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Case report

Postoperative acute appendicitis after laparoscopic gastricband placement

Nicholas R. Leonardi, D.O.a,*, Rami E. Lutfi, M.D., F.A.C.S.baDepartment of General Surgery, University of Illinois at Chicago, Metropolitan Group Hospitals Residency in General Surgery, Chicago, Illinois

bDepartment of Minimally Invasive Surgery, Mercy Hospital and Medical Center, Chicago, Illinois

Surgery for Obesity and Related Diseases 8 (2012) e49–e51

Received April 6, 2011; accepted April 12, 2011

Since the laparoscopic adjustable gastric banding (LAGB)system was approved for use in the United States in 2001,its use has increased steadily. A recent worldwide surveyrevealed the LAGB accounted for 24% of obesity opera-tions [1].

Band infection from erosion of the band and the tubinghas been well described [2–5]. The management of suchomplications with gross contamination of the band haseen agreed on, with removal of the band, with or withoutntibiotics [3, 6]. However, management of acute, nonband-elated intra-abdominal infection after band placement hasot been well described, and the appropriate management isnclear.

We report a case of early appendicitis 2 weeks afterneventful LAGB placement.

ase report

A 38-year-old woman with a body mass index of 43g/m2 presented to the emergency room 16 days after lapa-

roscopic placement of an AP standard LapBand (Allergan,Irvine, CA) and repair of hiatal hernia. Her chief complaintwas right-sided abdominal pain with nausea and vomitingfor 1 day. She was otherwise healthy, with tubal ligation asher only previous surgery.

On presentation, she was febrile at 38.7°C and tachy-cardic at 118 beats/min, but normotensive. She was not indistress, but she appeared uncomfortable, with right-sidedtenderness without rebound. All her wounds were wellhealed.

*Correspondence: Nicholas R. Leonardi, D.O., Department of GeneralSurgery, Metropolitan Group Hospitals Residency in General Surgery, 836West Wellington Avenue, Room 4807, Chicago, IL 60657.

E-mail: nrleonardi@uwalumni.com

550-7289/12/$ – see front matter © 2012 American Society for Metabolic andoi:10.1016/j.soard.2011.04.225

Her laboratory values were all normal, except for anelevated white blood cell count of 11.2 � 103/�L, with aleft shift of 74% neutrophils.

Computed tomography of the abdomen and pelvisshowed an expected small amount of fluid and fat strand-ing around the port. Evidence was also seen of acuteappendicitis. A small amount of free pelvic fluid waspresent (Figs. 1 and 2).

Laparoscopic appendectomy was proposed, along withthe recommendation to remove the band and port at surgeryto prevent infectious complications. The patient stronglywished to keep her band in place and elected to undergoonly appendectomy, with the knowledge that this would puther at risk of delayed band infection, which would neces-sitate additional explant surgery.

Laparoscopic appendectomy was performed with all newport sites, and care was taken to avoid violating the subcu-taneous port. An inflamed vermiform appendix was foundthat was nonsuppurative and not perforated. The upperabdomen was inspected, and well-formed adhesions werefound in the gastrohepatic region, sequestering the band. Nointra-abdominal pus was present. The appendectomy wasperformed, and the LapBand was left in place. The patientwas given intravenous antibiotics (cefoxitin) for 2 days andthen discharged with oral amoxicillin-clavulanate for 2weeks. Pathologic examination revealed acute appendicitiswith periappendicitis.

She returned to the emergency room on postoperativeday 16 (postoperative day 32 from band placement) com-plaining of anorexia, nausea, emesis, and persistent left-sided abdominal pain. She was afebrile, but slightly tachy-cardic (pulse 104). Her abdomen was benign, with theexception of mild tenderness around the port, but withoutcellulitis or fluctuance. Her white blood cell count was

normal (7.7 � 103/�L), without a left shift (neutrophils

Bariatric Surgery. All rights reserved.

e50 N. R. Leonardi and R. E. Lutfi / Surgery for Obesity and Related Diseases 8 (2012) e49–e51

70.3%). Urinalysis showed a urinary tract infection (posi-tive for Trichomonas).

Computed tomography of the abdomen and pelvis dem-onstrated “slightly worsened stranding of the fat planessurrounding the subcutaneous band port, including organiz-ing, enhancing soft tissue components suggestive of cellu-litis and phlegmon formation.”

More extensive stranding and edema were present withinthe omental fat, with an increase in the volume of free fluidin the pelvis and some abnormal enhancement of the peri-toneum within the pelvis (Fig. 3).

Given her symptoms and computed tomography find-ings, a preoperative diagnosis of a port, and possible, bandinfection was made, and the patient underwent laparoscopicexplant of the band and port. No gross evidence was foundof band or port infection, and the intraoperative cultures didnot reveal any organisms on Gram stain or growth onculture.

Fig. 1. Computed tomography demonstrating acute appendicitis. Arrowpoints to inflamed, dilated vermiform appendix.

Fig. 2. Computed tomography of the abdomen and pelvis demonstrated anexpected small amount of fluid and fat stranding around the port. The arrow

points to the port tubing.

The patient had an uncomplicated postoperative courseand was discharged home on postoperative day 1. She madea complete recovery during follow-up and resumed her dietand exercise with plans for LAGB replacement in the nearfuture.

Discussion

Although many infections are related to the actual LAGBprocedure, such as wound infection and erosion or perfora-tion, incidental unrelated intra-abdominal infections can oc-cur and pose a dilemma regarding how to manage the bandas a foreign body.

Although it is clear that band removal is required withgross enteric soilage, a paucity of information is availableregarding the management of nonperforative transmural in-flammatory conditions such as appendicitis, uncomplicateddiverticulitis, and Crohn’s ileitis. It seems reasonable thatany condition in which bacterial translocation can occurwould put the band at risk of infection.

One report from New York Methodist Hospital describedintragastric band erosion because of uncomplicated diver-ticulitis [7]. It was thought that a subacute band infectionfrom the intra-abdominal sepsis resulted in the erosion.After a trial of intravenous antibiotics, persistent abdominalsymptoms led to removal of the band. Their recommenda-tions were close follow-up of band patients with an intra-abdominal infection owing to the risk of a subacute bandinfection [7].

Additional support for band removal in scenarios suchas this is found in a histologic study of periprosthesictissue taken from patients undergoing repeat surgery forintragastric band migration. That study showed histologicchanges that did not appear to account for the endoluminal

Fig. 3. Post appendectomy computed tomography demonstrates slightlyworsened stranding of the fat planes surrounding the subcutaneous bandport, including organizing, enhancing soft tissue components suggestive ofcellulitis and phlegmon formation. The arrow points to the port tubing.

migration of the gastric band and, possibly, even demon-

e51Postoperative Acute Appendicitis After LAGB / Surgery for Obesity and Related Diseases 8 (2012) e49–e51

strated a biologic periprosthesic wall that separates andprotects the gastric wall from the band. The investigators ofthat study suggested that band erosion could have a closercorrelation with other causes, such as infection or intraop-erative surgical damage [8].

In the present case, the band was removed because of theclinical history and computed tomography findings suspi-cious for port infection. Intraoperative cultures, however,did not show any evidence of true infection. It is not clearwhether this was a result of the prophylactic antibiotics thepatient was taking or, in fact, the patient did not actuallyhave a true band infection.

Although we strongly believe in the need for bariatricsurgery for the morbidly obese, it remains an electiveprocedure, and the operative risks should be minimizedto improve the overall outcome. Thus, we recommendalways explanting the band when gross soilage and peri-tonitis are present. We also recommend a low thresholdfor band removal when operating to treat nonsuppurativeintra-abdominal infection. At a minimum, the patientshould be educated about this option because of thepossibility of future band infection if the band is left insitu. Our patient was disappointed but ultimately satis-fied, because she had the expectation of possibly havingthe band explanted.

More reported cases are needed to have guidelinesplaced when managing such problems. Until then, we ad-vise caution when deciding to leave the band in situ with anactive abdominal infection. The key point is to discuss with

the patients their options and to educate them about the

possibility of needing future explant surgery should theydecide to keep their band.

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

References

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