To describe a major and frequent complication after gastric band complication for morbid obesity.

We report a case of young woman with abdominal pain and uncontrollable vomit. The CT scan showed a gastric band slippage with abnourmous gastrectasis above the band and full tickness ischemic distress. The same day the patient was submitted to laparoscopy and a large NG tube was placed. The next day a second look was planned to checked the integrity of the gastric body and fundus. Patient was safely discharged in the 14 th dpo after 2 gastroscopy and a normal post operative course.

Band slippage is a well known complication of gastric banding. The overall complication rate following this procedure has been reported to be up to 20% Slippage and pouch dilation represent the most common surgical complications requiring revisional surgery.

A 35 years old woman presented at the emergency department complaining abdominal pain and untreatable vomit. At the entrance vital signs were b.p. 110/60, h.r. 51, Sat. O 2 97%, vas scale 8/10, b.t. 36°C. Blood tests reported wbc 16.4 x10 3 /µL, Hb 15.1 g/dl, Ht 45.4, Na+ 138 mEq/L, K+ 4.3 mEq/L, CPR <0.10 mg/dl. Patient was submitted to a CT scan which reported gastric band slippage with abnormous gastrectasis above the band without wall interruption [fig. 1]. The same day laparoscopy was performed with demonstration of the CT findings. The gastric wall appeared blue and sofferent above the band. [fig. 2] The band was removed and a gastric tube was placed. We decided to keep the whole organ and we planned a second look for the next day. The 1 st dpo patient felt much better but from the gastric tube 500 ml haematic fluid spilled out. Vital signs showed no changes. We decided to confirm the laparoscopic second look. The second procedure showed a normal size stomach with more than 50% of vital, well perfused gastric fundus . During the 7 th dpo the patients was submitted to an endoscopic procedure. The gastroscopy demonstrated a normal esophagus. Serpiginous ulcers covered by fibrin were found in the gastric body and in the fundus. Mucosa was eritematose and congested. During the 13 th dpo another gastroscopy was performed with a general improvement of mucosa condition and more than 60% of ulcers healed. Patient was discharged in the 14 th dpo. An endoscopy check was planned after 1 month after the discharge.

Laparoscopic adjustable gastric banding (LAGB) is a surgical treatment for morbid obesity. Because of its feasibility it is a very popular bariatric procedures worldwide since 1985. Complications include pouch dilatation, prolapse or ‘slippage’ of the stomach through the band (normally with obstruction), erosion of the band into the stomach with or without gastric necrosis, migration of the band. Posterior prolapse: an important entity even in the modern age of the pars flaccida approach to lap-band placement .There are different types of band slippage and the classification by Eid is reported in the table 1. clinical findings Normally patients with slippage of the stomach through the band come to the hospital for occlusive symptoms and pain. Different radiology investigations could be helpful to confirm the diagnosis. Two different signs, in the standard abdominal Radiography (+/- PO contrast), could lead the radiologist and the surgeons: alterations of the phi angle (normal range 4°-58°) and the O sign (large central lume visualised). CT abdomen is normally performed when the presence of complication is suspected. CT scan for LAGB evaluation includes oral administration of the water-soluble contrast agent. CT is important not only to assess the position of the Band (band migration rate 0.6%-1%) but also to rule out all the others possible complications such as: gastric perforation (0.1%-0.8%) pouch and esophageal dilatation (0%-24%), gastric band slippage (3%-9%), intragastric erosion (0.3%-14%), connector tube or port related complications (3.5%) and gastric volvulus (0%-7%).Some authors suggest the utility of abdomen ultrasound to diagnose the band dislocation. Laparoscopy could be diagnostic as well. In this case after the insufflation of the abdomen we found a big gastrectasis with a full thickness ischaemia (Images 1 and 2). We decide to remove the band , free the peritoneal adhesions and we planned the second look in the next 24h. To sum up slippage and pouch dilatation it's the most frequent late complication of LAGB. Clinical findings normally are mostly related to occlusive symptoms. This kind of patient should be referred always to bariatric high volume centers.