Irfan Halim, MBBS, FRCS, MSc, DIC, LLB, C L Fontaine, MBBS, Yashwant Koak, MBChB, FRCS, MS, MBA, MDCH. Homerton Hospital
Introduction
The laparoscopic adjustable gastric band (LAGB) procedure is commonly used in obese patients (BMI >35) to aid in weight loss. Complications of the LAGB are well documented and are now being seen with increasing frequency within the outpatient setting and emergency departments. We describe a rare presentation of a gastric band erosion-migration resulting in an unusual gastro-duodenal fistula that presented with both a diagnostic and operative challenge.
Case History
A 39 year old female presented with abdominal pain and nausea following a top-up instillation into her LAGB. Physical examination was unremarkable. A serosanguinous collection was noted around the port site and subsequent culture of this collection grew candida and pseudomonas. Attempts to deflate the band via the port on admission were unsuccessful.
Abdominal X-ray identified both the gastric port and tubing, however the LAGB was radiolucent and therefore could not be visualised. The patient was started on IV broad-spectrum antibiotic and antifungal therapy.
Two attempts to remove the LAGB endoscopically were unsuccessful but revealed that the majority of the LABG had eroded into the gastric cardia with partial erosion into the duodenal bulb. Further endoscopy was performed intraoperatively with the LAGB observed in the gastric lumen, partly embedded in the gastric mucosa. The formation of a gastro-duodenal fistula from D1 back to the stomach was also noted and large enough to transmit the scope easily, with no abnormalities detected in D2. Gastrostomy was performed, with division of the cardia – enabling LAGB removal, and closed with 60mm stapling device.
The patient made an uneventful recovery on IV broad spectrum antibiotics and antifungal therapy.
Discussion
Erosion-migration, is a recognised complication of gastric bands with a reported incidence ranging from 0.23 – 32.65%[1]. Although erosion-migration of gastric bands into the small bowel, with subsequent obstruction, and penetration of the pulmonary system, colon and jejunum are increasingly being reported this is the first case of gastro-duodenal fistula due to erosion-migration[2],[3],[4],[5].
In this case both port site infection and band pressure are likely to have contributed to erosion-migration of the band and fistula formation. The manufacturer guidelines recommend the band to be maximally filled to 9ml only.
Conclusion
Erosion-migration is a recognised complication of gastric bands. This case describes the first reported erosion-migration of gastric band leading to formation of gastro-duodenal fistula, likely secondary to band pressure and port infection.