Endoscopic removal of bands in Roux-en-Y gastric bypass: ask your friendly surgeon what he did!

The use of bands or rings is common in bariatric surgery, namely in silastic ring vertical gastroplasty and in laparoscopic adjustable gastric banding (LAGB). Band slippage, gastric pouch outlet stenosis, and band or ring erosion with intragastric migration are the classical late complications that often lead to pain, nausea, vomiting, and possible infection. The frequency of these complications has led to the development of endoscopic procedures that allow the removal of gastroplasty rings or partially migrated Lap-Bands (Apollo Endosurgery, Inc., Austin, Texas, USA) [1] [2]. The treatment may be simple and involve only a section of the ring, such as in cases of almost complete intraluminal migration.

However, in the absence of migration, for example in gastric pouch outlet stenosis after vertical gastroplasty, the placement of a self-expandable plastic stent (SEPS) or a fully covered metal stent (FCSEMS) for a few days allows, by pressure necrosis of the wall, to expose the ring and induce its total migration [2].

Although it might appear risky to induce a necrosis of the whole gastric wall, this technique is usually safe because, during surgery, the rings are fixed and embedded into the outer gastric wall. Therefore, even in the absence of any endoscopically visible migration, the risk of perforation is negligible and has, to our knowledge, never been reported.

In LAGB, endoscopic removal is considered only in cases of partial endoluminal migration (with a part of the band being visible endoscopically), and must include removal and disconnection of the subcutaneous port. Pressure necrosis using an SEPS or FCSEMS is also useful to further expose the ring before cutting it into sections, which is essential for its removal through the esophageal lumen [2] [3]. The rationale in cases of partial migration is that the inflammatory reaction around the stomach will prevent a free peritoneal perforation after ischemia of the gastric wall. This seems to be the case, and only one symptomatic pneumoperitoneum has been reported to date after a wire section technique, with a spontaneous favorable outcome [4].

Conversely, band slippage without intraluminal migration after LAGB is considered to be a contraindication to this endoscopic technique of intraluminal stent placement to induce pressure necrosis. Indeed, adjustable Lap-Bands are fixed around the proximal part of the stomach but are not covered by or embedded into the outer wall. Therefore, placing a stent to induce pressure necrosis might result in peritoneal perforation or even a transection of the stomach.

Primary banding of Roux-en-Y gastric bypass (RYGB) remains controversial [5], although recent evidence suggests that it results in greater weight loss and weight stability [6] than standard RYGB. It is, however, at the cost of a much higher incidence of vomiting and possible complications, including gastric outlet stenosis, band erosion, and band slippage leading to a band-specific reoperation rate exceeding 4 % [7].

In the current issue of Endoscopy, Campos et al. [8] report excellent results in removing rings in patients with a banded RYGB. The authors placed an SEPS for 15 days, which resulted in complete exposure of the ring and successful removal in all cases. In most of the cases, the ring was removed together with the stent or during the same session as stent removal. This is very similar to the technique used for removal of rings after vertical gastroplasty. Although not mentioned in the paper, it is highly probable that banding during surgery was done using standard silastic or Fobi rings, which are usually embedded into the outer wall of the anastomosis [9]. If this is the case, then the technique described by Campos et al. has every chance of being performed safely.

One should be aware, however, that some surgeons use adjustable bands around the gastrojejunal anastomosis [10], and in these cases, a similar technique might be associated with a high risk of perforation. Similarly to LAGB, if such an adjustable band has been used, only those patients with a visible partial migration of the band should be considered for band removal through the placement of an SEPS.

As stressed by Campos et al., the timing of stenting is also important and, in our experience, 2 weeks is considered to be a maximum, as illustrated by the three migrations observed among patient who kept the stent for a longer period [8]. Such a migration usually results in asymptomatic spontaneous elimination but some cases of impaction, particularly at the ileocecal valve, have been reported.

The data presented by Campos et al. further illustrate the role of endotherapy in the management of complications associated with bariatric surgery. These approaches offer a valid and safe alternative for band and ring removal without jeopardizing future bariatric surgery should it be needed in the setting of a chronic disease. It is, however, of paramount importance that these techniques are developed by multidisciplinary teams that are perfectly aware of the different techniques and materials used.

• References

• 1 Blero D, Eisendrath P, Vandermeeren A et al. Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures. Gastrointest Endosc 2010; 71: 468-474
• 2 Hookey LC, Mehdi A, Le Moine O et al. Removal of a gastroplasty ring. Gastrointest Endosc 2005; 61: 594
• 3 Wilson TD, Miller N, Brown N et al. Stent induced gastric wall erosion and endoscopic retrieval of non-adjustable gastric band: a new technique. Surg Endosc 2013; 27: 1617-1621
• 4 Sakai P, Hondo FY, de Almeida Artifon EL. Symptomatic pneumoperitoneum after endoscopic removal of adjustable gastric band. Obes Surg 2005; 15: 893-896
• 5 Mahawar KK, Parikh C, Carr WR et al. Primary banded Roux-en-Y gastric bypass: a systematic review. Obes Surg 2014; 24: 1771-1792
• 6 Rasera Jr I, Coelho TH, Ravelli MN et al. A comparative, prospective and randomized evaluation of Roux-en-Y gastric bypass with and without the Silastic ring: a 2-year follow-up preliminary report on weight loss and quality of life. Obes Surg 2016; 26: 762-768
• 7 Buchwald H, Buchwald JN, Mc Gennon TW. Systematic review and meta-analysis of medium-term outcomes after banded Roux-en-Y gastric bypass. Obes Surg 2014; 24: 1536-1551
• 8 Campos JM, Moon RC, Magalhães Neto GEJ et al. Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent. Endoscopy 2016; 48: 516-520
• 9 Fobi MA. Placement of the GaBP ring system in the banded gastric bypass operation. Obes Surg 2005; 15: 1196-1201
• 10 Vijgen GH, Schouten R, Bouvy ND et al. Salvage banding for failed Roux-en-Y gastric bypass. Surg Obes Relat Dis 2012; 8: 803-808