Endoscopic removal of eroded laparoscopic adjustable gastric bands: a preferred approach.

BACKGROUND: Complications related to laparoscopic adjustable gastric banding (LAGB) have led to an increased number of removals. An uncommon but potentially devastating complication is gastric band erosion into the gastric lumen, which can be managed by open surgical, laparoscopic, and endoscopic approaches. OBJECTIVE: A wide array of management techniques has been reported for removal of LAGB that have eroded into the stomach. We describe the preferred method for successful endoscopic band removal at our institution. SETTING: Community tertiary-care referral hospital accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. METHODS: A single-center, retrospective review of a prospectively maintained database was used to identify patients who underwent LAGB removal from 2009 to 2019. We identified the subset of patients with band erosion. We analyzed patient characteristics, presenting symptoms, diagnostic modalities, and method of band extraction. RESULTS: A total of 132 patients underwent LAGB removal, among whom 22 (16.7%) patients were diagnosed with erosion. Seven (32%) patients underwent laparoscopic removal, 14 (64%) patients underwent endoscopic removal, and 1 patient (4%) underwent combined laparoscopic and endoscopic approach. These latter patients had variable amounts of erosion and buckle visibility, but all underwent endoscopic retrieval. We found that using an endoscopic retrograde cholangiopancreatography guidewire with an endoscopic retrograde cholangiopancreatography mechanical lithotriptor for band transection and snare for retrieval have been effective. CONCLUSIONS: A standardized, multidisciplinary, and minimally invasive endoscopic approach for LAGB erosion has been found to be successful without the need for further surgical intervention and may be offered to patients upon discovery of erosion.

A comparison of rates of lymph node metastases between patients undergoing sentinel and axillary lymphadenectomy.

BACKGROUND: Recommendations regarding credentialing for sentinel lymphadenectomy in the staging of breast cancer emphasize the need for a trial period during which novice surgeons remove both the sentinel lymph node and the axillary packet, to demonstrate acceptably low rates of both operative failure and inaccuracy. METHODS: We initiated sentinel lymph node mapping in our institution without planned axillary dissection. To establish our ability to accurately stage patients using sentinel lymphadenectomy, we compared 225 patients who underwent that procedure and 343 patients previously staged with axillary lymph node dissection. RESULTS: No differences in node positivity were found between the two groups. Among sentinel lymphadenectomy patients, no differences were found between patients in the first and second half of the institutional experience. CONCLUSIONS: We question the need for a trial period of planned axillary node dissection with sentinel lymph node mapping, and review the evidence from other investigators regarding its necessity.