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CASE REPORT
Unique complication of laparoscopic adjustable gastric band? A misplaced band encircling the abdominal aorta
  1. Mohamed Sahloul1,
  2. Douglas Bowley1,2 and
  3. Martin Richardson1
  1. 1 General surgery, Heart of England NHS Foundation Trust, Birmingham, UK
  2. 2 Royal Centre for Defence Medicine, Birmingham, UK
  1. Correspondence to Mr Mohamed Sahloul, mohammadsahloul{at}live.com

Abstract

In the recent past, laparoscopic adjustable gastric bands (LAGBs) have been used extensively in bariatric surgery. Despite questionable long-term efficacy, they are generally safe and reversible. We report a possibly unique presentation of a potential hazard of the insertion technique; a misplaced LAGB encircling the abdominal aorta, which was confirmed radiologically and on operative removal of the gastric band. This is a dramatic complication of LAGB, representing an important anatomical hazard for gastric band insertion.

  • general surgery
  • obesity (nutrition)

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Background  

Laparoscopic adjustable gastric bands (LAGBs) have been used extensively in bariatric surgery over the past two decades. Although there is ongoing debate about their long-term efficacy, LAGBs are generally considered safe and reversible. We report an unusual late presentation of a potential hazard of the insertion technique, where a LAGB has been erroneously placed to encircle the abdominal aorta along with the gastric pouch. This is a unique case report; never previously having been reported in the surgical literature.

Case presentation 

A 50-year-old female patient presented with an exacerbation of chronic abdominal pain. She had undergone placement of a LAGB 10 years previously; her preband body mass index (BMI) had been 40.5 kg/m² and her nadir BMI was 24.4 kg/m². In response to persistent abdominal pain, the band had been completely deflated 6 years prior to presentation and her BMI at the time of the acute admission was 32.6 kg/m². She had generalised abdominal tenderness and blood tests revealed mildly raised inflammatory markers and early stage acute kidney injury. The patient was resuscitated, and a CT scan was undertaken to identify any significant intra-abdominal pathology.

Investigations 

A CT scan confirmed that the gastric band was encircling the abdominal aorta along with the gastric pouch (figure 1). The erroneous position was also confirmed on operative removal of the gastric band.

Figure 1

Gastric band encircling the abdominal aorta; (A) axial CT image at the level of the band, (B) three-dimensional reconstruction.

Differential diagnosis 

Although failed weight loss (typically defined as a loss of less than 30% of excess weight) is the most common late complication of LAGB; other acute postoperative complications may occur. Abdominal pain in LAGB patients may represent band slippage, prolapse and erosion, late port infection, stomal obstruction with pouch dilation and severe gastro-oesophageal reflux disease. Obesity and rapid weight loss after bariatric surgery are also risk factors for gallstones and their complications, including acute pancreatitis.

Treatment 

Diagnostic laparoscopy was undertaken to confirm the band position and remove the LAGB; however, internal herniation of the whole length of the small bowel through a loop of the gastric band tubing within the peritoneal cavity was identified causing small bowel strangulation and ischaemia, The patient underwent a major small bowel resection, sparing only 80 cm of the proximal jejunum (from duodenojejunal junction) and distal ileum 10 cm from the ileocaecal valve.

Outcome and follow-up

The patient underwent a subsequent relook laparotomy for restoration of bowel continuity and required temporary total parenteral nutrition (TPN) to compensate for the loss of small bowel. Unfortunately, she also developed a low output enterocutaneous fistula. She is currently maintaining her nutritional needs by oral intake only and is being followed up by the nutritional team.

Discussion

Aortic complications of bariatric surgery are rare, with trocar-associated injury reported in 0.043% of patients in a Swedish review (1 in 2325 patients).1 Non-trocar iatrogenic injury to the aorta has also been reported during LAGB revision2; however, to our knowledge, this is a unique report of aortic encirclement by LAGB. Complications related to LAGB surgery resulting in small bowel ischaemia (as in this case), bowel perforation or erosion with intestinal or biliary obstruction have been previously reported in the literature,3–7. In our own practice, we tend to shorten the gastric band tubing before connecting it to the subcutaneous port to prevent any intraperitoneal tube redundancy and also to pass the tubing in the left upper quadrant of the abdominal cavity on top of the body of the stomach and over the omentum8; this method of gastric band tube shortening has been advocated by other experts.5

Although this is the first reported instance of aortic encirclement, it represents an important anatomical consideration for LAGB insertion which has the potential for serious hazard to the patient. The pars flaccida technique was designed to minimise dissection and limit it to the lesser curvature of the stomach, in order to reduce the chances of gastric band slippage. Dissection to create the posterior tunnel for the gastric band behind the gastric pouch is crucial and needs to be done under direct vision9; this case underlines the vital importance of correctly identifying the margin of the posterior gastric wall and the gastro-oesophageal junction prior to placement of the band.

Patient’s perspective 

I never expected a miracle cure for my weight. I just hoped that the lap band would make losing weight a bit easier but most importantly would help me to maintain a healthy weight in the long term. I was aware that all surgery comes with risks, but so does obesity. It is fair to say however that I certainly was not aware that what has happened to me was possible at all. When I booked the procedure, the potential risks were listed as a couple of lines in the middle of a very detailed form and so were not highlighted at all.

Once I had the lap band fitted, for the most part it was empty of saline and so it had little impact on my weight. When I became really ill, I was in hospital for nearly 3 months and had two major surgeries. Once I finally got out of hospital, I have managed to eat enough to not require TPN and have even gained some weight, but my quality of life has been changed immeasurably. I face chronic fatigue daily and have to plan all of my activities outside the home to ensure that I always have access to a toilet. I can’t work as I don’t have enough energy, and I don’t have much of a social life now as I can never be sure if I will be well enough to go out. All in all this makes my life challenging.

My recommendation for anyone considering bariatric surgery would be to think long and hard before making any decision. Bariatric surgery is not a quick fix to obesity. There is no quick fix; and ask about potential risks and complications and take them seriously. If the risk is 1 in every 100 people, think about what your life might be like if you end up being that one person. Being overweight doesn’t seem so important to me now. I just wish that I had gone to Weight Watchers instead!!!

Learning points

  • The pars flaccida approach for laparoscopic adjustable gastric band (LAGB) insertion, where a tunnel is made in the posterior gastric fatty tissue at the level of the gastro-oesophageal junction and just inferior to the crural confluence, is easy to perform yet requires great care in order to avoid risk of injury to surrounding structures, or anatomical misplacement of the band.

  • There should be a low threshold for imaging for patients with abdominal pain after LAGB.

  • Shortening of the gastric band tubing to prevent intra-abdominal redundancy of the tubing is mandatory, yet must also allow safe connection to the gastric band port without tension.

References

Footnotes

  • Contributors MS was responsible for the idea, writing a draft for the case report and reviewing literature.DB and MR were responsible for reviewing and editing the manuscript and also patient management and follow-up. MS and MR were involved in the operation.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.