Laparoscopy-assisted trans-hiatal endoscopic removal of an intragastric balloon after placement-related esophageal perforation

Intragastric balloon placement is a minimally invasive endoscopic procedure for the treatment of obesity [1] [2]. Severe adverse events such as gastric perforation, migration, and intestinal obstruction, albeit rare, may occur [3] [4]; esophageal perforation due to balloon insertion has been reported in only a handful of cases [5].

A 29-year-old man (body mass index [BMI] 44 kg/m²) presented with acute chest pain and abrupt onset respiratory failure during the endoscopic placement of an intragastric balloon (BioEnterics intragastric balloon [BIB]) in another hospital. He was initially treated with pleural drainage before emergent referral to our center. Computed tomography revealed the presence of the 12-cm intragastric balloon in the apex of the left pleural cavity ([Fig. 1]), with evidence of pneumothorax and pneumomediastinum next to the lower third of the esophagus.

Fig. 1 Preoperative computed tomography scan showing the intragastric balloon in the left pleural cavity.

Because of his life-threatening condition, a damage-control two-stage surgery was planned. During the first stage, a laparoscopy-assisted trans-hiatal endoscopic removal of the balloon was performed. After the abdominal cavity had been accessed, a standard gastroscope (Olympus GIF-1100) was guided through the esophageal hiatus into the mediastinum ([Fig. 2]), where a wide esophageal laceration was observed. After the balloon had been located at the apex of the left pleural cavity ([Fig. 3] a), balloon deflation was performed by needle puncture ([Fig. 3] b). The deflated balloon was then grasped with a rat-toothed alligator forceps ([Fig. 3] c) and dragged through the hiatus; the definitive trans-hiatal removal being performed with the help of surgical forceps ([Video 1]).

Fig. 2 Laparoscopic view of the gastroscope entering the abdominal cavity through a 12-mm surgical port.

Fig. 3 Endoscopic views showing: a the intragastric balloon located at the apex of the left pleural cavity; b the balloon being deflated by needle puncture; c the deflated balloon being grasped by foreign-body forceps.

Laparoscopy-assisted endoscopic removal of an intragastric balloon from the pleural cavity, after esophageal rupture during its placement.Video 1

After this, esophageal transection was performed under endoscopic control and a gastrostomy tube was placed. Once the patient had been discharged from the intensive care unit and was receiving total enteral nutrition, second-stage surgery was scheduled after a 3-month interval and a totally mini-invasive laparoscopic/thoracoscopic esophagogastric anastomosis was subsequently performed (BMI 31 kg/m² at the time of surgery).

At 6-month follow-up, the patient was in good condition and asymptomatic.

Endoscopy_UCTN_Code_CPL_1AH_2AG

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Klinger MJ, Kroh M. Endoscopic balloon therapy. Surg Clin N Am 2021; 101: 355-371
• 2 Abu Dayyeh BK, Maselli DB, Rapaka B. et al. Adjustable intragastric balloon for treatment of obesity: a multicentre, open-label, randomised clinical trial. Lancet 2021; 398: 1965-1973
• 3 Ribeiro IB, Kotinda APST, Sánchez-Luna SA. et al. Adverse events and complications with intragastric balloons: a narrative review (with video). Obes Surg 2021; 31: 2743-2752
• 4 Lee KG, Nam SJ, Choi HS. et al. Efficacy and safety of intragastric balloon for obesity in Korea. Clin Endosc 2023; 56: 333-339
• 5 Nijhof HW, Steenvoorde P, Tollenaar RAEM. Perforation of the esophagus caused by the insertion of an intragastric balloon for the treatment of obesity. Obes Surg 2006; 16: 667-670

Publication History

Article published online:
07 November 2023