Slipped gastric band

Case contributed by Dr Ammar Ashraf

Presentation

Abdominal pain and vomitting. No hematemesis, melena, or fever. Past history of gastric banding.

Patient Data

Age: 30 years
Gender: Female
X-ray

A gastric band is seen in place which has migrated distally and has an abnormal O shape orientation (O sign) and a phi angle greater than 58o. Two small air-fluid levels are seen in the gastric fundus. No abnormal bowel dilatation, significant air-fluid levels, or pneumoperitoneum is seen.  

Fluoroscopy

Baseline Upper GI Series 5 years ago

A gastric band is seen in place, which is normally oriented (profile view) and positioned just below the left hemidiaphragm. Phi angle is 27o (normal range is 4-58). No abnormal gastric pouch is seen.

Correct positioning of the gastric band; normal emptying of the proximal pouch, which has a diameter of less than 4 cm; and a normal stoma with a diameter of less than 4 mm.

Photo

Upper GI Endoscpy

  • Severe esophagitis (grade D) in the mid and lower esophagus.
  • Incompetent cardia.
  • Food residue in the gastric fundus.
  • Gastric band migration causing severe obstruction in proximal body (2 cm below the GE junction). Scope could not pass through this stenosis. 
CT

Findings: Abnormally oriented and inferiorly displaced gastric band associated with dilatation of the gastric fundus anterior as well as posterior to the gastric band due to the anterior and posterior gastric slips. Due to this combined gastric slippage, there is significant gastric obstruction at the level of the band with collapsed gastric body. No abnormal wall enhancement, fat stranding, free air or fluid collection is seen around the stomach. No free fluid or collection is appreciable along the port of the gastric band which is visualized within the right lower anterior abdominal wall.  Mild free fluid is noted in the cul-de-sac which may be physiological in nature. No significant collection, pneumoperitoneum, or significant abdominopelvic lymphadenopathy is noted.  Mildly thickened lower esophagus.

Fluoroscopy

Small bowel follow through after removal of gastric band

An extrinsic impression is seen over the proximal body of the stomach which is likely related to the previous gastric banding. There is free unobstructed transit of the contrast through the stomach into the duodenum and then into the small bowel. No oral contrast leakage or extravasation is seen.

Case Discussion

Procedure: Laparoscopic removal of the gastric band and a small mesenteric cyst.

Findings: Multiple adhesions were seen between the gastric band, stomach, and upper anterior abdominal wall. Multiple adhesions and constrictive bands were seen around the gastroesophageal area and gastric fundus. Adhesiolysis was done, constrictive bands were released and the gastric band was removed.  A small mesenteric cyst was seen adjacent to the proximal greater curvature of the stomach which was excised and sent for histopathology.

Histopathology: Organized encapsulated hematoma. No atypia or malignancy was identified.

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Case information

rID: 80163
Published: 21st Jul 2020
Last edited: 31st Dec 2020
Inclusion in quiz mode: Included
Institution: King Abdulaziz Hospital Al Ahsa (MNGHA)

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