A gastric band (Lap-Band and Realize band are the ones sold in the United States) can erode into the stomach and have no symptoms. In fact 1/3 of all bands that have eroded into the stomach have no symptoms, and are found with a high degree of suspicion by the band surgeon.
Causes of Band Erosion:
The only known cause of band erosion is when a patient has a history of overwhelming infection in the past – especially if the infection has been in the abdomen or the pelvis. The mechanism is thought to be that the band becomes colonized with the bacteria, and cannot be sterilized in spite of prolonged antibiotics. The stomach is irritated by the bacteria and seeks to locally control them, leading to a local area of inflammation and ultimately a phagocytosis by the stomach.
Patients who are on drugs such as Humera (adalimumab), Enbrel (etanercept) have also been found to have band erosions. Prednisone and methotrexate are not associated with an increase in band erosion. We no longer offer these patients on Humera or Enbrel the Lap-Band for a weight loss procedure. In our series of six patients who had those medications, all ended up with a band erosion.
Some surgeons have suggested operative trauma (all operations are traumatic), over use of non-steroidal anti-inflammatory drugs leading to an ulcer that ulcerates by the band (no one has ever seen or reported one of these), or patients that repeatedly get food stuck and vomit. Some surgeons find that if the gastric-gastric sutures used to cover the band in the original surgery are intra-luminal that this will lead to an erosion (since these would become colonized it makes sense).
The peri-gastric technique used to place a band (bands placed before 1999) led to a high incidence of eroded bands (about 9%). It was felt that the pars-flaccida approach provided a bit of safety for the buckle to not pinch the stomach leading to local trauma. In addition, too tight of a wrap has led to an increase in erosions.
Incidence of Band Erosion:
Prior to 1999 the incidence of band erosion was 9-12%. Once the surgical technique changed the incidence dropped to 1-2%. Some surgeons report less erosions, however, they do not routinely survey their patients.
One third of patients are asymptomatic.
One third of patients present with a port site infection
One third of patients present with local stomach irritation and the loss of sensation of the band (it no longer curbs their appetite).
Removal of the band can be done laparoscopically, although some have been removed endoscopically if the port has been removed and the tubing disconnected (this is difficult).
Laparoscopic approach should be done by an experienced bariatric surgeon. Typically the omentum has walled off the band and the tubing. Once the tubing is exposed it can be followed using a harmonic or ultrasonic device to the band where the band can be unbuckled and slid out. The hole is difficult to close (highly inflamed) and sometimes has to be patched (Graham patch). A drain left, and the patient can start clear liquids on the floor and be discharged later.
Occasionally the only way to remove the band is to make an enterotomy into the stomach, cut the band and remove it, then close the stomach with a plicating suture. Methylene blue to find the hole, and closing it, or patching it is then done with a drain left in place.
An eroded band is NOT an emergency. Some patients have been followed with erosions for a long time, without consequence. Serial endoscopies have shown that the bands will erode, then not be in the lumen of the stomach, only to appear later (private communication w Ariel Ortiz).
Even patients who present with a gastric bleed secondary to a band erosion are best served with endoscopic control and stabilization prior to elective removal of the band.
Band removal is complex, especially in the hands of a surgeon who is unfamiliar with Lap-Bands or Realize Bands and there is always time to get the patient to an experienced band surgeon.
Some physicians survey their bands by endoscopy once a year to rule out an erosion. There is no evidence that this is warranted. Endoscopy is warranted if the patient (a) has a port site infection (b) suddenly loses the effect of the lap-band (c) has had a major systemic infection (especially abdominal).
Patients who have had major infections and been septic should, once stablized, have their bands electively removed. It is much easier to remove a band electively than to hope a band does not become infected.
When to Provide a Follow Up bariatric Surgery
Patients will ask when to have a band replaced. Waiting six months seems to be the consensus among bariatric surgeons. Six months would also be the minimum should a patient decide upon wishing another bariatric procedure.
Some surgeons, after the band has eroded, feel strongly that a patient should not have another band, but have another procedure for weight loss – such as the gastric sleeve.