Abdominal imaging
Case TypeClinical Cases
Authors
João Louro, Diogo Rodrigues, João Pereira, Margarida Praça, Pedro Maganinho
Patient53 years, female
A 53-year-old female patient with history of obesity, hypertension, C-section, and laparoscopic adjustable gastric band (LAGB) 5 years prior. She presented to the emergency department with abdominal colic-like pain and bloating. Physical examination revealed a tender and tympanic abdomen, and no signs of rectal bleeding or faecaloma.
Abdominal radiography (fig. 1) showed multiple dilated small bowel loops with air-fluid levels. There were no signs of pneumoperitoneum. The gastric band had a normal position, exhibiting a phi angle of 41,9° (normal: 4-58°), with the connective tube in the periumbilical region.
Abdominopelvic contrast-enhanced computed tomography (CECT) confirmed the presence of small bowel obstruction (SBO) and thickening of its walls due to mechanical obstruction. A transition point was seen in the periumbilical region (fig. 2), due to bowel torsion around a redundant connector tube, which formed a loop deep in the abdominal cavity (fig. 3). The colon and small bowel showed normal parietal enhancement, and there were no signs of intragastric band erosion, pouch dilation or pneumoperitoneum (fig. 4).
LAGB is a restrictive surgical procedure that preserves gastrointestinal tract continuity, in which a silicone band is placed around the proximal part of the fundus, creating a small gastric pouch. This band is connected through a tube to a subcutaneous access port, allowing its postoperative inflation or deflation [1]. Despite its previous popularity, LAGB is being replaced by other bariatric procedures due to suboptimal weight loss and high incidence of complications, which can be related to the subcutaneous port, the connective tube, or the band itself [2]. Early complications include band malposition, infection, and gastric perforation, while delayed complications comprise pouch dilatation, gastric band slippage, intragastric erosion, and oesophagal dilatation and dysmotility [3,4].
SBO related to the band-tubing is a rare complication, mostly secondary to adhesions or a long and redundant connective tube, which facilitates the development of internal hernia or bowel torsion [5]. Clinical presentation is similar to other cases of SBO and comprises symptoms like nausea, vomiting, and colic-like abdominal pain. Initial imaging evaluation includes abdominal ultrasound and radiography. Assessment of the risk of gastric band slippage is based on the phi angle measured in the plain abdominal film. CT is the most useful technique to identify SBO and associated complications. [1,2]
These emergencies require decompression through band deflation and nasogastric tube (NGT) insertion, and if bowel strangulation is present, urgent exploratory surgery is performed [4,5]. Surgery may proceed with gastric band removal, intra-abdominal repositioning with adhesions debridement, and/or band-tubing shortening [4].
The patient here reported had an NGT inserted, anticipating complications related to her history of LAGB. The latter, coupled with a previous C-section, may have caused intra-abdominal adhesions, which contribute as risk factors for band-tubing associated complications. She was then submitted to laparotomy, which confirmed SBO with normal bowel viability and allowed bowel detorsion and the debridement of adhesions. The connector tube was then sutured to the anterior abdominal wall, which has been reported to prevent future obstruction [5].
In conclusion, although rare, SBO secondary to a redundant gastric band connective tube should be promptly identified and treated to avoid bowel strangulation, ischemia, and perforation.
Written informed patient consent for publication has been obtained.
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[2] B. Wernick, M. Jansen, S. Noria, S. P. Stawicki, and M. El Chaar, ‘Essential bariatric emergencies for the acute care surgeon’, Eur J Trauma Emerg Surg, vol. 42, no. 5, pp. 571–584, Oct. 2016, doi: 10.1007/s00068-015-0621-x. (PMID: 26669688)
[3] H. Prosch, R. Tscherney, S. Kriwanek, and D. Tscholakoff, ‘Radiographical imaging of the normal anatomy and complications after gastric banding’, BJR, vol. 81, no. 969, pp. 753–757, Sep. 2008, doi: 10.1259/bjr/95353541. (PMID: 18508872)
[4] O. H. Hamed, L. Simpson, E. LoMenzo, and M. D. Kligman, ‘Internal hernia due to adjustable gastric band tubing: review of the literature and illustrative case video’, Surg Endosc, vol. 27, no. 11, pp. 4378–4382, Nov. 2013, doi: 10.1007/s00464-013-3024-2. (PMID: 23771273)
[5] K. J. L. Suter, N. Rajasagaram, and P. Nottle, ‘Gastric band connection tube results in small bowel obstruction: an acute emergency’, p. 3, doi: 10.1093/jscr/rjw082. (PMID: 27170704)
URL: | https://www.eurorad.org/case/17336 |
DOI: | 10.35100/eurorad/case.17336 |
ISSN: | 1563-4086 |
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