Acute appendicitis in the setting of laparoscopic adjustable gastric banding: A case report and literature review

Josue Chery, MD, Amy Maselli, MD, Krystyna Kabata, PA, Anthony Tortolani, MD, Piotr Gorecki, MD. New York Methodist Hospital.

Background: Laparoscopic adjustable gastric band (LAGB) remains an established modality for the surgical treatment of morbid obesity. Acute appendicitis remains the most common cause of acute abdomen. Since the lifetime prevalence of acute appendicitis reaches 8-10%, the risk of developing this clinical condition among the LAGB patients is considerable. This clinical situation remains remarkably under reported in the literature; therefore the actual incidences as well as guidelines for treatment are not available.

Case Report: A 25- year old, 116 kg female, with a BMI of 40 kg/m2, underwent an uneventful laparoscopic band placement. Post-operative contrast radiogram demonstrated the band in satisfactory position. The patient’s subsequent recovery was uneventful. Nine months after the operation, with an 18 kg weight loss, the patient presented with a 24-hour history of abdominal pain. Her clinical signs and symptoms were consistent with acute appendicitis. Computed tomography (CT) scan of the abdomen confirmed the clinical diagnosis of acute appendicitis. The patient was started on intravenous piperacillin-tazobactam, and underwent an uneventful laparoscopic appendectomy for phlegmonous appendicitis with no diffuse peritonitis. At laparoscopy, the band was observed to be in good position with no gross contamination and without any evidence of slippage and was left in situ. The patient had an uneventful and routine post-operative course. At a 1-year follow up post appendectomy, a CT scan of the abdomen and pelvis demonstrated a well-positioned band without any radiological evidence of intra-abdominal infection. The patient remains with no clinical signs of infection or erosion, however was diagnosed with systemic scleroderma, likely unrelated to LAGB or appendicitis.

Discussion: LAGB placement represents a clean procedure with a low risk of infection. However, very little data is available on the incidence and risk of lap band infection in face of intra-abdominal infection, such as acute appendicitis. The incidence of appendicitis in the setting of LAGB is not well reported and there is no data to support either the explanation or retention of the lap band system at the time of appendectomy. Review of the literature reveals only a few case reports of intra-abdominal and thoracic infections in this clinical scenario. The ensuing management of lap band system varied. Here, we report a case of acute appendicitis in a patient with a lap band system. The patient was treated with a laparoscopic appendectomy leaving the lap band intact.

Conclusion: Laparoscopic appendectomy can be performed without simultaneous band explanation. However, close follow up should be continued in search for subacute infection, port infection or erosion of the LAGB. More data and evidence based recommendations should become available in order to facilitate management of LAGB in face of intraabdominal infection or contamination.

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