Scientific letter
Migration and Perforation of a Gastric Band in the Small Bowel
Migración y perforación de una banda gástrica en el intestino delgado
Federico Oppliger
, Horacio Ríos, Luis Manríquez
Corresponding author
Departamento de Cirugía, Universidad del Desarrollo – Clínica Alemana, Santiago, Chile
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Luis Manríquez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Federico" "apellidos" => "Oppliger" "email" => array:1 [ 0 => "foppliger@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Horacio" "apellidos" => "Ríos" ] 2 => array:2 [ "nombre" => "Luis" "apellidos" => "Manríquez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cirugía, Universidad del Desarrollo – Clínica Alemana, Santiago, Chile" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Migración y perforación de una banda gástrica en el intestino delgado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 788 "Ancho" => 1300 "Tamanyo" => 189529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Segment of ileum perforated by the gastric band; (B) complete surgical specimen showing several perforations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoscopic adjustable gastric banding (LAGB) is a safe and reversible procedure that entails low mortality and morbidity (approximately 0.05% and 11.3%, respectively).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Even so, it has a high readmission and revision surgery rate of 52%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Late-onset postoperative complications are frequent and are probably not completely documented. Erosion and migration of gastric bands have an incidence of 0.6%–3%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> We present a rare case of gastric band erosion through the stomach and later migration towards the ileum, while causing several bowel perforations.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 51-year-old woman with a history of morbid obesity who had undergone a LAGB procedure one year before and had lost 25<span class="elsevierStyleHsp" style=""></span>kg with 2 adjustments. She had sought treatment at the emergency room of another hospital due to diffuse abdominal pain and bilious vomiting. Analyses showed amylase 4000<span class="elsevierStyleHsp" style=""></span>mg/dL and lipase 1100<span class="elsevierStyleHsp" style=""></span>mg/dL; the patient was diagnosed with acute pancreatitis, which was classified as Balthazar B on computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous (iv) contrast. The patient was immediately treated with NPO, intravenous hydration and analgesia; partial response was observed, but the abdominal pain and vomiting continued. An upper gastrointestinal series demonstrated a herniated fundus, and the gastric band was not visualised. She was finally transferred to our centre.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient continued to have abdominal pain, with no peritoneal irritation. Amylase and lipase levels were normal, but C-reactive protein was 21<span class="elsevierStyleHsp" style=""></span>mg/L and leukocytes 13<span class="elsevierStyleHsp" style=""></span>200/mm<span class="elsevierStyleSup">3</span>. Upper gastrointestinal endoscopy detected a large ulcerated lesion with a foreign object in the area of the fundus and proximal antrum, which was the connector tube of the gastric band. Under fluoroscopy, contrast medium was injected into the pouch, which showed evidence of migration of the band to the right iliac fossa. Another abdominal/pelvic CT scan with contrast revealed the intraluminal position of the band (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Surgery was indicated, so we carried out exploratory laparoscopy, which revealed the connector tube penetrating the gastric wall. The gastric band, however, could not be located, so the procedure was converted to open surgery. While exploring the cavity, multiple small bowel perforations were detected and the band was finally found 20<span class="elsevierStyleHsp" style=""></span>cm from the ileocecal valve. We resected 40<span class="elsevierStyleHsp" style=""></span>cm of the ileum, which was reconstructed with an end-to-end anastomosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Postoperative recovery was uneventful.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Long-term complications of gastric bands include port and connector problems, reflux, pouch dilation, prolapse, oesophageal dilatation and erosion. These often lead to revision surgeries that result in the withdrawal of the band and patient rejection of the technique.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Band erosion and intragastric migration are feared complications that persist as long as the band is installed. Proposed causes are related to subclinical gastric lesions at the time of placement, overly tight closure, elevated internal pressure after the ingestion of very large food quantities, and abnormal reaction of the tissue in contact with the prosthesis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the literature, there are 8 case reports of band migration towards the small bowel, one of which presented perforations.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–9</span></a> There have also been cases in which the connector tube becomes disconnected and perforates the intestinal wall from the outside.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Clinically, these patients can present symptoms compatible with intestinal obstruction, port infection or failure to lose weight.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–8</span></a> As the perforations are slow to develop, they normally do not present peritonitis, which allows the chronic inflammatory reaction to isolate them. In our case, it is interesting that the patient had pancreatitis previously, which seems to have been circumstantial.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis is complex, and a high rate of suspicion is necessary. Persistent infection of the port site can be the first manifestation. CT scan with iv contrast should be the diagnostic technique of choice as it is able to more precisely identify the location of the band and determine its repercussions.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Fluoroscopy, on the other hand, is simple to do and detects the migration of the band, while upper gastrointestinal endoscopy can be therapeutic for withdrawal of the band when possible.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment will depend on symptoms and degree of band migration. If more than 50% of the band's circumference is within the stomach, endoscopic extraction can be attempted, which is less invasive and causes less morbidity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In cases where it has migrated towards the small bowel or further and is associated with perforations, an open approach is required. The withdrawal of the band followed by immediate reinstallation is not recommended because of the high rates of failure and risk.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Oppliger F, Ríos H, Manríquez L. Migración y perforación de una banda gástrica en el intestino delgado. Cir Esp. 2015;93:601–603.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 396 "Ancho" => 1300 "Tamanyo" => 90072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Fluoroscopy demonstrating the gastric band in the area of the right iliac fossa; (B) cross-sectional CT scan of the abdomen and pelvis showing the gastric band within the intestinal lumen.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 788 "Ancho" => 1300 "Tamanyo" => 189529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Segment of ileum perforated by the gastric band; (B) complete surgical specimen showing several perforations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolution of laparoscopic adjustable gastric banding" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 14 | 6 | 20 |
| 2024 September | 24 | 6 | 30 |
| 2024 August | 33 | 4 | 37 |
| 2024 July | 19 | 2 | 21 |
| 2024 June | 16 | 10 | 26 |
| 2024 May | 14 | 5 | 19 |
| 2024 April | 17 | 7 | 24 |
| 2024 March | 27 | 6 | 33 |
| 2024 February | 27 | 2 | 29 |
| 2024 January | 47 | 5 | 52 |
| 2023 December | 47 | 4 | 51 |
| 2023 November | 48 | 4 | 52 |
| 2023 October | 76 | 6 | 82 |
| 2023 September | 45 | 0 | 45 |
| 2023 August | 32 | 1 | 33 |
| 2023 July | 39 | 2 | 41 |
| 2023 June | 46 | 3 | 49 |
| 2023 May | 65 | 2 | 67 |
| 2023 April | 57 | 0 | 57 |
| 2023 March | 74 | 3 | 77 |
| 2023 February | 37 | 7 | 44 |
| 2023 January | 67 | 7 | 74 |
| 2022 December | 53 | 6 | 59 |
| 2022 November | 44 | 5 | 49 |
| 2022 October | 43 | 9 | 52 |
| 2022 September | 57 | 6 | 63 |
| 2022 August | 57 | 8 | 65 |
| 2022 July | 43 | 8 | 51 |
| 2022 June | 42 | 5 | 47 |
| 2022 May | 24 | 4 | 28 |
| 2022 April | 34 | 13 | 47 |
| 2022 March | 64 | 9 | 73 |
| 2022 February | 71 | 8 | 79 |
| 2022 January | 98 | 8 | 106 |
| 2021 December | 59 | 8 | 67 |
| 2021 November | 56 | 13 | 69 |
| 2021 October | 61 | 10 | 71 |
| 2021 September | 55 | 13 | 68 |
| 2021 August | 61 | 6 | 67 |
| 2021 July | 40 | 16 | 56 |
| 2021 June | 51 | 6 | 57 |
| 2021 May | 69 | 11 | 80 |
| 2021 April | 129 | 13 | 142 |
| 2021 March | 71 | 6 | 77 |
| 2021 February | 68 | 7 | 75 |
| 2021 January | 81 | 11 | 92 |
| 2020 December | 58 | 9 | 67 |
| 2020 November | 47 | 10 | 57 |
| 2020 October | 39 | 2 | 41 |
| 2020 September | 39 | 10 | 49 |
| 2020 August | 56 | 15 | 71 |
| 2020 July | 51 | 6 | 57 |
| 2020 June | 22 | 15 | 37 |
| 2020 May | 33 | 21 | 54 |
| 2020 April | 19 | 6 | 25 |
| 2020 March | 35 | 10 | 45 |
| 2020 February | 29 | 3 | 32 |
| 2020 January | 33 | 11 | 44 |
| 2019 December | 50 | 11 | 61 |
| 2019 November | 28 | 9 | 37 |
| 2019 October | 44 | 9 | 53 |
| 2019 September | 38 | 7 | 45 |
| 2019 August | 16 | 4 | 20 |
| 2019 July | 20 | 11 | 31 |
| 2019 June | 56 | 25 | 81 |
| 2019 May | 111 | 67 | 178 |
| 2019 April | 66 | 23 | 89 |
| 2019 March | 18 | 6 | 24 |
| 2019 February | 23 | 4 | 27 |
| 2019 January | 9 | 3 | 12 |
| 2018 December | 18 | 6 | 24 |
| 2018 November | 22 | 8 | 30 |
| 2018 October | 26 | 2 | 28 |
| 2018 September | 10 | 7 | 17 |
| 2018 August | 9 | 0 | 9 |
| 2018 July | 11 | 1 | 12 |
| 2018 June | 10 | 3 | 13 |
| 2018 May | 13 | 6 | 19 |
| 2018 April | 14 | 1 | 15 |
| 2018 March | 6 | 3 | 9 |
| 2018 February | 12 | 0 | 12 |
| 2018 January | 17 | 3 | 20 |
| 2017 December | 7 | 5 | 12 |
| 2017 November | 14 | 2 | 16 |
| 2017 October | 16 | 0 | 16 |
| 2017 September | 15 | 3 | 18 |
| 2017 August | 16 | 2 | 18 |
| 2017 July | 17 | 4 | 21 |
| 2017 June | 21 | 8 | 29 |
| 2017 May | 17 | 1 | 18 |
| 2017 April | 13 | 1 | 14 |
| 2017 March | 31 | 31 | 62 |
| 2017 February | 26 | 3 | 29 |
| 2017 January | 14 | 3 | 17 |
| 2016 December | 21 | 6 | 27 |
| 2016 November | 12 | 7 | 19 |
| 2016 October | 37 | 9 | 46 |
| 2016 September | 57 | 3 | 60 |
| 2016 August | 12 | 3 | 15 |
| 2016 July | 15 | 1 | 16 |
| 2016 June | 19 | 9 | 28 |
| 2016 May | 17 | 7 | 24 |
| 2016 April | 11 | 9 | 20 |
| 2016 March | 27 | 24 | 51 |
| 2016 February | 12 | 6 | 18 |
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