Case Presentation: A 48-year-old morbidly obese man who underwent laparoscopic adjustable gastric banding (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 and a thick-walled cavity in the right lower lobe with an air-fluid level, consistent with a lung abscess. Additional consolidations were seen in the bilateral upper lobes. An esophagram was done due to a suspicion for aspiration pneumonia (PNA), and this confirmed a dilated distal esophagus with impaired peristalsis and nonpropulsive contractions indicative of dysmotility. The patient’s esophageal abnormalities 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: Obesity has become a major public health concern and has been recognized as a global epidemic by the World Health Organization. After its introduction in 1993, LAGB had become one of the most commonly performed bariatric procedures for morbid obesity due to several advantages over other surgical procedures including band adjustability, reversibility of the procedure, and small surgical risk. However, the prevalence of LAGB has declined significantly over the last 10 years due to several long-term complications including esophageal dilatation and dysmotility. In fact, one study reported esophageal dilatation in 25% and esophageal dysmotility in 68% 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.
Conclusions: Esophageal pathologies are significant yet under-reported complications of LAGB. We report a case of LAGB-associated esophageal dilatation and dysmotility that resulted in multifocal aspiration pneumonia and lung abscess 8 years after LAGB. It is important to monitor for symptoms such as reflux and regurgitation long term in patients who have undergone LAGB, as these may predict the occurrence of the known complications of LAGB.