Management of an Eroded Gastric Ring Following the Third Metabolic Bariatric Surgery: A Multimedia Article

Category	Detail
Condition	Ring erosion after ring-augmented Roux-en-Y gastric bypass (rRYGB)
Key Mechanisms	Silicone ring induces earlier satiety by exerting pressure on the gastric wall when full; ring erosion can cause dysphagia and ulceration
Target Population	Patients undergoing revisional metabolic bariatric surgery with ring-augmented RYGB, especially tertiary procedures after prior LSG and RYGB
Care Setting	Specialized bariatric surgery centers with multidisciplinary teams and access to advanced endoscopic and laparoscopic interventions

rRYGB shows greater weight loss than standard RYGB but carries risks including ring erosion (0–2% long-term rate).
Ring erosion presents with progressive dysphagia, reduced food tolerance, and gastric ulceration despite medical therapy.
Combined laparoscopic and endoscopic approaches are effective for removal of eroded rings and management of complications.

Evaluate persistent upper gastrointestinal symptoms post-rRYGB with imaging (CT scan) and upper GI endoscopy.
Use virtual 3D CT volumetry to assess gastric pouch volume and anatomy.
Identify ring erosion and associated ulceration endoscopically.

Initial medical management with proton pump inhibitors and nutritional modifications.
Consider surgical options including resizing gastric pouch/stoma, distalization, and ring placement for suboptimal weight loss.
Remove eroded rings via combined laparoscopic adhesiolysis and endoscopic techniques when endoscopic removal alone fails.
Reinforce erosion site with sutures and omental patch during ring removal surgery.

Monitor weight loss progress and symptom resolution postoperatively.
Follow up with imaging and endoscopy as indicated to assess healing and complications.
Prescribe and continue PPIs and sucralfate for up to six months post ring removal to promote mucosal healing.

Ring erosion leading to dysphagia, ulceration, and potential need for surgical intervention.
Suboptimal weight loss or weight recurrence after primary and revisional bariatric surgeries.
Complications related to ring placement including obstruction and intolerance.

Patients with suboptimal weight loss or weight regain after primary and revisional bariatric surgeries, including those with GERD symptoms.

Ring augmentation can improve weight loss outcomes but requires careful patient selection and monitoring for complications such as ring erosion.

Use multidisciplinary evaluation to tailor revisional bariatric surgical options based on patient anatomy and symptoms.
Employ virtual 3D imaging and endoscopy for precise anatomical assessment before revisional surgery.
Perform ring placement loosely and secure with non-absorbable sutures to minimize erosion risk.
Promptly investigate persistent dysphagia or upper GI symptoms post-rRYGB to detect ring erosion early.
Utilize combined laparoscopic and endoscopic approaches for safe and effective removal of eroded rings.
Provide prolonged acid suppression and mucosal protective therapy after ring removal to facilitate healing.

Clinical Scorecard: Addressing an Eroded Gastric Ring After Tertiary Metabolic Bariatric Surgery: A Multimedia Overview