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A Challenging Misleading Diagnosis in a Patient with Suspicion of Gastric Banding Slippage and Strangulation: Diagnosis and Laparoscopic Treatment

Abstract

A 51-year-old female (height 160 cm, weight 89 kg, BMI 34.8) presented at the emergency department complaining of sudden onset of sharp abdominal pain in the epigastrium, colicky in nature, dysphagia, nausea, and repeated retching with non-productive vomiting. She has had an adjustable gastric banding implanted laparoscopically 11 years earlier. Since then, she reported to have had only a moderate weight loss (initial BMI 44), although she was closely followed up and the reservoir properly filled by her obesity surgeon. A gastrografin was performed and showed no clear signs of slippage of the gastric band nor of gastric strangulation/ischemia. Nonetheless, the passage of the contrast through esophagogastric junction was slightly slow and restricted suggesting a moderate stenosis from the band. Two cubic centimeters of saline were aspirated from the reservoir to loosen the gastric band. However, on the following minutes, no significant relief of the sharp pain was observed. NSAIDS and morphine were repeatedly given without significant pain relief, and after a few hours, the pain was more intense and diffused to the upper abdomen. I.V. contract CT scan showed a large amount of free fluid, with severe small bowel distension and suspected volvulus and a transition point at the port site of the reservoir, suggesting a strangulated incisional hernia on this site and/or strangulating band adhesion. Urgent surgery was planned, and a laparoscopic approach was chosen. A large amount of free bloody fluid was found, and a long segment of small bowel was twisted around a strangulating band adhesion on the port site of the reservoir, incarcerated within an incisional hernia on the same port site. The strangulating band was cut, and the strangulated bowel was released. Gradual reversion of bowel ischemia was observed, and the gastric banding was removed according to the patient’s preoperative request.

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Conflict of Interest

The authors declare that they have no competing interests.

Compliance with Ethical Standards

This article being a case report does not need ethical approval.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Author’s Contribution

GMG and SDS wrote the manuscript. SDS operated on the patient as the operating attending surgeon. GMG and SB were assisting surgeons in O.R. GMG and SDS edited the video and the images. SDS, GMG, SB, AB, RL, MZ, and EJ revised critically the manuscript and the video for technical and intellectual content. All authors reviewed and approved the final draft of the manuscript.

Author information

Correspondence to Salomone Di Saverio.

Additional information

Brief Resume

Emergency laparoscopy for small bowel ischemia and an incarcerated port-site incisional hernia with small bowel volvulus on a single adhesion, in an obese patient presenting with epigastric pain 11 years after gastric banding insertion

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Di Saverio, S., Guiducci, G.M., Boschi, S. et al. A Challenging Misleading Diagnosis in a Patient with Suspicion of Gastric Banding Slippage and Strangulation: Diagnosis and Laparoscopic Treatment. OBES SURG 25, 1758–1762 (2015). https://doi.org/10.1007/s11695-015-1759-7

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Keywords

  • Obesity surgery
  • Gastric banding
  • Complications
  • Dysphagia and abdominal pain
  • Differential diagnosis
  • CT scan
  • Small bowel obstruction
  • Adhesional band
  • Incarcerated incisional hernia
  • Bowel ischaemia
  • Laparoscopic emergency surgery