S2138 Gastric Erosion in Laparoscopic Gastric Banding

Abstract

INTRODUCTION: Laparoscopic gastric banding(LAGB) was first introduced in 1993 and consisted of placement of an inflatable gastric band, controlled by a subcutaneous port, below the gastroesophageal junction resulting in the creation of a gastric pouch. LAGB is the least invasive and frequently used procedure to treat morbid obesity(BMI >40 kg/m2). CASE DESCRIPTION/METHODS: A 67-year-old man with metastatic gastric diffuse large B-cell lymphoma being treated with R-CHOP and past surgical history of LAGB presented with anemia and black stools of unclear duration. He was first admitted 6 months back for anemia and hemoglobin 7.4 g/dL. EGD showed several ulcerated gastric masses with biopsies consistent with lymphoma. Shortly following the procedure, the patient had hemorrhagic shock requiring massive transfusions and clipping of the oozing ulcerated gastric mass. The patient was stable and had no further bleeding for 6 months later until this presentation, when he was hemodynamically stable. Melena was noted on rectal exam. His hemoglobin was 6.2 g/dL for which he received one unit of packed RBCs. On EGD, a foreign body was seen eroding into the fundus of the stomach, identified to be the gastric band (Figures 1a and 1b). The laparoscopic gastric band was then removed with primary repair of gastrotomy and placement of an omental patch. EGD and CT scan after the surgery confirmed no evidence of extravasation to suggest a leak. DISCUSSION: Gastric erosion is a serious complication of laparoscopic gastric banding seen in 0.3 to 14% of patients. The pathogenesis of gastric erosion is varies depending on when the erosion occurs. In the early period, infection causing micro-perforation, iatrogenic damage, NSAID use, and formation of adhesions are attributed to erosions. However, in the late period, erosions may occur due to pressure-induced ischaemia secondary to overfilling of the band or inclusion of excess gastric mucosa during the surgery or foreign body reaction leading to the formation of fibrous tissue which eventually erodes.Most patients with erosions remain asymptomatic but nonspecific symptoms such as abdominal pain, hematemesis, or cessation of weight loss. In the early stage, radiographs and CT may show band migration. In later stages, radiography may show extravasation of oral water-soluble dye. EGD remains the gold standard for diagnosis. Treatment involves endoscopic removal of the gastric band by endoluminal division, repair of the defect and band replacement if required.Figure 1a.: Foreign Body seen on Endoscopy.Figure 1b.: Foreign Body seen on Endoscopy.