Overview
Definition:
Gastric band erosion is a late complication of laparoscopic adjustable gastric banding (LAGB) where the band material migrates through the gastric wall, often into the gastric lumen
It represents a failure of the implanted device.
Epidemiology:
The incidence of gastric band erosion is estimated to be between 1% and 11% over a 10-year period after LAGB
It is considered a late complication, typically presenting months to years post-implantation.
Clinical Significance:
Gastric band erosion can lead to significant morbidity, including gastric perforation, peritonitis, fistula formation, and malabsorption
Timely diagnosis and management are crucial to prevent life-threatening complications and ensure patient safety
It is a recognized complication that exam candidates must understand for surgical board preparation.
Clinical Presentation
Symptoms:
Intermittent or persistent epigastric pain
Nausea and vomiting, often refractory to antiemetics
Feeling of food intolerance or early satiety that changes significantly from pre-erosion state
Heartburn or acid reflux
Weight loss or failure to lose weight
Sepsis or fever in cases of perforation
Passage of band material in stool (rare).
Signs:
Tenderness in the epigastrium or upper abdomen
Signs of peritonitis (guarding, rigidity, rebound tenderness) if perforation has occurred
Fever
Tachycardia
Hypotension in septic shock
Palpable mass in the epigastrium (rare).
Diagnostic Criteria:
Diagnosis is typically based on a combination of suggestive clinical symptoms, characteristic findings on imaging studies (especially CT scan and upper GI endoscopy), and, in some cases, direct visualization during surgery
There are no specific laboratory-based diagnostic criteria, but inflammatory markers may be elevated.
Diagnostic Approach
History Taking:
Detailed history of the LAGB procedure, including date of implantation and any previous adjustments or complications
Onset, duration, and character of current symptoms
Changes in eating habits and weight
History of abdominal pain, nausea, vomiting, or fever
Previous investigations or treatments for similar symptoms.
Physical Examination:
Systematic abdominal examination focusing on the epigastric region for tenderness, guarding, rigidity, and masses
Assess for signs of peritonitis
Evaluate vital signs for evidence of sepsis or hemodynamic instability.
Investigations:
Upper gastrointestinal endoscopy: Allows direct visualization of the band, evidence of partial or complete erosion, and can assess the gastric mucosa
CT scan of the abdomen and pelvis with oral and IV contrast: Highly sensitive for detecting intraluminal band material, gastric wall thickening, perigastric fluid collections, or abscesses
It can also identify migration of the band into adjacent organs
Barium swallow: Can demonstrate luminal obstruction or abnormal band position, but less sensitive for early erosion than endoscopy or CT
Blood tests: Complete blood count (CBC) to assess for anemia or leukocytosis, electrolytes, renal function, and liver function tests
Blood cultures if sepsis is suspected.
Differential Diagnosis:
Gastric ulcer
Gastric outlet obstruction from other causes
Gastric volvulus
Pancreatitis
Cholecystitis
Peptic stricture
Intra-abdominal abscess.
Management
Initial Management:
Fluid resuscitation if dehydrated or septic
Broad-spectrum antibiotics if peritonitis or sepsis is suspected
Analgesia
Nasogastric tube decompression if there is significant vomiting or obstruction.
Medical Management:
Primarily supportive
Management of associated symptoms like nausea and pain
Antibiotics if infection is present
However, medical management alone is generally insufficient for confirmed erosion
surgical intervention is usually required.
Surgical Management:
The definitive treatment for gastric band erosion is surgical removal of the band
Laparoscopic band removal is the preferred approach, but conversion to open surgery may be necessary depending on the extent of erosion, adhesions, and the patient's stability
In cases of associated gastric perforation or necrosis, gastrorrhaphy, partial gastrectomy, or gastrostomy may be required
Management of associated abscesses or peritonitis is critical
The goal is complete removal of the foreign body and management of any secondary complications.
Supportive Care:
Close monitoring of vital signs and urine output
Nutritional support, often starting with parenteral nutrition if oral intake is not feasible
Pain management
Regular monitoring for signs of infection or anastomotic leak if any reconstructive surgery was performed
Psychological support for patients undergoing removal of a weight-loss device.
Complications
Early Complications:
Perforation of the stomach or esophagus
Peritonitis
Intra-abdominal abscess
Bleeding
Sepsis
Wound infection
Damage to adjacent organs during removal (e.g., spleen, colon).
Late Complications:
Stricture formation at the site of erosion or repair
Recurrence of obesity
Dumping syndrome (less common with band erosion itself, more with associated procedures)
Adhesions leading to bowel obstruction.
Prevention Strategies:
Proper patient selection and counseling for LAGB
Meticulous surgical technique during band placement
Careful band adjustments to avoid overtightening
Patient education on recognizing early warning signs of complications
Regular follow-up appointments.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and intervention
Presence and severity of complications such as perforation or sepsis
Patient's overall health status and comorbidities
Skill of the surgical team.
Outcomes:
With prompt diagnosis and appropriate surgical management, the prognosis is generally good
Most patients can have the band removed successfully without significant long-term sequelae
However, those with severe sepsis or perforation may have a more complicated recovery
Re-operation rates can be high if not all eroded material is removed.
Follow Up:
Regular follow-up is essential to monitor for signs of recurrent infection or complications
Patients may require psychological counseling and nutritional support to manage weight regain
If revisitation to bariatric surgery is considered, it should be carefully planned after full recovery.
Key Points
Exam Focus:
Gastric band erosion is a late complication of LAGB
CT scan and endoscopy are key diagnostic tools
Definitive management is surgical removal of the band
Perforation and sepsis are major concerns.
Clinical Pearls:
Always suspect band erosion in a patient with LAGB who develops new, persistent, or worsening upper GI symptoms, especially refractory nausea/vomiting or pain
Early suspicion and prompt investigation are vital.
Common Mistakes:
Delaying diagnosis due to attributing symptoms to other causes
Inadequate imaging leading to missed diagnosis
Incomplete band removal during surgery
Underestimating the risk of peritonitis and sepsis.