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Obesity Surgery, 11, pp-pp

© FD-Communications Inc. Obesity Surgery, 11, 2001 1

Background: Prosthetic devices have been used inbariatric operations to control the outlet of the gas-tric pouch and thus maintain weight loss. A compli-cation of these prostheses is erosion or migrationinto the gastric lumen.The transected banded verti-cal gastric bypass (TBVGBP) is one of the modifica-tions of gastric bypass. This modification has asilastic ring placed around the pouch to form thestoma.

Method:The records of patients with band erosion(BE) after this operation were reviewed, to determinethe incidence, etiology, management and outcomeduring a 9-year period.

Results: From May 1992 through May 2001, 2,949primary and secondary TBVGBP were performedthrough the Center for Surgical Treatment of Obesity,utilizing 3 hospitals. 48 patients (1.63%) were docu-mented to have BE: 40 documented by us and 8 bysubsequent treating surgeons or at other facilities.Presenting symptoms were weight regain (18),stenosis or obstruction (17), pain (9), bleeding (7),and 5 were incidental findings. Some patients pre-sented with more than one symptom. 8 were treatedexpectantly with spontaneous extrusion of the band.16 bands have been removed endoscopically in 14patients.26 patients had open surgical revision,with12 having band removal only and 14 band removaland revision of either the gastroenterostomy with orwithout band replacement or conversion to a distalRoux-en-Y gastric bypass (DRYGBP). Two patientswho had revision to DRYGBP were re-revised to alonger common limb because of protein malnutri-tion. Three patients who had revision of the gas-troenterostomy with band removal and replacementdeveloped leaks that were managed non-surgically.Two of these re-eroded and the band was removed

e n d o s c o p i c a l ly with a subsequent revision to aDRYGBP. There was no death due to BE.

Conclusion: BE is an uncommon complication ofTBVGBP. Infection,previous bariatric operations andsurgical technique play a role in BE. BE is best man-aged by endoscopic removal but can be treatedexpectantly or by open surgical intervention. Bandremoval without replacement or revision to DRYGBPmay result in weight regain.

Key words: Morbid obesity, bariatric surgery, gastricbypass, device, weight loss, endoscopy, surgical compli-cation

Introduction

The use of prosthetic devices around the stomachin weight loss operations includes the Wilkinsonband (Figure 1) and gastric wrap,1 the Marlex meshband by Mason (Figure 2),2 the Silastic ring bandby Laws (Figure 3), the dual Mesh band by Molina(Figure 4), the silicone band and more recently theLap-Band® by Kuzmak (Figures 5 and 6),5,6 theDacron® and Gore-tex® band by Kolle,7 the silasticring and fascial band by Linner (Figure 7),8 theS wedish Band (Obtech) (Fi g u re 8),9 and theSilastic ring band by Fobi (Figures 9 and 10).10-12

One of the complications of these pro s t h e t i cdevices is intra-luminal migration or intrusion,usually called band erosion (BE). There have beenreports of erosion of various devices.13-15 Thispaper examines the incidence of BE of the silasticband which is used to support the stoma in the tran-sected banded (silastic ring) vertical gastric bypass

R e p rint requests to: M A L Fobi, MD, Center for SurgicalTreatment of Obesity, 21520 S. Pioneer Blvd., Suite 204,Hawaiian Gardens, CA 90716, USA. Fax: (562) 402-8381;e-mail:[email protected]

(Reproduced with permission from OBESITY SURGERY)

Band Erosion: Incidence, Etiology, Managementand Outcome after Banded Vertical Gastric Bypass

Mal Fobi, MD; Hoil Lee, MD; Daniel Igwe, MD; Basil Felahy, MD; ElaineJames, MD; Malgorzata Stanczyk, MD; Nicole Fobi, MD

Center for Surgical treatment of Obesity, Hawaiian Gardens; Tri-City Regional Hospital,Hawaiian Gardens; Bellwood General Hospital, Bellflower; and Cedars Sinai Medical Center,Los Angeles, CA, USA

2 Obesity Surgery, 11, 2001

Fobi et al

Figure 1. Wilkinson’s Band, 1978. Figure 2. Vertical banded gastroplasty (Mason, 1980).

Figure 3. Silastic ring vertical gastroplasty (Laws, 1981).

Figure 6. A d j u s t a ble gastric band (Lap-Band®,BioEnterics).(Figures 1, 3, 4, 5, and 6 reproduced with permission from Deitel M.Update Surgery for the Morbidly Obese Pa t i e n t . To r o n t o : F DCommunications 2000)

Marlex MeshBand

Marlex Mesh(Polypropylene)

Band

Figure 5. Inflatable gastric band (Kuzmak).

Figure 4. Molina’s band, 1980.

Dual Mesh Band

Band

(TBVGBP).11,12 Causes of BE, presenting symp-toms, management and outcome are analyzed.

Methods

Between May 1992 and May 2001, 2,949 patientshad the TBVGBP through the Center for SurgicalTreatment of Obesity. This operation involved theuse of a silastic tubing made by Bentec Medical asa band to control the stoma of this modification ofgastric bypass (Figure 10).10-12 The data on patientshaving TBVGBP have been collected prospec-tively as part of the study of this modification in the

management of morbid obesity and also for oursubmissions to the International Bariatric SurgeryR egi s t ry. The re c o rds of these patients we rereviewed to determine the incidence of BE, pre-senting symptoms, m a n age m e n t , outcome andcauses.

Results

T B VGBP was perfo rmed on 2,949 pat i e n t sbetween May 1992 and May 2001: 2,386 as a pri-mary operation, 380 as a secondary operation (i.e.revision to the TBVGBP) and 183 as a revision of

Obesity Surgery, 11, 2001 3

Erosion of Silastic Ring in Transected Gastric Bypass

Figure 7. Linner’s band, 1984. Figure 8. Swedish adjustable gastric band (Obtech).

Figure 9. Silastic ring vertical banded gastric bypass(Fobi, 1986).

Figure 10. Transected banded (Silastic ring) verticalgastric bypass with jejunal interposition (Fobi, 1992).

Silastic ring orFascial Band

SilasticRing Band

Silastic RingMarker

the TBVGBP (Figure 11). Band erosion was docu-mented in 48 patients (1.63%), 40 by us and eightby other subsequent treating doctors.

Eighteen patients presented with a history ofbeing able to eat more than usual and weight regain(Table 1). Seventeen presented with symptoms ofoutlet stenosis or obstruction, with solid food intol-erance and vomiting. Nine presented with pain anddyspepsia. Seven presented with bleeding, and fivewere incidental findings in the routine upper GIendoscopy and x-rays that we perform at 5 yearfollow-up intervals or as part of the pre-operativeevaluation before reconstructive procedures. Somepatients presented with more than one symptom.

Eight patients were treated expectantly, withspontaneous extrusion of the band into the lumen.The band was re m oved endoscopically in 14patients (Figure 12). Open surgical interventionwas performed in 26 patients, and 12 of these hadopen surgery for removal only. Eight had bandremoval with revision of the gastroenterostomy, ofwhich seven had band replacement. Six had bandremoval and revision to a distal Roux-en-Y gastricbypass (DRYGBP) without band replacement.

Three patients with band replacement and surgi-cal revision developed a leak that healed sponta-neously. Two of these developed band erosionagain, and the band was removed endoscopicallyand these patients had revision to a DRYGBP. Two

of the eight patients who we re revised to aDRYGBP were re-revised to lengthen the commonlimb because of intractable protein malnutrition.

Forty-three of the 48 patients are thus without aband, and five have a replaced band. Six of the 43without a band have a DRYGBP instead of a band.Twenty-one of the patients have regained an aver-age of 14 of the percent excess weight lost(%EWL). The five patients who had the bandreplaced have an average of 6 %EWL gained. Thesix patients who were revised to a DRYGBP andthe 16 who had the band removed in the first 9months after the initial surgery have not had anyweight gain but have recorded weight loss.

Discussion

Stomal dilatation has been long recognized as oneof the causes of weight regain after short limb gas-tric bypass.8,16-21 Linner attempted to prevent thisby reinforcing the gastroenterostomy anastomoticsite with a silastic ring prosthesis.8 The resultanthigh incidence of band erosion forced him to aban-don the use of the prosthetic band and use a fascialband obtained from the linea alba (Figure 7). Thisconcept of reinforcing the anastomotic site hasbeen reintroduced by Kini and Gagner,22 using abiodegradable porcine graft around the anasto-


Fobi et al

Table 1. Presenting symptoms of band erosion

Symptoms No. of (%)Patients

Weight Regain 18 37.50Outlet Obstruction 17 36.42Pain 9 18.75Bleeding 7 14.58

Figure 11. Incidence of band erosion May 1992 - May2001.

Transected Banded Vertical Gastric Bypass2,949 (100%)

Primary Secondary Revision2,386 (80.9%) 380 (12.9%) 183(6.2%)

Band Band BandErosion Erosion Erosion

22 (0.9%) 21 (5.53%) 7 (3.80%)

Figure 12. Treatment of band erosion.

Total Band Erosion48 (100.0%)

Expectant Endoscopic SurgicalTreatment Removal Treatment8 (16.67%) 14 (29.17%) 26 (54.17%)

Band Band Removal & Band removal &Removal revision to DRYGBP revision of

12 without band replacement gastroenerostomy(25.0%) 6 (12.50%) 8 (16.67%)

DRYGBP Revised to With band Without4 (14.58%) RYGBP replacement replacement

2 7 1

Revision to Band eroded Band replacedDRYGBP 2 5

2

motic site. Linner’s concept of preventing weightregain by reinforcing the stoma against dilatingwas reintroduced in 1989 by Fobi et al11 by placingthe band around the gastric pouch, as used in thevertical banded gastroplasty and silastic ring verti-cal gastroplasty, rather than around the gastroen-terostomy anastomosis. The anastomosis in theTBVGBP is made 1.5 to 2.5 cm distal to the band.No band erosion was seen in the first 200 cases thatwere evaluated. This resulted in the silastic ringvertical gastric bypass (Figure 9).11 This bandedgastric bypass evolved to what is now TBVGBP(Figure 10). This method of banding the pouch tocontrol stoma dilatation has been substantiated byCrampton,23 Zorilla24 and Capella.25,26 This modi-fied gastric bypass appears to provide more weightloss in more patients that is maintained over alonger period of time.27 However, one of the com-plications of this modification is band erosion(BE).

Incidence of Band Erosion

The overall incidence of BE in this series was1.63% (48/2,949). The incidence was 0.92%(22/2,386) in primary operations, 5.53% (21/380)in secondary operations and 28.57% (2/7) inp atients with band replacement after ero s i o n(Figure 11).

Causes of Band Erosion

Possible causes of BE include: 1) constrictingbands, 2) suturing the band to the stomach, 3)imbricating the band with stomach and 4) infec-tion. A band that is placed tightly around the stom-ach may result in necrosis and erosion. A review ofthe immediate post-operative x-rays of patientswho subsequently had BE showed narrower outletsthan in the other patients, indicating that the bandsmight have been placed tighter than thought(Figure 13A and B). This was confirmed in threepatients where we found that the Prolene® insidethe tubular band had a shorter length than the tub-ing. Incorporating the stomach wall in placing theband or placing the sutures through the stomachwall to hold the band in place appears to increasethe incidence of BE. Anecdotal review of the fre-quency of BE in our experience with the vertical

banded gastroplasty and silastic ring vertical gas-troplasty and reports in the literature, indicate thatthere have been more cases of silastic ring erosionby passing the suture that held the ring through thestomach wall as described by Laws (Figure 3)3

than with the Marlex mesh placed through a win-d ow with no sutures through the stomach asdescribed by Mason (Figure 2).2

We changed the method of band placement afterthe first 1,100 cases and noticed a significantdecrease in the incidence of BE (Figures 14A andB) (27/1,107 [2.43%] vs 21/1,842 [1.14%]). Thediameter of the band is usually larger than that ofthe pouch (Figure 15). Covering the band with thes t o m a ch has been rep o rted to increase BE.1 2



Figure 13.A. X-ray of the stoma after TBVGBP with sub-sequent band erosion. B. X-ray of the stoma, afterTBVGBP without band erosion.

Figure 14. A. Band placement up to 1998. B. Bandplacement after 1998.

A B

A B


Fobi et al

Figure 15. Cross-section of silastic ring band and pouch.

Figure 16. A. Partial band erosion.

A B

ERODED SILASTIC RING

Figure 16. B. Complete band erosion.

Infection can contribute. Infection around a foreignbody is a nidus for long-term smoldering infection,which is rarely controlled with antibiotics and ulti-mately results in rejection and extrusion of the for-eign body. Five patients with BE had had post-operative leaks that were treated without bandremoval. Another four of the patients with BE haddocumented post-operat ive subclinical leakstreated with antibiotics. Five other patients had per-sistent tachycardia for 2-3 days that was consistentwith leaks or infection around the pouch, but sincethey responded to fluids, pulmonary toilet andantibiotic therapy, surgical intervention was notnecessary; three of these patients not only had BEbut also developed a gastro-gastric fistula, suggest-ing a leak and infection between the pouch and thebypassed stomach in the immediate post-operativeperiod. The role of infection in BE has also beenreported with the Lap-Band®.13,14 There is also ahigher incidence of BE in patients who had a pre-vious bariatric operation [21/380 (5.53%)] and inpatients who had a revision operation with bandreplacement [2/7 (28.57%)] (Figure 11).

Mechanism of Band Erosion

BE usually starts with an inflammatory reactionbetween the stomach wall and the band. This ulti-mately results in band extrusion into the pouchlumen, as is documented in stitch abscess forma-tion and extrusion of the stitch. Operative findingsin patients with BE confirm the dense fibrous reac-tion around the banded pouch.

Symptoms of Band Erosion

The inflammatory reaction around an eroding bandresults in swelling, causing narrowing of the outlet,resulting in symptoms of outlet stenosis or obstruc-tion or progressive weight loss. Seventeen patientsin this series presented with symptoms of stenosisor obstruction. Upper GI x-rays showed narrowingof the outlet. Endoscopic eva l u ation showe dinflammatory changes and ulceration, with partialerosion of the band (Figure 16A and B). In sevencases, the ulceration caused bleeding that presentedas hematemesis, melena or anemia. In 18 cases thepatients presented with complaints of weight gain,the ability to eat more and an increased frequency

of feeling hungry. The finding at endoscopy inthese patients showed almost complete extrusion ofthe band with a dilated stoma (Figure 16B). A care-ful history from some of these patients confirmedthat they had had transient episodes of dyspepsia,nausea, symptoms of stenosis with solid food intol-erance and weight loss, but gradually the symp-toms improved to a point where they could eatmore, with resultant weight gain. Nine patientspresented with epigastric pain that radiated to theback, worsened by eating, resulting in progressiveweight loss. These patients also had symptoms ofobstruction, and BE was confirmed on endoscopicevaluation. Three also had gastro-gastric fistulas oncontrast study.

Diagnostic Evaluation

The best diagnostic test for BE is endoscopic eval-u ation. Occasionally plain x-rays may showabsence of the band at the pouch level, with orwithout an abnormal location of the band. Threepatients were diagnosed on plain films but hadendoscopic evaluation for confirmation.

Management

BE can be managed expectantly, endoscopically orby open surgical intervention. Expectant treatmentis indicated for patients who are diagnosed with BEbut the endoscopist did not remove the band at thetime of diagnosis and the patient is asymptomaticand either cannot afford or does not want anotherendoscopic procedure. Eight patients were treatedexpectantly with spontaneous extrusion of the bandin this series. They were also treated with H2-blockers because of the findings of pouch ulcers.

Endoscopic band removal is the management ofchoice for BE. Fourteen patients in this series had16 successful endoscopic band removal. Thesepatients are placed on H2-blockers for 30 to 60days because of ulceration at the site where theband extrudes into the lumen. They are usuallyhospitalized for 24 hours after the band removal,and are monitored without oral intake for symp-toms of leak or bleeding. An upper GI series isdone after 24 hours to rule out a leak, and thepatient is started on liquids and advanced to a reg-ular diet. The last four endoscopic band removals



have been done as outpatient procedures; they hadno evidence of leaks on contrast studies, and feed-ing was resumed on the same day. There were fivefailed attempts at endoscopic band removal. In twopatients, it was due to the limitations of the endo-scopist and in three patients it was due to lack ofappropriate equipment. Four of the patients had theband removed at a second trial by another endo-scopist or when the correct instruments were avail-able. One patient required open surgical interven-tion. Five had repeat endoscopic evaluation within6 weeks, with findings of complete healing.

Open surgical treatment was done in 26 patients.Twelve involved surgery for band removal only.This was in the early stages of our experience,when the ga s t ro e n t e ro l ogists we re reluctant toattempt endoscopic band removal. Patients sub-jected to open surgery for band removal had peri-gastric drains placed and temporary gastrostomytubes for interim feeding until x-rays confirmed noevidence of a leak on the fourth or fifth post-oper-ative day. Eight patients had band removal withrevision of the gastric bypass to a DRYGBP. Thesepatients were the ones who had not lost sufficientweight with the TBVGBP before the BE. We alsoused open band removal in patients who neededanother surgical operation such as cholecystec-tomy, hernia repair, and/or revision of the gas-troenterostomy.

Outcome after Band Erosion

Of the eight patients who were diagnosed andtreated at other facilities, four were treated withonly endoscopic removal after a phone consulta-tion with us, three with only surgical band removal,and one with band removal and revision of the gas-troenterostomy. All reported uncomplicated out-come.

Five patients developed leaks after operativeband removal: three after band removal and revi-sion of the gastroenterostomy and two after bandremoval and revision to DRYGBP. Drains wereused in all five patients, and the leaks healed spon-taneously while the patients were fed via the gas-trostomy tube that is inserted routinely. None of the14 patients that had the band removed endoscopi-cally bled or leaked. Intra-operative band removalis difficult and more complicated in patients who

have BE. There is usually a dense fibrous inflam-matory reaction associated with a BE that makeso p e rat ive tre atment difficult. Endoscopic bandremoval is our treatment of choice for BE. Even inpatients who need another operation, we prefer toremove the band endoscopically before the otheroperation.

The effect of band removal on weight loss andmaintenance is still to be determined. Appreciableweight gain occurred in 21 patients who had BEand re m ova l , with an ave rage of 14% EWLregained (75% to 61% EWL). The average follow-up in this group of 21 since the original operationis 6 years. The EWL regained in the patients with6 years follow-up is 8% (75% to 67% EWL),28

which is less than that in those with the bandremoved, 14% (75% to 61% EWL).

Patients who had the band removed during thefirst 6 months after the initial surgery have lost fur-ther weight. The patients who had a replaced bandhave only regained 6% of the EWL. The patientswho had revision to the DRYGBP after bandremoval lost more weight. The net effect of BE inTBVGBP is the approximation of a short-limb gas-tric bypass.

Conclusion

Band erosion is an uncommon complication of theTBVGBP (< 1% in primary TBVGBP). The tech-nique of placing the band, whether it is a primary,secondary or revision operation, and the presenceof any infection appear to be contributing factors toBE. BE can be asymptomatic or it can present withsymptoms of outlet stenosis or obstruction, weightrega i n , dy s p ep s i a , ep i ga s t ric pain, a n e m i a ,hematemesis or melena. The best diagnostic test isendoscopic eva l u ation. In some cases, e ro d e dbands extrude spontaneously into the GI tract andare passed out with the stool. Endoscopic bandremoval is the management option of choice. Bandreplacement after erosion will like ly result inanother erosion. Open surgical treatment of BEshould be the last resort because of the inherentrisks. The findings in this series further confirm therole of the band in weight loss maintenance.


Fobi et al

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( R e c e ived September 6, 2001; accepted October 9, 2 0 0 1 )



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