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Complications of Adjustable Gastric Banding, a Radiological Pictorial Review

Mayssoun J. Mehanna1, Ghina Birjawi1, Hicham A. Moukaddam1, Ghattas Khoury2, Maher Hussein2 and Aghiad Al-Kutoubi1

1 Department of Diagnostic Radiology, American University of Beirut Medical Center, PO Box 11-0236, Beirut, Lebanon.
2 Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.


Figure 1
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  		Fig. 1 —Photographic images of Swedish Adjustable Gastric Band (SAGB, Obtech), MIDBAND, (Médical Innovation Développement) AMI Soft Gastric Band (C. J. Medical), and Lap-band (INAMED Health) (clockwise from left to right).

 

Figure 2
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  		Fig. 2A —Gastric band position. Normal position of gastric band. Phi angle, corresponding to angle between vertical axis and gastric band, is estimated at 55°. Note large width (2 cm) of Swedish Adjustable Gastric Band.

 

Figure 3
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  		Fig. 2B —Gastric band position. Schematic illustration of a typical gastric band placed few centimeters below diaphragm and forming angle of 55° with vertical line. Normal pouch is usually small and concentric.

 

Figure 4
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  		Fig. 3 —Normal barium swallow. Band lies few cm below diaphragm. Phi angle (arrows) is within normal limits. Pouch (asterisk) is concentric and not dilated.

 

Figure 5
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  		Fig. 4 —Misplaced band. Barium sip shows gastroesophageal junction outside the lumen of band (arrows) with no pouch formation. Swedish adjustable gastric band was placed in perigastric fat.

 

Figure 6
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  		Fig. 5A —46-year old man presenting with fever and chills. Barium swallow examination shows band (white arrow) in normal position with small concentric pouch. Two large air-fluid levels (black arrows) are noted in subphrenic region. No leak can be identified. Left pleural effusion and left lower lobe consolidation-collapse are also seen (asterisk).

 

Figure 7
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  		Fig. 5B —46-year old man presenting with fever and chills. Enhanced CT scan shows free air (arrows) around band and large abscess (asterisk) with an air-fluid level along anterior surface of liver. Abscess had right subphrenic extension (not shown). Fluid noted around spleen (arrowheads).

 

Figure 8
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  		Fig. 5C —46-year old man presenting with fever and chills. Minimal leak noted around antrum (arrows). Fluid is seen around spleen (arrowheads). Small fluid collection also seen along connector tube in subcutaneous tissues (curved arrow).

 

Figure 9
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  		Fig. 6 —Band placed at level of gastroesophageal junction just below diaphragm. Phi angle estimated at 78°. No gastric pouch seen; however, distal esophagus dilated with small concentric pouch (arrows) is seen.

 

Figure 10
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  		Fig. 7 —Schematic representation of medial eccentric pouch dilatation with anterior slippage. Note vertical position of band.

 

Figure 11
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  		Fig. 8 —Dilated eccentric lateral pouch with air-fluid level (asterisk). Note position of band with phi angle > 90°. Stoma is markedly narrowed (arrows); no contrast material is passing to rest of stomach. No contrast material reached stomach after 30 min (not shown). Complete obstruction was diagnosed.

 

Figure 12
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  		Fig. 9A —Increased phi angle indicating band slippage in two different patients. 35-year-old woman. Pouch is lateral eccentric (asterisk) showing air-fluid level (arrowhead) with narrowed stoma of 2 mm (arrows).

 

Figure 13
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  		Fig. 9B —Increased phi angle indicating band slippage in two different patients. Similar findings in 23-year-old man with dilated eccentric pouch (asterisk), increase in phi angle, and narrowed stoma (arrows).

 

Figure 14
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  		Fig. 10A —32-year-old woman. Oblique image from barium swallow after inflation of band (arrows) with saline shows small concentric pouch (asterisk).

 

Figure 15
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  		Fig. 10B —32-year-old woman. Six months later, patient noticed stabilization of weight. Barium swallow showed band in same position (arrows) with virtual pouch (asterisk) and large stoma, illustrating spontaneous variation in size of stoma.

 

Figure 16
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  		Fig. 11A —24-year-old man operated on for abdominal wall abscess with removal of connector tube and access port. No pouch can be identified on barium swallow. Contrast material seen flowing outside band (arrows) is pathognomonic of band erosion.

 

Figure 17
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  		Fig. 11B —24-year-old man operated on for abdominal wall abscess with removal of connector tube and access port. Before removal of band, barium examination shows leak outside stomach into well-defined collection (asterisk).

 

Figure 18
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  		Fig. 11C —24-year-old man operated on for abdominal wall abscess with removal of connector tube and access port. After removal of band, barium examination shows persistent leak outside stomach into described collection (asterisk) where drainage catheter (arrows) is seen.

 

Figure 19
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  		Fig. 12 —24-year-old woman with normally positioned gastric band (phi angle, 52°). Barium swallow shows contrast material flowing inside (arrowhead) and outside lumen of band (arrows) consistent with erosion.

 

Figure 20
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  		Fig. 13A —25-year-old woman presented for reinflation of band placed 5 years ago. While inflating band, patient experienced acute pain. Barium swallow shows contrast material flowing exclusively outside band lumen (arrow).

 

Figure 21
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  		Fig. 13B —25-year-old woman presented for reinflation of band placed 5 years ago. While inflating band, patient experienced acute pain. CT scan and endoscopy show band (arrow in CT) partially inside gastric lumen.

 

Figure 22
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  		Fig. 13C —25-year-old woman presented for reinflation of band placed 5 years ago. While inflating band, patient experienced acute pain. CT scan and endoscopy show band (arrow in CT) partially inside gastric lumen.

 

Figure 23
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  		Fig. 14 —Lateral film showed rotation of access port in subcutaneous tissue (arrow). This was irreversible in supine position and required surgical repositioning.

 

Figure 24
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  		Fig. 15 —Disconnection of connector tube (arrows) in this explanted band.

 

Figure 25
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  		Fig. 16 —Leak of contrast material at junction of port and connector tube (arrows). Band in normal position.

 

Figure 26
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  		Fig. 17 —Oblique image shows leak of contrast material around connector tube (arrows).

 

Figure 27
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  		Fig. 18 —19-year-old man. Contrast material leakage at junction of port and connector tube (arrows).

 

Figure 28
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  		Fig. 19A —40-year-old woman. Contrast material injected through port outlines gastric lumen (arrows) indicating disconnection of banding system and band erosion into stomach.

 

Figure 29
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  		Fig. 19B —40-year-old woman. Barium examination shows contrast material flowing outside lumen of band (arrows), confirming gastric erosion.

 

Figure 30
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  		Fig. 20 —27-year-old woman. Perisplenic collection (arrowhead) with peripheral enhancement around connector tube (arrow).

 

Figure 31
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  		Fig. 21 —39-year-old man. Whole small bowel filled with oral contrast material. Hypodense collection with peripheral enhancement (arrowhead) seen around connector tube (arrow) in midabdomen.

 

Figure 32
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  		Fig. 22 —21-year-old woman. Streaking and thickening of fat with some free fluid (arrowheads) seen around connector tube (arrows). Minimal free air also noted (curved arrow).

 

Figure 33
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  		Fig. 23 —29-year-old man presented with fever, chills, and abdominal pain. Crescent of air is noted around band (black arrows) consistent with infection.

 

Figure 34
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  		Fig. 24 —Gastric band is placed at level of gastroesophageal junction with dilatation of distal esophagus. Note tertiary contraction or nonperistaltic small waves (white arrows).

 

Figure 35
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  		Fig. 25 —Band removed for erosion into stomach wall. Barium swallow shows deformity of upper stomach (arrowhead) resembling the band and probably related to fibrosis.

 

Figure 36
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  		Fig. 26A —30-year-old woman presented with diffuse abdominal pain. CT scan shows small-bowel volvulus with dilated small-bowel loops (asterisks). A transitional zone (curved arrow) is noted at level of intraperitoneal part of connector tube (arrows).

 

Figure 37
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  		Fig. 26B —30-year-old woman presented with diffuse abdominal pain. Small-bowel series shows complete small-bowel obstruction. Multiple dilated small-bowel loops (asterisk) are seen with holdup of contrast material at level of connector tube in left lower quadrant (curved arrow).

 

Figure 38
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  		Fig. 27A —34-year-old woman presenting with right lower quadrant pain. CT scan shows gastric band and connector tube adjacent to spleen (arrows).

 

Figure 39
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  		Fig. 27B —34-year-old woman presenting with right lower quadrant pain. Same patient presented 3 months later with fever and left upper quadrant pain. CT scan revealed splenic collection (white arrows). Connector tube has changed its location and now projects within collection (black arrows).

 

Figure 40
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  		Fig. 27C —34-year-old woman presenting with right lower quadrant pain. Barium examination reveals gastric erosion (arrows), leak toward left upper quadrant (arrowheads). CT slices after swallow shows leak to be within splenic collection. Findings indicate gastric erosion, perforation, and splenic erosion.

 

Figure 41
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  		Fig. 27D —34-year-old woman presenting with right lower quadrant pain. Barium examination reveals gastric erosion (arrows), leak toward left upper quadrant (arrowheads). CT slices after swallow shows leak to be within splenic collection. Findings indicate gastric erosion, perforation, and splenic erosion.

 

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