Clinical Report: Management of Eroded Gastric Ring After Tertiary Bariatric Surgery

Overview

This report details a complex case of ring erosion following ring-augmented Roux-en-Y gastric bypass (rRYGB) performed as a tertiary metabolic bariatric surgery. Despite initial postoperative weight loss, the patient developed progressive dysphagia and ring erosion requiring surgical removal, ultimately achieving significant weight reduction and symptom resolution.

Background

Revisional metabolic bariatric surgery (MBS) is increasingly necessary due to suboptimal outcomes or complications after primary procedures. Ring-augmented RYGB has shown improved weight loss compared to standard RYGB but carries risks such as ring erosion, reported in up to 2% of cases. Management of ring erosion typically involves endoscopic removal, though surgical intervention may be required in complex cases. This case highlights the challenges and multidisciplinary approach needed for managing ring erosion after tertiary bariatric surgery.

Data Highlights

Key Findings

• Ring-augmented RYGB can provide significant weight loss but carries a risk of ring erosion, reported between 0-2% in literature.
• In this case, early ring erosion caused progressive dysphagia and ulceration despite medical management.
• Endoscopic removal of the eroded ring was unsuccessful, necessitating laparoscopic adhesiolysis and surgical ring removal.
• Postoperative management with PPIs and sucralfate facilitated healing and symptom resolution.
• The patient achieved a total weight loss of 27 kg and BMI reduction to 27.9 kg/m2 after ring removal and revision surgery.
• A multidisciplinary approach is essential for evaluating and managing complex revisional bariatric surgery cases.

Clinical Implications

Clinicians should maintain a high index of suspicion for ring erosion in patients presenting with persistent upper gastrointestinal symptoms after rRYGB. Comprehensive evaluation including imaging and endoscopy is critical. When endoscopic removal fails, a combined laparoscopic approach can safely remove the eroded ring and repair the gastric wall, improving patient outcomes.

Conclusion

Ring erosion is a rare but serious complication of ring-augmented RYGB that requires prompt diagnosis and tailored surgical management. Multidisciplinary care and individualized surgical strategies can achieve symptom resolution and sustained weight loss in complex revisional bariatric patients.

References

1. Dapri et al. 2019 -- Non-adjustable silicone ring placement after RYGB
2. Systematic review on revisional MBS -- Indications and outcomes
3. Long-term outcomes of rRYGB vs standard RYGB
4. Ring erosion rates and management strategies