and dyscopic removal of eroded gastric bands, a case series. Bariatric interventions have been available since the mid-1960s, but today there are four predominant interventions that are offered. These include Roux-en-Y gastrectomy, biliopancreatic diversion surgery, adjustable gastric banding, or AGB, and vertical gastric banding, or VGB. Each of these procedures has its own risks and benefit profiles, but broadly the top two alter anatomy significantly more and thus have a greater risk of adverse events, but are also associated with a greater weight loss profile, while AGB and VGB are less anatomy altering, so they have a significantly lower risk profile, but are associated with less weight loss. Historically, adverse events in the top two are managed surgically, while some adverse events in AGB and VGB can actually be managed endoscopically. More specifically, the most common long-term AGB and VGB adverse events can be seen below. Dilation and herniation have both been described in 5% to 40% of patients that undergo these procedures long-term. Erosion, on the other hand, has been seen in 1% to 7% of the population, and the rare band prolapse is identified in less than 1% of the population. While dilations, herniations, and band prolapse require surgical interventions, erosion can be managed endoscopically. In this case series, we will discuss the endoscopic removal of gastric bands in three patients that underwent either a VGB or an AGB and had an erosion. Case one is a 30-year-old female with a past medical history of a laparoscopic AGB 11 years prior to presentation. Her initial presentation consisted of intermittent severe epigastric pain associated with eating, nausea, and emesis. She reported an excess weight loss, or EWL, of approximately 50% to 55%, and her last gastric band adjustment was nine years prior to presentation. Given these symptoms, imaging was obtained that was concerning for a gastric band erosion into the gastric lumen, so an EGD was pursued. On EGD, we can see nearly a 75% erosion of the gastric band into the lumen of the stomach. To remove this, first we attempted to use endoscopic scissors to cut the band, however it became clear that the band was too large to be cut by the scissors. Then we passed a wire and deployed a fully covered esophageal metal stent into the gastric lumen at the level of the gastric band, which was sutured in place, as we can see here. This was done in an attempt to promote complete erosion of the band into the gastric lumen by causing ischemia to the non-eroded mucosa. Unfortunately, following stent placement, the patient developed persistent abdominal and chest discomfort, so a repeat EGD was pursued that showed the stent stable in place. Even so, given the patient's symptoms, the sutures were cut with endoscopic scissors, and the stent was removed with a rat tooth forceps. Given this, a repeat attempt at endoscopic removal with concurrent laparoscopic intervention was attempted using a mechanical lithotriptor. Here we can see the instruments needed to use this device, including the mechanical lithotriptor on the left, a stiff wire in the middle, and a standard set of forceps on the right. To use the device, first the wire is loaded into the endoscope and advanced through the lumen of the band, seen here as the white circle. Next, the wire is grasped by the forceps and withdrawn into the channel in a short exchange with the endoscope. We then attach the metal sheath to the mechanical hand crank of the lithotriptor and pass both ends of the wire through the hole on the central handle. Once the wire has been through, the metal sheath is advanced over the wire through the band and the lithotriptor is cranked until the wire cuts through the band. On laparoscopy, we can see a view from inside the abdominal wall looking at the external stomach mucosa. Here we can identify the white AGB connection tubing that leads from the gastric band to the access port coming out of the stomach, indicating that the gastric band was almost completely eroded into the stomach lumen. Next, we can see the connection tubing cut laparoscopically as the gastric band was simultaneously manipulated endoscopically to remove it from the stomach wall using rat tooth forceps. The stiff wire was then passed into the stomach. It was grasped with the rat tooth forceps and the wire was attached to the lithotriptor as previously demonstrated. However, the wire appeared to break after attempting to cut the band. We then passed a thinner 0.025 inch biliary guide wire into the stomach and grasped it in a similar fashion. This time, the band was successfully cut. The band was then grasped with a snare and removed through the patient's mouth. On repeat endoscopic inspection, there was no evidence of gastric perforation and the erosion site was reinforced laparoscopically using surgical staples. Case number two is a 60 year old male with a past medical history of a VGB with a celastic non-adjustable band placed more than 20 years prior to presentation. His presenting symptoms include dysphagia, intermittent nausea, and emesis. After presentation, the patient underwent imaging and an EGD that showed severe stenosis of his gastric pouch due to the celastic band, but there was no erosion identified. Given this, he underwent eight balloon dilations over the course of four years with temporary relief, as well as an EUS guided gastro gastrostomy or GG anastomosis to provide bypass that also only provided temporary relief after it repeatedly stenosed. The patient deferred any surgical interventions, so advanced GI was consulted. First, the patient underwent an EGD that identified the stenosed VGB and the stenosed GG anastomosis. Next, a 0.035 inch guide wire was passed through the stenosed VGB and a 20 by 10 millimeter lumen opposing metal stent or LAMS was placed into the stenosis in an attempt to erode the bands into the gastric mucosa to facilitate removal. Repeat EGD one and a half months later can be seen here with visualization of the now patent VGB stenosis with a LAMS in place and the GG anastomosis. Next, the LAMS was removed through the mouth with a rat tooth forceps revealing evidence of an eroded band across two thirds of the circumference of the gastric lumen with some blue surgical sutures evident. Endoscopic scissors were used to cut the surgical sutures and a visible portion of the band and attempts were made to even create a superficial incision over the remaining gastric tissue to further erode it, but these attempts were ultimately unsuccessful. With this, a wire was passed and another 20 by 10 millimeter LAMS was placed over the celastic band. Two months later, the patient again underwent an EGD, however, this time we can see that the previously placed LAMS had migrated to the gastric antrum. The band was then visualized and rat tooth forceps can be seen grabbing the previously cut band and successfully removing it through the mouth. The scope was then replaced into the patient's stomach and the LAMS was grasped with a rat tooth forceps and removed. Case number three is a 61 year old female with a past medical history of a VGB with a celastic non-adjustable band placed more than 20 years prior to presentation. When the patient presented, she had been having multiple years of progressively worsening acid reflux, nausea, and emesis and ultimately underwent imaging that showed a severe stricture in the stomach near the gastroesophageal junction. Similar to the previous cases, this patient had a severely stenosed celastic band that was not fully eroded as can be visualized in these images viewed proximally from the cardia and distally from the antrum. Given this, a wire was guided through the stenosis and a LAMS was placed across it to erode the band. The patient was ultimately sent home after this procedure. Approximately two months later, the patient underwent a repeat EGD with LAMS removal that is not seen here that revealed a nearly completely eroded celastic band. This band was first cut with endoscopic scissors, which caused it to break into a few pieces and the main portion of the band was grasped with a rat tooth forceps and removed through the mouth. The remaining piece of the band was then grasped with the rat tooth forceps and also removed. Remaining blue surgical sutures were then cut with endoscopic scissors and the scope was removed. To conclude, endoscopic removal of both AGBs and celastic VGBs is an effective method for patients with eroded bands. Additionally, a lithotriptor can effectively be used to cut thick AGB bands that are unable to be traversed and cut with endoscopic scissors. Finally, for partially eroded bands, LAMS deployment is an effective method to facilitate mucosal disruption and later band removal.

endoscopic management

gastric band erosion

bariatric surgery

lumen-apposing metal stents

minimally invasive techniques