Gastric Pseudocyst associated with a prolapsed Laparoscopic Adjustable Gastric Band.

Tianming Liu, MD¹, Ziyad Nasrawi, MD¹, George John, MS², Darren Kong, BS², Piotr Gorecki, MD, FACS¹. ¹New York Presbetyrian Brooklyn Methodist Hospital, ²Rowan School of Osteopathic Medicine

Introduction: Due to long term failures and complications, the number of laparoscopic adjustable gastric bands (LAGB) being performed in the United States each year is decreasing. We report a case of the prolapsed (slipped) gastric band associated with perigastric pseudocyst and discuss the pathophysiology.

Case report: A 42-year-old woman with a history of morbidobesity and LAGB placed 8 years ago presented emergently with abdominal pain, dehydration, vomiting and severe gastroesophageal reflux (GERD). Emergent plain radiogram revealed prolapsed LAGB. Postoperatively the patient experienced an excellent weight reduction with 94 % Excess Weight Loss and a BMI of 23.5 kg/m2. At emergent laparoscopy, a 6 cm cystic mass was found in association with the prolapsed LAGB. The perigastric cyst was dissected and excised. Intraoperative endoscopy did not reveal communication to the gastric lumen. The LAGB was explanted without evidence of gastric erosion. Pathologic evaluation revealed a smooth thin walled pseudocyst with inflammatory and mesothelial cells. The patient recovered well and was discharged the following day.

Discussion: Perigastric pseudocyst associated with LAGB has been reported in the literature. It's pathogenesis may be connected to foreign body reaction. We propose collagen and granulomatous tissue deposits around the LAGB and the gastro-gastric plication area contributed to this rare entity. The fibrotic tissue blocks lymphatic channels which may result in an accumulation of lymphatic fluid. This condition may be revealed during emergent exploration or during the preoperative advanced imaging such as the CT imaging. Pathological findings consistent with fibrotic and inflammatory tissue confirm the diagnosis and rules out malignancy and true gastric cyst. Lack of epithelial lining confirms the diagnosis of pseudocyst.

Conclusion: Pseudocysts may form as a mechanism of foreign body reaction. Slipped LAGB could be a contributing factor as in this case. Intraoperative photographs and endoscopic images will be presented. Additional observational studies and reports are needed to further understand the pathophysiology of this entity and to determine the causal association with a band and particularly a prolapsed LAGB.

Figure 1: B marks the normal location and position of the LAGB. * marks the flow of contrast which is normal through the GE junction and stomach.