Open Journal of Gastroenterology, 2011, 1, 1-6 OJGas
doi: 10.4236/ojgas.2011.11001 Published Online August 2011 (http://www.SciRP.org/journal/ojgas/).
Published Online August 2011 in SciRes. http://www.scirp.org/journal/OJGas
Emergency gastrectomy for gastric necrosis 5 years after
laparoscopic adjustable gastric banding (LAGB)
Rani Kanthan1, Jenna-Lynn Senger1, Selliah Chandra Kanthan2
1Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Canada;
2Department of Surger y, University of Saskatchewan, Saskatoon, Canada.
Received 27 June 2011; revised 3 August 2011; accepted 10 August 2011.
ABSTRACT
Laparoscopic adjustable gastric banding (LAGB) is
currently one of the most common bariatric surgical
procedures performed worldwide for the treatment
of morbid obesity. Among bariatric surgeries, the
percentage of LAGB has increased from 24.4% to
42.3%. In North America alone, the number of LAGB
procedures has increased exponentially by 944.2%
(from 9,270 to 96, 800 cases). Though early and late
complications following LAGB are well-understood,
data regarding long term complications remains in-
definite due to the limited follow-up periods. We re-
port a case of acute gastric necrosis associated with
band slippage presenting as a surgical emergency five
years after LAGB. Gastric necrosis represents a rare,
but life threatening complication of gastric banding
that has been reported in the early post-operative pe-
riod. To the best of our knowledge, this case report is
the longest time-interval reported between LAGB and
the diagnosis of this very rare complication. Accurate
diagnosis is often delayed due to its rarity and non-
specific clinical presentation. Increased awareness of
this delayed complication should facilitate early recog-
nition as it often requires urgent surgical interven-
tion to prevent fatal outcomes.
Keywords: LAGB; Gastric Necrosis; Band Slippage
1. INTRODUCTION
Since its introduction in 1993, worldwide, more than
100,000 laparoscopic adjustable gastric banding (LAGB)
procedures have been performed as the surgical treat-
ment of choice for morbid obesity [1]. Features includ-
ing the a) ease of the procedure, b) minimally invasive
nature, c) the potential reversibility, and d) the ability to
calibrate the stoma contribute to the continued growing
popularity of this technique [2]. Early or late complica-
tions related to LAGB include band slippage, pouch
dilatation, band erosion, gastric perforation, injection-
port malfunctio n and rarely gastric ne crosis [3]. Though,
specific late complications associated with this proce-
dure are recognized in 10% - 20% of cases [1] the data
remains incomplete due to limited follow-up periods.
Gastric necrosis is a very rare complication that is po-
tentially life threatening and constitutes an absolute sur-
gical emergency with dire consequences if unrecognized.
Including this report, a total of eighteen cases have been
reported in the literature (Table 1) [1-16].
We report the case of a patient who, five years after
LAGB, presented with vague abdominal symptoms to
the Emergency Room (ER) on two occasions prior to
being accurately diagnosed as gastric pouch necrosis
which necessitated urgent surgical intervention.
2. CASE REPORT
A 46-year-old woman presented to our emergency de-
partment with progressive abdominal pain, abdominal
distension, nausea and vomiting. Abdominal examina-
tion showed mild tenderness in the epigastrium on pal-
pation with no other positive signs. She had been to the
ER on two previous occasions in the past few weeks for
similar complaints. Relevant past history included a
laparoscopic adjustable gastric band placement in Mex-
ico five years ago for weight reduction (225 lbs). Due to
the repeated visits and the persistence of symptoms over
24 hours a surgical consult with radiological investiga-
tions were undertaken.
Plain films of the abdomen confirmed the presence of
a LAGB attached to its external port as seen in Figure 1.
A contrast enhanced abdominal CT scan revealed mark-
edly dilated esophagus (Figure 2a) and stomach with a
distal migration of the LAG band (Figure 2b) at the py-
lorus (Figure 2c). An abnormal enhancement pattern
with early ‘target sign’ of alternating layers of high and
low attenuation suggestive of submucosal edema and/or
hemorrhage in keeping with mucosal ischemia is de-

R. Kanthan et al. / Open Journal of Gastroenterology, 2011, 1, 1-6 2
Figure 1. Plain x-ray abdomen demonstrates the presence of
adjustable gastric band (AGB) and port.
Figure 2. Contrast enhanced helical-axial images—CT scan of
the abdomen demonstrating a) marked distension of the eso-
phagus (*) posterior to the heart, b) LAGB (*) seen in the dis-
tal portion of the dilated stomach, c) LAGB position confirmed
to be at the pylorus (*) and d) early ‘target sign’ (arrow )
with alternating layers of high and low attenuation suggestive
of submucosal edema and/or hemorrhage in keeping with mu-
cosal ischemia is identified.
monstrated in Figure 2d. The CT scan confirmed gastric
outlet obstruction with query migration/slippage of the
LAGB and the suggestion of intramural gas raised the
strong suspicion of imminent gastric ischemia. The posi-
tion of the gastric band appeared to have changed in ori-
entation and was found to be located more distally than
expected.
The patient was taken to the operating room for
emergency exploratory laparoscopy, which revealed an
adherent, abnormal-appearing stomach with vascular
compromise. It was decided to proceed with an open
laparotomy that showed the gastric band had slipped to
the pylorus, causing ischemia of the entire stomach
above the band up to the gastroesophageal junction. The
gastric band was removed. As there was no reversal of
is chemia despite intra-operative warming aids, a total gas-
trectomy was performed, with an esophagojejunostomy,
Roux-en-Y reconstruction and the creation of a feeding
jejunostomy.
Pathological examination of the stomach showed dark
blackened nonviable mucosa of the entire stomach with
pink viable proximal and distal resection margins at the
esophagus and the duodenum respectively (Figure 3a).
Histological examination of stomach sections proximal
to the band revealed full-thickness ische mic necrosis with
excessive hemorrhage, extensive submucosal edema, di-
lated vessels, inflammatory infiltrate and edema of the
muscularis layer (Figures 3b and c). Distal to the band,
microscopic sections continued to show regions of in-
terrupted focal mucosal necrosis with surviving islands
of viable mucosa (Figure 3d). Post-operatively the pa-
tient was discharged on jejunostomy tube an d oral feed s.
Figure 3. a, Open gastrectomy specimen demonstrating
ischemic non-viable mucosa in the center with viable margins
at the periphery; b, Haematoxylin and eosin stained slide of the
gastroesophageal junction (magnification objective lens x2)
showing viable squamous-lined esophagus (*) adjacent to co-
lumnar-lined GE junction (#) with evidence of acute ischemic
changes in the adjacent mucosa with congestion, submucosal
edema, and dilatation of vessels (arrow ). An insert image in
the top left-hand corner (#) is a high-power magnification of
the adjacent columnar-lined epithelium with no evidence of
metaplasia.; c, Haematoxylin and eosin stained slide (magnifi-
cation objective lens x2) showing full-thickness ischemic ne-
crosis of the stomach (arrow ) adjacent to focal partial-
thickness ischemia (arrowhead ); d, Haematoxylin and eosin
stained slide (magnification objective lens x2) showing ‘mu-
cosal islands’ (arrowhead ) amidst ongoing ischemic regions
(arrow ).

R. Kanthan et al. / Open Journal of Gastroenterology, 2011, 1, 1-6 3
One week later she returned to the ER complaining of
abdominal pain with cramping, depression and a general
sense of being overwhelmed. She was admitted with the
suspicion of a partial small bowel obstruction; however,
abdominal CT scan, HIDA scan and gastroscopy all
failed to demonstrate the same. She was started on TPN
to give bowel rest, and upon re-starting oral feeds did
well. She was followed up in the clinic 6 weeks post-
operatively and is progressing well. Her current weight
is 121 lbs.
3. REVIEW AND DISCUSSION
Using PubMed, a literature search was performed using
the text words ‘laparoscopic gastric band*’ and ‘gastric
necrosis’. Overall, 27 results including case reports and
case series were retrieved. All papers relevant to this
study were reviewed and of these, 22 papers have been
included in this study. The findings of the cases with
gastric necrosis following LAGB includ ing details o f : a)
reference #, b) author, c) study type, d) number of
cases/patients reported, e) age and sex, f) time interval
between LAGB and gastric necrosis, g) presenting
symptoms, h) management, i) outcome and j) cause of
the gastric necrosis are summarized in Table 1 [1-16].
Since its introduction in 1993 and approval by the
Foods and Drug Administration in 2001, Laparoscopic
Adjustable Gastric Banding (LAGB) has gained popu-
larity for the treatment of morbid obesity, making it one
of the most common surgeries in Europe, Australia,
Latin America, and the USA [4,5]. The ease of this sur-
gical technique coupled with the minimal invasiveness
and its reversibility has contributed to its increasing
popularity over the past five years [2]. Worldwide, while
the percentage of LAGB carried out among bariatric
surgeries has increased from 24.4% in 2003 to 42.3%; in
North America alone in 2008 the number of LAGB pro-
cedures has increased exponentially by 944.2% (from
9,270 to 96, 800 cases) [17].
It is estimated that band related complications arise in
12.2% of LAGB cases [5,18]. These can occur as early
or late postoperative events. Band related complications
include band migration/erosion, band dislocation/ leak-
age, band slippage/prolapse and port related leaks/rup-
ture [19]. The most common complication is band slip-
page or gastric prolapse occurring in 4.5% - 5% of pa-
tients [5,18]. Additional complications may include
bleeding, gastric perforation, pouch or esophageal dila-
tation, stoma obstruction, band erosion and gastric ne-
crosis [5,8]. Rarely, small bowel obstruction secondary
to intragastric erosion and migration of a gastric band
has also been reported [20]. Clinical presenting symp-
toms of these late complications usually include gradual
onset of reflux, dysphagia, and vomiting [2]; however,
acute retrosternal chest pain has also been reported as
the primary presenting complaint [6]. In many cases,
band deflation relieves symptoms [1]. When this is in-
sufficient, laparoscopic treatment, including band repo-
sitioning,replacement, or removal is an adequate remedy
for many of these complications. Though specific late
complications associated with this procedure are recog-
nized in 10% - 20% of cases [1] the data remains indefi-
nite due to limited follow-up period s. Gastric necrosis is
a very rare complication that is potentially life threaten-
ing and constitu tes an absolute surgical emergency.
As seen in Ta b l e 1 , several mechanisms as the cause
of gastric necrosis were identified by individual authors
in their respective reports. In agreement with the litera-
ture, gastric prolapse was the most commonly reported
cause of necrosis [21]. Additional mechanisms reported
as the cause of necrosis include band slippage [22], fun-
dal herniation [1], pouch dilatation [16], late prolapse
[10], Type II paraesophageal hernia with strangulation [6]
paragastric Richter’s hernia [22] and organo-axial vol-
vulus [11]. Though many complications arising from
LAGB occur during the immediate or early post-opera-
tive phase of healing, gastric necrosis appears to be a
late delayed complication, with the majority of cases
occurring 1-3 years after LAGB (Ta ble 1). If the necro-
sis is detected early, conservative treatment with com-
plete deflation of the adjustable band with close fol-
low-up [7], or limited gastrectomy procedures such as
sleeve gastrectomy [8] have been reported as effective
treatment. In the event of complete gastric necrosis, a
total gastrectomy is often required. Therefore, early de-
tection of gastric necrosis is crucial to satisfactory pa-
tient management. The reported data of follow-up peri-
ods following LAGB are generally less than five years
[4]. As gastric necrosis can occur as a late delayed com-
plication (after five years) as seen in this reported case, a
more vigilant long term follow-up of LAGB cases is
recommended.
The stomach is a highly vascular organ with an exten-
sive arcade of arterial anastomotic network which there-
fore rarely succumbs to ischemic necrosis [3]. In this
context, for ischemia to occur, several predisposing risk
factors have been identified to contribute to the onset of
gastric devitalization. These i nclude:
A) Gastric prolapse occurs where a part of the stom-
ach slips through the band. This can decrease the blood
flow within the gastric pouch. This band slippage may
occur immediately after surgery or many mon ths later, in
either an anterior or posterior direction which causes an
obstruction between the upper and lower stomach [21].
B) Pouch dilatation increases the pressure on the
gastric wall, impairing the vasculature [8]. This can be
caused by patients who chronically overeat, and will

R. Kanthan et al. / Open Journal of Gastroenterology, 2011, 1, 1-6 4
Table 1. Composite literature review of gastric necrosis following LAGB (pubmed listed 2001-2011) in descending chronological
order.
a)
Ref
#
b)
Author
c)
Study
Type
d)
#Cases
#Pa-
tients
e)
Age
(Sex)
f) Time
interval
since
LAGB
g) Presenting symptoms
of this complication h) Management i) Outcome j) Cause of Necrosis
Kanthan
2011 Case Report 46 (F) 5 yearsAbd pain, Distension, Nausea, Vomiting Emergency total gastrectomy Recovery Band slippage
4 Polat,
2010 Case
Series 1/232 NR 1 year NR Laparoscopic band removal NR NR
5 Fragkouli
, 2010 Short Report 37 (M) 8 days Vomiting, Abd pain, Fever,
Hypotension, Tachycardia,
Leukocytosis
Surgical explora-
tion Death NR
6 Bernante,
2008 Case
Report 42 (F) 16 mo Chest pain, Vomiting,
Tachycardia, Tachypnea,
Leukocytosis
Laparoscopic
band removal,
sleeve gastrec-
tomy
Recovery Paraesophageal
hernia
2 Iannelli,
2005 Case
Report 45 (F) 2 yearsAbd pain, Vomiting, Fever, Tachycardia, LeukocytosisUpper polar gastrectomy Recovery Gastric prolapse
7 Foletto,
2005 Case
Report 59 (F) 2 yearsVomiting, Dysphasgia, Adb pain, Leuko cytosis
Laparoscopic
band removal and
drainage Recovery Gastric
prolapse
8 Lunca,
2005 Case Report 41 (F) 3 yearsAbd p ain, Vomiting, Dysphagia Sleeve gastrectomy Recovery Gastric prolapse
45
(F) 3 yearsChest pain, Food
intolerance Laparoscopic band deflation Recovery Pouch dilata-
tion, gastric
strangulation
1 Landen,
2005 2 Case
Reports 55
(F) 4 months Food intolerance, Abd painTotal gastrectomy and splenectomy Recovery Herniation of
fundus, cardiac
ulcer
3 Yitzhak,
2005 Case
Report 43 (F) 3 yearsAbd pain, Food intolerance, Tachycardia
Endpouch
retriever with
fundectomy Recovery Band slippage,
fundus stran-
gulation
9 Irtan,
2004 Obser- vation 45 (F) 2 yearsAbd p ain, Vomiting,
Leukocytosis,
Hyperthermia, Aphagia Total gastrectomy Recovery Band slippage
10 Yoffe,
2004 Case Report 20 (F) 3 yearsVomiting, Abd pain, FeverLaparoscopic
band removal and
drainage Recovery
Gastric
prolapsed,
pouch
dilatation
11 Bortul,
2004 Case Report 19 (F) 17 months Abd pain, Vomiting, Leukocytosis Total gastrectomy & splenectomy Recovery Organo-axial volvulus
12 Dargent,
2004 Case
Series 1/1 180 NR NR NR NR Death NR
13 Zinzin- dohoué,
2003
Case
Series 1/500 NR NR NR Gastrectomy NR NR
NR 20
months NR Proximal gastrectomy Death
14 Angri-
sani,
2003
Case
Series 2/1 863 NR NR NR Gastrectomy and
esophagojeju-
nostomy Recovery NR
15 Cheval-
lier, 2002 Case Series 1/400 45 (F) 13 months Abd tenderness, PeritonitisTotal gastrectomy Recovery NR
16 Kir-
chmayr,
2001
Case
Report 24 (F) 20 months
Dysphagia, Vomiting, Abd
Pain, Vomiting,
Leukocytosis
Resection of
greater curve Recovery
Pouch dilata-
tion, gastric
perforation,
herniation
often present with vomiting caused by stoma obstruction
and gastroesophageal junction motility disorders [16,21].
C) Band slippage/migration/erosion may result in
the exertion of pressure against the fundus, limiting
blood flow to the gastric wall [6,19]. The risk of a slipped
band increases dramatically in patients who self-vomit
after meals and in those who ingest large amounts of
food [7].
D) Despite the rich arterial anastomoses in the stom-
ach that can prevent necrosis, pre-existing co-morbid-
ities found among obese people may fu rther increase the
risk of gastric necrosis [5].

R. Kanthan et al. / Open Journal of Gastroenterology, 2011, 1, 1-6 5
E) Finally, over-inflation of the gastric band can
cause the same increased pressure, limiting blood flow.
No more than 0.5cc should be injected per visit and
checked monthly [10].
Due to its rarity, the recognition and accurate diagno-
sis of gastric n ecrosis is often delayed; therefore, its pres-
entation often constitutes a medical emergency necessi-
tating urgent surgical intervention. As illustrated by our
index case, gastric necrosis can present as a delayed
complication five years after LAGB. Though delayed
gastric necrosis has been reported earlier as listed in Ta-
ble 1, this case has the longest post procedural time in-
terval (5 years). Failure to recognize this urgent clinical
situation can have dire consequences which, if untreated,
will result in death of the patient. [5]. While conserva-
tive treatment has been described in some cases of focal
limited early necrosis, most cases require surgical inter-
vention with procedures ranging from minimally inva-
sive resection [3,16] including emergency sleeve gas-
trectomy [6] to emergency total gastrectomy [1,9,14,
15].
In conclusion, as obesity rates rise to epidemic pro-
portions, it is likely that LAGB will continu e to escalate
in popularity as the preferred method of surgical treat-
ment. Awareness and recognition of complications that
may arise immediately or years following LAGB is im-
portant data to be collected for continued best practice
care of these patients. Delayed occurrence of gastric
necrosis represents a rare but life threatening complica-
tion of gastric banding. Accurate diagnosis is often de-
layed due to its rarity and nonspecific clinical signs at
presentation. Increased awareness of this delayed com-
plication should facilitate early recognition as it will
often require urgent surgical intervention to avert dire
consequences.
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