Obesity Surgery, 10, 167-170

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Background: Laparoscopic adjustable gastric band-ing (LAGB) is the most used procedure for bariatricsurgery in Europe. Although a low complication rateis reported, band migration within the first 2 yearsafter LAGB is still observed in nearly 5% of cases,requiring operative band removal. To avoid increasedrisk of complications due to laparotomy, we proposea minimally invasive technique for this purpose.

Methods: We performed this operation in fivepatients who suffered from band migration after LAGB(1.9% in our series of 211 patients, one patient wasoperated elsewhere). The described method consistsof gastroscopic band and tube removal, combinedwith removal of the port under local anesthesia.

Results: The described procedure was developedin the endoscopy unit without additional equipment.The mean operating-time ranged from 65 to 180 min-utes (mean 135 minutes). No perioperative complica-tion were observed. In-patient treatment was neces-sary for 4 days.

Conclusions: A novel technique for minimallyinvasive band removal after adjustable gastric bandmigration is described, offering the patient a low-riskprocedure and a better chance for further laparo-scopic approaches.

Key words: Morbid obesity, gastric banding, complica-tions, band migration, gastroscopic band removal

Introduction

Adjustable gastric banding is an effective surgicaltreatment for morbid obesity and is the most com-monly performed bariatric operation in Europe.

Excellent results have been published for both theSwedish Adjustable Gastric Band® (SAGB,Obtech)1 and the LapBand® (AGB, BioEnterics).2

These devices can be placed laparoscopically andhence offer the patients the advantage of low-riskminimally invasive surgery.3 Thereby, the inci-dence of early postoperative complications, such aswound infections or hematomas, can be reduced to< 2%.4 Late complications, such as incisional her-nias, gastroesophageal reflux disease, pouch dilata-tion or port/band leakages are described in about4% to 11%.1 Band migration occurs in 0.6%4 to11%5 within the first 2 postoperative years and isone of the most common complications thatrequire reoperation.3,6 Band removal is mandatoryto prevent intraabdominal infection or acute intesti-nal obstruction. Almost all of these proceduresneed laparotomy with a considerably higher risk ofperioperative complications.

The purpose of this study was to develop a newminimally invasive technique for band removal aftermigration of adjustable gastric bands. This tech-nique consists of port removal under local anesthe-sia (LA), combined with gastroscopic band openingand transoral removal of the band and tube.

Patients and Methods

In our series of 211 consecutive morbidly obesepatients who underwent laparoscopic adjustablegastric banding with the SAGB at our department(January 1997 to October 1999), four patientsdeveloped band migration (1.9 %). One patient was

Gastroscopic Band Removal after IntragastricMigration of Adjustable Gastric Band: A NewMinimal Invasive Technique

H. Weiss1, MD; H. Nehoda1, MD; B. Labeck1, MD; R. Peer2, MD; F.Aigner1*, MD

1General Surgery Department and 2Radiology Department, University Hospital, Innsbruck, Austria

Reprint requests to: F. Aigner, MD, General SurgeryDepartment, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. Fax: ++43-512-504-4607; e-mail:f.aigner@magnet.at

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primarily operated on elsewhere and referred to ourclinic. In these five patients, gastroscopic bandremoval was performed. The patients’ characteris-tics are shown in the Table 1.

The perioperative course was uncomplicated inall five patients. In all patients after wrapping theband, the end-flaps were brought together over thelesser curve, which is no longer recommended byother authors.1 All five patients had a silent presen-tation of band migration, with sudden weight gainand an ability to eat without restriction.Esophagogastric transit radiography and endoscopyconfirmed the diagnosis of band migration.7

Operative Procedure

The operation was divided into two parts: gastro-scopic band and tube removal and port removal.Patients received 5 mg midazolam (I.V.) and 10 mlxylocaine 2% (S.C.) for local anesthesia at the portsite. Patient no. 3 had to be operated under generalanesthesia due to port infection. Proton-pumpinhibitors were administered to all patients(omeprazole 40 mg I.V. three times daily).

The first step of the procedure was to identify theinner part of the partially migrated band (Figure 1).A two-channel gastroscope was used (Olympus GIF-2T100, Vienna). It is advisable to loosen the end-flaps or the connection site to the tube. Therefore, theprocedure was postponed in two patients 2 and 3months respectively, to allow further migration,enabling loosening of the connection.

Next was the gastroscopic opening of the band.We preferred to cut the two sutures on the end-flaps (Figure 1) with endoscopic scissors (Suture-scissors, Olympus, Vienna) and then burn throughthe silicone bridge of the closure site of the bandwith laser technique (SLT-LASER®, Neodym-YAG100, U.S.A and Sharplan Bare Fiber®, U.S.A.,using energy 25 Watt, contact mode, air-cooled)(Figure 2). The same result could be achieved with

Table 1. Patient’s characteristics

Patient number 1 2 3 4 5Age (years) 44 45 32 43 32Gender f f f f fInitial BMI (kg/m2) 38.7 36.7 46.1 47.3 42Initial weight (kg) 98 94 130 152 103Date of implantation 05.1998 02.1998 04.1998 09.1998 03.1998Postoperative interval (months) 16 20 14 16 16Possible reasons for migration rapid overfilling infection poor pregnancy

filling techniqueSite of migration g g g p gActual BMI (kg/m2) 23.3 25.8 34.8 26.8 33.5Actual weight (kg) 60 66 98 82 81Maximal band filling volume (ml) 8 12 5 0 0Port/band infection no no yes no nof = female, g = greater curve, p = posterior gastric wall

Figure 1. Band migration. The adjustable gastric band hasmigrated through the greater curve of the stomach.Closure site with two end-flaps of the band (small arrow),cutting of the sutures (big arrow) and the tube (arrow tip)are indicated. The endoscope is in inverted position.

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Gastroscopic Band Removal after Migration of Adjustable Band

transection of the body of the band near the con-nection site, but this maneuver was more time-con-suming. As soon as the band was opened (Figure3), it was displaced into the stomach.

The next step was disconnection and removal ofthe port under LA. The disconnected tube was

pulled into the stomach. Wound closure was per-formed as usual.

Finally both the band and the tube were removedtransorally.

Results

The operation took place in the Endoscopy Unit ofour department. No additional equipment was nec-essary, so that the costs could be kept low. One bandwas cut with scissors only, but we abandoned thistechnique in favor of the more rapid laser technique.The mean operating-time was 135 minutes (range65-180 minutes). No perioperative complicationswere observed. Mild postoperative pain was treatedsuccessfully with tramadol 30 mg daily. Patientswere mobilized immediately after the interventionand recovered quickly. On postoperative day 2, aswallow with water-soluble contrast (Gastrografin®)revealed an undisturbed esophagogastric transitwithout signs of free gastric perforation (Figure 4).However, the fine scar-lined channel which hadenclosed the tube was detectable. Patients remainedasymptomatic. Solid food could be gradually takenafter the radiography. All patients were dischargedon postoperative day 3. Two out of five patients

Figure 3. Band and tube removal. The band is openedand displaced completely into the stomach and thenremoved together with the tube.

Figure 2. Gastroscopic band opening. The band closuresite is opened at the silicone bridge (arrow) with lasertechnique. Arrow tip indicates laser fiber.

Figure 4. Esophagogastric transit radiography. Water-soluble contrast swallow reveals an undisturbed esoph-agogastric transit. A fine channel which had enclosedthe tube can be detected (arrow).

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expressed their wish to have another adjustable bandplaced as soon as possible.

Discussion

Morbid obesity is becoming a more importantproblem in public health.8,9 Using a multidiscipli-nary therapeutic approach, the adjustable gastricbanding procedure has been shown to achieve goodresults in long-term weight reduction.1 A reason-able complication rate has been further reducedover the years since the laparoscopic technique wasestablished.3,4 However, band migration-erosion isstill observed in about 5% of patients afteradjustable gastric banding. Several reasons are dis-cussed. The overfilling or the rapid filling of theballoon might be fateful in terms of band migra-tion. Two of the patients reported in this studyshowed an increased filling volume of 12 ml (no.1) or a rapid filling of 8 ml (no. 2) within a fewmonths. The band migration in patient no. 3 isobviously due to an infection of the implanteddevice. The microbiologic specimen grewStaphylococcus aureus. The fourth band showedgastric penetration 3 weeks after the primary pro-cedure, which was apparently caused by inappro-priate intraoperative dissection technique along theposterior wall of the gastroesophageal junction.The site of the migration varies (Table 1). Onepatient (no. 5) developed band migration afterpregnancy in the postoperative period. The balloonremained deflated for this reason.7

Generally, laparotomy has been necessary in casesof band migration to remove the displaced band.1,3-5

The disadvantage of this reoperation is primarilycaused by the laparotomy itself, which potentiallycarries a higher risk for surgical complications. Forband removal, two operative techniques were dis-cussed: 1) Intragastric replacement of the band withthe need to perform a gastrotomy; or 2) opening thescar capsule around the tube to remove the bandtransabdominally. In both open techniques, the twogastric penetration sites are opened and a connectionwith the abdominal cavity created, which is difficultto manage accurately (especially the perforation onthe posterior gastric wall). An infected system(port/band) would strengthen even more the argu-

ment to prevent gastric fistula.The technique described in this study provides a

method for gastroscopic removal of intragastricmigrated bands without laparotomy. The connec-tion between gastric mucosa and the scarred tunnelthat surrounds the tube prevents intraabdominalleakage and heals within a few days without clini-cal symptoms. The operation is minimally invasiveand well-tolerated by the patients. It offers a lowrisk procedure with a better chance for furtherlaparoscopic approaches.

The authors gratefully acknowledge the valuable discussionswith E. Bodner, MD (Chief of General Surgery), and theskilled technical support from E. Weissengruber, G. Klein, H.Salcher and K. Hourmont in preparing the manuscript.

References

1. Forsell P, Hallerback B, Glise H et al. Complicationsfollowing Swedish adjustable gastric banding: along-term follow-up. Obes Surg 1999;9:11-6.

2. Favretti F, Cadiere GB, Segato G et al. Laparoscopicadjustable silicone gastric banding (Lap-Band): Howto avoid complications. Obes Surg 1997;7:352-8.

3. Weiner R, Wagner D, Bockhorn H. Laparoscopicgastric banding for morbid obesity. J LaparoendoscAdv Surg Tech A 1999;9:23-30.

4. Miller K, Hell E. Laparoscopic adjustable gastricbanding: A prospective 4-year follow-up study.Obes Surg 1999;9:183-7.

5. Westling A, Bjurling K, Ohrvall M et al. Silicone-adjustable gastric banding: Disappointing results.Obes Surg 1998;8:467-74.

6. Meir E, Van Baden M. Adjustable silicone gastricbanding and band erosion: Personal experience andhypotheses. Obes Surg 1999;9:191-3.

7. Weiss H, Nehoda H, Labeck B et al. Deflatedadjustable gastric band: migration through anteriorgastric wall. Endoscopy 2000; in press.

8. Oster G, Thompson D, Edelsberg J et al. Lifetimehealth and economic benefits of weight loss amongobese persons. Am J Public Health 1999;89:1536-42.

9. Roberts L, Haycox A. Obesity. About the size of it.Health Serv J 1999;109:28-9.

(Received November 20, 1999; accepted January 3, 2000)