S6325 Twenty Years Later, Trouble Returns: Late-Onset Gastric Band Erosion Unmasked

Introduction: We describe a rare case of acute abdominal pain initially misdiagnosed as acute cholecystitis, which was ultimately found to be gastric band erosion occurring 20 years after Laparoscopic adjustable gastric band (LAGB) placement, complicated by abscess formation along the epithelialized tract. Case Description/Methods: A woman in her 60s came to the emergency department (ED) complaining of severe abdominal pain, fever and chills. Patient has a past history of LAGB placement 20 years ago. Upon arrival, she was vitally stable. Physical examination showed the epigastric and right upper quadrant tenderness. Labs showed white blood cells (WBCs) 22.6 × 10*3 u/L with 90% neutrophilia. Computed tomography (CT) abdomen/pelvis showed unremarkable gastric band. The ultrasound of the abdomen showed nonspecific gallbladder wall thickening. Patient was managed for acute cholecystitis. Next day, her labs showed C-reactive protein 308 mg/L, ESR >130 mm/hr, WBCs 20.8 × 10*3 u/L. HIDA scan was normal. Due to worsening abdominal pain esophagogastroduodenoscopy (EGD) was performed showing band erosion into the stomach. Laparoscopy revealed the band erosion of 50% into the stomach, intra-abdominal abscess throughout the epithelized tubing track. The band was removed, abscesses were drained, and a partial gastrectomy was performed. Next day, she had worsening right upper quadrant pain. Upper GI series showed leak at lesser curvature, managed conservatively. Following day, she spiked a fever with white blood cell increased to 25 × 10*3 u/L. Computed tomography (CT) abdomen/pelvis with intravenous contrast showed no contrast leak, no evidence of drainable collection, but some fluid in the right upper abdominal wall. Bedside IandD yielded purulent drainage. Patient improved thereafter. Discussion: Highlight this case is gastric band erosion after 20 years of LAGB placement. It is frequently associated with the cessation of weight loss, and progressive weight regain. However, this symptom is often attributed to late procedural failure—an interpretation that may lead clinicians to under-look erosion as a possible cause due to it occurring relatively earlier in the course. Another takeaway point in our study is that CT scan failed to show band erosion and diagnosis of band erosion is made through direct exploration by endoscopy. CT scan is sensitive (88%) to diagnose gastric band erosion, endoscopy is gold standard (100%). We emphasize here that band erosion and other complications of LAGB must be taken into consideration even decades after its placement. Although imaging modalities are good at diagnosing this, endoscopy should be considered after the common conditions are ruled out or even before, if suspicion is very high.