Gastric Band Slippage and IntestinalObstruction

The aetiology of intestinal obstruction include internal hernias, adhesions, jejunojejunostomy angulations, stenosis at anastomosis, incarcerated ventral or trocar hernia, intussusceptions, bezoars and the procedure-specific problems.

In gastric banding, band slippage and adhesions with a twist around the tubing can result in obstruction. Band slippage was a major concern with the bursa omentalis approach (Fig. 3). Now with the perigastric (pars flaccida) approach, the incidence has dropped to below 5%. The consequence of a slippage, be it anterior, posterior or complete, is a stricture or complete closure of the stoma through the band. The diagnosis is

Figure 4.

Plain abdominal X-ray of slipped band.

Established by a plain abdominal X-ray that would show an abnormal band position and further confirmation can be done with a UGI series or a CT scan (Figs. 4 and 5). Band slippage with obstruction is an acute emergency and would require deflating the band, nasogastric decompression followed by surgery to remove or reposition the band.

Figure 5.

Gastrografin meal showing gastric outlet obstruction due to band slippage.

In patients who undergo an antecolic gastric bypass, the space between the mesentery of the Roux limb and transverse mesocolon called the Petersen’s defect and jejunojenunostomy defect are common sites of herniation (Fig. 6). An added defect through the transverse mesocolon is a potential site for internal hernias with the retrocolic technique. Antecolic Roux limb, routine closure of mesenteric defects, anti-obstruction suturing

Figure 6.

Mesenteric defects through which internal hernia can potentially occur after gastric bypass.

At JJ site, and use of dilating trocars can reduce the incidence of small bowel obstruction in patients undergoing gastric bypass. Patients can present with vague abdominal pain an hour or so after meals or with overt signs of intestinal obstruction, including vomiting, abdominal distention and failure to open bowels and pass flatus. A plain abdominal X-ray will show signs of intestinal obstruction. CT scan aids in confirming the diagnosis: it would show dilated loops of small bowel, mesenteric congestion or twisting call “swirl sign” or free gas if there is a perforation (Fig. 7).

Swirl sign on CT scan.

The principles of management of internal hernia obstruction include nasogastric decompression, fluid resuscitation, early confirmation of diagnosis to prevent gangrene, and surgical exploration. At surgery, a careful adhesiolysis is done followed by identifying the gastrojejunostomy, the duodenojejunal flexure and running the bowel to ileocaecal junction. Any mesenteric defect that is detected is closed with a nonabsorbable suture.

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