Surgery for Obesity and Related Diseases ] (2014) 00–00
Case report
Esophageal rupture: a pseudo-achalasia related delayed complication after laparoscopic adjustable gastric banding Shafaque Shaikh, M.B.B.S., M.R.C.S., Ph.D.a, Simon P.L. Dexter, M.B.B.S., M.D., F.R.C.S.b, Jainudeen K.A. Jameel, M.B.B.S., M.Sc., F.R.C.S.a,* a
Upper GI & Bariatric Surgery Unit, Department of General Surgery, Dewsbury & District Hospital, Mid-Yorkshire Hospitals NHS Trust, Dewsbury, United Kingdom b Department of Upper GI, Bariatric & Minimally invasive Surgery, St. James0 University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom Received September 6, 2013; accepted September 9, 2013
Keywords:
Laparoscopic adjustable gastric banding; Complications; Esophageal dysmotility; Pseudoachalasia; Esophageal rupture
Obesity surgery is now widely prevalent, and laparoscopic adjustable gastric banding (LAGB) is a common procedure in the United Kingdom [1,2] and worldwide. It is a popular choice, both with patients and surgeons, for its ease of performance and reversibility. However, the frequency of this procedure has been steadily declining in recent years, possibly due to the greater acceptance of the sleeve gastrectomy technique. LAGB was originally pioneered in 1990s [3] and has now been around for more than 2 decades. Most of the reported complications after LAGB have been in the first few years after surgery [1,4]. Complications can be related to either the band itself or the port and range from band slippage, band erosion, and band intolerance to port site infection, port erosion, or tubing issues [1,4]. Esophageal dysmotility appears to have a higher incidence in the obese [5]. Pseudo-achalasia, a condition that belongs to the category of esophageal dysmotility disorders and megaesophagus is now becoming an increasingly reported problem postLAGB [6], but its consequences are not well-known. We report a rare complication of an esophageal rupture secondary to longstanding pseudo-achalasia in a patient 12 years postLAGB.
* Correspondence: Jainudeen K. A. Jameel, Upper GI & Bariatric Surgery Unit, Department of General Surgery, Dewsbury & District Hospital, Mid-Yorkshire Hospitals NHS Trust, Halifax Road, Dewsbury, WF13 4 HS, United Kingdom. E-mail:
[email protected]
Case report A 58-year-old partially blind patient presented acutely under the care of physicians with a long-standing cough and chest pain. A chest roentgenogram revealed a widened mediastinum, which triggered a computed tomographic (CT) scan of the thorax (Fig. 1). The CT scan showed a massively dilated esophagus with a small contained perforation. On taking a detailed history, it was found that the patient had undergone an LAGB 12 years earlier. Her postoperative recovery was uneventful, and she was discharged from hospital follow-up 2 years after the operation. She was certain that she had not had any band adjustment for almost 10 years, having achieved a satisfactory weight loss 2 years postsurgery. For the past 3 years, she had been experiencing gradually worsening dysphagia along with episodes of cough, chest pain, and recurrent chest infections. She appeared malnourished on examination, with a body mass index (BMI) of 17kg/m2 A gastrograffin contrast swallow showed no evidence of band slippage or erosion (Fig. 2). The port in the epigastrium was accessed, and the band was deflated with the aspiration of 9 mL. This greatly relieved her symptoms of chest pain and coughing. She was managed conservatively with nasogastric drainage, intravenous antibiotics, complete restriction of oral intake, and total parenteral nutrition. She had regular blood tests to check her inflammatory markers and her nutritional status. She also underwent serial CT scans on a weekly basis to assess the progress of the perforation (Fig. 3). After 3 weeks of conservative
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.09.021
S. Shaikh et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Fig. 1. Megaesophagus (left), air in mediastinum, small contained perforation in distal esophagus, no pleural contamination (right).
management, the perforation had healed, and her nutritional status had improved. She was discharged home once she was tolerating a full diet and was followed in the clinic 3 months later. Her health had improved, and she had gained 13 kg. She requested a band fill to control her weight gain; however, this was denied in the interest of her safety. Discussion With the alarmingly increasing rates of obesity, LAGB has been a popular procedure worldwide. The ideal position of LAGB is at the cardia of the stomach just below the gastroesophageal junction. In the past, it was assumed that LAGB works by limiting the amount of food intake in one sitting by restricting the volume of food that can be accommodated in the small gastric pouch proximal to the band. It was also assumed that this small volume of food stretched the gastric pouch and caused early satiety and gradual emptying of the gastric pouch into the infra-band stomach, causing prolonged intermeal satiety. Recently, however, Burton et al. reported that the mechanism of action of LAGB is far more complex [7]. Their studies using high-resolution video manometry, isotope transit studies, endoscopy, and contrast imaging have increased our understanding on various intraluminal events that occur during food passage after LAGB. Esophageal peristalsis and various feedback mechanisms arising from the lower esophageal contractile segment (LECS) that are vagally mediated have now been proven to play a crucial role in the mediation of satiety and weight loss. Weight loss in the first few months to a year postgastric banding is less compared with other obesity surgical interventions, such as gastric bypass and sleeve
gastrectomy, but despite this, the ease of performing the procedure and its reversible nature are attributes largely responsible for its popularity. The reversibility “benefit” comes with the regain of all lost weight and the increased risk of performing a more definitive procedure such as gastric bypass or sleeve gastrectomy. However, like any other surgical procedure, LAGB is not without its complications. Most complications after LAGB happen relatively early in the postoperative period. Esophageal dysmotility and pseudo-achalasia are recognized delayed complications of LAGB [4,8]. Naef et al. [5] studied the incidence of esophageal dysmotility in obese patients postLAGB and found nearly two-thirds of their patients developing esophageal dilation ranging from moderate to major achalasia-like dilation over a 12-year period. Approximately 4% of their patients developed major achalasia-like dilation of the esophagus as per Dargent’s staging on barium swallow [9]. Although esophageal dysmotility is now recognized as an increasingly common occurrence in obese patients, especially after LAGB, to our knowledge, its presentation with esophageal perforation more than a decade after surgery has not been previously reported. We do not know the preoperative status of our patient’s esophagus, because it was not our practice to perform routine endoscopies or manometric studies before LAGB. However, it is likely that the gastric band, which had 9 mL of fluid removed, was the cause of the obstruction, resulting in achalasia-like dilation of the esophagus. We also do not know why the esophagus perforated. It is possible that the perforation occurred during an episode of reflux-associated coughing, The high intrathoracic pressure achieved during cough, would be transmitted directly to the fluid-filled esophagus, which could at times be obstructed at both ends
Esophageal Rupture / Surgery for Obesity and Related Diseases ] (2014) 00–00
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of esophageal dysmotility and pseudo-achalasia in patients undergoing LAGB, because it is important to consider that there may be an entire cohort of patients who underwent LAGB nearly a decade ago who have developed megaesophagus with its potential complications waiting to happen. The risk of megaesophagus was initially highlighted by Kothari et al. [6] in 2002, when they found 5 of their patients experiencing failed weight loss with associated esophageal dilation. Whether esophageal perforation is a risk only for the minority of patients who develop major undiagnosed pseudo-achalasia merits consideration. Conclusion
Fig. 2. Small esophageal perforation.
in the context of an overtight distal band, and any cricopharyngeal spasm proximally in response to reflux. Although esophageal perforation is a potentially lifethreatening complication, this patient survived because she presented to the hospital soon after the rupture occurred. Had she been under long-term follow-up from her bariatric surgery, pseudo-achalasia may have been picked up earlier from her history and appropriate investigations such as contrast studies and esophageal manometry instituted. Appropriate remedial measures can be taken to prevent such life-threatening events. Resolution of symptoms and return of normal esophageal peristalsis have been reported after timely deflation/removal of LAGB [7,10]. This reinforces the importance of life-long commitment to follow-up in patients who undergo bariatric surgery. Further long-term cohort studies are needed to determine the exact prevalence
Fig. 3. Healed perforation.
Patients with potential symptoms of esophageal dysmotility and pseudo-achalasia after LAGB should be investigated by contrast study with or without esophageal manometry and as soon as achalasia-type changes are noticed, the band fluid should be deflated enough to allow recovery of the esophagus. These patients should be kept under close follow-up, and surgeons should have a low threshold to completely deflate the band or even remove it if symptoms persist to avoid such life-threatening complications. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Alhamdani A, Wilson M, Jones T, et al. Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery. Obes Surg 2012;22:1029–38. [2] Bariatric Times. Available from: https://mail.midyorks.nhs.uk/ exchweb/bin/redir.asp?URL ¼ http://www.freedomfromobesity.net/ assets/latest-news/2012-bariatric-times.pdf. [3] Suter M, Calmes JM, Paroz A, et al. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates. Obes Surg 2006;16:829–35. [4] Owers C, Ackroyd R. A study examining the complications associated with gastric banding. Obes Surg 2013;23:56–9. [5] Naef M, Mouton WG, Naef U, et al. Esophageal dysmotility disorders after laparoscopic gastric banding—an underestimated complication. Ann Surg 2011;253:285–90. [6] Kothari SN, DeMaria EJ, Sugerman HJ, Kellum JM, Meador J, Wolfe L. Lap-band failures: conversion to gastric bypass and their preliminary outcomes. Surgery 2002;131:625–9. [7] Burton P, Brown W. The mechanism of weight loss with laparoscopic adjustable gastric banding: induction of satiety not restriction. Int J Obes 2011;35(Suppl 3)S26–30. [8] Khan A, Ren-Fielding C, Traube M. Potentially reversible pseudoachalasia after laparoscopic adjustable gastric banding. J Clin Gastroenterol 2011;45:775–9. [9] Dargent J. Esophageal dilatation after laparoscopic gastric banding: definition and strategy. Obes Surg 2005;15:843–8. [10] Robert M, Golse N, Espalieu P, et al. Achalasia-like disorder after laparoscopic adjustable gastric banding: a reversible side effect? Obes Surg 2012;22:704–11.
