DOI:10.2214/AJR.04.0655
AJR 2006; 186:522-534
© American Roentgen Ray Society
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.
Received April 26, 2004;
accepted after revision January 3, 2005.
Address correspondence to A. Al-Kutoubi
(mk00{at}aub.edu.lb).
Abstract
OBJECTIVE. The purpose of this article is to review the radiologic
appearance of complications of the adjustable gastric band.
CONCLUSION. Continuous progress in surgical technique of adjustable
gastric banding and the increasing experience of surgeons have decreased the
rate of complications. However, because different complications may have the
same clinical presentation but require different treatment, to give a
definitive diagnosis, the radiologist must be aware of the surgical procedures
and possible sequelae.
Keywords: abdominal imaging • bariatric surgery • barium • gastric band • implantable devices • stomach
Introduction
Morbid obesity is a commonly encountered problem in society. It is usually
refractory to conservative treatment, diets, and behavioral therapy. A
surgical approach may be required to prevent or treat the associated
morbidities. Since its first introduction in 1993, laparoscopic adjustable
gastric banding has gained a major role as a first-line surgical treatment for
morbid obesity. It is associated with an acceptable success rate and
relatively low morbidity. Multiple complications of this laparoscopic
technique have been described, both in early and late phases.
Normal Anatomy
The adjustable gastric banding system is composed of three parts: the band,
the access port, and the connector tube. Four different systems are available:
adjustable silicone lap banding (ASGB) Lap-band (INAMED Health [formerly
BioEnterics]), the Swedish Adjustable Gastric Band (SAGB, Obtech), the AMI
Soft Gastric Band (C. J. Medical), and the new MIDBAND (Médical
Innovation Développement). These differ in a few anatomic
characteristics (Fig. 1). The
ASGB and the SAGB are commonly used in North America, whereas AMI bands are
popular in Europe and Mexico. The ASGB is composed of radiopaque silicone, has
a width of 1 cm, and can contain a maximum of 4 mL of fluid for stoma
calibration. The SAGB is nonradiopaque, measures 2 cm in width, and can
contain a maximum of 8 mL of fluid for stoma calibration
[1,
2].
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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).
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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.
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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.
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The adjustable band is placed around the upper part of the stomach,
approximately 2 cm from the gastroesophageal (GE) junction, thus causing
formation of a small pouch or neostomach, which limits food intake and slows
the emptying process from the stomach into the intestines
[3]. The band may also be
placed on the esophagus, leaving no pouch at all. This serves as a restrictive
device but does not give the patient a feeling of satiety produced by the
stretching of the stomach wall
[3]. The access port is placed
outside the peritoneal cavity, either within the rectus abdominis muscle
sheath or under the external thoracic fascia
[4].
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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).
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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).
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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).
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In an anteroposterior (AP) projection, the band is inclined 45° to the
patient left (phi angle corresponding to the angle between the spinal column
and the gastric band has a normal range between 4-58°) and lies about 5 cm
below the diaphragm (Figs. 2A
and 2B). After adequate filling
with contrast or solid meal, the gastric pouch diameter is normally about 4
cm, which corresponds to a volume of 15-20 mL. The pouch normally shows a
grossly regular contour and is concentric in shape
[4,
5]. The stoma diameter normally
measures 3-4 mm, causing adequate emptying of the pouch within 15 to 20 min
[6]
(Fig. 3).
Complications Related to the Banding System
Early complications are seen in the immediate postoperative period and
include misplacement of the band, perforation, and early slippage with
secondary acute pouch dilatation. Late complications include pouch dilatation,
band herniation, spontaneous variation in volume, erosion of the gastric wall,
and migration of the band.
Misplacement
Misplacement of the band is usually caused by the surgeon's lack of
experience and rarely occurs when the surgeon is experienced
[1]. The band may be placed in
the perigastric fat (Fig. 4) or
in the lower part of the stomach, the latter causing severe gastric outlet
obstruction.
Perforation
Early gastric perforation is usually due to surgical trauma to the stomach
wall. The patient presents with fever, pain, and leukocytosis. Water-soluble
contrast imaging may reveal the leakage from the stomach. However, leakage is
not a constant finding [7], and
the diagnosis may be delayed for few days. The use of barium has been
controversial because it may cause inflammation and fibrosis in these
critically ill patients and is probably better avoided if there is definite
evidence of leakage [7,
8]. CT is also diagnostic,
showing the leakage and the possible associated subphrenic abscess (Figs.
5A,
5B, and
5C).
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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.
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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.
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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).
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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).
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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.
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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.
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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).
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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.
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Pouch Dilation
Early pouch dilatation has been described in low-positioned bands
[7]. Pouch dilatation is also a
common late complication. After surgery, the pouch gradually increases in
volume but retains a grossly concentric shape. The upper limit of the
acceptable volume in these cases is not yet established
[5]. Concentric dilatation may
be secondary to reactive perigastric fibrosis as a result of tight fastening
at surgery or of the natural reaction of the body to foreign implants
(silicone) [6]. It may also be
secondary to overinflation of the band or to eccentric band herniation that
results from focal band weakness
[9]. Chronic concentric pouch
dilatation, secondary only to chronic nutritional overload, is diagnosed by
exclusion [9]
(Fig. 6).
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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.
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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).
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Medial eccentric pouches are directly related to intraperitoneal band
positioning in the transbursal operative technique where dissection is
performed through the lesser sac and the band is placed on the stomach near
the short gastric vessels. This is in contrast to the new technique, pars
flaccida, where minimal dissection is performed and the band is placed in the
hepatogastric ligament, leaving the lesser sac untouched. This leads to higher
position of the band, away from the peristalting stomach
[5]. In these cases, the axis
of the band is oriented to the right of the vertical axis of the spine (phi
angle, < 4°), the pouch is dilated and prominent medially, and there is
abnormal stasis of the solid food in the pouch for more than 30 min
[5,
6]
(Fig. 7).
Lateral eccentric pouches are secondary to posterior slippage of the band.
Slippage is defined as herniation of the stomach from below the band upward,
resulting in pouch enlargement. In such cases, the band is oriented to the
left of the vertical line with a phi angle > 58°
[5]. This is associated with
eccentric lateral dilatation of the neostomach that can show an air-fluid
level and delayed emptying. Peternac et al.
[5] suggested that this
complication is not dependent on the operative technique; rather it results
from tears of the anterior sero-muscular fixative sutures
[5,
10]. Other authors have
encountered this complication only in the transbursal approach
[9] (Figs.
8,
9A, and
9B). Eccentric pouches are
always abnormal and dilated
[5]. In severe eccentric pouch
dilatation, the pouch may cause complete obstruction of the stoma. In such
cases, gastric volvulus may be encountered
[6,
9].
Intermittent slippage due to an unstable band is a difficult diagnosis. It
manifests by intermittent obstruction and abnormal band position only after
filling the pouch. In these cases, the posterior slippage is discrete and the
band returns to its normal position after deflating the system or emptying the
pouch [9].
Variation in the Stoma Size
The spontaneous increase in the stoma diameter in the Lap-band is related
to the semi-permeability of the silicone. The system, therefore, should be
filled only with isoosmotic, isotonic solution. This will prevent both
spontaneous increase in stoma size when using saline and stoma narrowing with
pouch dilatation when using hyperosmolar contrast
[11] (Figs.
10A and
10B).
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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.
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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.
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Erosion
The clinical presentation of chronic gastric erosion varies between
asymptomatic conditions and acute abdominal emergency. Mechanical damage to
the wall may be secondary to intraoperative trauma to the muscular layers,
inflammatory reaction to foreign bodies, infection, and use of nonsteroidal
antiinflammatory medication [3,
9,
12]. The passage of the
contrast out of the lumen around the band is a certain indication of band
erosion. Gastric erosion is highly likely if an open band is seen. Findings
may be associated with a change in band position
[12] (Figs.
11A,
11B,
11C,
12,
13A,
13B, and
13C).
Rotation of the Access Port
Partial rotation of the access port may be most easily corrected by
supportive manual compression when the patient is in a supine position.
Completely inverted ports require surgical repositioning
(Fig. 14).
Disconnection
Disconnection can occur between the proximal and distal parts of the
connector tube or at the junction of the connector with the band or with the
access port. These disconnections are easily diagnosed on a radiograph (since
the connector tube is usually made of silicone). Surgical treatment is
mandatory [9]
(Fig. 15).
Leakage of the Banding System
Leakage is typically a late complication. It may occur at the level of the
band or the connector tube or at the access port. It is first suspected when
filling and insufficient deflating volume of the banding system combined with
loss of eating restriction are observed
[13]. Leakage of contrast
material is usually detected while adjusting the band diameter (Figs.
16,
17,
18,
19A, and
19B). However, contrast
studies sometimes fail to detect the leakage even in typical clinical
presentations [2]. In such
cases, 99mTc pertechnetate scintigraphy shows strong uptake in the
gastric mucosa on delayed images, whereas the tracer has almost cleared from
the reservoir [13]. Similar
findings are seen with the use of thallium-201 chloride. This examination is
limited by its inability to localize the site of the leak. Localizing the leak
is possible with the use of 99mTc-albumin, which shows a decrease
in the count in the defective part with accumulation of the tracer adjacent to
it [2]. Nuclear medicine
studies are probably indicated only in extreme cases.
Infection
As around any foreign body, soft-tissue infection around the access port is
possible. In addition, even the sterile puncture and adjustment of the stoma
size may introduce infection, which then extends along the connector tube and
along the band, with possible abscess formation. Infection increases the risk
of perforation and fistulization and may necessitate surgical
débridement and removal of the band (Figs.
20,
21,
22, and
23).
Esophageal Dysmotility and Reflux
Esophageal dysmotility represents an early stage of esophageal paresis and
dilatation [5]. The extreme
form is esophageal gastrification (enhanced reservoir capacity of the
esophagus) [5]. This indicates
the end point of a successful restrictive bariatric surgery. Secondary
achalasia has also been described in association with preoperative lower
esophageal sphincter insufficiency
[14]. Reflux and regurgitation
are common complications associated with pouch dilatation and may be
associated with esophagitis (Fig.
24).
Miscellaneous
Food trapping within the stoma has been described
[9]. It presents with dysphagia
and appears as an intraluminal filling defect within the stoma. The
inflammatory reaction around the band may lead to significant fibrosis
(Fig. 25). The long
intraperitoneal tract of the connector tube may cause small-bowel volvulus and
obstruction (Figs. 26A and
26B). Inflammatory reaction
around the connector tube can be extensive, eroding into adjacent organs
(Figs. 27A,
27B,
27C, and
27D).
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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).
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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).
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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).
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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.
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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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Conclusion
Since its introduction in 1993, laparoscopic adjustable gastric banding has
been the subject of many studies and evaluations. The continuous progress in
surgical technique and increasing experience of surgeons have decreased the
rate of many complications. However, because different complications may have
the same clinical presentation but require different treatment, to give a
definitive diagnosis, the radiologist must be aware of the surgical procedures
and possible sequelae.
Acknowledgments
We thank Masa Al-Kutoubi for her artistic illustrations in Figures
2B and
7.
References
- Mortele KJ, Pattijn P, Mollet P, et al. The Swedish laparoscopic
adjustable gastric banding for morbid obesity: radiologic findings in 218
patients. AJR 2001;177
: 77-84[Abstract/Free Full Text]
- Weiss H, Peer R, Nehoda H, et al. Improved scintigraphic assessment
of occult leakages in adjustable gastric bands using 99mTc-labelled
human albumin colloid. Obes Surg 2001;11
: 502-506[Medline]
- Szold A, Abu-Abeid S. Laparoscopic adjustable silicone gastric
banding for morbid obesity: results and complications in 715 patients.
Surg Endosc 2002;16
: 230-233[CrossRef][Medline]
- Toppino M, Cesarani F, Comba A, et al. The role of early
radiological studies after gastric bariatric surgery. Obes
Surg 2001; 11:447
-454[CrossRef][Medline]
- Peternac D, Hauser R, Weber M, Schob O. The effects of laparoscopic
adjustable gastric banding on the proximal pouch and the esophagus.
Obes Surg 2001;11
: 76-86[Medline]
- Pretolesi F, Camerini G, Bonifacino E, et al. Radiology of
adjustable silicone gastric banding for morbid obesity. B J
Radiol 1998; 717:722
- Nehoda H, Hourmont K, Mittermair R, et al. Is a routine liquid
contrast swallow following laparoscopic gastric banding mandatory?
Obes Surg 2001;11
: 600-604[Medline]
- Cochran DQ, Almond CH, Shucart WA. An experimental study of the
effects of barium and intestinal contents on the peritoneal cavity.
AJR 1963; 89:883
-887
- Weisner W, Schob O, Hauser RS, Hauser M. Adjustable laparoscopic
gastric banding in patients with morbid obesity: radiographic management,
results, and postoperative complications. Radiology2000; 216:389
-394[Abstract/Free Full Text]
- Neri A, Mariani F, Testa M, et al. Initial experience with
laparoscopic adjustable gastric banding and pouch dilatation: two cases.
Obes Surg 2001;11
: 229-231[Medline]
- Weisner W, Hauser M, Schob O, Weber M, Hauser R. Spontaneous volume
changes in gastric banding devices: complications of a semipermeable membrane.
Eur Radiol 2001;11
: 417-421[Medline]
- Pretolesi F, Camerini G, Gianetta E, Marinari GM, Scopinaro N,
Derchi LE. Intraluminal penetration of the band in patients with adjustable
silicone gastric banding: radiological findings. Eur
Radiol 2001; 11:412
-416[Medline]
- Van den Eeckhaut AC, Villeirs GM, Van de Wiele C, Versijpt JJ,
Pattyn P, Dierckx RA. Laparoscopic adjustable silicone gastric banding leakage
assessed by 99mTc-pertechnetate scintigraphy. J Nucl
Med 1999; 40:783
-785[Abstract/Free Full Text]
- Weisner W, Hauser M, Schob O, Weber M, Hauser RS. Pseudo-achalasia
following laparoscopically placed adjustable gastric banding. Obes
Surg 2001; 11:513
-518[Medline]
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Abstract
Introduction
