A 68-year-old man initially presented with a one-month history of cough, heartburn, and episodes of nocturnal regurgitation. Eight months prior to presentation, he had undergone LAGB for class III obesity with a body mass index (BMI) of 41 kg/m2. Preoperatively, he had radiographic evidence of a small hiatal hernia but no history of gastro-esophageal reflux disease (GERD). His medical history was also notable for chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, type II diabetes, hypertension, and hyperlipidemia.
His vital signs were normal, and there were no significant findings on physical examination. A clinical diagnosis of GERD was made and Omeprazole 20 mg twice daily was initiated. An upper gastrointestinal series was ordered which demonstrated a more dilated hiatal hernia, significant reflux, and probable stricture formation. He had an upper endoscopy which revealed the hiatal hernia but was otherwise normal. There was normal peristalsis on manometry, but the lower esophageal sphincter was not well assessed during the procedure. Barium swallows under fluoroscopy guidance showed evidence of esophageal dysmotility and hiatal hernia (Fig. 1). He had his band loosened, but his symptoms persisted.
Over a period of 15 months, he had three surgical repairs for recurrent hiatal hernias and suffered from progressively worsening symptoms with nasal and oral regurgitation. He remained reluctant to have his band completely deflated as the procedure had resulted in a significant reduction in his BMI from 41 to 27.
One month after being discharged from the pneumonia admission, he presented with a productive cough, worsening dyspnea, anorexia, and fatigue. On examination, he was hypoxemic with an oxygen saturation of 88% and tachypneic with a respiratory rate of 28 breaths per minute. Other vital signs were normal. His breath sounds were normal but there was dullness to percussion at the left lung base and bilateral, pitting lower extremity edema. Blood tests showed leukocytosis with a white blood cell count of 11,200 cells/ml. Chest radiograph indicated persistent left lower lobe infiltrate (Fig. 2) and a chest computed tomography (CT) scan revealed bilateral pulmonary nodules that were too numerous to count along with left lower lobe consolidation (Fig. 3a and b). In light of these findings, there was concern for metastatic disease.
After 7 days of levofloxacin and prednisone, he underwent bronchoscopy with evacuation of copious amounts of vegetable matter and mucus plugs. Lung biopsy was consistent with organizing aspiration pneumonia, and follow-up chest CTs at 1 and 3 months showed continued resolution of the nodules, strongly supporting an inflammatory etiology.
With persistent symptoms of reflux and aspiration, resulting in poor quality of life, and radiographic evidence of esophageal dysmotility, the decision was made to completely deflate the gastric band.
Over the next 4 months, his symptoms improved remarkably with no further pulmonary complications.