Erosion is a long-term complication of lap band surgery, and occurs when the Gastric Band fastened around the upper stomach gradually erodes into the stomach wall and extends into the gastric lumen. Intragastric LapBand Erosions have been reported at rates that vary from 0.6% to 10% depending of the operative technique, the doctor’s experience, the device used and the most important factor:the patient’s follow up.
The use of NSAIDS, alcohol and smoking have been proposed as three of the main factors contributing to hyperacidity and irritation of the mucosal layer of the stomach. This important layer prevents us from acquiring ulcers in normal conditions. When the irritation is persistent, it can cause erosion of the wall layers of the stomach, which may allow the lapband to migrate into the stomach (“inside out” erosion theory). Repeated vomiting has also been suggested as a possible accelerant, especially when a high degree of obstruction is present (For example, an over-filling of the lapband). Due to the erosion, saliva or food leaks through the hole or ulcer in the stomach and flows along the LapBand tubing, causing the tissue under the skin of the LapBand Port to become infected.
Figure 1.0 Intragrastric Lap Band Migration – Drawing of radiographic findings illustrates passage of liquid contrast material (Barium) around left section of band that has eroded into the stomach (small arrow).
In some cases, Lap-band erosion occurs gradually and may be silent or go unnoticed. However, several clinical symptoms may develop and should raise the suspicion of Lap Band Erosion: (1) cessation of weight loss, (2) weight regain with loss of restriction in the lap band, or (3) a port site infection. The Clinical Symptoms and Radiological or Endoscopic findings depend on the degree of Erosion.
The diagnosis of LapBand Erosion can be made at the radiological evaluation performedunder fluoroscopy during a gastric band adjustment in both symptomatic and asymptomatic patients. If the radiological evaluation does not show signs of lap-band erosion and the patient has the symptoms, the doctor is obligated to perform an Endoscopy.
Figure 1.1 LapBand Port Infection
Due to the fact that LapBand Erosions usually open with a port infection (35%), the infection will continue after removal of the port, especially if erosion was not diagnosed. In these cases of chronic infection, further radiological and endoscopic tests are needed to demonstrate the presence of LapBand Erosion.
Figure 1.2 Endoscopic View of LapBand Erosion
Figure 1.3 Intragastric LapBand Erosion – Note the “tips” of a Swedish band into the gastric lumen
Figure 2.0 – Intragastric LapBand Erosion – Radiological evaluation shows 2 channels of contrast material, instead of one, clearly demonstrated in the later view of Fig. 2.1
Fig. 2.1 – Intragastric LapBand Erosion – In this lateral view you can see the “bridge” between the upper (the pouch) and the lower stomach, the barium contrast material bypasses the part of the lap band that has eroded through the stomach’s wall.
Figure 3.0 – Missing Port – AP plain film shows a lap band without the port. The Patient had a history of port removal secondary to port infection with a persistent infected fluid coming out from the port area.
Figure 3.1 Intragastric LapBand Erosion demonstrated by fistulography.
Note the injected contrast material at the skin level is going through the fistula into the lower stomach.
The upper GI x-ray does not reveal lap band erosion in itsearly stages. However, the radiological appearance of late-stage intragastric band erosion on the upper gastrointestinal series is pathognomonic when the “stair sign” is observed. Barium swallow during the upper GI shows a flow of contrast fluid aroundthe portion of the band that has eroded into the stomach. As mentioned before, in cases where the radiological findings are missing, an endoscopic evaluation is mandatory.
Figure 4.0 Intragastric LapBand Erosion – Radiograph from upper gastrointestinal series shows characteristic appearance of intragastric lapband erosion. Note the liquid contrast material on both sides of penetrating portion of the lap-band, “the stair sign”.
Figure 4.1 – Radiologic evaluation shows a complete eroded gastric band – Note the location of the migrated band; the lapband device is found in its totality intragastric at the level of stomach antrum (the lower stomach). The patient had not been loosing weight for 3 years.
Figure 4.2 – Complete erosion of the gastric band (seen in Figure 4.1) the gastric band was removed by endoscopy
Treatment of lapband erosion requires removing the lapband by laparoscopy or by endoscopy. Weight regain typically occurs following this procedure. However, it is necessary to remove the gastric band in order to avoid further complications. It is recommended to treat LapBand Erosions with another bariatric procedure 6 to 8 months after a de-banding procedure (LapBand removal). This is due to the high incidence of complications and failures when the procedure is done immediately following removal, or sooner than 6 months after removal, since the portion of stomach that has been eroded is weak and prone to leaking.
It is true that LapBand Migration means the failure of the operation and leads to a second bariatric procedure; however, erosion is considered a complication with a benign course if it is managed properly.
Arturo Rodriguez MD