Endoscopic removal of dysfunctioning rings or bands after restrictive bariatric procedures
Article Outline
Abbreviation: SFB, surgical foreign body
I want to congratulate the authors on their innovative work regarding the complementary use of endoscopy for remedial bariatric surgery.1 As obesity continues to progress, and the only effective and enduring treatment for it continues to increase in use, bariatric surgery will inevitably encounter significant success but also potential complications.2 This study demonstrates the need and documented potential for GI surgeons and gastroenterologists to work together. Through a collaborative paradigm, we can partner toward providing optimal care for the bariatric patient. Blero et al1 describe a case series of postoperative bariatric surgery patients who sustained complications of surgical foreign body (SFB) migrations, which were treated endoscopically. Their case series describes a thoughtful, tiered, and safe approach to dealing with these complications.
It is well known that foreign bodies near, on, or within the GI tract have the potential to migrate and erode. This potential problem has been traditionally dealt with by revisional surgery, which is known to carry significantly more risk than primary bariatric surgery.3, 4 Even when these technically challenging cases are performed well, there are clearly increased risks to revisional bariatric surgery versus primary bariatric surgery.
Another consideration is that the initial revisional surgery may carry downstream risks that might imperil any future remedial operation. In most cases, patients who had their SFBs removed remained obese, or at minimum, have a future risk of becoming obese. Given the potential for weight recidivism, these patients may require future bariatric surgical intervention. With this consideration, the endoscopic approach to dealing with these SFBs becomes very compelling. The need to avoid potential gastrostomies, staple/suture lines, and disruption of blood supply is an argument for endoscopic management of these complications. These SFBs may engender a profound inflammatory response extraluminally, requiring surgical lysis of adhesions and occasionally partial gastric resection. The surgical course of these revisional surgeries may then preclude a less-invasive approach to future weight loss. A better option, if accomplished safely as demonstrated here, is an endoscopic retrieval of these SFBs.
The time of presentation varied widely from 2 to 170 months after initial surgery, indicating the need for long-term vigilance and surveillance of the bariatric surgery patient. The chief complaint for these patients was generally abdominal pain, followed by nausea, which can help alert the treating physician to further evaluation. Interestingly, in the bariatric surgery community, weight gain is often seen as a presenting sign for dysfunction of these bands or rings. In this case series, the number of patients with weight gain was exactly the same as those with weight loss (n = 4). Most likely, the patients presenting with weight loss had accompanying symptoms of nausea and pain, which inhibited their ability to eat. What is generally surprising is how these SFBs migrate and are generally well-tolerated by patients. This finding gives reassurance to both the endoscopic and tiered methods the authors describe here. Particularly noteworthy is how they use the self-expandable plastic stent to achieve the removal of a partially eroded SFB, essentially creating a “seton” effect whereby the partially eroded SFB is gradually extruded intraluminally. These techniques should become part of the armamentarium of the bariatric team in dealing with SFB complications. Hopefully, the authors can build upon their early success with more experience, perhaps eventually performing these interventions without general anesthesia.
With past proliferation of vertical-banded gastroplasty and the current explosion of the use of adjustable gastric banding, we can expect further SFB complications. The authors demonstrate a multidisciplinary approach that provides innovative and safe relief for these patients. Future endeavors should include further training and experience in these techniques.
Disclosure
The author disclosed no financial relationships relevant to this publication.
References
- Endoscopic removal of dysfunctioning rings or bands after restrictive bariatric procedures. Gastrointest Endosc. 2010;71:468–474
- Gastric bypass surgery in the United States, 1998-2002. Am J Public Health. 2006;96:1187–1189
- Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality?. Am J Surg. 2009;197:391–396
- Conversion of failed vertical banded gastroplasty to biliopancreatic diversion, a wise option. Obes Surg. 2009;August 29. [Epub ahead of print]
PII: S0016-5107(09)02738-2
doi:10.1016/j.gie.2009.11.014
© 2010 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
