It’s nearing the end of a busy shift, and the last patient you pick up is a 45-year-old female with nausea and vomiting – a rather uninteresting complaint, at first glance. However, after speaking with her, you learn that her symptoms, initially intermittent, have been increasing over the past 4 weeks to the point where solids and liquids “just won’t go down.” She also reports that she has lost more than 50 pounds since undergoing laparoscopic adjustable gastric band placement 9 months prior.

On physical exam she is tachycardic at 110 bpm, and afebrile with a normal blood pressure and oxygen saturation. She is in visible discomfort and the nurse informs you that she has vomited twice since being brought back from triage. The physical examination is remarkable for a soft abdomen with slightly increased bowel sounds and mild tenderness in the left upper quadrant without guarding or rebound.

Laboratory evaluation reveals a potassium of 3.3 mEq/L, but the remainder of the electrolytes, liver function, renal function, complete blood count, and lipase are unremarkable. A two-view abdominal series, ordered out of concern for possible small bowel obstruction, is read by the radiologist as “negative for obstruction” without other acute findings. Following IV fluids and antiemetics, the patient was feeling much improved. She was discharged home with instructions to call her bariatric surgeon the next morning to arrange a follow-up visit.

Dx: Slipped Gastric Band

The following morning the patient called the bariatric surgery clinic with ongoing severe vomiting and was told to return for an upper gastrointestinal series. The UGI study demonstrated an aberrantly positioned gastric band without passage of contrast into the duodenum (Fig. 1) – findings very concerning for gastric outlet obstruction. The patient was taken urgently to the OR for exploratory laparoscopy and explantation of the gastric band.

While the diagnosis of slipped gastric band was unfortunately overlooked on the patient’s first emergency department visit, there are a few radiographic clues to help determine if your next patient with a gastric band and obstructive symptoms has an incorrectly positioned band that could be causing problems.

Correct position on AP radiograph (Fig. 2): The gastric band appears as a discoid opacity as you view the band on its side. The gastric band should be positioned in the left upper quadrant of the abdomen at an acute angle to the long axis of the spine, ranging anywhere from 4 to 58 degrees.¹

Incorrect position on AP radiograph (Fig. 3): Look for the “O” orientation of the band, which is created when a portion of the stomach wall herniates superiorly through the band and

causes a tilt on the horizontal axis. Furthermore, the gastric band will likely be positioned outside of the normal 4 to 58 degree orientation angle in relation to the spine. These findings denote slipping of the gastric band and portend gastric outlet obstruction, requiring immediate surgical consultation as untreated cases can progress to gastric volvulus, tissue necrosis, upper gastrointestinal bleeding, and even perforation.²

Laparoscopic adjustable gastric banding is the most frequently performed bariatric procedure worldwide. Less invasive than other bariatric techniques, it produces effective weight loss while reducing postsurgical comorbidities. However, recent long-term follow-up studies indicate a high rate of overall complications for gastric banding. The most common major band complication and leading cause of reoperation is band slippage, occurring with a frequency of 5%-25%, depending on surgical technique.³

If gastric band slippage is suspected based on symptoms and radiography, urgent surgical treatment is required for reduction of the obstructed and prolapsed stomach. As a temporary measure, the band can be deflated from the subcutaneous port, which may alleviate severe symptoms and help prevent gastric necrosis and perforation.

In one recent case report of a 47-year-old female with laparoscopic gastric banding presenting with severe vomiting, deflation of her gastric band resulted in spontaneous reduction of gastric outlet obstruction.⁴

As North American obesity rates continue to rise, so too does the volume of postbariatric patients presenting to our emergency departments. As emergency physicians, we must be prepared to recognize complications that present in this unique population. With the simple tools outlined in this article, you should be well prepared to recognize the complication of gastric band slippage.

References

1. Mehanna MJ, Birjawi G, Moukaddam HA, et al. Complications of adjustable gastric banding, a radiological pictorial review. AJR 2006;186:522-34.
2. Pieroni S, Sommer EA, Hito R, et al. The “O” sign, a simple and helpful tool in the diagnosis of laparoscopic adjustable gastric band slippage. AJR 2010;195:137-41.
3. Eid I, Birch DW, et al. Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guide. Can. J. Surg. 2011;54:61-6.
4. Darius T, Aelvoet C, Tollens T, Vanrykel JP. Spontaneous reduction of the prolapsed stomach in a case of anterior band slippage after laparoscopic adjustable gastric banding. Acta. Chir. Belg. 2007;107:710-2.

David Hoffelder, M.D., is an ACEP member and Chief Resident at the University of Wisconsin Emergency Medicine Residency Program. Thomas Meyer, M.D., FACEP, is an Assistant Clinical Professor of Emergency Medicine and Chair of Quality Management at the University of Wisconsin in Madison.