J Korean Surg Soc 2012;82:18-27 JKSS http://dx.doi.org/10.4174/jkss.2012.82.1.18 Journal of the Korean Surgical Society pISSN 2233-7903ㆍeISSN 2093-0488 ORIGINAL ARTICLE

Early experience with diagnosis and management of eroded gastric bands

Chang Ik Yoon, Kyung Ho Pak, Seong Min Kim1

Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, 1Department of Surgery, Gachon University Gil Hospital, Gachon University of Medicine and Science, Incheon, Korea

Purpose: Band erosion is a well-known complication of laparoscopic adjustable gastric band placement. We gained experi- ence with laparoscopic removal of an eroded gastric band. Methods: We retrospectively reviewed the operative log of our surgery unit to identify all operations performed for band erosion from March 2009 to May 2011. Results: During the study period, a total of six of 96 patients (6.3%), five females and one male, were diagnosed with band erosion and under- went surgical removal of the band system. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 8.5 months (range, 7 to 22 months), with most band erosion occurring within the first year (5/6, 83%). The median at band removal was 28.4 kg/m2. Upper abdominal was the most common symptom (5/6, 83%), and other signs and symptoms were port site (3/6, 50%) and loss of restriction and weight regain (1/6, 17%). All eroded bands were removed using . Further complications after laparoscopic removal of the band system were observed in three cases. One patient showed multiple intra-abdominal abscesses requiring insertion of a pigtail catheter for drainage. The other two patients experienced sepsis with localized peritonitis, eventually requiring laparoscopic washout and drainage. Conclusion: Gastric band erosion requires the removal of the gastric band. Laparoscopic removal is technically achievable in the majority of patients with eroded gastric band. The method can be challenging, has potential postoperative complications (fistula, abscess), and should be attempted only by experienced surgeons.

Key Words: Gastric banding, , Band erosion, Morbid obesity, Complications

INTRODUCTION the literature, the medium-term excess ranges from 50 to 70% [1-6]. However, in the long term, a small Laparoscopic adjustable gastric banding (LAGB) is one group of patients who undergo LAGB suffer from compli- of the most popularly performed bariatric surgical proce- cations such as band slippage, pouch dilatation, prosthesis dures worldwide. Its advantages include adjustability, rel- infection, and band erosion (BE). Unlike other complica- ative ease of performance, acceptable weight loss effect, tions, BE always requires removal of the band system be- and the low perioperative complication rate. According to cause long-standing inflammation associated with the

Received July 4, 2011, Revised September 23, 2011, Accepted September 30, 2011

Correspondence to: Seong Min Kim Department of Surgery, Gachon University Gil Hospital, Gachon University of Medicine and Science, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea Tel: ＋82-32-460-3244, Fax: ＋82-32-460-3247, E-mail: [email protected] cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © 2012, the Korean Surgical Society Diagnosis and management of band erosion

eroded gastric band has proven to be associated with a va- a laparoscopic grasper and removed the band system. riety of serious morbidities [7-11]. Controversy exists re- Four steps were performed for safe closure of the remain- garding the management of a patient with an eroded gas- ing gastric perforation after band removal; 1) primary re- tric band. In this paper, we aimed to present our experi- pair (PR): using 2-0 Ethibond (Ethicon Inc.), an interrupted ence with diagnosis and the surgical removal of an eroded suture was used to close the defect, 2) omental plugging gastric band. (OP): segmentation of the vascularized omentum was fashioned and gently inserted through the tunnel (i.e., that leads into the ) that is usually left behind by the METHODS extracted band and fixed in place using multiple sutures through a relatively healthy gastric wall [14], 3) drainage From March 2009 to May 2011, 96 morbidly obese pa- catheter insertion (DR): one subhepatic (at the level of su- tients (85 females and 11 males) with an average age of 33.6 ture line) and one left subphrenic Jackson-Pratt (JP) drain years (range, 18 to 58 years) underwent LAGB. The LAGB were inserted through a left subcostal incision, and 4) na- procedure was performed as described previously [12]. In sogastric tube insertion (NT): a nasogastric tube was in- brief, the port positions included a 15-mm umbilical port serted for decompression of the air and drainage of gastric for the camera and two 5-mm ports, one in each subcostal juice, and the tube was maintained for postoperative 48 area, for the acting instruments. A Nathanson re- hours. Patients with documented BE requiring surgical tractor (Cook Medical, Queensland, Australia) was in- re-intervention were identified from a database and case serted through a 5-mm skin incision in the subxiphoid lo- notes were reviewed. We retrospectively reviewed the cation and curved upward to retract the left hepatic lobe. demographic findings (age, gender, preoperative body We used a pars flaccida technique of dissection in all cases, mass index [BMI], ), band, and port fixation and two or three gastrogastric sutures were inserted using technique of each patient. We also reviewed the time inter- 2-0 Ethibond (Ethicon Inc., Somerville, NJ, USA). After val between BE diagnosis and initial LAGB placement, LAGB, all band adjustments were performed in a fluoro- BMI at band removal, associated clinical signs and symp- scopy room in our surgical office. A swallow test toms, band filling volume, stage and site of BE, operative was also performed whenever there were clinical suspi- findings at the time of band removal, further complica- cions of BE (i.e., unusual abdominal pain, port site in- tions and operative management, and length of hospital fection, loss of restriction and weight regain). Abdominal stay. computed tomography (CT) scan was performed when the barium swallow test showed abnormal flow patterns compatible with BE. It was also performed if the patient RESULTS was considered to have localized peritonitis or a septic fo- cus associated with BE, and esophagogastroduodeno- Case oriented description scopy (EGD) was performed to confirm the diagnosis of Case 1 BE. Based on the EGD findings, the degree of migration A 21-year-old female patient with BMI of 41.9 kg/m2 un- was classified according to Nocca et al. [13] as follows; derwent an uneventful LAGB (Lap-Band 10.0, Allegan stage I, a small part of the band visible through a hole in Inc., Irvine, CA, USA). The patient had shown good the gastric mucosa; stage II, partial migration (＞50% of weight loss with up to postoperative 20 months. She com- the band free in the gastric lumen), and stage III, complete plained gradual loss of restriction and weight regain (＋10 migration. The previous laparoscopic incisions were used kg from the nadir body weight). The barium swallow test for laparoscopic re-exploration in all patients. We care- showed no abnormal findings. EGD a showed BE in the fully dissected and identified the lap-band tubing up to left inferior banding site. The patient underwent an un- the band buckle, then debuckled the locking system using eventful laparoscopic band removal.

thesurgery.or.kr 19 Chang Ik Yoon, et al.

Case 2 at postoperative 8 months, port infection was re- A 18-year-old female patients with BMI of 33.9 kg/m2 developed, and he complained intermittent severe ab- (her comorbidities were dyslipidemia, non-alcoholic fatty dominal pain around the port site. The barium swallow liver disease [NAFLD], and polycystic ovary syndrome test did not show abnormal findings. Infection and ab- [PCOS]), underwent an uneventful LAGB (Lap-Band 9.75, dominal pain were relieved with local wound treatment. Allegan Inc.). On the 15th postoperative day, the patient However at postoperative 9 months abdominal pain showed signs of port infection, which was treated with lo- recurred. He also complained on liquid as well cal wound care and healed uneventfully. Her weight loss as solid food. An EGD diagnosed BE. Five days after lapa- was excellent. At postoperative 9 months, her BMI was roscopic band removal, the patient showed localized peri- 21.9 kg/m2. The patient showed a recurrent port infection tonitis in the right lower quadrant (RLQ) . associated with left upper abdominal pain, which was not Abdominal CT scan showed multifocal, loculated, and en- subsided with conservative management. The barium capsulated fluid collection in the RLQ abdomen (diameter: swallow test did not show abnormal findings. Abdominal 6.5 cm), eventually requiring laparoscopic washout and CT scan showed small collection of air around the band. drainage. EGD confirmed the BE. The patient underwent a laparo- Case 5 scopic band removal (omental patch technique). After A 36-year-old female patient with BMI of 36.7 kg/m2 un- band removal, the patient became severely septic from the derwent an uneventful LAGB (Lap-Band APS, Allergan first postoperative day, and follow-up abdominal CT scan Inc.). She had showed good weight loss until post- showed multiple intraabdominal abscesses. Six pigtail operative 6 months, when she developed and left up- catheters were inserted for drainage via a modified per quadrant abdominal pain not relieved by analgesics Seldinger technique. The recovery of the patient required and oral antibiotics. The barium swallow test showed ba- a prolonged period of total parenteral nutrition and intra- rium flow outside of the normal band . Abdominal venous (IV) antibiotic treatment. Length of hospital stay CT scan showed left subphrenic abscesses originating was 74 days. from gastric microperforation due to BE. However EGD Case 3 did not showed a definite mucosal defect. As the symp- A 47-year-old female patient with BMI of 35.2 kg/m2 toms were relieved by conservative treatment during the (her comorbidities were dyslipidemia and NAFLD) un- admission, future endoscopic band removal was derwent an uneventful LAGB (Lap-Band 9.75, Allegan suggested. After one month, however, she redeveloped Inc.). After operation, the patient was satisfied with the spiking fever, pyrexia, and severe myalgia. Follow-up ab- gradual weight loss, and did not show up to the hospital dominal CT scan showed a huge intrahepatic abscess for band adjustment. At postoperative 8 months, the pa- within the left lobe of the liver (8 cm in diameter). tient complained about sudden redness and swelling of Emergent laparoscopic band removal was performed. port site and severe upper mid-abdominal pain. Local Intraoperative EGD showed a small mucosal defect in the wound exploration showed greenish mucous collection left inferior banding site. around the port site. EGD confirmed the BE. The patient Case 6 underwent an uneventful band removal surgery. A 35-year-old female patient with her BMI of 41.5 kg/m2 Case 4 underwent an uneventful LAGB (Lap-Band, Allergan A 46-year-old male patient with BMI of 37.2 kg/m2 (his Inc.). At postoperative 7 months, she developed severe ab- comorbidities were , variant angina) under- dominal pain from epigastrium to right lower quadrant went an uneventful LAGB (Swedish adjustable gastric abdomen. The barium swallow test and abdominal CT band, SAGB; Ethicon Endo-Surgery Inc., Cincinnati, Ohio, scan showed findings compatible with BE. On EGD mu- USA). At postoperative 3 months, he showed mild port cosal erosion lesion was located in the posterosuperior site infection which was treated by local wound care, and banding area. On the third days after laparoscopic band

20 thesurgery.or.kr Diagnosis and management of band erosion

removal, the patient showed a spiking fever, tachycardia, of six patients at the time of LAGB placement was 33.8 and left pleuritic chest pain. Abdominal CT scan showed a years, and their average pre-LAGB BMI was 37.7 kg/m2 suspicious perigastric abscess near the suture line and lo- (range, 33.9 to 41.9 kg/m2). Four patients had comorbid- culated fluid collections or abscess indenting left lateral ities; four required subcutaneous ports in the anterior rec- segment of liver, eventually requiring laparoscopic wash- tus fascia, and two had subfascial ports as described pre- out and drainage. viously [15] (Table 1). The median time interval from the initial LAGB placement to the diagnosis of BE was 8.5 Identification of the tendency or statistics months (range, 7 to 22 months), with most BE occurring During the study period, six of 96 patients (6.3%), five within the first year after initial LAGB placement (5/6, females and one male, were diagnosed with BE and under- 83%). The median BMI at band removal was 28.4 kg/m2, went surgical removal of the band system. The mean age thus the average of BMI change (rapidity of weight loss) of

Ta ble 1 . Patient demographics, comorbidities, and port fixation techniques at the time of LAGB placement Patient Sex/Age Preop BMI Comorbidities Band Port fixation technique

1 F/21 41.9 NAFLD Lap-Band 10.0 Subcutaneous 2 F/18 33.9 Dyslipidemia, NAFLD, PCOS Lap-Band 9.75 Subcutaneous 3 F/47 35.2 Dyslipidemia, NAFLD Lap-Band 9.75 Subcutaneous 4 M/46 37.2 HTN, variant angina SAGB Subcutaneous 5 F/36 36.7 None Lap-Band APS Subfascial 6 F/35 41.5 None Lap-Band APS Subfascial LAGB, laparoscopic adjustable gastric banding; BMI, body mass index; NAFLD, non-alcoholic fatty liver disease; PCOS, polycystic ovary syndrome; HTN, hypertension; SAGB, Swedish adjustable gastric band; APS, advanced flatform-standard.

Fig. 1. Flow chart showing the diagnosis procedure in patients with band erosion (BE). UGI, upper gastrointestinal; CT, computed tomography; EGD, esophagogastroduodenoscopy.

thesurgery.or.kr 21 Chang Ik Yoon, et al.

these patients and the non-complicated patients at post- showed normal barium passage along the band stoma. Six operative 8.5 months was 8.4 and 7.2, respectively. Upper of them underwent abdominal CT scans for further evalu- abdominal pain was the most common symptom (5/6, ation of their persistent abdominal discomfort. Among 83%), and the other signs and symptoms were port site in- these 6 patients, 2 patients were diagnosed to have BE. fection (3/6, 50%) and loss of restriction and weight regain Abdominal CT scan was positive in one patient (patient (1/6, 17%). As far as diagnosis of erosion is concerned, a to- #2), and negative in the other patient (patient #3). The oth- tal of eight patients underwent abdominal CT scan. er five patients did not undergo abdominal CT scan. Among the 96 patients, a total of 13 patients underwent Among them, two patients were diagnosed to have BE. study for questionable signs and symptoms suggestive of These two patients were diagnosed to have BE by EGD BE. Two of 13 patients showed barium flow outside the (patients #1, 4) (Fig. 1). The most common erosion site was normal band stoma (patients #5, 6). Both patients under- the left inferior banding site (4/6, 66.7%) (Fig. 2). All cases went an abdominal CT scan, which showed localized of BE were grade I and were treated via laparoscopic re- small collections of the air around the silicon band sugges- moval of the band system. Further complications after lap- tive of microperforations of the stomach. Eleven patients aroscopic removal of the band system were observed in three patients. One patient (patient #2) showed fever and suspicious sepsis on the first day after band removal. Five days after the surgery, the patient required the insertion of multiple pigtail catheters for multiple intra-abdominal abscesses. The recovery of the patient required a pro- longed period of total parenteral nutrition and IV anti- biotic treatment. The other two patients (patients #4, 6) had a fever and localized peritonitis after band removal, eventually requiring laparoscopic washout and drainage (Fig. 3). The median length of hospital stay (LOS) for all pa-

Fig. 2. Location of band erosion on esophagogastroduodenoscopy. tients was 9.5 days (range, 4 to 74 days), and there was no 1, anterosuperior; 2, posterosuperior; 3, anteroinferior; 4, postero- mortality (Table 2). All of the patients who underwent re- inferior.

Fig. 3. (A) Five days after band removal, the patient (#4) showed localized peritonitis in the right lower quadrant (RLQ) abdomen. Abdominal computed tomopgraphy (CT) scan showed multifocal, loculated, and encapsulated fluid collection in the RLQ (diameter: 6.5 cm) (arrow). (B) Third days after band removal, the patient (#6) showed a spiking fever, tachycardia, and left pleuritic chest pain. Abdominal CT scan showed a suspicious perigastric abscess near the suture line and loculated fluid collections or abscess indenting anterior surface of the left lateral segment of liver (long arrows). A closed-suction drain was located in the subhepatic space (short arrows).

22 thesurgery.or.kr Diagnosis and management of band erosion

Ta ble 2 . Overview of patients who underwent laparoscopic removal of the migrated gastric band

Time at BMI at Vol a) Stagec)/ Second operative Pt# Clinical presentations Further complication Third operative LOS BE (mo) BE (mL) Site PR OP DR NT 1 22 28.2 Loss of restriction, 4.0/4.0 I/4 ＋＋＋－ - - 4 weight regain 2 9 21.0 Abdominal pain port 2.7/4.0 I/1 －＋－－Multiple intra- Pigtail insertion 74 infection abdominal abscesses 3 8 31.0 Abdominal pain port 0.0/4.0 I/4 ＋＋＋＋ - - 5 infectionb) 4 9 28.5 Abdominal pain port 8.0/9.0 I/4 ＋＋＋－Peritonitis Relaparoscopy 21 infection 5 8 27.5 Abdominal pain liver 8.0/10.0 I/4 ＋＋＋＋ - - 6 abscess 6 7 28.5 Abdominal pain 9.0/10.0 I/2 ＋＋＋－Peritonitis sepsis Relaparoscopy 13 Pt, patient; BE, band erosion; BMI, body mass index; PR, primary repair; OP, omental plugging; DR, drain catheter insertion; NT, nasogastric tube insertion for postoperative 48 hours; LOS, length of hospital stay. a)Vol means band filling volume when patient was diagnosed with BE. b)Mucous collection at the port site. c)The degree of migration was classified as suggested by Nocca et al. [13] moval of eroded gastric band started to regain their weight BE is yet to be determined. Current understanding is that after one month. All revisional operations were performed BE is initiated by acute and chronic tissue damage. In this by the patients’ requests. Revisional laparoscopic sleeve regards, we should perform pars flaccida technique accu- was performed in patients #1 and 4. Second rately to avoid entering the lesser sac, and injuring the pos- laparoscopic gastric band was inserted in patients #2 and terior gastric wall, which could minimize the occurrence 6. As the patients did not want more surgery, no more bari- of erosion. Gastrogastric suture should be performed to atric procedure was performed in patients #3 and 5. minimize tissue damage in making the fundal wrap, and therefore to avoid BE. As chronic ischemic tissue damage is regarded as possible cause of erosion, excessive band DISCUSSION filling should be avoided (currently, we do not fill the band more than 2 mL at one time). All these technical consid- BE is a major complication of LAGB, requiring removal erations could minimize the occurrence of BE in our recent of the gastric band system. According to the literature, BE patients. Second, we routinely conduct radiologic band after LAGB occurs in about 0.5 to 11% of cases [16,17]. In adjustment using for all patients underwent this study, six of 96 patients (6.3%) were diagnosed with gastric banding surgery. Therefore, we are able to detect a BE and underwent surgical removal of the band system, small barium leakage outside the stoma. This policy might which is a slightly higher incidence than in other reported differ from those of other institutions with a higher thresh- series. It is well known that there is a significant correla- old for performance. Third, we preferred tion between BE rate and surgeon experience. The annual ‘bolus’ filling for optimal band adjustment in patients who risk of BE during the first two years of surgical practice is showed suboptimal weight loss because it is more focused much higher than those of subsequent years [18]. Data on adjusting the ‘stomal diameter’. In general, band-filling from a systemic review of BE also showed that the rate of starts 6 to 8 weeks postoperatively with a total of three to erosion is as high as 17% in reports involving less than 100 six adjustments during the first year. This stepwise filling patients, and the rate of erosion decreases over time [19]. strategy is used with caution and is based on the intention Therefore, the erosion in our series of patients actually oc- to enable sufficient healing of the band device within the curred in the learning phase. However, definite cause of gastro-gastric tunnel [20]. However, there is no scientific

thesurgery.or.kr 23 Chang Ik Yoon, et al.

data on the effects of the different filling protocols on the port infection even in the presence of BE, which is one of incidence of BE. Usually, we fill the band gradually (at the advantages of subfascial port implantation. Port site least 2-week interval) for postoperative 2 to 3 months to infection and breakdown originated from BE is quite an- reach the “Green zone” (optimal restriction). One time fill- noying for both patients and clinicians, and therefore it ing volume is less than 1.5 mL. However, if weight loss is hinders conservative treatment and postponement of not sufficient or unsatisfactory (e.g., less than 0.5 kg per band removal surgery when the BE does occur. We agree week), we adopt ‘bolus’ filling protocol, that is, we fill the with Clough et al. [15] in that subfascial space is resistant band at one time until appropriate radiologic appearance to sepsis. It can be explained by sufficient vascularity of the meet our criteria (stoma diameter less than 3 mm, mild to surrounding muscles originating from the superior and moderate barium reflux). In this circumstance, one time inferior epigastric arterial branches. Actually in terms of filling volume is occasionally more than 2.0 mL. The clin- the subfascial space being resistant to sepsis, this is just a ical manifestations of BE can range from asymptomatic to theory based on the observation that we have had no in- acute peritonitis and sepsis. Occasionally, BE is undetec- fections from subfascial port placement - particularly no- ted until found at diagnostic laparoscopy. Asymptomatic table after previous where the port was re- individuals can often increase their food intake and gain moved from the standard position and placed subfascially weight. In our series of patients, abdominal pain was the at a later date without further infection setting in. We won- predominant symptom, which is in line with findings der whether many port infections are due to infected hem- from other studies [18]. In our series of patients with BE, atoma from the subcutaneous dissection required in the 83% complained of upper abdominal pain, and port in- obese patient to place the port. Perhaps the fascia separates fection was present in 50%. There are several potential the port from this and from the skin where superficial in- causes of abdominal pain after LAGB placement. For ex- fection may arise. It is just a theory and our numbers are ample, abdominal pain can be caused by pouch distention, far too small unfortunately to adequately examine this small bowel ileus, , overeating, and peritoneal outcome properly. With regard to erosion, we have seen irritation of the connecting tube. However, abdominal many recurrent port infections in the setting of BE pain associated with BE is constant and is not related to (presumably infection tracking down the tubing) but be- eating. It usually starts in the epigastrium and may radiate cause we have never had a subfascial port become infected to the upper back, left subcostal area, and under the breast it is hard to comment on the relationship between erosion bone. As time passes, bacterial inflammation originates and subfascial infection (so called ‘fasciitis’). Another clin- from the ‘gastric perforation’ in BE and migrates along the ical manifestation of the patients with BE in this study was connecting tube due to the dense adhesive capsule formed a relatively higher filling volume. The average filling vol- by the chronic foreign body reaction. Therefore, patients ume of patients who did not have BE was 2.8 ± 0.9 with a 4 complain of intermittent, severe pain in the lower mL band and 5.9 ± 2.0 with a 10 mL band. Based on the clin- abdomen. When re-laparoscopy is performed, localized ical signs and symptoms suggestive of BE, upper gastro- abscesses or inflammatory adhesions along the band sys- intestinal (UGI) and abdominal CT scan are helpful. The tem are often observed. Port site infection is quite bother- barium swallow test typically shows barium passing from some for both clinicians and patients because it does not the upper to the lower gastric pouch outside the band. respond to local wound treatment such as drainage and Abdominal CT scan can detect small free air or localized antibiotics. The relatively poor immunologic ability of the abscess formation around the band, tube, and reservoir subcutaneous fat layer to adequately handle the presence port. EGD is the definitive study instrument of choice. On of even small amounts of gastric secretions results in EGD, the band typically protrudes into the gastric lumen. chronic irritation, which eventually results in infection However, special attention should be paid to the identi- and often presents as wound breakdown. Of note, the two fication of small erosive lesions just beneath the gastro- patients who had a subfascial port did not present with esophageal (GE) junction and around the corners of the

24 thesurgery.or.kr Diagnosis and management of band erosion

fundal wrap and bulged gastric mucosa with no visible ter removal of the band, closure of the remaining gastric erosion. Occasionally, pus (infected purulent fluid) de- perforation is very difficult, and repaired gastrostomies scending down from the LAGB ‘‘pouch’’ near the GE junc- are more prone to leakage and breakdown. In our series, tion may be the only sign of BE on retroversion at UGI en- three patients suffered from postoperative complications doscopy [18]. BE is due to multifactorial causes. It has been after band removal. In this regard, transgastric removal, generally accepted that early BE is related to micro-injury which is laparoscopic with intraluminal divi- during operation, and late BE is related to foreign body sion and removal of the eroded band, seems to be a more responses. However, the etiology of BE is still obscure. Our relevant procedure [22]. Recent reports also suggest that cohort of patients had relatively early erosion around the endoscopic removal of the eroded band is a feasible proce- first postoperative year, and therefore small erosion below dure [23-27]. Transgastric techniques are possible only if a 25% of the total band area, and all but one presented with considerable portion of the eroded band is located in the symptoms of inflammation. A potential source of BE is in- gastric lumen, when the band is not easily identified out- jury during surgery. For example, the laparoscopic grasp- side the stomach following a dissection along the connect- er or band passer can damage the posterior wall of the ing tube. Endoscopic removal of an eroded band may re- stomach during band placement. In this series, all but one quire multiple sessions [28], and patient symptoms might erosion occurred on the left side of the band, where the prevent postponement of the procedure while waiting for gastrogastric sutures were placed. We agree with Niville the erosion to progress. For example, one of patients in this et al. [21] in that the chronic ischemic change caused by too study (patient #5) was diagnosed with small, shallow ero- tight and excessively deep stitches or a tight band tunnel sion, and we planned a future endoscopic removal. may result in BE. Usually, mucosal defect in BE is observed However, while waiting, the patient developed a spiking in the left inferior banding site, where gastrogastric su- fever, pyrexia, and multiple intrahepatic abscesses, which tures are placed and pressure from filled band is maximal. required urgent surgical removal. Therefore, the endo- Occasionally, on screening EGD (as many Korean people scopic approach should only be indicated in asympto- underwent a screening EGD annually), we could observe matic patients. Most cases of BE in our series were early small stitch inside the gastric lumen in asymptomatic with small erosion (grade I), and well-developed patients. We have also observed friable mucosa like mo- symptoms. As described above, the band was easily iden- saic (‘snakeskin’) pattern on endoscopy in the left inferior tified outside the stomach following dissection along the banding site in asymptomatic patients. All these are ac- connecting tube. In this situation, we think an extragastric tually pre-erosion. Therefore, we recommend three im- approach is more effective. Fistula and leakage after re- portant technical considerations during gastrogastric su- moval of the eroded bands were serious complications in ture to minimize tissue damage in making the fundal our series. However, as shown in two cases (patients #3, 5), wrap, and therefore to avoid BE. First, the sutures should no postoperative complications developed after codifica- be placed superficially and should not enter the gastric tion of techniques for band removal. Another important mucosa. Second, the stitch should not be tied too tightly. consideration should be suture materials. We have used Third, the band tunnel created by pulling the fundus 2-0 Ethibond (Ethicon Inc.) suture materials in gastric should be sufficiently large to avoid overstretching during banding surgery mainly because it can hold the tissue adjustment. There is no consensus on the technique of re- permanently. When we repair the perforation site after re- moval of the eroded gastric band. In this series of patients, moval of the eroded band, we feel it technically difficult to all eroded bands were removed via direct dissection out- perform a tension-free repair of perforation site. In this re- side the stomach because we decided that the band was gards, we think 2-0 Ethibond ideal to repair the perfo- easily identified along the connecting tube following ration site. Two important technical considerations in re- dissection. However, the fibrous capsule around the band pair of the perforation site are - 1) healthy gastric wall is actually ‘unhealthy’ phlegmonous tissue. Therefore, af- should be included in the suturing, 2) suture material

thesurgery.or.kr 25 Chang Ik Yoon, et al.

should not enter the mucosa layer. In general, absorbable Surg 1999;86:113-8. suture material is preferred in GI suture and monofila- 3. Favretti F, Enzi G, Pizzirani E, Segato G, Belluco C, Pigato P, et al. Adjustable silicone gastric banding (ASGB): the ment suture material is preferred in order to prevent tissue Italian experience. Obes Surg 1993;3:53-6. damage when the tissue is friable. It would be valuable to 4. Parikh MS, Fielding GA, Ren CJ. U.S. experience with 749 laparoscopic adjustable gastric bands: intermediate out- compare the surgical outcome of removal of eroded band comes. Surg Endosc 2005;19:1631-5. according to the suture material to close the gastric 5. Vertruyen M. Experience with Lap-band System up to 7 perforation. Based on our experience, we highly recom- years. Obes Surg 2002;12:569-72. 6. O'Brien PE, Dixon JB, Brown W, Schachter LM, Chapman mend the use of the four steps described below for safe clo- L, Burn AJ, et al. The laparoscopic adjustable gastric band sure of the defect after removal of eroded gastric band: 1) (Lap-Band): a prospective study of medium-term effects primary repair: an interrupted non-absorbable suture on weight, health and quality of life. Obes Surg 2002;12: 652-60. should be used to close the defect, 2) omental plugging: 7. Egbeare DM, Myers AF, Lawrance RJ. Small bowel ob- segmentation of the vascularized omentum is fashioned struction secondary to intragastric erosion and migration and gently inserted through the tunnel that is usually left of a gastric band. J Gastrointest Surg 2008;12:983-4. 8. Rao AD, Ramalingam G. Exsanguinating hemorrhage fol- behind by the extracted band and fixed in place using mul- lowing gastric erosion after laparoscopic adjustable gastric tiple sutures through a relatively healthy gastric wall, 3) banding. Obes Surg 2006;16:1675-8. drainage catheter insertion: one subhepatic (at the level of 9. Campos J, Ramos A, Galvão Neto M, Siqueira L, Evangeli- sta LF, Ferraz A, et al. Hypovolemic shock due to intra- suture line) and one left subphrenic JP drain should be in- gastric migration of an adjustable gastric band. Obes Surg serted through a left subcostal incision, and 4) nasogastric 2007;17:562-4. tube insertion: a nasogastric tube should be inserted for 10. Wylezol M, Sitkiewicz T, Gluck M, Zubik R, Pardela M. Intra-abdominal abscess in the course of intragastric mi- decompression of the air and drainage of gastric juice, and gration of an adjustable gastric band: a potentially life- the tube should be maintained for postoperative 48 hours. threatening complication. Obes Surg 2006;16:102-4. In conclusion, gastric BE requires the removal of the 11. De Roover A, Detry O, Coimbra C, Hamoir E, Honoré P, Meurisse M. Pylephlebitis of the portal vein complicating gastric band. Laparoscopic removal is technically achiev- intragastric migration of an adjustable gastric band. Obes able in the majority of patients with eroded gastric band. Surg 2006;16:369-71. The method can be challenging, has potential post- 12. Fielding GA, Allen JW. A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system. Am J operative complications (fistula, abscess), and should be Surg 2002;184:26S-30S. attempted only by experienced surgeons. 13. Nocca D, Frering V, Gallix B, de Seguin des Hons C, Noël P, Foulonge MA, et al. Migration of adjustable gastric band- ing from a cohort study of 4236 patients. Surg Endosc 2005;19:947-50. CONFLICTS OF INTEREST 14. Cherian PT, Goussous G, Sigurdsson A. Management of band erosion with omental plugging: case series from a 5-year laparoscopic gastric banding experience. Obes Surg No potential conflict of interest relevant to this article 2009;19:1409-13. was reported. 15. Clough A, Layani L, Sidhu M, Wheatley L, Shah A. Subfascial port placement in gastric banding surgery. Obes Surg 2011;21:604-8. 16. Abu-Abeid S, Szold A. Results and complications of lapa- REFERENCES roscopic adjustable gastric banding: an early and inter- mediate experience. Obes Surg 1999;9:188-90. 17. Silecchia G, Restuccia A, Elmore U, Polito D, Perrotta N, 1. Cunneen SA, Phillips E, Fielding G, Banel D, Estok R, Genco A, et al. Laparoscopic adjustable silicone gastric Fahrbach K, et al. Studies of Swedish adjustable gastric banding: prospective evaluation of intragastric migration band and Lap-Band: systematic review and meta-analysis. of the lap-band. Surg Laparosc Endosc Percutan Tech Surg Obes Relat Dis 2008;4:174-85. 2001;11:229-34. 2. O'Brien PE, Brown WA, Smith A, McMurrick PJ, Stephens 18. Cherian PT, Goussous G, Ashori F, Sigurdsson A. Band M. Prospective study of a laparoscopically placed, adjust- erosion after laparoscopic gastric banding: a retrospective able gastric band in the treatment of morbid obesity. Br J analysis of 865 patients over 5 years. Surg Endosc 2010;24:

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