Small bowel obstruction caused by a migrated Obalon gastric bariatric balloon: nonsurgical management by antegrade double-balloon panenteroscopy.

A 46-year-old woman presented with small-bowel obstruction (SBO) 2 months after placement of two Obalon gastric balloons (Obalon Therapeutics, California, USA) for weight loss [1]. A computed tomography (CT) scan confirmed SBO caused by a partially deflated balloon that had migrated into the ileum; the other balloon remained inflated and in situ within the stomach (●" Fig.1 and ●" Fig.2). After 72 hours of conservative management, a sudden worsening of her symptoms warranted intervention. For avoidance of surgery, we performed an antegrade double-balloon enteroscopy (DBE) with the patient under general anesthesia. The first (intragastric) balloon was deflated and extracted to enable friction-free DBE. The enteroscope was then inserted down to the distal ileum to an estimated depth of 6.4m from the pylorus, where the second partially deflated retained balloon was identified approximately 20cm proximal to the ileocecal valve (ICV). The retained balloon was then completely deflated by aspirating through an endoscopic injection needle before the balloon was carefully pushed through the ICV into the ascending colon with endoscopic graspers (●" Fig.3). No strictures were encountered during the uncomplicated panenteroscopy. The patient’s symptoms of obstruction resolved completely and the balloon was passed in the stools 2 days later (●" Fig.4). Migration of partially deflated gastric balloons into the small bowel is a recognized but uncommon complication that may warrant surgical intervention [2]. Although DBE has been shown to be useful for retrieval of foreign objects retained within the small bowel [3,4], to the best of our knowledge, this is only the second reported case of management of gastric balloon-related SBO by DBE [5]. Ours is the first report of this being achieved through antegrade panenteroscopy with endoscopic deflation of the impacted balloon and advancement of this through the ICV into the ascending colon. The antegrade route was the only DBE approach possible in this patient with SBO and an unprepared colon. Our case highlights the usefulness of DBE for the potential avoidance of surgery in such cases.