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Small bowel obstruction from small bowel volvulus and gram-positive peritonitis in laparoscopic adjustable gastric banding
Surgery for Obesity and Related Diseases 6 (2010) 211–212
Case report
Small bowel obstruction from small bowel volvulus and gram-positive peritonitis in laparoscopic adjustable gastric banding Walter F. DeNino, B.Sc., Patrick M. Forgione, M.D., F.A.C.S.* Department of Surgery, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, Vermont Received August 4, 2009; revised October 20, 2009; accepted November 30, 2009
As the prevalence of obesity increases, the number of bariatric operations performed increases as well. Laparoscopic adjustable gastric banding (LAGB) presents an attractive option for patients who prefer minimally invasive, adjustable, reversible surgical approach with lower morbidity and mortality than other forms of bariatric surgery. Thus, LAGB is the most commonly performed bariatric procedure in Europe and Australia and growing in popularity in the U.S. [1] However, LAGB is not without complications. Complications are typically related to the port (infection, tube disconnection, dislocation) or band itself (slippage, erosion, pouch dilatation) [2,3]. We report a rare case of small bowel obstruction (SBO) from small bowel volvulus around the band tubing and gram-positive chylous peritoneal fluid following LAGB. Case report A 48-year-old woman was admitted to our institution with a 4-day history of intermittent crampy abdominal pain, nausea, diarrhea, and dehydration. Five months earlier (March 2008), she had undergone laparoscopic adjustable gastric banding (Lap-Band, Allergan AP Standard, Allergan, Irvine, CA) at Fletcher Allen Healthcare (Burlington, VT) using the pars flaccida technique. Before surgery, her body mass index had been 46.0 kg/m2. Her co-morbidities included asthma, irregular menses, and osteoarthritis. Her past surgical history included breast fibroadenoma, cesarean section, meniscal tear repair, and cosmetic surgery. Before the primary adjustment at 6 weeks postoperatively, she had lost 25 kg. A review of systems revealed fever, chills, and flushness. The significant vital signs at admission were a *Correspondence: Patrick M. Forgione, M.D., F.A.C.S., Department of Surgery, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, VT 05401. E-mail: [email protected]
temperature of 37.7°C and a heart rate of 105 bpm. The white blood cell count was 14,500 (95% neutrophils, 1% basophiles, 2% lymphocytes). Examination of the abdomen revealed left upper quadrant tenderness to palpation, distension, and absent bowel sounds. A fluctuant bulge was present at her 15-mm port site that was fluctuant. The remainder of physical examination findings were within normal limits. An acute abdominal series showed air–fluid levels and dilated loops of small bowel with a decompressed colon. Computed tomography of the abdomen and pelvis demonstrated a large amount of free fluid, stranding of the mesentery, and thickened loops of distended bowel throughout, with a decompressed colon. The patient was admitted to our surgical service (Fletcher Allen Healthcare, Burlington, VT), and intravenous fluids and antibiotics were started. The right subcostal port was accessed under fluoroscopic guidance, 3 mL of sterile fluid was removed from the band system, and a nasogastric tube was placed. The cavity adjacent to the port was aspirated, and 5 mL of purulent material was removed and sent for Gram stain and culture. The decision was made to proceed to the operating room for diagnostic laparoscopy and intraoperative esophagogastroduodenoscopy to rule out erosion. In the operating room, the esophagogastroduodenoscope was passed through the banded portion of the stomach, and the scope was retroflexed without evidence of band erosion or gastric necrosis. Cut-down at the 15-mm trocar site capsule revealed 20 mL of purulent-appearing fluid that was aspirated and sent for culture. The fluid grew gamma hemolytic streptococcus (non-enterococcus). An omental fat hernia was present in the 15-mm port site. The omentum was incarcerated and necrotic. On laparoscopy, a large amount of chylous ascites was visualized that was different in color and texture from the fluid seen at the port site. The tubing of the band was very taut because it exited to the left of the stomach along the greater curvature and
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W. F. DeNino & P. M. Forgione / Surgery for Obesity and Related Diseases 6 (2010) 211–212
draped across the abdomen to exit out the right subcostal port. Coursing over the tubing in the left upper quadrant was a segment of small bowel and omentum that was draped and twisted over the Lap-Band tubing. This segment was dilated and thickened, with an inflammatory exudate along its surface. The bowel distal to this area was decompressed and appeared normal. An inflammatory rind was present along the left colic gutter cephalad to the area of omentum overlying the band tubing. The omentum and Lap-Band tubing were adherent to the posterior abdominal wall. On inspection of the entire small bowel, a large amount of fibrinous exudate and multiple collections of tan, murky fluid were discovered. This fluid was sent for Gram stain and culture and grew gamma hemolytic streptococcus. At this point, the case was converted to laparotomy. No evidence of band slippage or gastric perforation was found during the esophagogastroduodenoscopy or gross intraoperative inspection. The band was left in place. The band tubing was cut, the bowel was reduced and untangled, and the tubing was rerouted to a new location. A new port was then repositioned in the left upper quadrant. The remainder of the small bowel to the ileocecal valve appeared normal, as did the appendix. The pelvis contained a large quantity of chylous ascites and was irrigated and suctioned. The fallopian tubes and ovaries appeared normal, as did the entire colon. The patient’s postoperative course was uneventful. She was treated with antibiotics and dressing changes and discharged 7 days later. Discussion Obstruction due to volvulus after bariatric surgery is rare [4]. Chylous ascites in the setting of small bowel obstruction is exceedingly rare [5] and has not been previously reported in a bariatric patient. The pathophysiology involves small bowel mesenteric twisting, leading to obstruction of lymphatic flow, resulting in chylous ascites. In the present patient, a portion of the small bowel and its mesentery was twisted around the tubing of the Lap-Band system, causing symptoms and intraoperative findings similar to those seen with small bowel volvulus. We identified 1 published report of a similar outcome caused by a drainage tube [6]. Five published connecting tube complications have been identified. Of these cases, 3 resulted in small bowel obstruction [7–9]. The remaining cases were related to bowel penetration by the connecting tube [10,11]. To our knowledge, ours is the first reported case of small bowel obstruction caused by mesenteric twisting around the Lap-Band tubing, with resultant gram-positive chylous peritoneal fluid. In the present patient, the purulent exudate aspirated from the 15-mm port site was most likely due to a missed intra-abdominal microperforation and subsequent gammahemolytic streptococcus colonization of the chylous fluid,
because gamma-hemolytic streptococcus is a ubiquitous gastrointestinal pathogen. It was very difficult to grossly differentiate between the fluid found in the 15-mm port site and the chylous gram-positive peritoneal fluid. It is possible that both collections of fluid had the same origin, because the fascia at the 15-mm port site had not been closed at the initial surgery and might have allowed for bidirectional egress of fluid. Although rare, involvement of the small bowel can occur after laparoscopic adjustable gastric banding. We believe the taut tubing behaved similarly to critical adhesions, facilitating mesenteric twisting and subsequent small bowel obstruction. Therefore, we recommend leaving laxity in the tubing to prevent this complication and allow for easier repositioning of the port, if needed. Subsequent to this incident, we have routinely closed the 15-mm fascial defect. Esophagogastroduodenoscopy to rule out band erosion as a cause of late port site infection is essential, although it can miss a microperforation, which we believe happened in the present case. Perhaps it would have been prudent to remove the Lap-Band system all together. However, because the patient has continued to lose weight and has not developed gastric erosion raises the question of whether microperforations can be managed with washout and antibiotics.
References [1] Buchwald H, Williams SE. Bariatric surgery worldwide. Obes Surg 2003;14:1157– 64. [2] Spivak H, Favretti F. Avoiding postoperative complications with the Lap-Band system. Am J Surg 2002;184:31S–7S. [3] Vertruyen M. Experience with Lap-Band system up to 7 years. Obes Surg 2002;12:569 –72. [4] Arbell D, Koplewitz B, Zamir G, Bala M. Midgut volvulus following laparoscopic gastric banding—a rare and dangerous situation. J Laparoscopic Adv Surg Tech A 2007;17:321–3. [5] Scheider GM, Curry J, DeCoppi P, Drake DP. Ascites and secondary bacterial peritonitis associated with small bowel obstruction. Am J Gastroenterol 1994;89:1238 – 40. [6] Rogers AM, Cherenfant J, Kipnis S, Haluck RS. Drain-associated intestinal obstruction after laparoscopic gastric bypass. Obes Surg 2007;17:980 –2. [7] Agahi A, Harle R. A serious but rare complication of laparoscopic adjustable gastric banding: bowel obstruction due to caecal volvulus. Obes Surg 2009;19:1197–200. [8] Zappa MA, Lattuada E, Mozzi E, et al. An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. Obes Surg 2006;16:939 – 41. [9] Shipkov CD, Uchikov AP, Uchikov EH. Small bowel obstruction by the silicone tube of the gastric band. Obes Surg 2004;9:1280 – 82. [10] Zengin K, Sen B, Ozben V, Taskin M. Detachment of the connecting tube from the port and migration into jejunal wall. Obes Surg 2006; 16:206 –7. [11] Hartmann J, Scharfenberg M, Paul M, Ablassmaier B. Intracolonic penetration of the laparoscopic adjustable gastric banding tube. Obes Surg 2006;16:203–5.
Case report
Small bowel obstruction from small bowel volvulus and gram-positive peritonitis in laparoscopic adjustable gastric banding Walter F. DeNino, B.Sc., Patrick M. Forgione, M.D., F.A.C.S.* Department of Surgery, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, Vermont Received August 4, 2009; revised October 20, 2009; accepted November 30, 2009
As the prevalence of obesity increases, the number of bariatric operations performed increases as well. Laparoscopic adjustable gastric banding (LAGB) presents an attractive option for patients who prefer minimally invasive, adjustable, reversible surgical approach with lower morbidity and mortality than other forms of bariatric surgery. Thus, LAGB is the most commonly performed bariatric procedure in Europe and Australia and growing in popularity in the U.S. [1] However, LAGB is not without complications. Complications are typically related to the port (infection, tube disconnection, dislocation) or band itself (slippage, erosion, pouch dilatation) [2,3]. We report a rare case of small bowel obstruction (SBO) from small bowel volvulus around the band tubing and gram-positive chylous peritoneal fluid following LAGB. Case report A 48-year-old woman was admitted to our institution with a 4-day history of intermittent crampy abdominal pain, nausea, diarrhea, and dehydration. Five months earlier (March 2008), she had undergone laparoscopic adjustable gastric banding (Lap-Band, Allergan AP Standard, Allergan, Irvine, CA) at Fletcher Allen Healthcare (Burlington, VT) using the pars flaccida technique. Before surgery, her body mass index had been 46.0 kg/m2. Her co-morbidities included asthma, irregular menses, and osteoarthritis. Her past surgical history included breast fibroadenoma, cesarean section, meniscal tear repair, and cosmetic surgery. Before the primary adjustment at 6 weeks postoperatively, she had lost 25 kg. A review of systems revealed fever, chills, and flushness. The significant vital signs at admission were a *Correspondence: Patrick M. Forgione, M.D., F.A.C.S., Department of Surgery, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, VT 05401. E-mail: [email protected]
temperature of 37.7°C and a heart rate of 105 bpm. The white blood cell count was 14,500 (95% neutrophils, 1% basophiles, 2% lymphocytes). Examination of the abdomen revealed left upper quadrant tenderness to palpation, distension, and absent bowel sounds. A fluctuant bulge was present at her 15-mm port site that was fluctuant. The remainder of physical examination findings were within normal limits. An acute abdominal series showed air–fluid levels and dilated loops of small bowel with a decompressed colon. Computed tomography of the abdomen and pelvis demonstrated a large amount of free fluid, stranding of the mesentery, and thickened loops of distended bowel throughout, with a decompressed colon. The patient was admitted to our surgical service (Fletcher Allen Healthcare, Burlington, VT), and intravenous fluids and antibiotics were started. The right subcostal port was accessed under fluoroscopic guidance, 3 mL of sterile fluid was removed from the band system, and a nasogastric tube was placed. The cavity adjacent to the port was aspirated, and 5 mL of purulent material was removed and sent for Gram stain and culture. The decision was made to proceed to the operating room for diagnostic laparoscopy and intraoperative esophagogastroduodenoscopy to rule out erosion. In the operating room, the esophagogastroduodenoscope was passed through the banded portion of the stomach, and the scope was retroflexed without evidence of band erosion or gastric necrosis. Cut-down at the 15-mm trocar site capsule revealed 20 mL of purulent-appearing fluid that was aspirated and sent for culture. The fluid grew gamma hemolytic streptococcus (non-enterococcus). An omental fat hernia was present in the 15-mm port site. The omentum was incarcerated and necrotic. On laparoscopy, a large amount of chylous ascites was visualized that was different in color and texture from the fluid seen at the port site. The tubing of the band was very taut because it exited to the left of the stomach along the greater curvature and
1550-7289/10/$ – see front matter © 2010 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2009.11.014
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W. F. DeNino & P. M. Forgione / Surgery for Obesity and Related Diseases 6 (2010) 211–212
draped across the abdomen to exit out the right subcostal port. Coursing over the tubing in the left upper quadrant was a segment of small bowel and omentum that was draped and twisted over the Lap-Band tubing. This segment was dilated and thickened, with an inflammatory exudate along its surface. The bowel distal to this area was decompressed and appeared normal. An inflammatory rind was present along the left colic gutter cephalad to the area of omentum overlying the band tubing. The omentum and Lap-Band tubing were adherent to the posterior abdominal wall. On inspection of the entire small bowel, a large amount of fibrinous exudate and multiple collections of tan, murky fluid were discovered. This fluid was sent for Gram stain and culture and grew gamma hemolytic streptococcus. At this point, the case was converted to laparotomy. No evidence of band slippage or gastric perforation was found during the esophagogastroduodenoscopy or gross intraoperative inspection. The band was left in place. The band tubing was cut, the bowel was reduced and untangled, and the tubing was rerouted to a new location. A new port was then repositioned in the left upper quadrant. The remainder of the small bowel to the ileocecal valve appeared normal, as did the appendix. The pelvis contained a large quantity of chylous ascites and was irrigated and suctioned. The fallopian tubes and ovaries appeared normal, as did the entire colon. The patient’s postoperative course was uneventful. She was treated with antibiotics and dressing changes and discharged 7 days later. Discussion Obstruction due to volvulus after bariatric surgery is rare [4]. Chylous ascites in the setting of small bowel obstruction is exceedingly rare [5] and has not been previously reported in a bariatric patient. The pathophysiology involves small bowel mesenteric twisting, leading to obstruction of lymphatic flow, resulting in chylous ascites. In the present patient, a portion of the small bowel and its mesentery was twisted around the tubing of the Lap-Band system, causing symptoms and intraoperative findings similar to those seen with small bowel volvulus. We identified 1 published report of a similar outcome caused by a drainage tube [6]. Five published connecting tube complications have been identified. Of these cases, 3 resulted in small bowel obstruction [7–9]. The remaining cases were related to bowel penetration by the connecting tube [10,11]. To our knowledge, ours is the first reported case of small bowel obstruction caused by mesenteric twisting around the Lap-Band tubing, with resultant gram-positive chylous peritoneal fluid. In the present patient, the purulent exudate aspirated from the 15-mm port site was most likely due to a missed intra-abdominal microperforation and subsequent gammahemolytic streptococcus colonization of the chylous fluid,
because gamma-hemolytic streptococcus is a ubiquitous gastrointestinal pathogen. It was very difficult to grossly differentiate between the fluid found in the 15-mm port site and the chylous gram-positive peritoneal fluid. It is possible that both collections of fluid had the same origin, because the fascia at the 15-mm port site had not been closed at the initial surgery and might have allowed for bidirectional egress of fluid. Although rare, involvement of the small bowel can occur after laparoscopic adjustable gastric banding. We believe the taut tubing behaved similarly to critical adhesions, facilitating mesenteric twisting and subsequent small bowel obstruction. Therefore, we recommend leaving laxity in the tubing to prevent this complication and allow for easier repositioning of the port, if needed. Subsequent to this incident, we have routinely closed the 15-mm fascial defect. Esophagogastroduodenoscopy to rule out band erosion as a cause of late port site infection is essential, although it can miss a microperforation, which we believe happened in the present case. Perhaps it would have been prudent to remove the Lap-Band system all together. However, because the patient has continued to lose weight and has not developed gastric erosion raises the question of whether microperforations can be managed with washout and antibiotics.
References [1] Buchwald H, Williams SE. Bariatric surgery worldwide. Obes Surg 2003;14:1157– 64. [2] Spivak H, Favretti F. Avoiding postoperative complications with the Lap-Band system. Am J Surg 2002;184:31S–7S. [3] Vertruyen M. Experience with Lap-Band system up to 7 years. Obes Surg 2002;12:569 –72. [4] Arbell D, Koplewitz B, Zamir G, Bala M. Midgut volvulus following laparoscopic gastric banding—a rare and dangerous situation. J Laparoscopic Adv Surg Tech A 2007;17:321–3. [5] Scheider GM, Curry J, DeCoppi P, Drake DP. Ascites and secondary bacterial peritonitis associated with small bowel obstruction. Am J Gastroenterol 1994;89:1238 – 40. [6] Rogers AM, Cherenfant J, Kipnis S, Haluck RS. Drain-associated intestinal obstruction after laparoscopic gastric bypass. Obes Surg 2007;17:980 –2. [7] Agahi A, Harle R. A serious but rare complication of laparoscopic adjustable gastric banding: bowel obstruction due to caecal volvulus. Obes Surg 2009;19:1197–200. [8] Zappa MA, Lattuada E, Mozzi E, et al. An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. Obes Surg 2006;16:939 – 41. [9] Shipkov CD, Uchikov AP, Uchikov EH. Small bowel obstruction by the silicone tube of the gastric band. Obes Surg 2004;9:1280 – 82. [10] Zengin K, Sen B, Ozben V, Taskin M. Detachment of the connecting tube from the port and migration into jejunal wall. Obes Surg 2006; 16:206 –7. [11] Hartmann J, Scharfenberg M, Paul M, Ablassmaier B. Intracolonic penetration of the laparoscopic adjustable gastric banding tube. Obes Surg 2006;16:203–5.