Mechanical ileus and mesenteric ischemia as complications of MiniMizer-gastric-ring after laparoscopic banded Roux-en-Y-gastric bypass: A case report

INTRODUCTION: Banded laparoscopic Roux-en-Y-gastric bypass (B-LRYGB) is a surgical technique that involves reinforcing the restriction by placing a silicone ring 2 cm above the gastrojejunostomy to prevent pouch dilation, thereby maintaining the achieved weight loss and preventing weight regain. Gastrojejunostomy stenosis, erosions, and ring-migration (slippage) are well-known complications in patients undergoing banded laparoscopic procedures. We believe that our study makes a significant contribution to the literature because, to the best of our knowledge, cranial slippage (herniation) of the alimentary limb through a non-slipped MiniMizer gastric ring after B-LRYGB as well as mesenteric ischemia because of ventral slippage have not been described before in the published literature. PRESENTATION OF CASE: This study presents two rare complications in middle-aged women 26 months after B-LRYGB. The first case presented with mechanical ileus due to herniation of the alimentary limb without slippage of the MiniMizer ring. The second case involved mesenteric ischemia following ventral migration of the MiniMizer ring with herniation of the alimentary limb and its mesentery through the ring with consequent torsion of the mesentery. Both patients were managed with surgical intervention and band removal. The postoperative course was uneventful. DISCUSSION: In cases of MiniMizer ring complications, the presentation can be either acute or chronic. Severe mesenteric ischemia is acute and can be fatal. Patients may also present with chronic recurrent abdominal pain or mechanical ileus. The loss of mesenteric fat after successful weight loss might lead to the cranial herniation of the alimentary limb. This could also be a result of dysmotility or reverse peristalsis secondary to ectopic pacemaker cells over a fixed point (in this case, the gastrojejunostomy with the MiniMizer ring) [4,5]. A gradual herniation of the intestinal wall over the fixed point can also occur due to recurrent dietary non-adherence (such as large portions and hard consistency of the food). CONCLUSION: A high sense of suspicion and radiological investigation are crucial factors in reaching the proper diagnosis. Further studies should be conducted to examine whether other forms of ring placement or fixation could help avoid the risk of potentially fatal complications.