Endoscopic removal of a migrated silastic gastric pouch ring using needle knife

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A middle-aged woman with a history of gastric bypass surgery and silastic ring placement was transferred to our hospital because of recalcitrant abdominal pain for 8 weeks. The pain was described as epigastric and...

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A middle-aged woman with a history of gastric bypass surgery and silastic ring placement was transferred to our hospital because of recalcitrant abdominal pain for 8 weeks. The pain was described as epigastric and right upper quadrant, post-prandial and associated with nausea and vomiting. Due to poor oral intake she was placed on total parenteral nutrition for one month. On clinical exam the patient was well nourished. Her abdomen was tender on palpation. Her laboratory values were within reference ranges. She had undergone a gastric bypass 13 years prior. In addition, a silastic ring was placed. The ring had malfunctioned occurred and a second silastic band was placed 5 years later. She had done well since then. An EGD at our hospital disclosed an eroded silastic ring. A second EGD using a therapeutic gastroscope was performed. A needle knife was advanced through the working channel and the entire needle was exposed. Using pure electrocautery (Endocut 1, 60 W, Erbe, Marietta, GA, USA) the string connecting the band was cut and transected (a). This resulted in release of the silastic tube) (b). No damage occurred to the stomach (Figure 2). Then the silastic band was grasped with a snare and retrieved in two pieces using fluoroscopic and endoscopic control (c). Careful attention was paid to reconstruct the silastic ring outside of the stomach to ascertain complete extraction (d).

Obesity is a problematic epidemic in developing countries. Because diet and medications often fail, surgery has become an important adjunct for its management. Gastric bypass is a popular approach to treat obesity (1). Placing a silastic ring around the pouch to band the gastric bypass operation increases the restriction mechanism. However, the ubiquitous use of the banded gastric bypass remains controversial (2). One of the controversies is the effect of the silastic ring on patients' perception of their well-being after surgery because of the frequency of vomiting (2). There are various endoscopic techniques to remove bands or rings (3,4 ). These include gastric band cutters, endoscopic scissors, or placement of self-expandable plastic stent to cause necrosis of remaining tissue then removal (4). Our case is interesting because we add another technique to remove silastic bands. Knowledge of the presence of an inner string which is tied at two ends with a knot is of paramount importance to decide on endoscopic approaches for removal. Transection of the string is best accomplished using scissors. The wire technique may be appropriate to cut through elastic tissue, but it may not be enough to transect the inner string. In our case we were able to transect the string using a needle knife. Therefore, we believe that this technique should be added to the armamentarium of endoluminal methods to treat migrated silastic rings.

References:

1. Thill V, Khorassani R, Ngongang C, Van De Winkel N, Mendes da Costa P, Simoens

CM.Laparoscopic gastric banding as revisional procedure to failed vertical

gastroplasty.Obes Surg. 2009;19(11):1477-80.

2. Rasera I Jr, Coelho TH, Ravelli MN, et al. A Comparative, Prospective and Randomized Evaluation of Roux-en-Y Gastric Bypass With and Without the Silastic Ring: A 2-Year Follow Up Preliminary Report on Weight Loss and Quality of Life. Obes Surg. 2016;26:762-8.

3. Chen Yi Mei SG, Tam W, Nind G, Singh R. Endoscopic removal of migrating silastic band after vertical banding gastroplasty. Endoscopy. 2010;42 Suppl 2:E253.

4. Blero D, Eisendrath P, Vandermeeren A, Closset J, Mehdi A, Le Moine O, Devière J.Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures. Gastrointest Endosc. 2010 ;71(3):468-74.

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