DOI:10.2214/AJR.05.1547
AJR 2007; 189:1469-1472
© American Roentgen Ray Society
Gastric Volvulus After Laparoscopic Adjustable Gastric Banding for Morbid Obesity
Gregory Kicska1,
Marc S. Levine1,
Steven E. Raper2 and
Noel N. Williams2
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2 Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA.
Received August 31, 2005;
accepted after revision October 25, 2005.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
Keywords: barium • gastrointestinal radiology • implantable devices • stomach
Introduction
Since it was approved for the management of morbid obesity in the United
States in 2001 [1],
laparoscopic adjustable gastric banding has become an increasingly popular
form of bariatric surgery. Some surgeons favor laparoscopic adjustable gastric
banding over Roux-en-Y gastric bypass because it is a less invasive procedure
with a lower morbidity and mortality
[1,
2]. Nevertheless, laparoscopic
adjustable gastric banding can have a variety of serious postoperative
complications that do not occur with more traditional bariatric procedures.
These complications include stomal stenosis with pouch dilatation, band
slippage and gastric prolapse, band erosion, chronic gastric perforation, and,
rarely, gastric volvulus
[1–4].
Although it is a potentially life-threatening condition, gastric volvulus as a
complication of laparoscopic adjustable gastric banding has received little
attention in the radiology literature
[5]. We encountered two
patients who had undergone laparoscopic adjustable gastric banding in whom
band slippage precipitated gastric volvulus that was detected on barium
studies, necessitating emergency surgical removal of the bands. We report our
experience with these patients.
Patient 1
A 28-year-old man who had undergone laparoscopic adjustable gastric banding
2 years earlier at an outside hospital presented to our emergency department
with severe epigastric pain that had lasted 4 days, intractable vomiting, and
hematemesis. Unenhanced abdominal CT revealed an air–fluid level in a
dilated stomach with a gastric band medial to the dilated portion of the
stomach (Fig. 1A). The symptoms
worsened, and a single-contrast barium radiographic study of the upper
gastrointestinal tract 6 hours after CT showed slippage of the band to the
distal portion of the stomach with tapered narrowing of the lumen adjacent to
the band (Figs. 1B and
1C). No barium passed through
the band into the gastric antrum or duodenum, indicating complete gastric
outlet obstruction. The portion of the stomach proximal to the band had
dilated and rotated so that the gastric body was above the fundus beneath the
left hemidiaphragm. A second area of tapered narrowing was identified in the
distal esophagus adjacent to the band. These findings were believed to be
compatible with a slipped band causing gastric volvulus with closed-loop
obstruction. Emergency laparotomy later in the day confirmed the presence of
gastric volvulus with twisting of the stomach around a slipped band and marked
gastric ischemia. Surgical removal of the band restored the normal anatomic
features and circulation of the stomach, and the ischemia rapidly resolved.
The patient had an uneventful postoperative course and made a complete
recovery.
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Fig. 1A —28-year-old man with gastric volvulus after laparoscopic
adjustable gastric banding. Unenhanced axial abdominal CT scan shows
air–fluid level in dilated stomach (black arrow) with
radiopaque gastric band (white arrow) medial to dilated portion of
stomach.
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Fig. 1B —28-year-old man with gastric volvulus after laparoscopic
adjustable gastric banding. Steep right posterior oblique spot image from
single-contrast radiographic examination of upper gastrointestinal tract shows
slippage of band to distal portion of stomach with tapered narrowing of lumen
(small white arrow) where it traverses band (black arrows)
and complete gastric outlet obstruction (no barium distal to band). Second
area of tapered narrowing (large white arrows) is evident in distal
portion of esophagus adjacent to band. E = esophagus, S = stomach.
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Fig. 1C —28-year-old man with gastric volvulus after laparoscopic
adjustable gastric banding. Frontal spot image from same examination as
B shows how stomach proximal to band has dilated and rotated so that
gastric body (large white arrows) is above gastric fundus (black
arrows) beneath left hemidiaphragm. Complete obstruction of distal
portion of stomach (small white arrow) is evident where stomach
traverses band (not shown). These findings were believed to be compatible with
slipped band causing gastric volvulus with closed-loop obstruction. At
surgery, patient was found to have torsed stomach with ischemic changes that
resolved rapidly after band was removed and volvulus relieved.
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Patient 2
A 26-year-old woman who had undergone laparoscopic adjustable gastric
banding 1 year earlier at an outside hospital presented to the emergency
department with severe postprandial vomiting that had lasted for 2 weeks. A
single-contrast barium radiographic study of the upper gastrointestinal tract
showed slippage of the band to the distal part of the stomach with tapered
narrowing of the lumen adjacent to the band and minimal emptying of barium
into the duodenum (Figs. 2A and
2B). The proximal portion of
the stomach was dilated and rotated so that the gastric body was located above
the fundus beneath the left hemidiaphragm. These findings were believed to be
compatible with a slipped band causing gastric volvulus with high-grade
obstruction. Laparotomy 1 day after the barium study confirmed the presence of
gastric volvulus with twisting of the stomach around a slipped band but no
evidence of ischemia. The band was removed, Roux-en-Y gastric bypass was
performed, and the patient had an uneventful postoperative recovery.
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Fig. 2A —26-year-old woman with gastric volvulus after laparoscopic
adjustable gastric banding. Frontal spot image from single-contrast
radiographic examination of upper gastrointestinal tract shows slippage of
band to distal part of stomach with tapered narrowing of lumen (black
arrow) adjacent to band (not shown) and only trace amount of barium
passing distal to band. Stomach proximal to band had dilated and rotated so
that gastric body (large white arrows) was above fundus (small
white arrow) beneath left hemidiaphragm. These findings were believed to
be compatible with slipped band causing gastric volvulus with high-grade
gastric outlet obstruction.
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Fig. 2B —26-year-old woman with gastric volvulus after laparoscopic
adjustable gastric banding. Right posterior oblique spot image from same
examination as A better delineates radiopaque band (black
arrows) with marked narrowing of gastric lumen (white arrow)
where it traverses band. Presence of gastric volvulus without evidence of
ischemia was confirmed at surgery. Removal of band resulted in immediate
relief of volvulus.
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Discussion
Laparoscopic adjustable gastric banding has been advocated increasingly as
a safe and effective alternative to gastric bypass surgery for management of
morbid obesity
[1–3].
This procedure entails laparoscopic placement of a silicone band around the
proximal portion of the stomach (adjacent to the gastroesophageal junction) to
make a small gastric pouch that limits food intake and facilitates weight loss
[6]. The band is attached by a
catheter to a subcutaneous port, and saline solution is percutaneously
injected into or withdrawn from the port to inflate or deflate the band. The
goal is to have a band width that restricts oral intake and promotes weight
loss without causing obstruction. Despite early success with this procedure,
laparoscopic adjustable gastric banding can have a variety of postoperative
complications, including stomal stenosis with dilation and delayed emptying of
the pouch; band erosion with gastric perforation; port eversion, dysfunction,
and infection; kinking and disruption of the catheter; and band slippage with
gastric prolapse through the band
[1–4].
Many of these complications can be detected on barium radiographic studies
[5,
7].
As surgeons in the United States have gained experience with laparoscopic
adjustable gastric banding, band slippage with gastric prolapse has become a
less frequent complication, occurring in approximately 5% of cases
[2]. Depending on the degree of
luminal encroachment by the band, patients may present with dysphagia,
vomiting, reflux symptoms, or a combination of these problems
[3]. Band slippage should be
suspected on radiographic studies when the portion of the stomach proximal to
the band (i.e., the gastric pouch) is more than several centimeters long.
Gastric prolapse can be anterior or posterior, producing a large anterior or
posterior gastric pouch above the band
[3]. The band can slip as far
distally as the gastric body or antrum with prolapse of a major portion of the
stomach through the band. Regardless of the degree of band slippage, dilation
and delayed emptying of the pouch occur when the gastric lumen is
substantially narrowed by the band.
In rare instances, band slippage can result in development of gastric
volvulus when the prolapsed portion of the stomach twists around the band,
potentially causing closed-loop obstruction. As in one of our patients, this
condition can be life-threatening because a torsed stomach is at risk of
strangulation, ischemia, and infarction
[8]. Wiesner et al.
[5] described two patients who
had undergone laparoscopic adjustable gastric banding in whom barium studies
revealed slipped bands causing partial gastric volvulus, although the fundus
of the stomach was located above the body in both cases. In contrast, both of
our patients had band slippage with twisting of the stomach around the band so
that the body of the stomach rotated upward above the fundus beneath the left
hemidiaphragm (Figs. 1B,
1C,
2A, and
2B). Both patients presented
with intractable vomiting due to associated obstruction. One patient had
high-grade gastric outlet obstruction with beaklike luminal narrowing at the
site of the band (Figs. 2A and
2B). The other had closed-loop
obstruction with two sites of beaklike narrowing in the distal portion of the
esophagus and distal stomach converging around the band without barium
emptying from the stomach (Fig.
1B). At surgery the latter patient was found to have a compromised
vascular supply to the stomach as the result of acute ischemia, which resolved
rapidly after the band was removed.
In patient 1, unenhanced abdominal CT several hours before the barium study
showed the radiopaque band and dilated adjacent stomach without definite
findings of gastric volvulus (Fig.
1A). The barium study better delineated the distorted anatomy
resulting from the volvulus and the site and degree of obstruction. Our
experience suggests that barium studies are helpful for evaluating patients
with acute symptoms of gastric outlet obstruction after laparoscopic
adjustable gastric banding to detect band slippage with gastric prolapse and
findings of gastric volvulus that may be difficult to visualize on
cross-sectional imaging examinations.
In conclusion, we report the cases of two patients with laparoscopic
adjustable gastric banding in whom barium studies revealed band slippage
causing gastric volvulus with associated gastric outlet obstruction. One
patient had the surgical finding of closed-loop obstruction with acute
ischemia of the torsed stomach. Because of the potentially life-threatening
consequences of gastric volvulus and the need for emergency surgical removal
of the band, it is important for radiologists to recognize these findings on
barium studies.
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Introduction
Patient 1
