Recurrent Pneumonia: The Answer Is in the Esophagus

Abstract

Laparoscopic adjustable gastric banding (LAGB) can impair esophageal peristalsis and relaxation of the lower esophageal sphincter, possibly leading to esophageal dilation. Stomach and esophagus dilation are rare; both are occasional complications of LAGB. Bronchoaspiration can occur as a late complication of gastric band placement, a serious complication that can be prevented by immediate deflation of the gastric band. We describe a case of a 44 year-old male patient who was treated for recurrent respiratory infections for several months and was subsequently found to have megaesophagus on further evaluation. A 44 year-old male with history of laparoscopic adjustable gastric band placement 4 years prior, presented to pulmonary clinic as a consultation for frequent respiratory infections requiring at least 7 courses of antibiotics over few months. He complained of persistent productive cough, exertional dyspnea and chest pain. Rest of review of systems was negative. His physical examination was normal. CT chest showed multiple tiny lung nodules representing a manifestation of recurrent and chronic aspiration and substantially dilated esophagus with fluid in the lumen (image 1). The patient was referred to GI clinic and after thorough evaluation, EGD was done that showed fluid in the lower third of the esophagus, dilated lumen of the lower third of the esophagus with no stenosis or stricture in the entire esophagus. It also showed a 4 cm gastric pouch in the stomach with fluid content proximal to the constriction from the lap band (EGD views are shown in images 2 and 3). Removal of the gastric band was performed with subsequent resolution of his symptoms. LAGB is approved for treatment of morbid obesity with successful outcomes by many bariatric surgeons worldwide. It is preferred due to ease of implementation and low rate of perioperative mortality. Megaesophagus with dysphagia can occur as a long term sequelae of LAGB. The preoperative manometry results cannot predict for its occurrence. The management of megaesophagus caused by LAGB requires band removal in most cases. Clinicians should be made aware of this rare entity when they encounter patients with frequent aspiration who had bariatric procedures. Inquiry about detailed relevant surgical history is also recommended.Figure 1Figure 2Figure 3