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LETTER TO THE EDITOR
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Delayed gastric emptying in a patient with an intragastric balloon In situ


1 Department of Anesthesia, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Oncoanesthesia, AIIMS, New Delhi, India

Date of Submission17-Dec-2019
Date of Decision30-Jan-2020
Date of Acceptance25-Jun-2020

Correspondence Address:
Gaurav Sindwani,
Department of Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_345_19



How to cite this URL:
Kohli M, Sindwani G, Suri A, Arora MK. Delayed gastric emptying in a patient with an intragastric balloon In situ. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=309952



Dear Sir,

Aspiration of gastric contents is a nightmare for an anesthetist. Various risk factors for perioperative aspiration include elderly patients, obesity, diabetes mellitus, gastroesophageal reflux disease, and renal failure patients.[1],[2] Patients with an intragastric balloon (IGB) in situ may come for its resizing, removal, or some other surgeries. Delayed gastric emptying and prolonged satiety are the main mechanisms by which an IGB decreases a patient's weight. We report a case of a 57-year-old male who was posted for resizing of an IGB after adequate fasting of 12 h. However, his procedure was abandoned due to the presence of residual food in his stomach.

A 57-year-old male, weighing 92 kg, known case of nonalcoholic steatohepatitis, was posted for resizing of an IGB under intravenous (IV) sedation. IGB was inserted 3 months ago. Due to inadequate weight loss, he was again posted for the upsizing of an IGB. His body mass index was 33.4. He had two chapattis and one bowl of vegetables at 9 pm. He was kept nil per oral for 12 h. On the day of the procedure, the patient was shifted inside the procedure room. Monitors such as pulse oximeter, noninvasive blood pressure, and electrocardiogram were attached. Oxygen was insufflated via nasal cannula at 3 l min−1. Midazolam 1 mg IV, fentanyl 50 μg IV, and propofol 100 mg IV were given slowly. During endoscopy, IGB along with residual food was seen in the stomach [Figure 1]. Immediately, an endoscopist tried to aspirate the food, but he failed as the food particles were of very thick consistency. The procedure was abandoned. No further sedation was given to the patient. The patient was kept in the lateral position and was shifted back to the recovery room after he became conscious.
Figure 1: Intragastric balloon in situ with residual food. IGB – Intragasric balloon

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Standard nil per oral guidelines state that a patient needs to be fasting for 6 h and 2 h for solid food and clear fluids, respectively.[3] There are already documented exceptions to these guidelines such as obesity, diabetes, peptic ulcer disease, esophageal, and upper abdominal surgery. However, as per our literature search, the presence of an IGB as an exception to standard nil per oral guidelines has not been reported.

The presence of IGB hinders the passage of food into the intestines and delays gastric emptying. Furthermore, our patient was obese and had chronic liver disease, which also could have contributed to his delayed gastric emptying. Therefore, despite 12-h fasting, residual food was seen in his stomach. Bonazzi et al. showed that the gastric emptying time gets delayed in the first 3 months after the placement of an IGB. This is the time when stomach musculature gets adapted to the presence of a foreign body and it returned to normal by 6 months. Our patient came for the resizing of an IGB after 3 months of its placement, which is in the same time frame as suggested by Bonazzi et al.[4]

To conclude, patients with IGB should be considered full stomach regardless of the time they have fasted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Snell C, Coleman S, Van Hal M, Rashidian F, Okum G, Green MS. Crohn's disease-associated silent aspiration in the outpatient setting: Anesthesiologists beware. Saudi J Anaesth 2018;12:339-42.  Back to cited text no. 1
    
2.
Petrini F, Di Giacinto I, Cataldo R, Esposito C, Pavoni V, Donato P, et al. Perioperative and periprocedural airway management and respiratory safety for the obese patient: 2016 SIAARTI consensus. Minerva Anestesiol 2016;82:1314-35.  Back to cited text no. 2
    
3.
Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, Søreide E, et al. Perioperative fasting in adults and children: Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28:556-69.  Back to cited text no. 3
    
4.
Bonazzi P, Petrelli MD, Lorenzini I, Peruzzi E, Nicolai A, Galeazzi R. Gastric emptying and intragastric balloon in obese patients. Eur Rev Med Pharmacol Sci 2005;9:15-21.  Back to cited text no. 4
    


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