Laparoscopic Sleeve Gastrectomy as a Treatment Modality for Prolapsed Adjustable Gastric Band Complicated By Gastric Necrosis

Minal Joshi, MD, Srikanth Eathiraju, MD, Krystyna Kabata, PAC, Michael Baek, MS, IV, Piotr Gorecki, MD

Department of Surgery, New York Methodist Hospital

Laparoscopic adjustable gastric banding (LAGB) has gained popularity as a first-line surgical treatment for morbid obesity. However with its short term advantages it carries a risk of long term complications. We report an unusual case of band slippage with extensive gastric necrosis treated with emergent sleeve gastrectomy.

Case Report
A 45 year-old man presented to the emergency department (ED) returning from out of state trip, with a 3-day history of progressive severe abdominal pain, nausea, vomiting and fever. He underwent laparoscopic placement of LAGB (Initial weight 344 Lbs. and BMI 50 kg/m2), two years prior to this presentation. Pars flaccida technique was utilized with subsequent uneventful and prompt recovery. The patient had subsequent weight loss of 130 lbs. and resolution of his comorbidities including Type II diabetes and reported excellent quality of life. In the ED, the patient was hypotensive, with tachycardia and oliguria. Physical examination revealed signs of peritonitis. Laboratory findings showed elevated serum glucose, blood urea nitrogen and creatinine. A CT scan revealed extensive free air and free intraabdominal fluid with edematous changes in the mesentery. The patient was resuscitated with intravenous crystalloids and decompressed with nasogastric tube, followed by emergent exploratory laparoscopy. At laparoscopy, a slipped band was found along with extensive gastric necrosis and multiple perforations involving most of the greater curvature of stomach. There was evident diffuse peritonitis. The LAGB was explanted, and laparoscopic sleeve gastrectomy of the gangrenous and ischemic parts of the stomach was performed. At the level of the incisura, gastric ischemia extended to the lesser curvature, however with no obvious necrosis as confirmed by intraoperative upper endoscopy. As a result, decision was made to preserve this segment as a “sleeve” therefore avoiding the need for total gastrectomy. Pathologic examination confirmed extensive transmural necrosis with perforations. Parenteral nutrition was started on postoperative day two, oral liquid diet on day 4, and he was discharged home on postoperative day 13. His futher recovery was uneventful.

Although LAGB is favored by many patients and surgeons due to its simplicity, minimal invasiveness, adjustability and reversibility, it carries a potential for severe long-term morbidity including gastric necrosis and perforation. Cumulative and long term LAGB related complications can occur and should be considered when selecting optimal bariatric procedure.

Gastric prolapse (slip) complicated by gastric necrosis is rare but life theatening complication of LAGB. Once slip is suspected, urgent attention and treatment is mandatory to minimize chance of gastic ischemia. Laparoscopic explantation of LAGB and “emergent sleeve gastrectomy” may be considered in similar clinical setting.

Session: Poster Presentation

Program Number: P419

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