Case Presentation: A 51-year-old woman with a history of rheumatoid arthritis and laparoscopic adjustable gastric band surgery presented to the hospital with right-sided paraesthesias, tachycardia, and palpitations after eating. During admission, vitals were normal, except for a heart rate ranging from 90-160 BPM during and after eating. The physical examination was unremarkable. CT/CTA of the head and neck and MRI of the brain and cervical spine revealed a chronically occluded left MCA and a convexity meningeal enhancement left more than right. A lumbar puncture revealed 3 RBC, TNC 2% (89% lymphocytes, 2% neutrophils, 9% monocytes), glucose 50 mg/dL, protein 39 mg/dL, and cytology showed atypical CSF with mononuclear predominant inflammatory infiltrate. She was empirically started on acyclovir and ampicillin for suspected meningitis; all infectious workup, including cryptococcal, Lyme, West Nile, Enterovirus, Herpes, Varicella, and Listeria returned negative, and all therapies were stopped. A CT of the chest, abdomen, and pelvis was unremarkable. Her paresthesias resolved spontaneously, but she had persistent tachycardia with palpitations associated with eating and movement. Telemetry revealed sinus tachycardia up to 160BPM. A transthoracic echocardiogram revealed a possible patent foramen ovale, not believed to be contributory. On review, the patient reported heart rate variability and presyncopal episodes whenever her gastric band fluid was adjusted. Her bariatric surgeon was consulted, and 4.2cc of fluid was removed, after which all symptoms completely resolved. The proximity of the vagal nerve to the lap band was identified as the likely mechanism.
Discussion: This case highlights a unique presentation of vagal nerve dysfunction associated with gastric banding. While episodes of vagal nerve stimulation, such as vasovagal syncope and bradycardia have been reported to be associated with gastric band surgery¹, long-term cases of isolated sinus tachycardia and palpitations have not been reported. The anterior vagal trunk, which courses near the gastroesophageal junction, can be irritated or compressed by an overly tightened gastric band, leading to aberrant autonomic responses causing unique presentations such as sinus tachycardia, palpitations, and paraesthesias.The reproducibility of symptoms during meals and their resolution following gastric band fluid removal strongly support a mechanical and neurogenic etiology rather than a primary cardiac or neurologic disorder. The nonspecific presentation led to a broad initial differential and prompted extensive evaluation, underscoring the diagnostic challenge of such cases. Detailed history taking and a multidisciplinary approach were critical to identifying the underlying etiology.
Conclusions: Although the use of adjustable gastric bands has declined, long-term potential complications remain clinically relevant. Vagal nerve irritation from gastric banding surgery should be considered in patients with unexplained autonomic symptoms. Early recognition can prevent unnecessary testing and facilitate prompt management. This case highlights the importance of recognizing neurologic and cardiovascular complications of gastric banding to provide appropriate management.