Incorrect position on AP radiograph (Fig. 3): Look for the “O” orientation of the band, which is created when a portion of the stomach wall herniates superiorly through the band and

causes a tilt on the horizontal axis. Furthermore, the gastric band will likely be positioned outside of the normal 4 to 58 degree orientation angle in relation to the spine. These findings denote slipping of the gastric band and portend gastric outlet obstruction, requiring immediate surgical consultation as untreated cases can progress to gastric volvulus, tissue necrosis, upper gastrointestinal bleeding, and even perforation.²

Laparoscopic adjustable gastric banding is the most frequently performed bariatric procedure worldwide. Less invasive than other bariatric techniques, it produces effective weight loss while reducing postsurgical comorbidities. However, recent long-term follow-up studies indicate a high rate of overall complications for gastric banding. The most common major band complication and leading cause of reoperation is band slippage, occurring with a frequency of 5%-25%, depending on surgical technique.³

If gastric band slippage is suspected based on symptoms and radiography, urgent surgical treatment is required for reduction of the obstructed and prolapsed stomach. As a temporary measure, the band can be deflated from the subcutaneous port, which may alleviate severe symptoms and help prevent gastric necrosis and perforation.

In one recent case report of a 47-year-old female with laparoscopic gastric banding presenting with severe vomiting, deflation of her gastric band resulted in spontaneous reduction of gastric outlet obstruction.⁴

As North American obesity rates continue to rise, so too does the volume of postbariatric patients presenting to our emergency departments. As emergency physicians, we must be prepared to recognize complications that present in this unique population. With the simple tools outlined in this article, you should be well prepared to recognize the complication of gastric band slippage.

References

1. Mehanna MJ, Birjawi G, Moukaddam HA, et al. Complications of adjustable gastric banding, a radiological pictorial review. AJR 2006;186:522-34.
2. Pieroni S, Sommer EA, Hito R, et al. The “O” sign, a simple and helpful tool in the diagnosis of laparoscopic adjustable gastric band slippage. AJR 2010;195:137-41.
3. Eid I, Birch DW, et al. Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guide. Can. J. Surg. 2011;54:61-6.
4. Darius T, Aelvoet C, Tollens T, Vanrykel JP. Spontaneous reduction of the prolapsed stomach in a case of anterior band slippage after laparoscopic adjustable gastric banding. Acta. Chir. Belg. 2007;107:710-2.

David Hoffelder, M.D., is an ACEP member and Chief Resident at the University of Wisconsin Emergency Medicine Residency Program. Thomas Meyer, M.D., FACEP, is an Assistant Clinical Professor of Emergency Medicine and Chair of Quality Management at the University of Wisconsin in Madison.