Management of Complex Silastic Ring Erosion Following Roux‐en‐Y Gastric Bypass

A 42-year-old female presented with worsening food intolerance. Ten years prior, she underwent Roux-en-Y gastric bypass (RYGB) with a 6.5 cm gastric pouch silastic ring (2 cm above the gastrojejunostomy). Background included: type 2 diabetes and cigarette smoking. Medications included: Empagloflozin, Galvumet, Pantoprazole, and Centrum multivitamin. The patient had undergone a proceduralist sedated gastroscopy which diagnosed an eroded silastic ring (left in situ) (Figure 1). Despite entry into the roux limb, gastrojejunal anastomotic balloon dilatation up to 16.5 mm was performed, causing a gastric pouch mucosal tear (closed with endoclips) (Figure 2A,B). She discharged 24 h later. Six weeks later, endoscopic ring removal under sedation was attempted but unsuccessful due to: endoscissors failure, presence of local endoclips, and poor procedure tolerance. The procedure was successful six weeks later under general anaesthetic (Figure 3). Through a dual-channel gastroscope, rat-tooth forceps stabilised the ring, which was divided with endoscissors and removed. She tolerated liquids and discharged that day. Two months post-procedure, she remains asymptomatic. This case highlights novel management considerations regarding post-bypass balloon dilatation and complex silastic ring erosion. Silastic rings enhance weight loss following RYGB by restricting pouch dilatation to limit weight recidivism [1, 2]. ≤ 5% of patients require ring upsizing or removal due to intolerance or erosion [1, 2]. Specific risk factors for band erosion are not well described. Smoking is a known significant risk factor for marginal ulceration and may have contributed to ring erosion in our patient [3, 4]. Other risk factors (not present in our case) are non-steroidal anti-inflammatory or steroid usage, presence of helicobacter pylori, local infection (e.g., previous anastomotic leak) and ring to pouch imbrication [4, 5]. Gastroscopic visualization of the eroded ring (Figure 1) and traversability through the gastrojejunostomy (fashioned over a 32F bougie) meant balloon dilatation was not indicated and led to mucosal injury (Figure 2). Balloon dilatation ≥ 15 mm also increases perforation risk [6]. Furthermore, attempting complex ring removal under sedation was unsuccessful. To improve safety and treatment success, we recommend: avoiding balloon dilatation of the scope-traversable post-RYGB gastrojejunostomy, performing complex therapeutic gastroscopy under general anaesthetic, and liaising with a specialized bariatric unit. The patient's food intolerance worsened following anastomotic dilatation, mucosal injury (with possible stricturing) and the presence of multiple endoclips (potential for partial obstruction)—all within the vicinity of the eroded ring and gastrojejunostomy. Endoscopic management of RYGB ring erosion has been reported previously, but not in the context of the aforementioned multiple complicating local factors [7-9]. Subsequent dilatation attempts were contraindicated and carried a higher risk for perforation [6]. Endoscopic ring extraction was our preferred management option to avoid the increased morbidity associated with revisional bariatric surgery [10]. This proved effective given clinical follow-up confirmed symptom resolution and no concern for anastomotic stricture or endoclip-related obstruction. Escalation to minimally invasive surgical ring removal (with consideration for anastomotic/pouch revision) would have been warranted if the endoscopic option had failed. Our patient was consented for this to occur if required, under the same anaesthetic. In summary, banded-RYGB ring erosions are challenging to treat and should be managed in a specialized bariatric center with access to experienced therapeutic endoscopists and bariatric surgeons. Careful consideration should be given to all management options and their expected outcomes. Unnecessary therapeutic endoscopy should be avoided to prevent complications. Open access publishing facilitated by The University of Auckland, as part of the Wiley - The University of Auckland agreement via the Council of Australian University Librarians.