Bowel Obstruction Caused by Migration of an Intra-Gastric Balloon: A Rare Case Treated Laparoscopically

Introduction

The global prevalence of obesity continues to rise, posing significant challenges to public health and individual well-being [1]. In the multifaceted approach to weight management, intra-gastric balloons (IGBs) have emerged as a minimally invasive, temporary intervention to facilitate weight loss in individuals with obesity [2]. Typically deployed endoscopically within the stomach, IGBs aim to induce satiety and reduce caloric intake [3]. Although generally considered safe and reversible, complications, while infrequent, can occur and require careful management.

Most patients experience transient and non-serious adverse effects such as nausea, vomiting, and generalized abdominal discomfort [4]. However, a rare but serious complication is the migration of the IGB from the stomach to the distal small bowel, leading to mechanical intestinal obstruction. This specific complication has been reported in less than 1% of patients undergoing IGB placement [4]. Historically, the management of such rare migrations resulting in bowel obstruction has often involved open surgeries [5].

This case report details an uncommon instance of an IGB migrating distally into the small bowel, resulting in a mechanical obstruction. This case is particularly noteworthy due to the successful management of this rare complication utilizing a laparoscopic surgical approach. To the best of our knowledge, while isolated cases of IGB migration exist [6–8], the combination of this specific complication leading to small bowel obstruction and its resolution via a minimally invasive laparoscopic technique is a unique contribution to the literature. By presenting this case, we aim to highlight the critical importance of maintaining vigilance for rare complications following IGB placement and to offer valuable insights into the diagnosis and minimally invasive surgical treatment of this uncommon event.

Case Report

A 32-year-old woman with a BMI of 35.3 kg/m2 underwent endoscopic IGB placement at a private clinic. She had no significant comorbidities. Initial post-procedure symptoms included persistent nausea and vomiting, attributed to balloon intolerance. Over the following 3 weeks, she developed diffuse abdominal pain, subjective fevers, and constipation.

At presentation, she had stable vitals but had abdominal distension and tenderness. Laboratory test results showed leukocytosis. Abdominal X-rays revealed dilated loops, and a contrast-enhanced computed tomography (CT) scan demonstrated distal ileal obstruction caused by a deflated, migrated intra-gastric balloon (Figures 1, 2).

The patient received IV fluids, antibiotics, and nasogastric decompression. She underwent laparoscopic exploration revealing a deflated balloon lodged in the distal ileum. The bowel was exteriorized via a mini-laparotomy (Figure 3). A 2-cm enterotomy 40 cm from the ileocecal valve allowed balloon retrieval (Figure 4). The IGB was removed intact and confirmed as the sole obstructing pathology (Figure 5). The site was closed transversely in 2 layers (Figure 6).

Postoperative recovery was uneventful. The patient resumed oral intake by day 2 and was discharged on day 5. At 2-week and 1-month follow-ups, she remained asymptomatic with normal bowel function.

Discussion

This case shows that although intra-gastric balloons (IGBs) are considered safe and effective for weight reduction in appropriately selected obese patients, clinicians must be aware of rare but serious complications such as migration and subsequent small bowel obstruction. Early suspicion, timely imaging, and proper surgical planning are essential to improve outcomes.

This case report presents a noteworthy instance of a rare but serious complication following IGB insertion: distal migration leading to mechanical small bowel obstruction, successfully managed via a laparoscopic surgical approach. While IGBs are generally considered a safe and minimally invasive tool for weight management, this case underscores the importance of recognizing and promptly addressing potential complications, even those occurring infrequently.

Although IGBs are associated with several common, non-serious adverse effects, such as nausea (reported in up to 63% of patients), vomiting (up to 55%), abdominal pain (up to 58%), and gastro-esophageal reflux disease (up to 20%), premature removal due to adverse effects has been documented in 2.6% to 9% of cases. A particularly uncommon but significant complication, occurring in 0.8% of IGB placements, involves spontaneous deflation (potentially due to inadequate filling volume) followed by migration to the small intestine [4–7].

While IGBs are typically placed and designed for endoscopic removal, the spectrum of risks and benefits can vary significantly depending on the specific device type, including its design, filling material, and intended duration [3]. Unlike swallowable balloons, which are designed for spontaneous passage with a smaller profile and a potential failure mode of incomplete deflation leading to obstruction, the endoscopically placed balloon in our case failed through partial deflation and distal migration, causing a small bowel obstruction requiring surgical intervention. This highlights the importance of considering these device-specific nuances for a comprehensive understanding of potential complications and weight management options.

The risks and benefits of IGBs are intricately linked to the specific device characteristics, including design (single vs dual, adjustable, swallowable), filling material (saline, air, gas), and intended duration. While most IGBs offer a minimally invasive, temporary approach to weight loss by promoting satiety, their safety and efficacy profiles can vary. Dual-balloon systems aim to reduce migration risk, adjustable balloons allow for personalized volume optimization, and swallowable balloons enhance convenience but may have shorter duration [3]. Saline-filled balloons are common and generally safe, air-filled options can improve initial tolerance, and gas-filled balloons offer shorter treatment cycles. Longer-duration balloons may yield greater weight loss but potentially increased complication risks [3]. Therefore, a thorough understanding of the specific IGB type is crucial for informed decision-making and managing expectations regarding potential outcomes and adverse events.

An initial presentation with persistent postoperative nausea and vomiting, progressing to abdominal pain and constipation, should raise the suspicion of potential IGB-related issues beyond the typical transient adverse effects, necessitating appropriate imaging to differentiate between various possibilities such as intra-abdominal collection or perforation (although less likely, given the lack of free air on initial imaging), alongside the less common complication of balloon migration. Abdominal CT scan has been established in past studies as the optimal and confirmatory test for diagnosing migrated IGBs [5,9,10]. In our patient, a contrast-enhanced CT scan, preceded by abdominal radiographs, proved crucial. Consistent with prior findings, the CT scan provided a confirmatory diagnosis of the migrated IGB, clearly revealing diffuse small bowel dilatation with a transition zone in the distal ileum caused by the deflated balloon. This case further highlights the value of cross-sectional imaging in cases of atypical or worsening symptoms after IGB placement.

The successful laparoscopic management of this complication is a significant aspect of this case. Historically, migrated IGBs causing bowel obstruction have been predominantly managed with open surgery. This makes the current case particularly noteworthy, as nearly 70% of previously reported instances of this complication were resolved via laparotomy [4]. The ability to identify, manipulate, and extract the balloon through a minimally invasive technique, requiring only a small enterotomy and subsequent primary repair, offers several advantages. These include potentially reduced postoperative pain, shorter hospital stay (as evidenced by the patient’s discharge on postoperative day 5), faster recovery, and decreased risk of incisional complications compared to traditional open surgery [10].

This case adds to the growing body of evidence supporting the feasibility and benefits of laparoscopic techniques in managing complex bariatric surgery-related complications. Furthermore, our patient’s postoperative recovery was notable. The rapid weaning off analgesia, early tolerance of oral intake, and the absence of complications leading to a timely discharge and uneventful follow-up period demonstrate a positive outcome following the laparoscopic intervention. The resolution of her symptoms, including the return of regular bowel function, confirms the effectiveness of the surgical management in addressing the mechanical obstruction. However, past evidence also offers a contrasting view, supporting laparoscopy for small bowel obstruction in carefully selected cases when performed by experienced laparoscopic surgeons.

This case aligns with similar reports such as Molina et al (2019), Hay et al (2019), and Djelil et al (2021), which document the rarity and potential severity of migrated balloon complications and affirm that surgical management, especially via minimally invasive methods, is both safe and efficacious in selected cases [5,6].

Conclusions

This case underscores the critical importance of recognizing that while IGBs are generally safe, their diverse designs and mechanisms of action are associated with distinct complication patterns. Clinicians managing IGB patients must be aware of the specific characteristics of the device used, educate patients about potential complications beyond common transient symptoms, and maintain a high index of suspicion for migration in cases of persistent abdominal pain, vomiting, or bowel changes. Timely and appropriate imaging, such as CT scans, is crucial for accurate diagnosis. Furthermore, this case supports considering laparoscopic surgery as a feasible and potentially advantageous approach for managing migrated IGBs causing small bowel obstruction, offering benefits such as reduced recovery time compared to traditional open surgery, particularly when performed by experienced surgeons. While this successful outcome adds to the growing evidence for minimally invasive management of this rare but serious IGB complication, further research comparing outcomes across different balloon types and failure modes is warranted to establish definitive management guidelines.