3 months after Perigastric subphrenic abscess surgery and band deflated No. 2 Other hospital Obtech Laparoscopy Weight regain Band deflated in other hospital No. 3 Other hospital Obtech Laparoscopy Weight regain Band deflated in other hospital No. 4 Our hospital Laparoscopy Port-site infection Band inflated with 3 ml.saline, Perigastric then deflated with port removal No. 5 Other hospital Laparotomy Weight regain and Band deflated in other hospital Perigastric epigastric pain No. 6 Our hospital Laparoscopy Port-site infection Port removed 6 months after surgery and band deflated No. 7 Other hospital Laparotomy Epigastric pain, Band never inflated Perigastric gastric ulceration No. 8 Other hospital Laparoscopy Weight regain and Band never inflated epigastric pain No. 9 Our hospital Laparoscopy Acute pancreatitis, Band inflated with 2 ml. saline cholelithiasis, choledocholithiasis 330 Obesity Surgery, 17, 2007
Treatment of Intragastric Band Migration wire is then pulled by means of a lever, cutting the band, which is then removed with the gastroscope. The following day, a Gastrografin swallow is done to rule out leak and assess flow. The patient is discharged on the second day. Results Figure 1. Gastrografin swallow showing an intragastric band migration. The contrast medium flows partially around the band. through the working channel of a gastroscope, passed around the band, and retracted out with the gastroscope. The upper ends of the wire are introduced in a guide that is pushed into the stomach; the Nine bands have been removed for intragastric migration thus far. Table 2 shows the procedure and methods used to remove the bands. The first patient was admitted with port-site infection and a subphrenic abscess; therefore we had to remove the migrated band by laparotomy. Thenafter, with the introduction of the gastric band cutter in our Department, we always attempted an endoscopic approach. Although the first intragastric band cutting with this device was successful, in the second patient in which it was used (no. 3), a technical problem occured: the cutting wire, after being passed around the band and retracted, got twisted in the esophagus and was blocked in the area of the cardia, Table 2. Removal of the eroded band: patients, methods, and outcome Patient Band Implant/ Endoscopic Endoscopic Removal Notes Cutting Wire Band Type Approach Band Cutting No. 1 Laparotomy No Laparotomy Gastrotomy + drainage No. 2 Laparoscopy Yes Yes Endoscopic Sedation Usual Obtech No. 3 Laparoscopy Yes No Laparoscpy Intragastric blockage Obtech of the cutting wire Usual No. 4 Laparoscopy Yes Yes Endoscopic Sedation Thicker No. 5 Laparotomy Yes Yes Endoscopic Sedation Thicker No. 6 Laparoscopy Yes Yes Endoscopic Sedation Thicker No. 7 Laparotomy Yes Yes Laparotomy Leak of gastrotomy Thicker No. 8 Laparoscopy Yes Yes Endoscopic General anesthesia Thicker No. 9 Laparoscopy No Laparoscopy Endoscopic sphincterotomy, Lap.cholecystectomy and jejunotomy Obesity Surgery, 17, 2007 331
Lattuada et al making it impossible to remove it with the band. The procedure had to be converted to a laparoscopy to remove both. Since then, we have been using a thicker cutting wire, which avoids the risk of twisting and was able to successfully cut the bands in all the other cases. In another patient (no. 7), it was impossible to remove the band after the endoscopic cutting because the band was firmly fixed by adhesions outside the stomach, in spite of nearly complete intragastric migration. In this patient the band had been implanted by open surgery, and we had to complete the procedure to remov it by a laparotomy, with a gastrotomy that had a partial leakage in the postoperative course and healed after several days on gastric suction and supportive therapy. In 5 out of 7 patients, the procedure was successfully completed by removing the band with the gastroscope. All patients required sedation, except one who needed general anesthesia for poor compliance (no. 8). Discharge of the patients treated endoscopically was on the second day. The last patient (no. 9) had been admitted with pancreatitis, choledocholithiasis and band migration into the jejunum; we performed first an endoscopic sphincterotomy, then a laparoscopic cholecystectomy, associated with a jejunotomy to remove the band. All patients regained weight after discharge from the hospital. In two cases, the patients requested rebanding, which was done after 6 months, and they are losing weight again. Discussion Laparoscopic adjustable gastric banding is effective and safe, and good results are universally reported, in spite of some complications. 9-11 Band erosion is a long-term complication reported in several series. 4,7,12 The presenting symptoms are nonspecific; 5 in our patients, the most common symptoms were weight regain and port-site infection: if a Gastrografin swallow and a study of the connecting tube are normal, we always perform a gastroscopy which is the only examination that can show an intragastric band migration. 8 Thus far, the underlying cause of erosion has not been found. Various factors have been suggested: gastric injury during band implantation, 6 excessive band inflation, 13 band infection. 5 In our series, 3 bands out of 9 (33%) had been implanted by a laparotomic conversion from a laparoscopy, whereas the reported average rate of conversion during band implantation is about 1%. 14 That might suggest that some problems arising during laparoscopic band implantation, such as perigastric lesions or bleeding, may be a contributing factor to band migration. Regarding infection, in our series it may have been the cause of migration in only one patient (no. 1): there was an early postoperative port-site infection that slowly spread to the band, leading possibly to erosion. Treatment of Erosion Most authors remove the band by laparoscopy, 15,16 and wait some months before implanting another band, 17 except one report of the possibility to reimplant the band at the same time. 18 Some recent papers report an endoscopic approach for the removal of the migrated band, 8,19-21 with the same technique that we described. Only one complication is reported: 20 a symptomatic pneumoperitoneum without evidence of perforation, that healed spontaneously with supportive treatment. No late complications occurred, and in some cases another band could be inserted at a second time by laparoscopy. 18 In our series, we could not use the endoscopic approach in only two cases: the first patient presented CT signs of subphrenic abscess, and the second had acute pancreatitis with choledocholithiasis and the band had migrated into jejunum. In the other 7 patients, we used the endoscopic approach but we could complete the procedure in only 5 of the patients. In one case, we had to convert to laparotomy because of dense adhesion of the band into the perigastric tissue (no. 7): the band had been implanted in another hospital by a laparotomy, and both the band and the tube presented firm peritoneal adhesions. In the other patient (no. 3), we converted to a laparoscopy because of twisting of the cutting wire in the esophagus and its blockage in the stomach. The introduction of a thicker cutting wire, which does not present the risk of esophageal looping, allowed us to cut the band successfully in all the other cases. In the patients treated endoscopically, a Gastrografin swallow was done on the 1st postoperative day, and the patients were discharged rapidly, except for the patient who had a longer postoperative 332 Obesity Surgery, 17, 2007
Treatment of Intragastric Band Migration course because of leakage of the gastrotomy (no. 7). In spite of these complications, the endoscopic approach appears to be the procedure of choice for the removal of a migrated band. The patient avoids an operation under general anesthesia, that may be technically difficult and show a high rate of complications, and is discharged early. The complications that occurred in our patients are mostly related to the learning curve, mainly due to poor endoscopic experience with the new device, and will likely decrease with our technical improvement. Conclusion Endoscopic removal of a migrated band with the gastric band cutter appears to be the method of choice for band erosion. It is a safe and effective technique, allows an early discharge of patients and avoids an operation. Some of the complications may have been related to the learning curve with the use of new instrumentation. Our experience indicates that if a patient had a laparotomic band implantation, the presence of perigastric adhesions around the band can make it difficult to remove the band endoscopically. It is therefore advisable to perform this procedure in the operating theater because of the possibility of complications that may require surgical conversion. References 1. Forsell P, Hellers G. The Swedish adjustable gastric banding (SGAB) for morbid obesity: 9-year experience and 4 year follow up of patients operated with a new adjustable band. Obes Surg 1997; 7: 345-51. 2. Doldi SB, Micheletto G, Lattuada E et al. Adjustable gastric banding: 5-year experience. Obes Surg 2000; 10: 171-3. 3. Belachew M, Legrand MJ, Vincent V. History of the Lap-Band : from dream to reality. Obes Surg 2001; 11: 297-302. 4. Abu-Abeid S, Keidar A, Gavert N et al. The clinical spectrum of band erosion following laparoscopic adjustable silicone gastric banding for morbid obesity. Surg Endosc 2003; 17: 861-3. 5. Biagini J. Intragastric band erosion (Correspondence). Obes Surg 2001; 11: 100. 6. Niville E, Dams A, Vlasselaers J et al. Lap-Band erosion: incidence and treatment. Obes Surg 2001; 11: 744-7. 7. Meir E, Van Baden M. Laparoscopic adjustable silicone gastric banding and band erosion: personal experience and hypotheses. Obes Surg 1999; 9: 191-3. 8. Regusci L, Groebli Y, Meyer JL et al. Gastroscopic removal of an adjustable gastric band after partial intragastric migration. Obes Surg 2003; 13: 281-4. 9. Zappa MA, Micheletto G, Lattuada E et al. Prevention of pouch dilatation after laparoscopic adjustable gastric banding. Obes Surg 2006; 16: 132-6. 10. Weiss HG, Nehoda H, Labeck B et al. Adjustable gastric and esophagogastric banding: a randomized clinical trial. Obes Surg 2002; 12: 573-8. 11. O Brien PE, McPhail T, Chaston TB et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006; 16: 1032-40. 12. Weiss H, Nehoda H, Labeck B et al. Deflated adjustable gastric band migration through anterior gastric wall. Endoscopy 2000; 32: S35. 13. Forsell P. Experience with the Swedish adjustable gastric band. In: Deitel M, ed. Update: Surgery for the Morbidly Obese Patient. Toronto: FD-Communications 2000: 359-78. 14. Angrisani L, Furbetta F, Doldi SB et al. Lap Band adjustable gastric banding system: the Italian experience with 1863 patients operated in 6 years. Surg Endosc 2003; 17: 409-12. 15. Nocca D, Frering V, Gallix B et al. Migration of adjustable gastric banding from a cohort study of 4236 patients. Surg Endosc 2005; 19: 947-50. 16. Kasalicky M, Fried M, Peskova M. Some complications after laparoscopic nonadjustable gastric banding. Obes Surg 1999; 9: 443-5. 17. Niville E, Dams A, Ven Der Speeten K et al. Results of lap rebanding procedures after Lap-Band removal for band erosion a mid-term evaluation. Obes Surg 2005; 15: 630-3. 18. Abu-Abeid S, Bar Zohar D, Sagie B et al. Treatment of intra gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replacement. Obes Surg 2005; 15: 849-52. 19. Mittermair RP, Weiss H, Nehoda H et al. Uncommon intragastric migration of the Swedish adjustable gastri band. Obes Surg 2002; 12: 372-5. 20. Sakai P, Hondo FY, de Almeida Artifon EL et al. Symptomatic pneumoperitoneum after endoscopic removal of adjustable gastric band. Obes Surg 2005; 15: 893-6 21. Baldinger R, Mluench R, Steffen R et al. Conservative management of intragastric migration of Swedish adjustable gastric band by endoscopic retrieval. Gastrointest Endosc 2001; 53: 98-101. (Received September 14, 2006; accepted December 5, 2006) Obesity Surgery, 17, 2007 333