AJR 2005; 184:109-112
© American Roentgen Ray Society
Intragastric Band Erosion After Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Imaging Characteristics of an Underreported Complication
Bernard Hainaux1,2,
Emmanuel Agneessens2,
Erika Rubesova1,
Vinciane Muls3,
Quentin Gaudissart4,
Constantin Moschopoulos1 and
Guy-Bernard Cadière4
1 Department of Radiology, Centre Hospitalier Universitaire Saint-Pierre,
Université Libre de Bruxelles, 322 rue Haute, Brussels 1000,
Belgium.
2 Department of Radiology, HIS Site Etterbeek-Ixelles, 63 rue Jean Paquot,
Brussels 1050, Belgium.
3 Department of Gastroenterology, Centre Hospitalier Universitaire Saint-Pierre,
Université Libre de Bruxelles, Brussels 1000, Belgium.
4 Department of Gastrointestinal Surgery, Centre Hospitalier Universitaire
Saint-Pierre, Université Libre de Bruxelles, Brussels 1000,
Belgium.
Received March 4, 2004;
accepted after revision May 11, 2004.
Address correspondence to B. Hainaux
(hainauxb{at}yahoo.fr).
Abstract
OBJECTIVE. Our purpose was to describe the imaging findings of
intragastric band erosion, an underreported complication after laparoscopic
adjustable gastric banding for the treatment of morbid obesity. In this
long-term complication, the gastric band fastened around the upper stomach to
create a small proximal gastric pouch gradually erodes into the stomach wall
and can extend into the gastric lumen. We present three cases of patients with
band erosion in whom findings on an upper gastrointestinal series and CT
established the diagnosis.
CONCLUSION. Diagnosis of intragastric band erosion after gastric
banding is usually made with endoscopy. However, the radiologic appearance of
band ersoion when visualized on an upper gastrointestinal series is
pathognomonic and allows initial imaging diagnosis. In patients with
extraluminal air or prosthesis infection, CT findings also are suggestive of
this postoperative complication.
Introduction
The increasing prevalence of obesity is a major public health problem in
all Western countries. Morbid obesity is associated with several chronic
diseases such as hypertension, diabetes, hyperlipidemia, degenerative
arthritis, and sleep apnea that lead to increased morbidity and mortality. The
U.S. National Institutes of Health Consensus Conference
[1] concluded that most
patients who were morbidly obese failed to achieve acceptable long-term weight
loss after behavioral modification or drug therapy. Therefore, surgery might
be considered in the treatment of morbidly obese patients. Gastric banding was
developed as a minimally invasive alternative to gastric bypass or
gastroplastic procedures. Since its introduction in 1992
[2], laparoscopic adjustable
gastric banding has been used extensively around the world, first in Europe
and since 2001 in the United States after the procedure was approved by the
U.S. Food and Drug Administration (FDA). To date, the gastric band has been
placed in more than 80,000 patients
[3]. Intragastric prosthesis
migration has only recently been described as one of the major long-term
complications. Diagnosis is usually made with endoscopy
[4], and to our knowledge, only
one case of band erosion visualized on an upper gastrointestinal examination
has been reported previously in the radiology literature
[5]. We present three cases of
patients with intragastric band erosion in whom diagnosis was based on
findings of upper gastrointestinal series and CT and describe the imaging
characteristics of this postoperative complication.
Subjects and Methods
Since October 1992, 537 morbidly obese patients have been treated at our
institution by laparoscopic adjustable gastric banding. The procedure consists
of placement of an implantable silicone band (BioEnterics LAP-BAND System,
INAMED Health) around the upper stomach, creating a channel between a small
proximal pouch and the distal stomach. The device is prevented from slipping
by placing stitches between the serosa of the stomach just proximal and distal
to the band and wrapping the gastric fundus around the device. The inner
surface of the band is inflatable and connected through a catheter to a
subcutaneous access port. This arrangement allows postoperative adjustment of
the size of the stoma by percutaneous injection or withdrawal of saline
solution via the port.
Initial imaging diagnosis of intragastric band erosion was made in three
patients. All three underwent single-contrast-enhanced upper gastrointestinal
examinations using water-soluble contrast material (meglumine amidotrizoate,
Gastrografin, Schering). Examinations were performed on digital fluoroscopy
equipment (Siregraph 2, Siemens Medical Systems). Two patients also underwent
abdominal MDCT (Somatom Plus Volume Zoom scanner, Siemens Medical Systems)
after receiving 120 mL, of iohexol (Omnipaque 350 mg I/mL; Amersham Health)
via a power injector. The MDCT examination was performed as a simultaneous
acquisition with parameters of 4 x 2.5 mm collimation, table speed of 14
mm/sec, 120 kV, and 150 effective mAs.
Results
Of the 537 patients treated, 437 (81%) were available for follow-up, with a
median follow-up period of 33 months (range, 12–109 months). The
diagnosis of intragastric band erosion was established by endoscopy in 18
patients (3%). The most common symptom was epigastric or abdominal pain (13
patients). Clinical findings also included gastrointestinal bleeding (two
patients), cessation of weight loss (three patients), access port infection
(three patients), and abdominal abscess (one patient). Some patients presented
with more than one symptom. One patient was asymptomatic. Laparoscopic band
removal and closure of the defect in the gastric wall were performed in all 18
patients without complication.
In three of the 18 patients with band erosion, diagnosis was first
established radiologically and then confirmed with endoscopy. The clinical and
radiologic findings in these three patients are summarized in
Table 1. The first patient was
asymptomatic, with the diagnosis of band erosion made at radiologic evaluation
performed before band adjustment. The second patient experienced mild
abdominal pain for a period of 3 months and acute pain only on the day of
admission to the hospital. The third patient was hospitalized for access port
infection. Upper gastrointestinal series performed in the three patients
showed a pathognomonic aspect of intragastric band erosion, with contrast
material surrounding the part of the band that lies in the lumen of the
stomach (Figs. 1A and
1B). MDCT was performed in the
second and third patients. In the second patient, MDCT showed the intragastric
position of the eroded section of the band. The lesion was associated with
small amount of peritoneal fluid and a few extraluminal bubbles of air (Figs.
2A and
2B). MDCT of the third patient
showed an abscess surrounding the gastric wall and along the catheter toward
the access port (Figs. 3A and
3B).
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Fig. 1A. —Intragastric band erosion in 23-year-old woman. Radiograph
from upper gastrointestinal series shows characteristic appearance of
intragastric band erosion. Note contrast material on both sides of penetrating
portion of band (arrow).
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Fig. 1B. —Intragastric band erosion in 23-year-old woman. Drawing of
radiographic findings shown in A illustrates passage of contrast
material through stoma of band (large arrow) and around left section
of band that has eroded into stomach (small arrow). Note normal
aspect of right section of band with gastric fundus wrapped around it.
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Fig. 2A. —Intragastric band erosion in 39-year-old woman. Radiograph
from upper gastrointestinal series shows typical image of intragastric band
erosion. Contrast material surrounds part of band that has eroded through wall
of stomach (arrow). Gastric fundus is indicated by asterisk.
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Fig. 2B. —Intragastric band erosion in 39-year-old woman. Axial CT scan
obtained at level of gastric banding shows good correlation with fluoroscopic
view in A. Air around eroded band (arrow) corresponds to
contrast material around band seen on gastrointestinal series. Gastric fundus
is indicated by asterisk.
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Discussion
Bariatric surgery is widely recognized as an effective treatment for
morbidly obese patients. Several surgical methods have been introduced,
including gastric bypass and vertical banded gastroplasty
[6]. Laparoscopic adjustable
gastric banding was first described in 1992 and is today the most commonly
performed bariatric procedure in Europe and Australia
[7]. The procedure was approved
for use in the United States by the FDA in June 2001. In the gastric banding
procedure, a silicone band is placed around the proximal part of the fundus to
create a small gastric pouch. The band is connected through a catheter to a
subcutaneous access port. Percutaneous puncture of the access port allows
postoperative adjustment of the stomal diameter of the band by adding or
removing saline solution and inflating or deflating a section of the band.
Complications after laparoscopic adjustable gastric banding reported in the
radiology literature include pouch dilatation, band slippage, and access port
complications [5,
8,
9]. As the results of long-term
follow-up have become available, a new complication has appeared: intragastric
band erosion, in which the silicone ring penetrates the gastric wall and, in
some patients, the lumen of the stomach
[4,
10]. Erosion of prosthetic
material previously had been reported after other bariatric procedures such as
vertical banded gastroplasty
[11]. It typically is a
late-stage complication caused by chronic ischemia due to pressure applied to
the gastric wall.
In a review of literature, the reported prevalence of intragastric band
erosion varies from none to as much as 11%
[4]. These variations could be
due to differences in the length of follow-up and the type of routine studies
performed during follow-up. In a series of 119 patients reported by Silecchia
et al. [4] with a minimum
follow-up period of 12 months (mean follow-up, 32 months), the rate of band
erosion was 7.5% because all patients, even if asymptomatic, underwent routine
gastrointestinal endoscopy. In that series, all patients with eroded
intragastric bands were asymptomatic at the time of endoscopic diagnosis.
However, if routine endoscopy had not been performed, it is likely that the
observed prevalence of erosion would have been lower, with more salient
clinical symptoms in most diagnosed cases. Clinical manifestations include
nonspecific epigastric or abdominal pain, cessation of weight loss,
gastrointestinal bleeding, abdominal abscess, and abscess at the port site.
One of our patients presented with peritonitis and pneumoperitoneum. The
appropriate treatment of intragastric band erosion is still controversial,
including endoscopic follow-up in asymptomatic patients, intragastric
endoscopically assisted removal of the band, or laparoscopic band removal (as
performed in our series).
A prospective evaluation of intragastric band erosion using barium swallow
and upper gastrointestinal endoscopy found that gastrointestinal series could
not reveal band erosion in its early stages
[4]. However, the radiologic
appearance of later-stage intragastric band erosion on upper gastrointestinal
series is pathognomonic. Barium swallow shows a flow of contrast material
around the part of the band that has eroded into the stomach. If symptoms
suggest intraabdominal abscess or open perforation, CT should be used to
assess the presence of perigastric abscess or extravisceral air associated
with the erosion.
In conclusion, intragastric band erosion is a major complication of
laparoscopic adjustable gastric banding, often leading to additional surgery.
The prevalence of this complication will probably increase over time because
patients may remain asymptomatic for long periods and because band erosion
occurs long after band placement. Radiologists in charge of postoperative
evaluation of patients after bariatric surgery should be aware of the
characteristic imaging findings of this underreported complication to detect
it at the earliest possible stage.
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Abstract
Introduction
