Gastric banding adjustment catheter dislodgement and perforation into the colon: case report

Introduction

The laparoscopic implantation of an adjustable gastric banding (LAGB) was first described by Belachew et al. in 1994 (1). The method has been one of the most popular bariatric procedures in the 90s and 2000s due to its minimal invasivity, reversibility, safety and effectivity. An overall-complication rate of 10–20% has been reported in the long term (2-5). Complications are related either to the band such as band slippage, pouch dilation, band erosion, intraluminal band migration or to the port-adjustment tube system such as infection, tube disconnection and dislocation (5-11). Intraluminal penetration of the dislodged adjustment tube into the small intestine or into the colon is extremely rare. Our present case is the third report of an intracolonic penetration of the gastric band adjustment tube (12,13). We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-240/rc).

Case presentation

A 66-year-old female patient [initial weight 138 kg, height 168 cm, body mass index (BMI) 48.5 kg/m²] had an adjustable gastric band (Lap-Band^®, Bioenterics, Carinteria, CA, USA) inserted at the age of 39, back in 1997. The postoperative course was uncomplicated, the patient lost 60 kg weight within one and a half years and reached a BMI of 27.6 kg/m². Because of cosmetically disturbing skin-folds, a dermolipectomy of the ilio-lumbosacral region and an abdominoplasty were performed. The gastric band was completely deflated 9 years after implantation and until 2023, it gradually came to a weight gain of 16 kg (height: 165 cm, weight 94 kg, BMI: 34.5 kg/m²). In 2013, a cholecystectomy had to be performed because of an acute cholecystitis.

In December 2023, 26 years after the implantation of the gastric banding system, the patient was investigated with prolonged coughing. A thoracic computed tomography (CT) scan revealed a tumor of the lower lobe of the right lung measuring 50 mm (Stadium T3, N0). Histological sampling proved a squamous cell bronchial carcinoma. The staging was completed by performing a positron emission tomography-computed tomography (PET-CT), which showed the dislodged adjustment catheter of the gastric band penetrating into the descending colon. A multidetector CT scan of the abdomen showed the catheter lying subphrenic and forming a small loop near by the spleen, before perforating the colon (Figures 1,2). We identified the entering site of the catheter during colonoscopy in the region of the left colonic flexure. A length of about 20 cm of the catheter was located in the lumen of the descending colon, without any sign of inflammation at the perforation site (Figures 3,4). Besides colon diverticulosis, several diverticula could be seen endoscopically in the region of the entering site of the catheter. Since the patient was asymptomatic regarding the penetrated adjustment catheter, she was primarily treated on the lung carcinoma. A thoracoscopic lobectomy and mediastinal lymphadenectomy were performed, followed by adjuvant chemotherapy and immuno-chemotherapy. Thereafter, the gastric band was removed laparoscopically. The catheter could not be prepared free on the entire length due to extended adhesions near to the suspected colonic entering site so that it had to be cut through and could only be removed partially. The day after the surgery, the remaining part of the catheter passed spontaneously via rectum. The patient remained asymptomatic during the postoperative observation, so that we supposed a spontaneous closure of the colonic perforation site. No further endoscopic or surgical treatment was needed. The patient remained symptomless also on further follow-up after 4 weeks.

Figure 1 Dislodged adjustment catheter. The visualized sections of the tube are marked with white stars subphrenic, near the spleen and in the descending colon. Contrast enhanced abdominal computed tomography (CT), frontal plane.

Figure 2 Visualized section of the catheter marked with a white star, forming a loop near the spleen. Contrast enhanced abdominal computed tomography (CT), coronal plane.

Figure 3 Endoscopic view of the catheter perforation site in the left colonic flexure.

Figure 4 Endoscopic view of the penetrated catheter in the descending colon.

All procedures performed in this case report were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

LAGB is a bariatric procedure that has lost popularity in the last two decades. At 10 years, up to 50% of patients with LAGB may require band removal with or without conversation to another bariatric procedure, usually a Roux-en-Y gastric bypass (14). Dislodgement of the adjustment catheter is a relatively rare complication of the method. Our present publication is the third published case report about a colonic perforation by the catheter tip and penetration of the dislodged catheter into the colon (12,13). In the case presented by Hartmann et al., the port had to be removed by an infection with abscess around the port. The remaining tube was shortened and replaced in the abdominal cavity with the intent of inserting a new port system an interval. After one year, the patient was admitted for the planned implantation of the new port. The laparoscopy revealed extensive adhesions and the adjustment tube penetrating the transverse colon. This patient was in good general health, however, she complained of continuous dull pain in the left upper abdomen (12). In the case published by Navarra et al., 3 years after gastric band insertion, an abdominoplasty was performed, where the port was accidentally disconnected from the connecting tube and removed. During the following year, the patient noted the appearance of the connecting tube through the anus during defecation, he was otherwise asymptomatic (13). In our case, the cause of the tube disconnection and migration remained unclear. However, the catheter dislodgement may eventually have occurred at the abdominoplasty or at the cholecystectomy. Port infection is also thought to facilitate such a process; however, our patient showed no clinical signs of an infection, and there were no signs of an inflammation detected at the port explantation either. We revealed a colonic diverticulosis at the colonoscopy with several diverticula in the region of the penetration site. We suppose, that the perforation site eventually may have been a diverticulum, as a potential “locus minoris resistentiae”, and together with bowel and respiratory movements may have played a role in developing this complication. The patient remained asymptomatic, we revealed the catheter dislodgement and penetration randomly in the course of a tumor staging of a newly diagnosed lung cancer. Clinical diagnosis of a complication after LAGB may be difficult, because signs and symptoms are often non-specific or even absent (13). CT scans showed a subphrenic course of the adjustment tube with looping near by the spleen before penetrating into the colon in the left flexure. The catheter could only be removed partially during the laparoscopy, the rest of the catheter passed spontaneously via rectum. As the patient remained symptomless postoperatively, we suppose a fast spontaneous closure of the entering site due to a trans-mesenteric catheter penetration into the colon. Otherwise the patient would have shown signs of an acute peritonitis after the spontaneous transrectal catheter passage. If the laparoscopically not removable part of the tube had remained on site, we would have tried to remove it endoscopically combined with and endoscopic closure of the perforation site.

Conclusions

Catheter dislodgement and bowel penetration by the sharp tip of the adjustment tube is extremely rare after gastric band implantation. Since abdominal operations after gastric banding may lead to such a complication, which may remain asymptomatic, performing radiological imaging to control the position of the adjustment tube after operations affecting the abdominal cavity or the abdominal wall should be considered. In general, relevant complications after gastric band implantation may remain undetected. During long-term follow up, occasionally performed imaging should be considered also in asymptomatic patients with implanted gastric banding system.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-240/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-240/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-240/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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