Slippage of Gastric Banding for Morbid Obesity:
case report and review of literature
Danilo Coco MD1 and Silvana Leanza MD2
1Department of General Surgery, Ospedali Riuniti Marche Nord, Pesaro (Italy)
ISSN: 0000-0000
https://orcid.org/0000-0002-5839-1767 Danilo Coco Author
Published 00 11 0000
2Department of General Surgery, Carlo Urbani Hospital, Jesi (Ancona) (Italy)
https://orcid.org/0000-0001-8672-7486 Silvana Leanza Co-Author
O R I G I NA L
Abstract
Background: laparoscopic adjustable gastric banding (LABG) was one the commonest and less
invasive bariatric operation and is associated with low morbidity and mortality rates. When a
Gastric Band Slippage (GBS) happens, part of the gastric fundus herniates through the band.
Removal of Gastric Banding (GB) is necessary to prevent necrosis of the herniated stomach.
Case report: We present a case of a 40-year-old female patient who was admitted for a huge
gastric pouch dilatation after 3 years of undergoing LAGB.
Conclusion: The LAGB is one of the most common procedures used for the treatment of morbid
obesity. The complications are generally not mortal but complications must be recognized by a
general surgeon and physicians should be aware of the symptoms. Diagnosis of GBS can be made
with signs or symptoms and patient’s medical history, with the use of oral contrast X-ray studies
or CT Scan. Surgical intervention is necessary.
Keywords : laparoscopic adjustable gastric banding (LABG), slippage, gastric pouch dilatation
Introduction
The laparoscopic adjustable gastric banding (LABG) is less invasive bariatric operation , though
sleeve gastrectomy is used more and more. Adjustable gastric banding is positioned 2cm away
from the gastro-oesophageal junction, creating a small proximal "gastric pouch" (15-30 ml capacity)
and causing early satiety from delayed transit of food bolus. LABG is reversible and has very few
early complications. In addition, concerns about its long-term eﬃcacy and safety are increasing,
with complications and the need for reoperation reported in 33-40% and 9-22% of patients within
10 years (1; 2; 3).
Gastric band slippage is a late complication performed for obesity by laparoscopic gastric banding
operation. This refers to distal stomach herniation by cephalad through the band, secondary to
insuﬃcient ﬁxation and increased pressure on the proximal pouch. It occurs in 4-13 percent of
cases, in 4.9-8.1% (up to 15-22% in some series) of patients. Patients can experience weight-loss
cessation, extreme gastroesophageal reﬂux, and vomiting (4; 5; 6). Untreated GBS may result in
obstruction, volvulus, gastric ischemia, hemorrhage, or stricture (5; 7; 8; 9). Consequently, early
OPEN ACCESS
recognition and treatment of band slippage are essential for the management of patients with
Edited by
laparoscopic adjustable gastric banding (10).
A.Hussain
Normally a gastric band appears at 40–50 degrees to the vertebral column as a single radio-
Citation
opaque circle, lying diagonally. When the fundus herniates through the gastric band, this gives
Danilo Coco , Silvana
Leanza.Slippage of Gastric
the stomach an annular appearance. It is important to highlight these complications within
Banding for Morbid Obesity:
obesity surgery. Emergency deﬂation and removal of the band are required to avoid herniated
case report and review of
stomach necrosis (11) . The band is normally obliquely oriented in the upper left quadrant and a
literature.
few centimeters below the diaphragm. In the setting of the gastric band slippage, because the
BJOSS.2021;1(1):14-19

stomach hernies the band superiorly, the weight of the herniated stomach causes the band to tilt
along its horizontal axis so that it no longer superimposes the anterior and posterior sides of the
band. This creates the appearance of an O-shaped radiography conﬁguration, the sign O. There
may also be signs of obstruction as associated pouch dilation occurs. The classic ’O’ sign is seen
on views of the antero-posterior, which represents the end-on visible gastric band. This is highly
suggestive of slippage of the posterior band.
CT Scan proves stomach herniation through the gastric band (4; 5; 6). Past ﬁndings indicated that a
slipped stomach band is more likely to have:1) an irregular vertical or horizontal orientation relative
to the midsagittal plane across the thoracic spine (i.e., the phi angle, with a standard range of 4–58
°),2) the central lumen of the band is more likely to be visualized than its superimposed sides (i.e.,
the "O sign"),3) inferior displacement of the superolateral gastric band margin from the diaphragm
by more than 2.4 cm (corresponding to two times the bandwidth, which is approximately 1.2cm
by our measurements of ex vivo bands and gastric bands on CT studies),4) the presence of an
air-ﬂuid level above the gastric band on an upright frontal radiograph obtained before barium
ingestion (12; 13; 14; 15). We present a case report of a late complication after LABG, focusing
on radiological ﬁndings.
Case report
A 40-year-old Caucasian woman came to the emergency department with a one-week history of
sudden onset regurgitation and complete dysphagia for solids and liquids. She had had gastric
banding three years ago for morbid obesity. Her medical history included arterial hypertension,
diabetes mellitus, and obesity because of BMI 35Kg/m². She had a Glasgow Coma Scale (GCS)
of 15. Her vital signs showed hypertension with an arterial blood pressure of 180/100 mmHg,
not tachycardia, and no fever. Routine blood investigations showed no leukocytosis, normal
hemoglobin, and protein Chain Reaction (PCR) in the range. Arterial Blood Gas was normal. Upon
physical examination, she presented with no signs of peritoneal irritation. As the ﬁrst maneuver,
her band was deﬂated in the emergency department without symptoms resolution.
A plain chest and abdomen radiograph plus gastrographin showed an annular appearance of
the band. Antero-posterior scout image at the time of acute presentation illustrates O-shaped
conﬁguration of the gastric band “O” sign and eccentric dilated pouch without passage of oral
contrast material into the distal stomach, marked dilatation of gastric pouch with herniation of
inferior stomach through the band( Figure 1) .
The patient was admitted for treatment and a nasogastric tube was inserted into the stomach.
Based on the history and this radiographic ﬁnding, a Thoracic-Abdomen CT Scan was performed
showing an” hourglass stomach”, a massive gastric pouch above the gastric band with a degree
of air-ﬂuid, O-shaped conﬁguration of a gastric band with air-ﬂuid level just above the band.
( Figure 2a Figure 2b).For this reason, the patient was referred to urgent laparoscopy. During the
exploration, we saw that the gastric band was prolapsed down in the middle of the stomach.
With the help of laparoscopic graspers, the gastric band was pulled up, the stomach was pulled
down through the band, the band was removed. A transit after surgery showed a normal digestive
tract ( Figure 3).The patient’s recovery was uneventful and she was discharged home on the 3rd
postoperative day. At the 20-month follow-up, she had no problems except that diﬃculty in had
weight loss for which awaits other bariatric surgery techniques.
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Figure 1. An annular appearance of the band and transit stopping in middle stomach.
(a)
(b)
Figure 2. CT Scan showed “hourglass stomach”
Figure 3. Postoperative digestive transit
Discussion
Bariatric surgery is an acceptable and preferred method of sustained weight loss in seriously obese
patients worldwide. The available procedural choices for bariatric surgery include restrictive,
malabsorption or a combination of both functions. The decision on the technique is aﬀected by
various factors such as BMI, general performance status, age, concurrent diseases, and also the
skills and experience of the surgeon (16). Laparoscopic adjustable gastric banding (LAGB) has
many advantages for the surgeons including tool easiness, relatively low surgical morbidity, rapid
recovery, adjustability, reversibility, and overall positive outcomes. Given the many beneﬁts it
provides, it has many early and late complications commonly known as band obstruction, stomach
perforation, wound infection, leakage, band slippage, pouch or esophagus dilation, band erosion,
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and band migration (17).
There are two diﬀerent methods for Laparoscopic adjustable gastric banding: the perigastric
technique and the pars ﬂaccida technique. Given the high complication rate attributed to the
perigastric technique, most surgeons preferred the technique of pars ﬂaccida (18). The ﬁrst LAGB
operation was carried out by Belachew in 1993 with a perigastric technique. In the perigastric
technique, a small window at the lower stomach curvature 3 cm below the gastroesophageal
junction is formed as the source of a tunnel below the stomach wall and extended to the angle of
His. Before locking the band, using a calibration bougie which is inserted orally into the stomach
and inﬂated with 25 cc saline helps to adjust a 15–30 ml gastric pouch above the band. To reduce
the risk of slippage, three to ﬁve anterior sutures between the greater curvature and gastric pouch
are placed to create gastric plication. In the pars ﬂaccida technique, dissection begins near His
angle, and the thin area of the gastrohepatic ligament, which is the ﬂaccid pars, is divided over
the caudate lobe. Once the dissection continues, the right crus is isolated and the peritoneum at
the crus’ border is cut. Then, a grasper is passed behind the gastro-esophageal junction to the
angle of His. Thus the band is placed in the same way as in the perigastric technique (18). With
time, it has been proven that the perigastric technique is associated with more frequent band
slippage than the pars ﬂaccida technique. Complications following gastric banding are becoming
increasingly obvious.
LAGB complications may be classiﬁed as minor complications such as pouch dilation (12%),
persistent gastroesophageal reﬂux disease (7%), port prominence (2.5% to 6%), port malfunction
(< 1%), and major complications such as band slippage (< 5%), late port infection (< 1%), band
erosion (< 1%), and stomach obstruction.Diagnosis of GBS can be made with signs or symptoms
and patient’s medical history, with the use of oral contrast X-ray studies or CT Scan and surgical
intervention is necessary (19; 20; 21). Eid et al. (22) classiﬁed band slips into 5 types: Anterior slip
(type 1 prolapse), Posterior slip (type 2 prolapse), Pouch enlargement (type 3 prolapse), immediate
postoperative prolapse (Type 4 prolapse), posterior or anterior slip with gastric perforation (Type
5 prolapse) which is the most dangerous. Kang et al. (23), in their 6-year experience with 1347
patients who underwent a LAGB procedure, reported that band prolapse is a signiﬁcant and
common late complication following LAGB with an incidence of approximately 5% (23). Lee et
al. (24) recorded that band slippage was 11.1% remarked that it is the most common long-term
complication after LAGB. The complications are generally not mortal but complications must be
recognized by a general surgeon and physicians should be aware of the symptoms.
Conclusion
The slippage complication is generally not mortal and can be recognized by a general surgeon.
Band deﬂation and early intervention is necessary to prevent gastric necrosis. Diagnosis of GBS
can be made with signs or symptoms and patient’s medical history, with the use of oral contrast
X-ray studies or CT Scan and surgical intervention is necessary (17; 25).
Conﬂict of interest statement
Authors declare no conﬂict of interest.
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