Emergent Management of Gastric Outlet Obstruction Post-Intragastric Balloon: A Case Report Highlighting the Importance of Preoperative Assessments and Postoperative Monitoring in Obesity Management

Background

Obesity is a ubiquitous pathology, significantly contributing to the global burden of chronic diseases, such as diabetes mellitus, cardiovascular disorders, and non-alcoholic fatty liver disease [1]. While metabolic and bariatric surgery (MBS) remains the criterion standard for durable weight loss and comorbidity resolution, intragastric balloons (IGBs) have emerged as a less invasive alternative, gaining FDA approval in 2015 [2].

Guidelines encourage MBS for patients with metabolic disease and a body mass index (BMI) of 30 to 34.9 kg/m2, or for patients with a BMI ≥35 kg/m2, regardless of co-morbidities [3]. A structured, conservative weight-loss program must prove ineffective or futile before MBS is considered, and the choice of MBS depends on its associated outcomes, long-term impacts, complications, and individual situations.

Although IGB promises a less invasive pathway to weight reduction by inducing early satiety through endoscopic balloon placement, it is not without risk. Significant complications have been reported, including balloon rupture, gastric outlet obstruction, and gastrointestinal bleeding [4,5]. As the adoption of IGB increases, a parallel rise in these adverse outcomes is conceivable.

In this report, we describe the case of a 35-year-old woman who developed gastric outlet obstruction 2 weeks after IGB placement, necessitating urgent intervention. This case serves as an instructive example for clinicians, amplifying the discourse on the risks associated with IGB and reinforcing the necessity for vigilant post-procedure monitoring. Our narrative also offers guidelines for early recognition and management of severe complications arising from IGB, aiming to improve patient outcomes and optimize healthcare resource utilization.

Case Report

A 35-year-old woman presented with intractable nausea and vomiting 2 weeks following an IGB placement in Mexico. The patient had a past medical history of class I obesity (BMI, 34 kg/m2), hepatomegaly, leiomyoma, and a small sliding-type hiatal hernia. Symptoms included postprandial nausea, which was initially managed by a liquid diet. Subsequently, the patient developed persistent vomiting, associated with non-radiating, burning chest pain.

Laboratory evaluations revealed hypokalemia (potassium, 2.5 mEq/L) and hypochloremia (chloride, 86 mEq/L), contributing to a metabolic alkalosis (serum bicarbonate, 30 mEq/L). An electrocardiogram showed prolonged QT intervals (Figure 1). Abdominal computed tomography indicated gastric distension, a dilated IGB, and pyloric wall thickening, suggesting gastric outlet obstruction (Figure 2). Management entailed immediate nil per oral status, intravenous fluid resuscitation, and electrolyte repletion. Esophagogastroduodenoscopy on the third day of admission confirmed the computed tomography findings, necessitating IGB deflation and removal (Figure 3).

After the procedure, the patient experienced symptom resolution and was discharged on day 4, with proton pump inhibitor therapy and scheduled follow-up.

Discussion

MBS has been robustly endorsed by leading organizations, such as the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders, for individuals with metabolic disease and a BMI ranging between 30 and 34.9 kg/m2, and for those with a BMI ≥35 kg/m2, regardless of other health conditions [3]. Prior to considering MBS, an unsuccessful conservative weight-loss program is usually required, and the decision on MBS selection relies on its potential complications and individual patient circumstances.

Sleeve gastrectomy has been the most commonly performed MBS since 2014, with Roux-en-Y gastric bypass following as the second most common procedure [6,7] and offering a distinct advantage of significant reduction in the acid-producing portion of the stomach, particularly benefiting patients with severe gastroesophageal reflux disease, and a greater decrease in the risk of coronary artery disease/adverse coronary events [8]. In contrast, sleeve gastrectomy has been reported to have an increased number of persistent or de novo gastroesophageal reflux disease cases after surgery [9]. Moreover, malabsorptive procedures, unlike restrictive surgeries, generally entail higher technical intricacy, involving anastomosis leading to bypass, which can result in vitamin and mineral deficiencies and, on rare occasions, protein malnutrition [10]. Therefore, when choosing an MBS approach, it is essential to consider varying risk-benefit ratios, which should be thoroughly communicated to the patient, as their choice ultimately affects outcomes [10,11].

IGBs, with their less invasive nature, have proliferated globally and received FDA approval in the United States as recently as 2015 [12,13]. The evolution of IGBs from early prototypes, such as the Garren-Edwards gastric bubble, to contemporary systems, like the Orbera and Obalon systems, has been marked by improvement but not the elimination of adverse effects [12,14,15]. A constellation of complications persists, such as accommodative symptoms like abdominal pain, dyspepsia, nausea, vomiting, pancreatitis, spontaneous hyperinflation, and gastric outlet obstructions [5,13,15]. The timing of gastric outlet obstruction after IGB appears unpredictable, as evidenced by varied cases in the literature [16–18]. The etiopathogenesis of these complications are varied. IGB can potentially induce gastrointestinal issues, such as gastritis, erosions, lacerations, and ulcers, by altering prostaglandin production due to direct contact and reducing blood supply through prolonged mucosal stretching. Microorganism contamination during IGB insertion or prolonged exposure to food residues in a slowly emptying stomach might lead to hyperinflation, believed to result from an overgrowth of Candida or other bacteria within the balloon causing gas production [19]. Mild to severe acute pancreatitis during IGB use can result from the balloon’s external mechanical pressure on the pancreas or from the displacement of the catheter to the second part of the duodenum [19,20]. The process through which the IGB induces gastric perforations remains unclear, although it is thought to involve the device’s direct and sustained pressure on the gastric wall, leading to mucosal ischemia and ulceration. Gastric outlet obstruction in IGB appears to be due to obstruction in the first part of duodenum by the mechanical obstruction by the balloon.

Medical tourism, primarily a late twentieth century phenomenon, is said to have recently and rapidly boomed, with thousands of patients seeking medical care viewed as too expensive, inadequate, or unavailable in their home countries [21]. The most frequently sought-after procedures include cosmetic surgery, dental procedures, cardiac surgery, orthopedic surgery, and bariatric surgery [22,23]. Based on a survey of bariatric surgeons worldwide, at least 2% of bariatric procedures are delivered to medical tourists, particularly from the United States, United Kingdom, and Germany, with nations like Mexico, Romania, and Lebanon being primary providers [24]. Certain concerns regarding medical tourism involve the quality of care, the certification of healthcare providers and facilities, the restricted options for patients in the event of complications, and the continuity of care, particularly for procedures such as bariatric surgery, which requires extended close postoperative follow-up [24].

Our case spotlights a patient who bypassed first-line, noninvasive weight management interventions, resulting in severe complications that necessitated intensive care unit admission. This underscores the imperative for thorough clinical evaluation and lifestyle counseling prior to invasive procedures. Of note, the patient’s hepatomegaly, enlarged uterus, and hiatal hernia presented as intriguing variables that may have influenced her clinical trajectory and warrant further investigation.

In the era of increasing obesity prevalence and medical tourism, the onus lies with healthcare providers to offer comprehensive, evidence-based counsel to patients. A case in point is our patient, who made her treatment choice based on anecdotal evidence and underwent the procedure in a different healthcare system. This decision may have exposed her to suboptimal medical standards and potentially increased her risk of complications. This observation accentuates the need for further research in stratifying risks, elucidating contraindications, and establishing standardized protocols for patient selection and post-procedure monitoring.

Conclusions

As the global obesity epidemic escalates, surgical interventions such as IGB become increasingly significant. While offering promise, they are not without serious complications, such as gastric outlet obstruction, that warrant immediate and comprehensive clinical attention. This study underscores the imperative for rigorous preoperative evaluations and sustained postoperative monitoring, particularly given the risks inherent in medical and surgical tourism, which compromise standard of care and continuity. Even minor symptoms following IGB placement should precipitate an immediate and thorough evaluation, with gastric outlet obstruction prominently featured as a differential diagnosis. Our case serves not only as a cautionary exemplar but also as a catalyst for future research, aiming to refine patient selection, enhance preoperative screening, and establish evidence-based guidelines for preventing severe complications.