Clinical, Radiologic and Endoscopic Correlation of Lap band Migration
In this long-term complication, the gastric band fastened around the upper stomach gradually erodes into the stomach wall and extends into the gastric lumen.
Intragastric lap band erosions have been reported at rates that vary from 0.6% to 10% depending of the operative technique (the doctor’s learning curve), the device used and the most important: the patient’s follow up.
There are two big categories of Lap band Erosions:
- FIRST: The erosions related to the amount of fluid injected into the balloon.
- SECOND: The erosions related to subclinical infection as a result of contamination of the Lap Band via injections into the port.
The use of NSAIDS, alcohol and smoking are proposed as three of the main factors contributing to hyperacidity and irritation of the mucosa layer of the stomach. This important layer prevent us from acquiring an ulcer and when the irritation is persistent causes its erosion and then the erosion of all the wall layers of the stomach favoring the lap band to migrate into the stomach (”inside out” erosion theory).
Repeated vomiting is also suggested to be a possible accelerant, especially when high degree of obstruction is present like when is an over filling of the lap band.
Erosion may be silent and go unnoticed, but nevertheless common; several symptoms may develop and should raise the suspicion of lap band erosion:
- Cessation of weight loss
- Weight regains with loss of restriction
- Port site infection (It is the first symptom in 35% of the patients with lap band erosion.
Due to the erosion caused by the Lap Band, saliva or food leaks through the hole or ulcer in the stomach and flows along the Lap Band tubing, causing the tissue under the skin of the Lap Band Port to become infected.)
Fig. 1 — Port site infection
The diagnosis of lap band erosion is made at the radiologic evaluation performed under fluoroscopy during a band adjustment in both asymptomatic and symptomatic patients. Fig. 2A
If the radiological evaluation does not show signs of erosion and the patient has the symptoms, the doctor is obligated to perform an endoscopy. Fig. 3A y 3B
Fig. 2A —Intragastric Lap Band Erosion.
Radiograph from upper gastrointestinal series shows characteristic appearance of intragastric lap band erosion. Note the liquid contrast material on both sides of penetrating portion of band, “the stair sign”.
Fig. 2B —Intragastric lap band migration.
Drawing of radiographic findings shown in A illustrates passage of liquid contrast material (Barium) around left section of band that has eroded into the stomach (small arrow).
Fig. 3A — Intragastric Lap Band Erosion.
Endoscopic view of Lap band Erosion.
Fig. 3B — Intragastric Lap Band Erosion.
Note the “tips” of a Swedish band into the gastric lumen by a lack of rotation of the end flaps of the lap band.(the “outside to inside” erosion theory)
Fig. 4A — Intragastric Lap Band Erosion.
Radiological evaluation shows 2 channels of contrast material, instead of one, clearly demonstrated in the later view of Fig. 4B
Fig. 4B — Intragastric Lap Band Erosion.
In this lateral view you can see the “bridge” between the upper (the pouch) and the lower stomach, the barium contrast material bypasses the part of the lap band that has eroded through the stomach’s wall.
Due to the fact that lap band erosions starts their symptoms with a port infection (35%), the infection will continue after removal of the port specifically if there is a lack of radiologic diagnosis. In these cases of lack of diagnosis and chronic infection further radiologic and endoscopic tests are needed to demonstrate the presence of lap band migration.
Fig. 5A — AP plain film shows a lap band without the port
The Patient has a history of port removal secondary to port infection with a persistent infected fluid coming out from the port area.
Fig. 5B — Intragastric Lap Band Erosion demonstrated by fistulography.
Note the injected contrast material at the skin level is going through the fistula into the lower stomach.
It is important to keep in mind that gastric erosion may be gradual and go unnoticed. The clinical symptoms and radiological or endoscopic findings depend on the degree of erosion and the close follow up from your doctor.
The upper GI could not reveal lap band erosion in its early stages. However, the radiologic appearance of later-stage intragastric band erosion on upper gastrointestinal series is pathognomonic when the “stair sign” is observed. In Mexico, the sign is known as Suzy’s sign because I described 12 years ago after doing many lap band fills to patients from several surgical teams.
Barium swallow during the upper GI shows a flow of contrast material around the portion of the band that has eroded into the stomach. As mentioned before, in those cases where the radiologic findings are missing, an endoscopic evaluation is mandatory.
Fig. 6A — Radiologic evaluation shows a complete eroded band.
Note the location of the migrated band; the lap band device is found in its totality intragastric at the level of stomach antrum (the lower stomach). The patient had not been loosing weight for 3 years.
Fig. 6B — Complete erosion of the lap band showed in Fig. 6A was removed by endoscopy.
It is true that lap band migration means the failure of the operation and leads to a second bariatric procedure; however, erosion is considered a complication with a benign course if it is managed properly.
Treatment of lap band erosion requires removing the Lap Band by laparoscopy or by endoscopy and a high likelihood of weight regain will be seen.
It is recommended to treat Lap Band Erosions with another bariatric procedure 6 to 8 months after a de-banding procedure (Lap Band removal) due to high incidence of complications and failures when are done at the same time or before 6 months since the portion of stomach that has been eroded is weak and more prone for leaking.
These weight loss surgery procedures should be completed in a second event with little cutting and manipulation of the eroded and scar tissue.
The leaking rate after any Gastric Bypass is 2% and goes as high as 35% in patients when the lap band has been removed.
Susana González, MD