Dear Friends and Colleagues:<O:p</O:p

After receiving numerous calls and email regarding the latest speculations about erosions on the boards I feel obliged to post some facts that should be of some relief and informative at the same time. There are very few reliable sources out there on Gastric Banding complications except the series that are published in the medical literature. My colleagues that post on these forums will agree that my team and I are considered one of the foremost authorities in gastric banding complications and treatments in the world and as such our intention is that our ongoing research results in a safer gastric banding procedure for everybody.

Folks, Lets start out by doing the math. Band erosions are not increasing as one would think. They have actually diminished noticeably in the past number of years. What is increasing is the number of patients having the procedure along with the ability to communicate this fact through forums such as this one. A surgeon that has performed 100 procedures may have 1% erosion, which is equivalent to 1 patient. While a surgeon with 3000 procedures under his belt will have 30 erosions, but this still represents 1%. Also the awareness of it's existence has prompted us to look for them purposely through endoscopic studies.

We now recommend that every band patient gets an upper endoscopy around 18 months after the surgery. For a surgeon to know exactly how many of his patients bands have eroded he would have to scope them all. Endoscopy is the only way to prove an erosion since some erosions are asymptomatic early on.

Erosions are unfortunate adverse reactions of gastric banding. They are also poorly understood. The term erosion has been popularized recently in the literature as one of the complications of gastric banding. It suggests the wearing out of the gastric wall, but the actual process seems to be more of a foreign body reaction where the body tries to eliminate the implant. Erosions are not new and it has been known for decades and reported in the medical literature that various materials near the stomach or intestine can slowly penetrate the wall and ultimately be eliminated through it. Implants, sutures, staples, mesh, rings, tubing, cloth and metal all have readily penetrated the gut.

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Though the actual process is not fully understood we do know the following:

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- Most bands erode from the outer edge of the implant into the stomach. Sometimes it is the tubing and not the band that penetrates the gut. This would discard the suggestion that bands that are too tight erode. (Conversely we now know that bands that are too tight actually slip more often)

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- Surgical technique is similar around the world. Most surgeons in the US and the rest of the world learned the technique from a handful of international surgeons who proctored them. In turn these surgeons have perfected the technique and the principles of band placement remain the same around the world.

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- Erosions can coexist with an infection process. Even though it would seem that the infection can start at the port and then ultimately cause an erosion, our recent studies have detected mircopenetrations of the stomach at the initial stages of the erosion (soon to be published data) then most likely stomach bacteria tract down though the tubing to the port and contaminate it. Again these ongoing studies will shed new light on the process and hopefully someday will totally eliminate the risk of gastric penetration.

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- Erosion is not selective of one band or another. Sooner or later every brand of gastric band has been reported to erode.

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- Latin bands do not erode more frequently. For one the implant used comes exactly from the same company and are made of the exact same materials. Contrary to a controversial post recently published in a forum, responsible surgeons performing gastric banding in Mexico have a comprehensive follow-up protocol. Fluoroscopy and Endoscopy is routinely performed which means that we detect the erosions more efficiently and earlier when present.

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- When an erosion is detected the band should removed. This gives the stomach time to heal and in given time receive a new band. It is the patient's responsibility to tell the doctor of his or her symptoms. The sooner it is detected the better the chances of performing a laparoscopic and uneventful surgery with a quick recovery.

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- We also stress the importance of follow-up. Most erosions have no symptoms early on, so a routine checkup with your doctor is always the best option.

NO NEED TO PANIC, erosions are still a rare occurrence, but if present when detected and treated early on the outcome is benign in nature.

You will all agree that gastric banding has touched hundreds of thousands of lives around the world. It is the safest weight-loss procedure but unfortunately no procedure is free of complications. Even though erosion rate is very low, it still exists. When present it should be detected and treated promptly. The earlier it is treated the better the outcome. In some cases patients have actually received a second band after a brief period of recovery and thus having the benefit of restriction and weight-loss again.

The only source of reliable medical advice is your doctor. Other sources of information only lead to speculation, anxiety and worst of all delay in treatment if needed. If you are to go out of the country for surgery, select a responsible surgeon that offers follow-up. Ask if he will always be available (my patients can reach me in a moments notice, they all have my cell#) Don't be enticed to go to the cheapest, usually they go hand in hand with poor to no follow-up. You must be able to trust the doctor you have chosen.

We as Surgeons also have our official Internet forums where we exchange knowledge with each other having only your best interests in mind. Remember, ultimately it is your success that results in our success.

My best wishes to all,<O:p</O:p

Respectfully<O:p</O:p

Ariel Ortiz Lagardere

Hi Lisa,

Karen and Francesca may have been asymptomatic, but I am assuming when they went for a fill it was done with flouroscopy not an endoscopy and only then a problem was discovered. Therefore, it supports my case that endoscopy is only needed when a problem is discovered by flouroscopy or the patient is experiencing something unusual. If flouroscopy can detect some of these problems, wouldnt it make more sense to start with that as an option first? Endoscopy is very invasive and requires a full day off and someone to be with you to make sure you get home OK if they sedate you. I do understand that not all erosions can be see with flouro, but an experienced doc could see if there was some kind of problem with the saline with a barium swallow at least some of the time. Thats why these two bandsters discovered their erosions. Unless they went to Mexico for an endoscopy which you say they didnt. I cant see how you could"prevent" an erosion by having an endoscopy andit seems that flouroscopy alerted their doctors of a problem.

And yes, I agree that one of the reasons it is easier for a Mexican surgeon to say go get it done is because it is 1/10 of the cost to have it done there in Mexico. Healthcare is less expensive there, so its easy to say have a costly procedure done every 18 months or so. What I would really like to know is if I am out of the woods at 2.7 years post op....... Any comments about this?

Babs in TX

334/180ish

-150 ish

This will all be a moot point as soon as DeLarla's At Home Pee Stick Erosion Kits are released.

Up until now I have resisted the urge to post anything on this thread but I have to say that this really cracked me up. Thank you, Delarla, I really needed that laugh!

Serena

This will all be a moot point as soon as DeLarla's At Home Pee Stick Erosion Kits are released.

How many sticks in a kit?? I will need a stick for everyday, sometimes two a day, seeing as I'm obsessed with my band!

Unfortunately you are never "out of the woods" for either erosion or slippage. I've operated on one patient with band erosion 5 years after it was placed in Mexico (not by Dr. Ortiz).

By the way, I do endoscopy. I had an additional 1 year of fellowship training in endoscopy. If I 'scoped all my band patients on an annual basis, I could increase my income nicely; but I don't because I don't think it is necessary. I get paid about $200-$250 for an endoscopy; hospital charge is somewhat less than $1000... so I don't know who came up with a price of $4200 for endoscopy in the USA.

Mark Pleatman MD

Dr. Pleatman, I was wondering if the statistics for erosion are comparable with bands places in Europe and Austrailia since they have about a 10 year jump on the US. Any idea?

Added: I have tried to research this myself online, but it seems the only information regarding lapband statistics is about five years old. Is there a set time in the medical world when stats such as these are updated for the public?

Unfortunately you are never "out of the woods" for either erosion or slippage. I've operated on one patient with band erosion 5 years after it was placed in Mexico (not by Dr. Ortiz).

By the way, I do endoscopy. I had an additional 1 year of fellowship training in endoscopy. If I 'scoped all my band patients on an annual basis, I could increase my income nicely; but I don't because I don't think it is necessary. I get paid about $200-$250 for an endoscopy; hospital charge is somewhat less than $1000... so I don't know who came up with a price of $4200 for endoscopy in the USA.

Mark Pleatman MD

I think the $4200 thing comes in when no two states are even close to the same.

Hence why we ended up Self Paying about $26,000 dollars for the wife's LapBand, when most anywhere else is $15,000 to $17,000.

(the initial price quoted was somewhere around $19,500, but it seems that this is a mere... ballpark figure as the bills, even though we payed up front, keep rolling in).

Thanks for sticking around Dr. P. Many harsh words have been spoken on both sides of the fence. With luck we can all place those behind us.

My understanding of a Fluroscopy is to be used to determine how the stomach empties after a fill. Please explain how this can show "any" sign of an erosion. And please correct me if I am wrong but if a Fill with Fluro only shows how the stomach empties then how is that different from an Upper GI which doesn't always show erosion either. By the way I had an UPPER GI prior to my Endo and the upper GI was clean as a whistle. So the only true way to diagnose an Erosion is by an ENDO.

I didn't have ANY symptoms either prior to my diagnosis of erosion. I just "felt" off.

Hi,

Penni: Floroscope is the machine. Upper GI is the actual procedure that usually includes a barium swallow after viewing your esophagus, stomach etc.. The barium swallow is usually part of the upper GI. They are using flouroscopy machine to see what is happening in there.

But as you mentioned, you thought that something was not right. So it doesnt always show up with a flouoscopy/upper GI and in your instance an endoscopy was the right decision. I beleive you have to go with your gut feeling which you did.

GOt this information from www.radiologyinfo.org/content/upper_gi.htm.

Babs in Tx

My understanding of a Fluroscopy is to be used to determine how the stomach empties after a fill. Please explain how this can show "any" sign of an erosion

Dr. Ortiz and Martinez both told me that it is possible to detect that something may be worng if they see under "fluoro" the barium flow over the band instead of through the band. This is how Francesca and both Karen were told they needed and endoscopy, both had flouro done with Ortiz while going in for a fill and both had the barium flow over the band and not through the band while under flouro.

Photonut asked for statistics on band erosion from Australia. O'Brien has the largest series, and his erosion rate is 3%; but he claims to have had no erosions in the last 600 cases. I've added below the abstract from his paper on the subject. Those of you who are interested in poking around the medical literature can go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed and look for yourself!

Mark Pleatman MD

O'Brien PE, Dixon JB.

Monash University Department of Surgery and the Alfred Hospital, Commercial Road, 3181, Melbourne, Victoria, Australia. paul.obrien@med.monash.edu.au

Following its introduction in 1993, the LAP-BAND (INAMED Health, Santa Barbara, CA) has been used extensively across the world for the treatment of obesity, and data on safety and effectiveness are now available. This review draws on the literature and our own clinical patient base to provide an overview of the early and late problems associated with LAP-BAND placement and its effects on weight loss. It has proved to be a remarkably safe procedure. A report analyzing international data on laparoscopic adjustable gastric bands identified 3 deaths in 5,827 patients (approximately 1 in 2,000). In our series of 1,120 patients, there have been no deaths and no life-threatening perioperative complications. Significant early complications occurred in 17 (1.5%) of our patients; late problems have been more common, particularly during our early experience. Prolapse of the stomach through the band occurred in 125 (25%) of our first 500 patients but has occurred in only 28 (4.7%) of our last 600 patients. Erosion of the band into the stomach occurred in 34 patients (3%); all occurred in the first 500 patients. No erosions have occurred in the last 600 patients. Both problems are treated laparoscopically by removal and replacement. Combined international data show that weight loss after LAP-BAND placement is characterized by steady progressive weight loss over a 2- to 3-year period, followed by stable weight out to 6 years. This pattern reflects the benefit of adjustability. For the international series, the percent excess weight loss (%EWL) at 2 years has been between 52% and 65%. In our series, %EWL at 5 years and 6 years was 54% and 57%, respectively. The LAP-BAND is proving to be extremely safe, able to facilitate good weight loss, and able to maintain weight loss over time.

Thank you Dr. for all this info. We talk about this amongst ourselves, but it's great to have a doctor who actually performs this surgery here to answer questions.

I'm new to all of this, pre-bander that I am, but is'nt 3% a bit more than the "rarity" we are told erosion is?

Thanks Doc.. appreciate that info.

Another question if you will. My surgeon tells me that there is a technique still being used in Mexico wherein the stomach is attatched to itself around the entire band including the buckle. He says that here in the states, that technique is no longer used because most of the erosions were started by the buckle (its harder and protrudes). He said that now surgeons are turning the buckle away from the stomach and only wrapping around the smooth part of the band.

Is this something you are also aware of and if so, which technique do you use? Do you think this change could be the reason they are seeing fewer erosions?

Thanks again for your time here. It's appreciated.

This will all be a moot point as soon as DeLarla's At Home Pee Stick Erosion Kits are released.

I just blew my coffee out of my nose, all over the keyboard. :spit: Where the hell do you come up with this stuff?! You crack me up. Thanks for the laugh.

Now...back to the thread.

It's hard to imagine that Mexican surgeons would be doing something different from what we do in the USA. Remember; the Mexicans were doing it before we were, and Ortiz trained many of us. The Mexicans attend Conventions where results/complications are discussed. Everybody puts in sutures to try to prevent prolapse, and everybody is aware that too many sutures, especially near the buckle, will increase the risk of erosion. This is what O'Brien taught all of us.

Mark Pleatman MD

Please, somebody send the men in the white coats with some pretty pills that will keep me out of this whacky thread!

I'm literally laughing my ass off over what this thread turned into. It's getting nowhere. If anyone wants info on erosion, here it is: IT HAPPENS, and it sucks! And it can happen to you! And even if you don't feel like getting an endoscopy, it can still happen to YOU. YOU might be eroded right this very minute. But if you're like Chuck Norris, you won't care.

What else can I help you with? GOOD NIGHT!