Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy.
Laparoscopic adjustable gastric banding (LAGB) is a well-established restrictive procedure, still popular among many bariatric surgeons, because of its adjustability, reversibility, and preservation of gastrointestinal tract continuity [
With a reported incidence of 1–3%, gastric erosion is a relatively rare but potentially life-threatening complication [
A 34-year-old female Caucasian patient presented at the emergency department with a 5-day history of protracted vomiting and epigastric pain. She had undergone LAGB (Bioring, Cousin Biotech, France) for morbid obesity 4 years before (height: 165 cm, weight: 100 kg, BMI: 36.7, and comorbidities: arterial hypertension, dyslipidemia, and low back pain) resulting in a weight loss of 30 kg (85% EBWL). The original band had been replaced laparoscopically 3 years after initial surgery, due to connection tubing failure.
Clinical examination revealed tachycardia, mild tenderness over the epigastrium, and signs of dehydration. Laboratory tests and plain abdominal radiographs were within normal range. Abdominal ultrasonography and CT scans were inconclusive; however the band was visible on upper GI endoscopy (Figure
Retroflexed inspection of the gastric fundus and gastric erosion by the band.
Duodenal erosion by the connection tubing.
The patient consented to surgical treatment and removal of the band. On laparoscopy, adhesions were taken down and the band was dissected free, cut near the buckle, and extracted. The duodenal erosion, about 1 cm in length, was repaired primarily by interrupted, absorbable polyglactin (Vicryl, Ethicon, Somerville, NJ, USA) 2/0 sutures, while a vascularized omental pedicle was fashioned and inserted into the gastric tunnel, to close the gastric defect. A vacuum-assisted drain was placed alongside the gastric repair and a Penrose drain at the duodenal repair. The band was sent for culture, which grew a multiresistant strain of
Postoperatively the nasogastric tube was removed on the 4th day, and the patient was started on clear fluids, after gastrografin swallow test showed no leakage. On the 8th postoperative day she developed pneumonia, for which she received appropriate antibiotics. She was discharged on the 12th postoperative day. Gradually she regained weight (height: 165 cm, weight: 110 kgr, and BMI: 40.4) and two years later she underwent open Roux-en-Y gastric bypass.
LAGB is generally considered a safe procedure, with less postoperative complications compared to other bariatric operations, which require more extensive dissections and anastomoses. Erosion is a relatively uncommon complication, where the band slowly erodes through the gastric wall and into the gastric lumen and becomes visible at endoscopy [
Most authors report erosion rates of 1–3%; however incidence varies greatly between different centers (0,23%–32%) and may reflect not only level of surgical experience and volume of patients but also length and method of followup [
The pathophysiology of erosion is still not completely understood. Early erosions are thought to be the result of microinjury to the gastric serosa, band infection, or too tight band placement [
A variety of risk factors have been implicated, but no single factor can cause erosion. Although it has not been definitely proven, newer band designs (high-volume, low-pressure systems) tend to be associated less frequently with gastric erosions than older designs (low-volume, high-pressure systems), due to improved geometry and more even distribution of pressure on the gastric wall [
Most cases of LAGB erosion develop gradually over time and thus are nonurgent and non-life-threatening [
Clinical suspicion of band erosion mandates further diagnostic workup. Contrast medium swallow test may reveal gastrografin passing from the upper to the lower gastric pouch outside the band but is usually inconclusive [
Management of erosions is a matter of debate. Band removal is the sine qua non of treatment, yet there is no consensus regarding timing of removal and type of future intervention. Surgical explantation can be performed as laparotomy or laparoscopy [
The majority of duodenal perforations can be effectively managed by simple repair [
Prognosis of gastric erosions is usually good. Evidence on LAGB-related duodenal erosions however is limited. Gastric banding causes a 360-degree sheath of reactive tissue around the band [
In the long run, band explantation leads almost inevitably to weight regain; therefore another bariatric intervention is warranted. Selection of patients depends on local factors and the efficacy of banding on weight control. Immediate band replacement in cases without serious infection has been described but leads generally to unacceptably high reerosion rates of up to 40% [
Gastric erosion is an uncommon but feared complication of adjustable gastric banding for morbid obesity. Symptoms are nonspecific and diagnosis is confirmed on upper gastrointestinal endoscopy. The mainstay of treatment is surgical or endoscopic band removal, with revision or conversion to other bariatric modalities at a later stage. Erosion of the connecting tubing into the duodenum is a much rarer complication, managed adequately by primary suture repair, omentopexy, and drainage.
This report is published with the written consent of the patient.
The authors declare that there is no conflict of interests regarding the publication of this paper.