1839 From the Lap to the Lung: The Esophagus Is the Answer

Abstract

INTRODUCTION: Esophageal pathologies are significant yet under-reported complications of laparoscopic adjustable gastric banding (LAGB). We report a case of LAGB-associated esophageal dilatation and dysmotility that resulted in multifocal aspiration pneumonia (PNA) and a lung abscess 8 years after LAGB. CASE DESCRIPTION/METHODS: A 48-year-old morbidly obese man who underwent LAGB in 2011 presented with productive cough, dyspnea, and pleuritic chest pain for 3 weeks. He also reported intermittent postprandial gastric reflux and regurgitation of food since his LAGB, which he had been managing with lifestyle modifications. In the Emergency Room, he was febrile to 102F with leukocytosis to 16.8k/uL. CT chest revealed a fluid-filled esophagus (Figure 1) and a thick-walled cavity in the right lower lobe with an air-fluid level, consistent with a lung abscess (Figure 2). Additional consolidations were seen in the bilateral upper lobes. An esophagram was done due to a suspicion for aspiration PNA, and this confirmed a dilated distal esophagus (Figure 3) with impaired peristalsis and nonpropulsive contractions indicative of dysmotility. The patient’s esophageal pathologies and multifocal PNA were determined to be complications from his LAGB. He completed 3 weeks of antibiotics and was discharged with bariatric follow up for revision or removal of his LAGB. DISCUSSION: LAGB has several advantages over other bariatric procedures including band adjustability, reversibility, and small surgical risk. Despite this, the prevalence of LAGB has declined significantly due to several long-term complications including esophageal pathologies. In fact, one study reported esophageal dysmotility in 68% and esophageal dilatation in 25% of patients 5-7 years after LAGB. Esophageal dilatation is thought to occur from an overly tight band and in patients who overeat and use their distal esophagus as a food reservoir. This results in unsynchronized esophageal contractions and, thus, dysmotility. These patients may report reflux, vomiting, and regurgitation, which put them at high risk for aspiration PNA and, more rarely, complications such as lung abscesses. Patients who present with aspiration PNA or lung abscesses require antibiotics, but esophageal pathology alone should lead to consideration of band deflation or removal in order to prevent future recurrences. This case of LAGB-associated esophageal dysfunction highlights the importance of long-term monitoring of LAGB patients, especially in the setting of continued reflux or regurgitation.