Gastric Prolapse following Laparoscopic Adjustable Gastric Banding is a Complication that Every Clinician Must be Aware of! Case Report O Jalil, Rhodri Codd, H Jones, A Kambal, R Radwan, C Patel, A Rasheed Gwent Institute for Minimal Access Therapy Royal Gwent Hospital Newport UK Case Report A 43-year-old lady presented to the medical assessment unit with haematemesis. Her past medical history included mild asthma, hypertension, hypercholesterolemia and a laparoscopic adjustable gastric banding (LAGB) insertion 4 years previously. An urgent upper endoscopy for was carried out without deflection of the band’s balloon. The endoscopy revealed mild erosive gastritis and a large volume of food residue in the stomach. A Barium meal reported a gastric prolapse with no contrast passage beyond the band on the delayed films. No further haematemesis was reported, the patient was completely asymptomatic and was discharged without any specific follow up plans. The patient was re-referred 6 weeks later to the surgical admission unit with vomiting and worsening epigastric pain. Her abdomen was soft with modest epigastric tenderness. The vital signs and all haematological and biochemical parameters were within normal limits. The band was completely deflated and an urgent laparoscopy was organized based on clinical history, epigastric pain, the previous endoscopy report and radiological findings. The laparoscopy revealed dusky oedematous anterior gastric prolapse. The peri-band adhesions were divided and the band was transacted then removed. The intra-abdominal pressure was reduced to 8 mmHg and the stomach appearance improved during the following 10 minutes. The viability of the gastric mucosa was confirmed by intra operative gastroscopy. The patient made a full and un- eventful recovery and was discharged home 5 days later. Discussion Complications associated with laparoscopic adjustable gastric banding (LAGB) include gastric prolapse “most common complication”, oesophageal and gastric pouch dilatation, stomal obstruction, band erosion and port problems. Gastric Prolapse Gastric prolapse is the postoperative development of an overly-large upper gastric pouch. It is often referred to as gastric slippage and often confused with pouch dilatation, this complication can occur anteriorly or posteriorly. Aetiology Management of Gastric Prolapse Gastric necrosis secondary to a LAGB is a very rare but life-threatening complication with only 11 previously reported cases in the literature. The treatment of gastric necrosis usually involves partial or total gastrectomy. The timely emergency laparoscopy and removal of the gastric band lead to the favourable outcome in our case and halted the progression from ischaemia to necrosis. Evolution of Insertion Technique & Reduction of Gastric Prolapse There has been a marked reduction in the rate of prolapse and pouch dilatation following the Introduction of the Pars Flaccida approach and placement of the band posterior to the gastroesophageal junction. The prolapse has fallen from 22% with the Peri-Gastric approach to less than 5% for the Pars Flaccida. Conclusions Our case highlights the importance of keeping a high index of suspicion of the possibility of such complication. Early intervention may avoid serious morbidity and the need for more radical surgery such as gastric resection. Performing an on table gastroscopy at the time of the emergency laparoscopy allowed us to confirm the viability of the gastric mucosa to permit active observation approach rather than resection. Should a conservative approach be followed , it is vital that the patient is observed very closely post-operatively. Despite its rarity, we feel that it is essential for clinicians to be aware of gastric prolapse as potential emergency in patients with gastric bands. Although the symptoms of epigastric pain, vomiting, dysphagia and food intolerance can seem benign they may indicate a potentially life threatening complication. Exercising a high index of suspicion and adopting a low threshold for early laparoscopy with on table gastroscopy can reduce significant morbidity. Gastric prolapse can occur due to technical error at time of placement, mal-eating habits “Patient non-compliance with meal sizes and frequency ” or as a result of band-balloon over-inflation. Failure to identify and repair a hiatal hernia (Cruroplasty) will often lead to improper placement of the band (too far down on the stomach). This, in turn, may lead to severe symptoms of heartburn, or even pouch dilation/band slip. Cruroplasty Gastric Prolapse Pars Flaccida Technique I. The gastric pouch may dilate as shown in the figure due to over- tightening of the band or mal-eating habits (over-eating). Concentric gastric pouch dilitation is typically caused over-tightening of the band and over-eating (Figure.1) II. With time, the pouch may distend further pulling part of the stomach up above the band causing gastric slip “Herniation”. This is a serious complication as the herniated part runs the risks of torsion and gastric necrosis. The diagram represents an anterior gastric herniation (the most common) (Figure.2). III. Un-treated more stomach will herniate above the band leading to obstruction and possible torsion of the part involved (Figure.3). Symptoms of Gastric Prolapse Gastric prolapsed should be suspected when patients who have had a normal postoperative course begin to experience changes in their eating ability. The symptoms are those of partial or complete obstruction and of fluid stasis in the lower oesophagus and upper distended gastric pouch. The symptoms are usually chronic and include heart burn, vomiting, free reflux of fluid into the mouth, dysphagia, coughing, choking spells, wheezing and Inability to tolerate semi-solid food.