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Postoperative acute appendicitis after laparoscopic gastric band placement
Surgery for Obesity and Related Diseases 8 (2012) e49 – e51
Case report
Postoperative acute appendicitis after laparoscopic gastric band placement Nicholas R. Leonardi, D.O.a,*, Rami E. Lutfi, M.D., F.A.C.S.b a
Department of General Surgery, University of Illinois at Chicago, Metropolitan Group Hospitals Residency in General Surgery, Chicago, Illinois b Department of Minimally Invasive Surgery, Mercy Hospital and Medical Center, Chicago, Illinois Received April 6, 2011; accepted April 12, 2011
Since the laparoscopic adjustable gastric banding (LAGB) system was approved for use in the United States in 2001, its use has increased steadily. A recent worldwide survey revealed the LAGB accounted for 24% of obesity operations [1]. Band infection from erosion of the band and the tubing has been well described [2–5]. The management of such complications with gross contamination of the band has been agreed on, with removal of the band, with or without antibiotics [3, 6]. However, management of acute, nonbandrelated intra-abdominal infection after band placement has not been well described, and the appropriate management is unclear. We report a case of early appendicitis 2 weeks after uneventful LAGB placement. Case report A 38-year-old woman with a body mass index of 43 kg/m2 presented to the emergency room 16 days after laparoscopic placement of an AP standard LapBand (Allergan, Irvine, CA) and repair of hiatal hernia. Her chief complaint was right-sided abdominal pain with nausea and vomiting for 1 day. She was otherwise healthy, with tubal ligation as her only previous surgery. On presentation, she was febrile at 38.7°C and tachycardic at 118 beats/min, but normotensive. She was not in distress, but she appeared uncomfortable, with right-sided tenderness without rebound. All her wounds were well healed.
*Correspondence: Nicholas R. Leonardi, D.O., Department of General Surgery, Metropolitan Group Hospitals Residency in General Surgery, 836 West Wellington Avenue, Room 4807, Chicago, IL 60657. E-mail: [email protected]
Her laboratory values were all normal, except for an elevated white blood cell count of 11.2 ⫻ 103/L, with a left shift of 74% neutrophils. Computed tomography of the abdomen and pelvis showed an expected small amount of fluid and fat stranding around the port. Evidence was also seen of acute appendicitis. A small amount of free pelvic fluid was present (Figs. 1 and 2). Laparoscopic appendectomy was proposed, along with the recommendation to remove the band and port at surgery to prevent infectious complications. The patient strongly wished to keep her band in place and elected to undergo only appendectomy, with the knowledge that this would put her at risk of delayed band infection, which would necessitate additional explant surgery. Laparoscopic appendectomy was performed with all new port sites, and care was taken to avoid violating the subcutaneous port. An inflamed vermiform appendix was found that was nonsuppurative and not perforated. The upper abdomen was inspected, and well-formed adhesions were found in the gastrohepatic region, sequestering the band. No intra-abdominal pus was present. The appendectomy was performed, and the LapBand was left in place. The patient was given intravenous antibiotics (cefoxitin) for 2 days and then discharged with oral amoxicillin-clavulanate for 2 weeks. Pathologic examination revealed acute appendicitis with periappendicitis. She returned to the emergency room on postoperative day 16 (postoperative day 32 from band placement) complaining of anorexia, nausea, emesis, and persistent leftsided abdominal pain. She was afebrile, but slightly tachycardic (pulse 104). Her abdomen was benign, with the exception of mild tenderness around the port, but without cellulitis or fluctuance. Her white blood cell count was normal (7.7 ⫻ 103/L), without a left shift (neutrophils
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.04.225
e50
N. R. Leonardi and R. E. Lutfi / Surgery for Obesity and Related Diseases 8 (2012) e49 – e51
Fig. 1. Computed tomography demonstrating acute appendicitis. Arrow points to inflamed, dilated vermiform appendix.
70.3%). Urinalysis showed a urinary tract infection (positive for Trichomonas). Computed tomography of the abdomen and pelvis demonstrated “slightly worsened stranding of the fat planes surrounding the subcutaneous band port, including organizing, enhancing soft tissue components suggestive of cellulitis and phlegmon formation.” More extensive stranding and edema were present within the omental fat, with an increase in the volume of free fluid in the pelvis and some abnormal enhancement of the peritoneum within the pelvis (Fig. 3). Given her symptoms and computed tomography findings, a preoperative diagnosis of a port, and possible, band infection was made, and the patient underwent laparoscopic explant of the band and port. No gross evidence was found of band or port infection, and the intraoperative cultures did not reveal any organisms on Gram stain or growth on culture.
Fig. 2. Computed tomography of the abdomen and pelvis demonstrated an expected small amount of fluid and fat stranding around the port. The arrow points to the port tubing.
Fig. 3. Post appendectomy computed tomography demonstrates slightly worsened stranding of the fat planes surrounding the subcutaneous band port, including organizing, enhancing soft tissue components suggestive of cellulitis and phlegmon formation. The arrow points to the port tubing.
The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. She made a complete recovery during follow-up and resumed her diet and exercise with plans for LAGB replacement in the near future. Discussion Although many infections are related to the actual LAGB procedure, such as wound infection and erosion or perforation, incidental unrelated intra-abdominal infections can occur and pose a dilemma regarding how to manage the band as a foreign body. Although it is clear that band removal is required with gross enteric soilage, a paucity of information is available regarding the management of nonperforative transmural inflammatory conditions such as appendicitis, uncomplicated diverticulitis, and Crohn’s ileitis. It seems reasonable that any condition in which bacterial translocation can occur would put the band at risk of infection. One report from New York Methodist Hospital described intragastric band erosion because of uncomplicated diverticulitis [7]. It was thought that a subacute band infection from the intra-abdominal sepsis resulted in the erosion. After a trial of intravenous antibiotics, persistent abdominal symptoms led to removal of the band. Their recommendations were close follow-up of band patients with an intraabdominal infection owing to the risk of a subacute band infection [7]. Additional support for band removal in scenarios such as this is found in a histologic study of periprosthesic tissue taken from patients undergoing repeat surgery for intragastric band migration. That study showed histologic changes that did not appear to account for the endoluminal migration of the gastric band and, possibly, even demon-
Postoperative Acute Appendicitis After LAGB / Surgery for Obesity and Related Diseases 8 (2012) e49 – e51
strated a biologic periprosthesic wall that separates and protects the gastric wall from the band. The investigators of that study suggested that band erosion could have a closer correlation with other causes, such as infection or intraoperative surgical damage [8]. In the present case, the band was removed because of the clinical history and computed tomography findings suspicious for port infection. Intraoperative cultures, however, did not show any evidence of true infection. It is not clear whether this was a result of the prophylactic antibiotics the patient was taking or, in fact, the patient did not actually have a true band infection. Although we strongly believe in the need for bariatric surgery for the morbidly obese, it remains an elective procedure, and the operative risks should be minimized to improve the overall outcome. Thus, we recommend always explanting the band when gross soilage and peritonitis are present. We also recommend a low threshold for band removal when operating to treat nonsuppurative intra-abdominal infection. At a minimum, the patient should be educated about this option because of the possibility of future band infection if the band is left in situ. Our patient was disappointed but ultimately satisfied, because she had the expectation of possibly having the band explanted. More reported cases are needed to have guidelines placed when managing such problems. Until then, we advise caution when deciding to leave the band in situ with an active abdominal infection. The key point is to discuss with the patients their options and to educate them about the
e51
possibility of needing future explant surgery should they decide to keep their band.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Buchwald H, Williams SE. Bariatric surgery worldwide. Obes Surg 2003;14:1157– 64. [2] Navarra G, Musolino C, Centorrino T, De Marco ML, Sarra G, Currò G. Perforation of an adjustable gastric banding connecting tube into distal transverse colon with intra-luminal migration. Obes Surg 2009; 19:125–7. [3] Lattuada E, Zappa MA, Mozzi E, et al. Band erosion following gastric banding: how to treat it. Obes Surg 2007;17:329 –33. [4] Tekin A. Migration of the connecting tube into small bowel after adjustable gastric banding. Obes Surg 2010;20:526 –9. [5] Hartmann J, Scharfenberg M, Paul M, Ablassmaier B. Intracolonic penetration of the laparoscopic adjustable gastric banding tube. Obes Surg 2006;16:203–5. [6] Lattuada E, Zappa MA, Mozzi E, Antonini I, Boati P, Roviaro GC. Injection port and connecting tube complications after laparoscopic adjustable gastric banding. Obes Surg 2010;20:410 – 4. [7] Naim HJ, Gorecki PJ, Wise L. Early lap-band erosion associated with colonic inflammation: a case report and literature review. JSLS 2005; 9:102– 4. [8] Lattuada E, Zappa MA, Mozzi E, et al. Histologic study of tissue reaction to the gastric band: does it contribute to the problem of band erosion? Obes Surg 2006;16:1155–9.
Case report
Postoperative acute appendicitis after laparoscopic gastric band placement Nicholas R. Leonardi, D.O.a,*, Rami E. Lutfi, M.D., F.A.C.S.b a
Department of General Surgery, University of Illinois at Chicago, Metropolitan Group Hospitals Residency in General Surgery, Chicago, Illinois b Department of Minimally Invasive Surgery, Mercy Hospital and Medical Center, Chicago, Illinois Received April 6, 2011; accepted April 12, 2011
Since the laparoscopic adjustable gastric banding (LAGB) system was approved for use in the United States in 2001, its use has increased steadily. A recent worldwide survey revealed the LAGB accounted for 24% of obesity operations [1]. Band infection from erosion of the band and the tubing has been well described [2–5]. The management of such complications with gross contamination of the band has been agreed on, with removal of the band, with or without antibiotics [3, 6]. However, management of acute, nonbandrelated intra-abdominal infection after band placement has not been well described, and the appropriate management is unclear. We report a case of early appendicitis 2 weeks after uneventful LAGB placement. Case report A 38-year-old woman with a body mass index of 43 kg/m2 presented to the emergency room 16 days after laparoscopic placement of an AP standard LapBand (Allergan, Irvine, CA) and repair of hiatal hernia. Her chief complaint was right-sided abdominal pain with nausea and vomiting for 1 day. She was otherwise healthy, with tubal ligation as her only previous surgery. On presentation, she was febrile at 38.7°C and tachycardic at 118 beats/min, but normotensive. She was not in distress, but she appeared uncomfortable, with right-sided tenderness without rebound. All her wounds were well healed.
*Correspondence: Nicholas R. Leonardi, D.O., Department of General Surgery, Metropolitan Group Hospitals Residency in General Surgery, 836 West Wellington Avenue, Room 4807, Chicago, IL 60657. E-mail: [email protected]
Her laboratory values were all normal, except for an elevated white blood cell count of 11.2 ⫻ 103/L, with a left shift of 74% neutrophils. Computed tomography of the abdomen and pelvis showed an expected small amount of fluid and fat stranding around the port. Evidence was also seen of acute appendicitis. A small amount of free pelvic fluid was present (Figs. 1 and 2). Laparoscopic appendectomy was proposed, along with the recommendation to remove the band and port at surgery to prevent infectious complications. The patient strongly wished to keep her band in place and elected to undergo only appendectomy, with the knowledge that this would put her at risk of delayed band infection, which would necessitate additional explant surgery. Laparoscopic appendectomy was performed with all new port sites, and care was taken to avoid violating the subcutaneous port. An inflamed vermiform appendix was found that was nonsuppurative and not perforated. The upper abdomen was inspected, and well-formed adhesions were found in the gastrohepatic region, sequestering the band. No intra-abdominal pus was present. The appendectomy was performed, and the LapBand was left in place. The patient was given intravenous antibiotics (cefoxitin) for 2 days and then discharged with oral amoxicillin-clavulanate for 2 weeks. Pathologic examination revealed acute appendicitis with periappendicitis. She returned to the emergency room on postoperative day 16 (postoperative day 32 from band placement) complaining of anorexia, nausea, emesis, and persistent leftsided abdominal pain. She was afebrile, but slightly tachycardic (pulse 104). Her abdomen was benign, with the exception of mild tenderness around the port, but without cellulitis or fluctuance. Her white blood cell count was normal (7.7 ⫻ 103/L), without a left shift (neutrophils
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.04.225
e50
N. R. Leonardi and R. E. Lutfi / Surgery for Obesity and Related Diseases 8 (2012) e49 – e51
Fig. 1. Computed tomography demonstrating acute appendicitis. Arrow points to inflamed, dilated vermiform appendix.
70.3%). Urinalysis showed a urinary tract infection (positive for Trichomonas). Computed tomography of the abdomen and pelvis demonstrated “slightly worsened stranding of the fat planes surrounding the subcutaneous band port, including organizing, enhancing soft tissue components suggestive of cellulitis and phlegmon formation.” More extensive stranding and edema were present within the omental fat, with an increase in the volume of free fluid in the pelvis and some abnormal enhancement of the peritoneum within the pelvis (Fig. 3). Given her symptoms and computed tomography findings, a preoperative diagnosis of a port, and possible, band infection was made, and the patient underwent laparoscopic explant of the band and port. No gross evidence was found of band or port infection, and the intraoperative cultures did not reveal any organisms on Gram stain or growth on culture.
Fig. 2. Computed tomography of the abdomen and pelvis demonstrated an expected small amount of fluid and fat stranding around the port. The arrow points to the port tubing.
Fig. 3. Post appendectomy computed tomography demonstrates slightly worsened stranding of the fat planes surrounding the subcutaneous band port, including organizing, enhancing soft tissue components suggestive of cellulitis and phlegmon formation. The arrow points to the port tubing.
The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. She made a complete recovery during follow-up and resumed her diet and exercise with plans for LAGB replacement in the near future. Discussion Although many infections are related to the actual LAGB procedure, such as wound infection and erosion or perforation, incidental unrelated intra-abdominal infections can occur and pose a dilemma regarding how to manage the band as a foreign body. Although it is clear that band removal is required with gross enteric soilage, a paucity of information is available regarding the management of nonperforative transmural inflammatory conditions such as appendicitis, uncomplicated diverticulitis, and Crohn’s ileitis. It seems reasonable that any condition in which bacterial translocation can occur would put the band at risk of infection. One report from New York Methodist Hospital described intragastric band erosion because of uncomplicated diverticulitis [7]. It was thought that a subacute band infection from the intra-abdominal sepsis resulted in the erosion. After a trial of intravenous antibiotics, persistent abdominal symptoms led to removal of the band. Their recommendations were close follow-up of band patients with an intraabdominal infection owing to the risk of a subacute band infection [7]. Additional support for band removal in scenarios such as this is found in a histologic study of periprosthesic tissue taken from patients undergoing repeat surgery for intragastric band migration. That study showed histologic changes that did not appear to account for the endoluminal migration of the gastric band and, possibly, even demon-
Postoperative Acute Appendicitis After LAGB / Surgery for Obesity and Related Diseases 8 (2012) e49 – e51
strated a biologic periprosthesic wall that separates and protects the gastric wall from the band. The investigators of that study suggested that band erosion could have a closer correlation with other causes, such as infection or intraoperative surgical damage [8]. In the present case, the band was removed because of the clinical history and computed tomography findings suspicious for port infection. Intraoperative cultures, however, did not show any evidence of true infection. It is not clear whether this was a result of the prophylactic antibiotics the patient was taking or, in fact, the patient did not actually have a true band infection. Although we strongly believe in the need for bariatric surgery for the morbidly obese, it remains an elective procedure, and the operative risks should be minimized to improve the overall outcome. Thus, we recommend always explanting the band when gross soilage and peritonitis are present. We also recommend a low threshold for band removal when operating to treat nonsuppurative intra-abdominal infection. At a minimum, the patient should be educated about this option because of the possibility of future band infection if the band is left in situ. Our patient was disappointed but ultimately satisfied, because she had the expectation of possibly having the band explanted. More reported cases are needed to have guidelines placed when managing such problems. Until then, we advise caution when deciding to leave the band in situ with an active abdominal infection. The key point is to discuss with the patients their options and to educate them about the
e51
possibility of needing future explant surgery should they decide to keep their band.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Buchwald H, Williams SE. Bariatric surgery worldwide. Obes Surg 2003;14:1157– 64. [2] Navarra G, Musolino C, Centorrino T, De Marco ML, Sarra G, Currò G. Perforation of an adjustable gastric banding connecting tube into distal transverse colon with intra-luminal migration. Obes Surg 2009; 19:125–7. [3] Lattuada E, Zappa MA, Mozzi E, et al. Band erosion following gastric banding: how to treat it. Obes Surg 2007;17:329 –33. [4] Tekin A. Migration of the connecting tube into small bowel after adjustable gastric banding. Obes Surg 2010;20:526 –9. [5] Hartmann J, Scharfenberg M, Paul M, Ablassmaier B. Intracolonic penetration of the laparoscopic adjustable gastric banding tube. Obes Surg 2006;16:203–5. [6] Lattuada E, Zappa MA, Mozzi E, Antonini I, Boati P, Roviaro GC. Injection port and connecting tube complications after laparoscopic adjustable gastric banding. Obes Surg 2010;20:410 – 4. [7] Naim HJ, Gorecki PJ, Wise L. Early lap-band erosion associated with colonic inflammation: a case report and literature review. JSLS 2005; 9:102– 4. [8] Lattuada E, Zappa MA, Mozzi E, et al. Histologic study of tissue reaction to the gastric band: does it contribute to the problem of band erosion? Obes Surg 2006;16:1155–9.