Endoscopic Management of Post-Bariatric Foreign Bodies: Dysfunctional Sutures, Staples, and Bands

Fig. 13.1

(a) Stomal stenosis in Roux-en-Y Gastric Bypass (RYGB) patient, approximately 8 mm in diameter. (b) Through-the-scope balloon dilation of stomal stenosis (images provided with permission to reproduce by Drs. Thompson and Ryou)

For refractory cases, it is important to consider and address underlying embedded foreign material restricting dilation. For example, sutures or staples can be endoscopically removed in order to allow for effective dilation [19]. Another reason for suture and staple removal includes ulcer pathogenesis [9] (Fig. 13.2) (discussed in detail below), and rarely, long visible sutures can trap food and lead to bezoar formation (Fig. 13.3a, b). Exposed staples may be removed using forceps. Endoscopic scissors tend to work better for silk suture, while loop cutters are better for prolene suture. Our group will often utilize a double-channel gastroscope with graspers down the second instrument port to provide traction if necessary.

Fig. 13.2

RYGB stomal ulceration with associated suture requiring removal (images provided with permission to reproduce by Drs. Thompson and Ryou)

Fig. 13.3

(a) Long exposed sutures at jejunojejunal anastomosis (RYGB) trapping food and causing bezoar. (b) Endoscopic scissors for suture removal (images provided with permission to reproduce by Drs. Thompson and Ryou)

If stomal stenosis remains refractory to dilation despite these steps, the operative report should be reviewed once again to ensure that a silastic band is not present. These can be cut with endoscopic scissors. Mylar mesh has also been use to reinforce the gastrojejunal stoma, and this can be difficult to remove endoscopically if not fully eroded into the intragastric lumen [20]. Self-expanding stents may be required to facilitate intraluminal migration [21]. (These topics are presented in more detail in the section below on removal of foreign bodies.) If endoscopic treatment is unsuccessful, surgical revision is ultimately warranted.

Dysfunctional Laparoscopic Adjustable Gastric Band

Laparoscopic adjustable gastric banding (LAGB) is the second most popular bariatric procedure in the United States [22, 23]. An adjustable restrictive silicone band is placed around the gastric cardia to create a small gastric pouch. The band is connected by plastic tubing to a subcutaneous port to allow for titration of the level of restriction.

LAGB carries a relatively high rate of revision, between 13 and 40%, since most complications associated with LAGB require its removal [24, 25]. Blero and coworkers have previously proposed a useful classification of band or ring dysfunction (Table 13.1) [7]. Early obstructive symptoms should prompt a consideration of stomal obstruction, which results from excess tissue or edema at the level of the band. The diagnosis is made by upper GI series or endoscopy. Conservative management with nasogastric tube decompression is the first-line therapy with surgery reserved for refractory symptoms or if concerns of gastric necrosis arise [7].

Table 13.1

Classification of band or ring dysfunctions, usual presenting symptoms, and diagnostic procedures (adapted from Blero, et al. [5, 7])

Ring/band dysfunction type	Symptoms	Diagnosis
Slipping	Weight gain, reflux, or obstruction	Contrast radiograph
Stenosis with pouch dilation	Nausea, vomiting, weight loss	Contrast radiograph/upper GI endoscopy
Minor erosion	Weight gain, abdominal pain (port-site infection)	Upper GI endoscopy
Major erosion or intragastric migration	Weight gain/loss, abdominal pain	Upper GI endoscopy

The most common reported complication after LAGB is band slippage, leading to gastric prolapse [7, 26]. The rate of slippage has been reported to be as high as 24% in one series, but recent modifications with the technique have decreased this rate to 2–14% [7, 23–25]. Similar symptoms of food intolerance, epigastric pain, and nausea/vomiting may present. Diagnosis can likewise be made with an upper GI series or endoscopy. Surgery is usually required for band adjustment or removal.

Band erosion represents a frequent late complication of LAGB, with reported incidences of 7–9% [24, 25]. Band erosion is usually caused by incorporation of excessive tissue within the band or the placement of an exceptionally tight band, resulting in ischemia. Most band erosion is chronic, whereby the band erodes into the gastric lumen over time. Such erosion could be the result of a localized perigastric inflammation, which is sustained until the stomach engulfs the band [7]. For additional discussion regarding endoscopic management of band erosion, please see the relevant section below.

Staple-Line Stenosis: Sleeve Gastrectomy

Sleeve gastrectomy is a restrictive surgery that tubularizes the stomach by stapling along the lesser curvature and resecting a significant portion of the greater curvature. Gastric-outlet obstruction may result, usually at the level of the gastroesophageal junction or at the incisura angularis due to oversewing of the staple line [27].

Similar to the dilation strategy of stomal stenosis, treatment of stenoses in sleeve gastrectomy also involves iterative endoscopic dilations up to 20 mm in diameter [28]. Refractory stenoses can be treated with temporary placement of self-expanding stents (both metal and plastic stents for up to 2 months) [29]. There have also been case reports of intraluminal migration of pericardial strips used for staple-line reinforcement; this can be addressed by simple endoscopic removal [30]. If endoscopic treatment fails, surgical revision and conversion to RYGB are usually required.

Stomal Stenosis: Vertical Banded Gastroplasty

Vertical Banded Gastroplasty (VBG), a restrictive procedure originally described by Mason, was previously popular until long-term outcomes were assessed [31]. The surgery consists of a proximal vertical stapling along the lesser curvature of the stomach ending with a band or tight prosthetic mesh. Stomal stenosis was estimated to occur in 20–33% of patients [32, 33].

Endoscopic dilation has been shown to be successful in up to 68% of VBG patients [32, 33]. One study showed a mean requirement of two endoscopic sessions [33]. In VBG patients, intragastric band migration can occur as a late complication and may therefore require removal (see below) [32, 33]. If endoscopic treatment is unsuccessful, surgical revision is ultimately warranted.

Endoscopic Removal of Dysfunctional/Eroded Foreign Materials

It is important to note that prosthetic materials and devices have been incorporated in various iterations of weight loss operations [34]. In rough chronological order, these include, but are certainly not limited to, the Wilkinson band (Marlex mesh) and gastric wrap (Fig. 13.4), the Marlex mesh band by Mason (Fig. 13.5), the silastic ring band by Laws (Fig. 13.6), the dual mesh band by Molina (Fig. 13.7), the silicone band and more recently the adjustable gastric band (LAP-BAND) (Fig. 13.8), the silastic ring and fascial band by Linner (Fig. 13.9), the Swedish band (Obtech) (Fig. 13.10), the silastic ring band by Fobi for vertical banded gastric bypass and the transected banded vertical gastric bypass (Fig. 13.11), and the silastic ring band for stomal reinforcement in RYGB.

Fig. 13.4

Wilkinson band (Marlex mesh) and gastric wrap (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 700, Mal Fobi, et al., Fig. 13.1, Original copyright reproduced with permission from Deitel M. Update: Surgery for the morbidly obese patient. Toronto: FD Communications 2000)

Fig. 13.5

Marlex mesh band by Mason (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 700, Mal Fobi, et al., Fig.13.2, Original copyright Mason EE. Vertical banded gastroplasty for morbid obesity. Arch Surg 1982; 117: 701–6)

Fig. 13.6

Silastic ring band by Laws (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 700, Mal Fobi, et al.,Fig. 13.3 Original copyright reproduced with permission from Deitel M. Update: Surgery for the morbidly obese patient. Toronto: FD Communications 2000)

Fig. 13.7

Dual mesh band by Molina (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 700, Mal Fobi, et al., Fig.13.4Original copyright reproduced with permission from Deitel M. Update: Surgery for the morbidly obese patient. Toronto: FD Communications 2000)

Fig. 13.8

Adjustable gastric band (LAP-BAND) (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 700, Mal Fobi, et al., Fig.13.6Original copyright reproduced with permission from Deitel M. Update: Surgery for the morbidly obese patient. Toronto: FD Communications 2000)

Fig. 13.9

Silastic ring and fascial band by Linner (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 701, Mal Fobi, et al., Fig. 13.7 Original copyright Linner JH. Gastric operations: In: Linner JH, ed. Surgery for morbid obesity. New York: Springer 1984: 65–107)

Fig. 13.10

Swedish band (Obtech) (with kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 701, Mal Fobi, et al., Fig. 13.8Original copyright permission from Obtech Medical)

Fig. 13.11

Silastic ring band by Fobi for vertical banded gastric bypass (a) and transected banded vertical gastric bypass. (b) (With kind permission from Springer Science + Business Media: Obesity surgery, Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass, Vol. 11, 2001, page 701, Mal Fobi, et al., Figs.13.9 and 13.10 Original copyright Fobi, 1986 and Fobi, 1992)

For more than two decades, successful endoscopic management of dysfunctional and/or eroded foreign materials has been reported and, depending on local expertise, can be considered first-line therapy with proper surgical backup [35–42]. The two standard endoscopic approaches entail (1) band/ring transection using endoscopic scissors, band cutters, and Nd: YAG laser and (2) use of self-expanding stents to facilitate full intraluminal migration of bands/rings. In certain scenarios, these general approaches can be combined.

Band/Ring Transection

The tourniquet method has been most frequently described for band transection. A metallic wire is passed through the biopsy channel of the endoscope, wrapped around the migrated band, and retracted back to the mouth using a grasper. In their series of 182 patients between 1996 and 2002 who underwent LAGB, Regusci and coworkers encountered seven cases of intragastric band migration (3.8%) [35]. Six of the seven cases were managed successfully by gastroscopy with a new Gastric Band Cutter device without complications. First, a cutaneous exploration at the port site was performed, and both the port and maximal length of the catheter tubing were surgically extracted. Then, the migrated portion of the band was intragastrically identified and mobilized with endoscopic graspers. The metallic thread of the band cutter was inserted into the endoscope, wrapped around the band in the stomach, and retracted orally with the grasper in order to transect the band.

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