Clinical History
A 43-year-old female patient, treated with laparoscopic adjustable gastric band for morbid obesity 4 years before, presented to the ER with persistent vomiting and food intolerance, lasting for 4 days.
Imaging Findings
An abdominal and pelvic CT was performed, after ingestion of positive oral contrast (gastrografin), which was poorly tolerated, and administration of IV iodinated contrast, in the portal venous phase of enhancement. Images showed distal positioning of the adjustable silicone gastric band due to anterior slippage and herniation of a portion of the lesser curve through the gastric band ring forming a small, postero-medial pouch, which did not opacify with oral contrast. Oral contrast did not progress beyond the gastric antrum, due to complete obstruction (Fig. 1, 2). An upper endoscopy was performed, showing a blind-ending pouch due to obstruction of the gastric outlet (Fig. 3).
Discussion
Bariatric surgery is generally categorized into two main categories, restrictive and malabsorptive. In restrictive procedures, gastric volume is reduced substantially to promote early satiety. In malabsorptive procedures, the gastrointestinal tract is surgically altered to induce malabsorption and hence decrease caloric uptake. Procedures may also combine techniques [1].
Laparoscopic adjustable gastric banding surgery is a purely restrictive procedure in which the stomach is divided into two pouches by placement of an adjustable silicone gastric band 2 cm below the gastroesophageal junction, so that the proximal gastric pouch is left with a volume of approximately 15 mL [2].
Complications of laparoscopic adjustable gastric banding may be band-related or port related. Relatively common band-related complications include stomal stenosis (8-11%); band slippage (2-13%); pouch dilatation (3-8%); band erosion into the stomach (3%); and band misplacement (2.3%). Port-related complications include port-rotation and inversion (1-5%); tubing disconnection (1-5%), leak from port-tubing connection (1-5%) and infection (<1%) [1].
Band slippage can be caused by recurrent vomiting or faulty surgical technique and can be posterior or anterior. Posterior slippage is associated with upward herniation of the posterior stomach wall through the band. In anterior slippage, the higher pressure in the upper pouch pushes the band downward over the anterior aspect of the stomach. Both complications manifest as vomiting, regurgitation, and food intolerance, but the conditions have different radiologic findings. Eccentric upper gastric pouch dilatation occurs in both, but the pouch is usually posterior and inferior in posterior slippage, and anterior and superior in anterior slippage. [2] The latter was found in this patient (Fig. 1, 2).
Besides the anterior slippage, our patient also presented with herniation of a portion of the lesser curvature through the gastric band ring, a finding which, to our knowledge, has not been previously described in the literature as a complication of laparoscopic adjustable gastric banding. Both the hernia and the slippage might have contributed to the clinical setting of upper gastrointestinal obstruction. The adjustable gastric band was surgically removed with no complications and subsequently the symptoms resolved.
Differential Diagnosis List
Anterior slippage and lesser curve hernia of the stomach
Stomal stenosis
Posterior slippage
Band erosion
Final Diagnosis
Anterior slippage and lesser curve hernia of the stomach
