DOI:10.2214/AJR.05.0293
AJR 2007; 188:472-479
© American Roentgen Ray Society
Laparoscopic Adjustable Gastric Banding Surgery for Morbid Obesity: Imaging of Normal Anatomic Features and Postoperative Gastrointestinal Complications
Arye Blachar1,2,3,
Annat Blank1,2,
Nancy Gavert2,4,
Ur Metzer1,2,
Gideon Fluser1,2 and
Subhi Abu-Abeid2,4
1 Department of Radiology, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel
Aviv 64239, Israel.
2 The Sackler School of Medicine, Tel Aviv University, Tel Aviv 64239,
Israel.
3 University of Pittsburgh Medical Center, Pittsburgh, PA 15213.
4 Department of Surgery B, Bariatric Surgery Service, Tel Aviv Soursaky Medical
Center, Tel Aviv 64239, Israel.
Received August 2, 2005;
accepted after revision February 27, 2006.
Address correspondence to A. Blachar
(ablachar{at}tasmc.health.gov.il).
Abstract
OBJECTIVE. The purpose of this essay is to describe the normal
anatomic findings after laparoscopic adjustable gastric banding surgery and
the imaging findings of postoperative gastrointestinal complications.
CONCLUSION. With the increasing prevalence of morbid obesity,
laparoscopic adjustable gastric banding surgery has evolved to be a leading
surgical technique. Radiologists need to be familiar with the normal anatomic
findings after laparoscopic adjustable gastric banding surgery and with the
imaging findings of postoperative complications.
Keywords: abdomen • abdominal imaging • gastrointestinal radiology • obesity • stomach
Introduction
Morbid obesity is a national health problem in most Western
industrialized countries and is increasing in prevalence. It is defined as a
body mass index of 35 with comorbidity or of 40 without comorbidity. Morbid
obesity is difficult to manage with medical or behavioral therapy. Surgical
methods of weight control (bariatric surgery), however, have been found to
provide immediate and long-term reduction in weight for most patients. There
are two main approaches to surgical treatment: bypass procedures based on
bypassing part of the digestive tract to generate malabsorption and
restrictive procedures based on stomach volume restriction. Surgical
procedures are usually performed with a laparoscopic approach. The most widely
accepted procedures are laparoscopic roux-en-Y gastric bypass and laparoscopic
adjustable gastric banding, both of which have been endorsed by a National
Institutes of Health consensus conference
[1]. Laparoscopic adjustable
gastric banding is the least invasive surgical procedure and has been proposed
as a primary operation for morbid obesity
[2]. The technique is simple,
safe, effective, and has relatively few complications.
Between November 1996 and December 2003, 2,134 patients underwent
laparoscopic adjustable gastric banding surgery at our institution. The
purpose of this pictorial essay is to familiarize radiologists with the normal
postoperative anatomic features and the imaging findings of postoperative
gastrointestinal complications of laparoscopic adjustable gastric banding
surgery.
Postoperative Anatomic Features and Imaging After Laparoscopic Adjustable Gastric Banding Surgery
In laparoscopic adjustable gastric banding surgery, the stomach is divided
into two pouches by placement of an adjustable silicone gastric band 2 cm
below the gastroesophageal junction to make a small gastric pouch with a
volume of approximately 15 mL. The inner part of the band is a sleeve
connected to a subcutaneous port in the left abdominal wall that enables
adjustment of the band diameter (Fig.
1A,
1B).
The radiologist plays an important role in the preoperative and
postoperative evaluation and care of patients undergoing laparoscopic
adjustable gastric banding surgery. Barium esophagography is performed
preoperatively to determine the normal anatomic findings and assess the
function of the upper gastrointestinal tract. The radiologist maintains the
optimal diameter of the band postoperatively by periodically inflating and
deflating it using the subcutaneous port and may diagnose and assist in the
treatment of postoperative complications.
Because of the possible long-term complications and because clinical
symptoms are not reliable indicators, annual follow-up esophagography is
recommended. Patients are also referred to the radiologist if weight loss is
not satisfactory or if symptoms develop. Esophagography is usually performed
with barium unless the study is performed immediately postoperatively or when
there is high clinical suspicion of a leak. In such cases water-soluble
contrast medium is used initially. If no leak is detected, barium is used for
better evaluation.
Normal findings on esophagography with water-soluble contrast medium (Fig.
2A,
2B) are the presence of the
adjustable band, catheter, and subcutaneous port and a small proximal pouch
with narrow passage of contrast material through the stoma to the stomach. CT
(Fig. 2A,
2B) is used when small-bowel
obstruction, port infection, intraabdominal leak, or abscess is suspected. Use
of multiplanar reconstruction with MDCT enables accurate delineation of the
gastric band and visualization of band slippage and migration.
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Fig. 2A —56-year-old woman with normal anatomic findings after laparoscopic
adjustable gastric banding. Esophagogram shows contrast material passing
through esophagus (E) and stoma into stomach (S). Band (arrow) is
properly located.
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Fig. 2B —56-year-old woman with normal anatomic findings after laparoscopic
adjustable gastric banding. Axial CT section at level of band (arrow)
shows small gastric pouch (GP) and contrast material in stomach.
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Gastrointestinal Complications of Laparoscopic Adjustable Gastric Banding Surgery
Stomal Stenosis
The most common complication after laparoscopic adjustable gastric banding
is gastric stomal stenosis and obstruction. In acute stomal stenosis, patients
have vomiting, nausea, and upper abdominal discomfort that may result from
blockage of the stoma by food or from postoperative stomal edema. Narrowing of
the gastric stoma and slow passage of contrast material are visualized on
barium esophagography (Fig. 3A,
3B). If the band remains in an
appropriate position, the treatment is conservative. The radiologist
performing esophagography deflates the band and refers the patient to the
surgeon.
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Fig. 3A —26-year-old woman with acute stomal stenosis 7 months after
laparoscopic adjustable gastric banding surgery. Symptom was recurrent
vomiting that increased in severity. Esophagogram shows dilated upper pouch
(P) and minute passage of contrast material through narrow stoma
(arrow).
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Fig. 3B —26-year-old woman with acute stomal stenosis 7 months after
laparoscopic adjustable gastric banding surgery. Symptom was recurrent
vomiting that increased in severity. Esophagogram after band deflation shows
normal passage of contrast material (arrow) from esophagus (E) to
stomach (S).
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If the stomal blockage is insidious and chronic, patients experience
stabilization of the weight loss curve and gastroesophageal reflux. Weight
stabilization can be caused by food accumulation in the esophagus, and the
result is increasing insensitivity to distention of the pouch or esophagus.
Chronic stomal stenosis can be caused by overfilling or too tight fastening of
the band at surgery or by the radiologist after surgery. Subsequent tissue
reaction to the silicone band causes perigastric fibrosis. Chronic pouch
dilatation can be caused by pouch overfilling if patients do not alter their
nutritional habits. Although this complication occurs in as many as 26% of
patients [3], the incidence of
chronic pouch dilatation usually ranges from 3% to 8%
[4,
5]. Barium esophagography shows
slow passage or lack of passage of contrast material through the stoma and
concentric dilatation of the upper pouch
(Fig. 4). The esophagus also
can dilate as a result of chronic obstruction
(Fig. 5). Stomal stenosis with
pouch dilatation is initially managed with band deflation to allow widening of
the stoma and improve emptying. Follow-up esophagography within 3-6 weeks is
performed to assess improvement. If there is no improvement after band
deflation, or if the pouch dilatation is severe and accompanied by severe
reflux, surgical intervention may be needed.
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Fig. 4 —32-year-old woman with chronic stomal stenosis with concentric
dilatation 1 year after surgery. Symptoms were intermittent vomiting and
weight gain. Esophagogram shows markedly dilated pouch (black arrows)
containing food debris. Band (white arrow) has migrated inferiorly
and is located just below diaphragm.
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Fig. 5 —57-year-old woman with severe chronic stomal stenosis necessitating
band removal, after which symptoms eventually resolved. Esophagogram shows
markedly dilated and tortuous sigmoid esophagus (E) with no passage of
contrast material through slightly malpositioned band (arrow).
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In evaluation of the distal portion of the esophagus, it is important to
carefully inspect filling defects. Although these defects are most commonly
food debris (Fig. 6), we found
two cases of metastatic melanoma (Fig.
7) and esophageal carcinoma.
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Fig. 6 —50-year-old woman with heartburn and difficulty swallowing.
Gastroscopy revealed presence of meat and dried fruit residue. Esophagogram
shows constant filling defect (black arrow) in distal esophagus (E)
just above band with normal passage of contrast material (white
arrow) to stomach (S).
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Fig. 7 —65-year-old man with filling defect due to tumor. Symptom was weight
gain; no obstructive symptoms occurred. Biopsy at gastroscopy showed
metastasis of malignant melanoma. Esophagogram shows large filling defect
(thin white arrow) in distal esophagus (E). Irregularity of
esophageal wall (thick arrow) and normal passage of contrast material
through band (black arrow) into stomach (S) are evident.
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Slippage of the Gastric Band
Another common cause of chronic stomal stenosis is band slippage, which has
been found in 4-13% of patients
[4,
6-10].
Band slippage can be caused by recurrent vomiting or faulty surgical technique
and can be posterior (82% of our cases) or anterior (18% of our cases)
[11]. Posterior slippage is
associated with upward herniation of the posterior stomach wall through the
band. In anterior slippage the higher pressure in the upper pouch pushes the
band downward over the anterior aspect of the stomach. Both complications
manifest as vomiting, regurgitation, and food intolerance, but the conditions
have different radiologic findings. Barium esophagography shows horizontal
orientation of the gastric band and delayed passage of contrast material
through the gastric stoma. Eccentric upper gastric pouch dilatation occurs,
and the pouch is usually posterior and inferior in posterior slippage (Fig.
8A,
8B) and anterior and superior
in anterior slippage (Fig. 9).
Severe band slippage can be complicated by bleeding, gastric volvulus
(Fig. 10), infarction, and
perforation. In these cases patients have abdominal pain and signs of
peritonitis. In our series of 125 patients with band slippage, the band was
removed in 70 (56%) of the patients, whereas in 55 (44%) of the patients, the
band was repositioned or replaced immediately and successfully.
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Fig. 8A —42-year-old woman with posterior band slippage 8 months after
surgery. Symptoms were recurrent vomiting, abdominal pain, regurgitation, and
chronic cough due to recurrent aspiration. Esophagogram shows posterior
slippage of proximal pouch (P) inferior in relation to vertically
malpositioned band (arrow). E = esophagus.
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Fig. 8B —42-year-old woman with posterior band slippage 8 months after
surgery. Symptoms were recurrent vomiting, abdominal pain, regurgitation, and
chronic cough due to recurrent aspiration. Coronal multiplanar CT
reconstruction shows band (arrow) has slipped from its normal
position immediately below gastroesophageal junction. Gastric pouch (GP) is
larger than expected. S = stomach.
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Fig. 9 —50-year-old woman with anterior band slippage with recurrent
vomiting and upper abdominal discomfort. Esophagogram shows proximal pouch (P)
is superior in relation to inferiorly positioned band (arrow). E =
esophagus.
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Fig. 10 —40-year-old woman with band slippage, persistent vomiting due to
posterior band slippage, and surgically proven gastric volvulus. Barium
esophagogram shows lateral position of band (thick arrow) with
inferior dilated pouch (P) consistent with posterior slippage. Distal part of
stomach (S) is above band, and because of gastric volvulus, greater curvature
(thin arrow) is superior in relation to lesser curvature.
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Acute Gastric Perforation
Gastric perforation occurs in 0.1-0.8% of cases
[5,
6,
9,
10,
12], has an extremely variable
clinical presentation, and can lead to lifethreatening sepsis. Patients
usually present soon after surgery with fever and abdominal pain or with less
specific signs of sepsis, such as tachycardia and anxiety. Patients with
suspected gastric perforation should be evaluated with CT, which may depict
the perforation and abscess. CT findings indicative of perforation include
free or loculated extraluminal air and extraluminal contrast material with
infiltration of the mesenteric fat (Fig.
11A,
11B). CT also shows
intraabdominal fluid collections and abscesses and enables guided drainage,
obviating difficult surgery (Fig.
12A,
12B).
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Fig. 11A —51-year-old man with band perforation and peritonitis 2 weeks after
surgery. Symptoms were fever and abdominal pain. Axial CT scan shows
extraluminal air (thin arrow) adjacent to band (white thick
arrow) and proximal stomach. Free perisplenic air and fluid (black
thick arrow) are evident.
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Fig. 11B —51-year-old man with band perforation and peritonitis 2 weeks after
surgery. Symptoms were fever and abdominal pain. Esophagogram shows free air
(thin arrows) surrounding band and catheter. Extraluminal contrast
material (thick arrow) around band and passage of contrast medium
through band from esophagus (E) into stomach (S) are evident.
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Fig. 12A —46-year-old man with large left subphrenic abscess managed with
CT-guided abdominal abscess drainage. Axial CT scan at level of gastric band
(arrow) shows large perisplenic fluid collection (C). S = stomach, SP
= spleen.
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Fig. 12B —46-year-old man with large left subphrenic abscess managed with
CT-guided abdominal abscess drainage. Axial CT scan at same level as A
after successful drainage of abscess. Pigtail catheter (thin arrow)
in remaining fluid collection and intraperitoneal portion of catheter
(thick arrow) are evident. S = stomach, SP = spleen.
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Band Erosion and Chronic Gastric Perforation
Chronic gastric perforation can be caused by transmural band erosion
[6] and occurs in 1-3% of
patients [3,
7,
8,
13,
14]. The erosion can be the
result of continuous pressure of the band against the gastric wall, faulty
surgical technique, and abuse of nonsteroidal antiinflammatory drugs. The time
from primary operation to diagnosis of band erosion in our series ranged from
3 weeks to 45 months (mean, 19 months). Patients may present with chronic
infection of the port site (40% of our patients), weight gain (12%),
hematemesis, and sometimes peritonitis or subphrenic abscess due to leak of
stomach contents or of saline solution from the port-band system. At
radiography and CT, contrast material may be visualized around the
intragastric part of the band (Fig.
13). Urgent surgery is usually performed.
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Fig. 13 —47-year-old woman with band erosion and sustained weight gain 2
years after surgery. Esophagogram shows contrast material (arrow)
passing around band instead of through it, suggesting intragastric band
location. E = esophagus.
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Port and Band Complications
Port and band complications are reported in 0-7% of cases
[4,
7,
8,
14] and include malfunction of
the catheter, the port-catheter connection, and the catheter-band connection.
Ninety-one (7.1%) of 1,272 patients available for a mean follow-up period of
37 months had port complications, and 103 (8.1%) of the patients needed
remedial operations. Sixty-two patients had system leaks, 19 had infectious
problems, and 10 had miscellaneous problems that led to the corrective
operation. Band removal was needed by only six patients (0.5%) and band
replacement by one patient.
Patients with port and band complications present with decreasing weight
loss and report no change in ability to eat after the procedure. Port and band
complications may be diagnosed on plain radiography or with injection of 5 mL
of nonionic contrast material into the band through the subcutaneous port
(portogram). In band disconnection (Fig.
14) and in cases of leakage, contrast material can be seen leaking
from the port-catheter connection (Fig.
15) or from the catheter-gastric band connection
(Fig. 16). The band also can
inflate in a nonuniform manner (Fig.
17), causing ineffective narrowing of the stomach by the band. A
leaking band or a disconnected port must be surgically removed and replaced.
The subcutaneous port can become infected, and an abscess can form. Because of
the body habitus of the patients, subcutaneous infection can be difficult to
diagnose, and CT or sonography may be needed for diagnosis
(Fig. 18).
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Fig. 14 —21-year-old man with port disconnection. Symptom was recent weight
gain after maintenance of 30-kg weight loss since surgery. Radiograph of
abdomen shows port end of catheter (thin arrow) disconnected from
catheter (thick arrow).
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Fig. 15 —27-year-old woman with catheter leakage 5 weeks after surgery.
Radiograph obtained after injection of contrast material through port
(thick arrow) shows leakage of contrast material from catheter into
peritoneal cavity (thin arrows).
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Fig. 16 —40-year-old man with band leakage 6 months after surgery. Symptom
was weight gain despite previous inflation of cuff. Fluoroscopic image with
contrast material injected through port shows extravasation of contrast
material from band (thick arrow). Contrast material (thin
arrows) is evident in peritoneal cavity.
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Fig. 17 —38-year-old woman with "aneurysm" of band 1 year after
surgery. Symptom was nonspecific upper abdominal discomfort developing over
previous 3 months and more apparent after eating. Radiograph obtained after
injection of contrast material through port (black thick arrow) shows
uneven inflation of sleeve inside band (white thick arrow) resembling
aneurysmal dilatation due to technical failure. Clips (thin arrow)
from cholecystectomy are evident.
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Fig. 18 —45-year-old woman with port infection. Symptom was pain in port
area. Port puncture yielded turbid fluid drawn from port-catheter system.
Axial CT scan shows fluid and infiltration of subcutaneous fat surrounding
port (thin arrows) and catheter (thick arrow).
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Summary
With the increasing prevalence of morbid obesity, laparoscopic adjustable
gastric banding surgery has evolved to be a leading surgical technique.
Radiologists need to be familiar with the postoperative normal anatomic
features and with the imaging findings of postoperative complications.
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Abstract
Introduction
