472 AJR:188, February 2007

AJR 2007; 188:472–479

0361–803X/07/1882–472

© American Roentgen Ray Society

Blachar et al.Imaging After Gastric Banding Surgery

G a s t ro i n t e s t i n a l I m ag i n g • P i c t o r i a l E s s ay

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

Subhi Abu-Abeid2,4

Blachar A, Blank A, Gavert N, Metzer U, Fluser G, Abu-Abeid S

Keywords: abdomen, abdominal imaging, gastrointestinal radiology, obesity, stomach

DOI:10.2214/AJR.05.0293

Received August 2, 2005; accepted after revision February 27, 2006.

1Department of Radiology, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv 64239, Israel. Address correspondence to A. Blachar (ablachar@tasmc.health.gov.il).

2The Sackler School of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.

3University of Pittsburgh Medical Center, Pittsburgh, PA 15213.

4Department of Surgery B, Bariatric Surgery Service, Tel Aviv Soursaky Medical Center, Tel Aviv 64239, Israel.

OBJECTIVE. The purpose of this essay is to describe the normal anatomic findings afterlaparoscopic adjustable gastric banding surgery and the imaging findings of postoperative gas-trointestinal complications.

CONCLUSION. With the increasing prevalence of morbid obesity, laparoscopic adjust-able gastric banding surgery has evolved to be a leading surgical technique. Radiologists needto be familiar with the normal anatomic findings after laparoscopic adjustable gastric bandingsurgery and with the imaging findings of postoperative complications.

orbid obesity is a national healthproblem in most Western industri-alized countries and is increasingin prevalence. It is defined as a

body mass index of 35 with comorbidity or of40 without comorbidity. Morbid obesity is dif-ficult to manage with medical or behavioraltherapy. Surgical methods of weight control(bariatric surgery), however, have been foundto provide immediate and long-term reductionin weight for most patients. There are two mainapproaches to surgical treatment: bypass pro-cedures based on bypassing part of the diges-tive tract to generate malabsorption and restric-tive procedures based on stomach volumerestriction. Surgical procedures are usuallyperformed with a laparoscopic approach. Themost widely accepted procedures are laparo-scopic roux-en-Y gastric bypass and laparo-scopic adjustable gastric banding, both ofwhich have been endorsed by a National Insti-tutes of Health consensus conference [1]. Lap-aroscopic adjustable gastric banding is theleast invasive surgical procedure and has beenproposed as a primary operation for morbidobesity [2]. The technique is simple, safe, ef-fective, and has relatively few complications.

Between November 1996 and December2003, 2,134 patients underwent laparoscopicadjustable gastric banding surgery at our in-stitution. The purpose of this pictorial essay isto familiarize radiologists with the normalpostoperative anatomic features and the im-aging findings of postoperative gastrointesti-nal complications of laparoscopic adjustablegastric banding surgery.

Postoperative Anatomic Features and Imaging After Laparoscopic Adjustable Gastric Banding Surgery

In laparoscopic adjustable gastric bandingsurgery, the stomach is divided into twopouches by placement of an adjustable siliconegastric band 2 cm below the gastroesophagealjunction to make a small gastric pouch with avolume of approximately 15 mL. The inner partof the band is a sleeve connected to a subcuta-neous port in the left abdominal wall that en-ables adjustment of the band diameter (Fig. 1).

The radiologist plays an important role inthe preoperative and postoperative evaluationand care of patients undergoing laparoscopicadjustable gastric banding surgery. Bariumesophagography is performed preoperativelyto determine the normal anatomic findings andassess the function of the upper gastrointestinaltract. The radiologist maintains the optimal di-ameter of the band postoperatively by periodi-cally inflating and deflating it using the subcu-taneous port and may diagnose and assist in thetreatment of postoperative complications.

Because of the possible long-term complica-tions and because clinical symptoms are not re-liable indicators, annual follow-up esophagog-raphy is recommended. Patients are alsoreferred to the radiologist if weight loss is notsatisfactory or if symptoms develop. Esopha-gography is usually performed with barium un-less the study is performed immediately post-operatively or when there is high clinicalsuspicion of a leak. In such cases water-solublecontrast medium is used initially. If no leak isdetected, barium is used for better evaluation.

M

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Normal findings on esophagography withwater-soluble contrast medium (Fig. 2) arethe presence of the adjustable band, catheter,and subcutaneous port and a small proximalpouch with narrow passage of contrast mate-rial through the stoma to the stomach. CT(Fig. 2) is used when small-bowel obstruc-tion, port infection, intraabdominal leak, orabscess is suspected. Use of multiplanar re-construction with MDCT enables accuratedelineation of the gastric band and visualiza-tion of band slippage and migration.

Gastrointestinal Complications of Laparoscopic Adjustable Gastric Banding SurgeryStomal Stenosis

The most common complication after lap-aroscopic adjustable gastric banding is gastricstomal stenosis and obstruction. In acutestomal stenosis, patients have vomiting, nau-sea, and upper abdominal discomfort thatmay result from blockage of the stoma byfood or from postoperative stomal edema.Narrowing of the gastric stoma and slow pas-sage of contrast material are visualized onbarium esophagography (Fig. 3). If the bandremains in an appropriate position, the treat-ment is conservative. The radiologist per-forming esophagography deflates the bandand refers the patient to the surgeon.

If the stomal blockage is insidious andchronic, patients experience stabilization of theweight loss curve and gastroesophageal reflux.Weight stabilization can be caused by food accu-mulation in the esophagus, and the result is in-creasing insensitivity to distention of the pouchor esophagus. Chronic stomal stenosis can becaused by overfilling or too tight fastening of theband at surgery or by the radiologist after sur-gery. Subsequent tissue reaction to the siliconeband causes perigastric fibrosis. Chronic pouchdilatation can be caused by pouch overfilling ifpatients do not alter their nutritional habits. Al-though this complication occurs in as many as26% of patients [3], the incidence of chronicpouch dilatation usually ranges from 3% to 8%[4, 5]. Barium esophagography shows slow pas-sage or lack of passage of contrast materialthrough the stoma and concentric dilatation ofthe upper pouch (Fig. 4). The esophagus also candilate as a result of chronic obstruction (Fig. 5).Stomal stenosis with pouch dilatation is initiallymanaged with band deflation to allow wideningof the stoma and improve emptying. Follow-upesophagography within 3–6 weeks is performedto assess improvement. If there is no improve-ment after band deflation, or if the pouch dilata-

tion is severe and accompanied by severe reflux,surgical intervention may be needed.

In evaluation of the distal portion of theesophagus, it is important to carefully inspectfilling defects. Although these defects aremost commonly food debris (Fig. 6), wefound two cases of metastatic melanoma(Fig. 7) and esophageal carcinoma.

Slippage of the Gastric BandAnother common cause of chronic stomal

stenosis is band slippage, which has beenfound in 4–13% of patients [4, 6–10]. Bandslippage can be caused by recurrent vomitingor faulty surgical technique and can be poste-rior (82% of our cases) or anterior (18% of ourcases) [11]. Posterior slippage is associatedwith upward herniation of the posterior stom-ach wall through the band. In anterior slippagethe higher pressure in the upper pouch pushesthe band downward over the anterior aspect ofthe stomach. Both complications manifest asvomiting, regurgitation, and food intolerance,but the conditions have different radiologicfindings. Barium esophagography shows hori-zontal orientation of the gastric band and de-layed passage of contrast material through thegastric stoma. Eccentric upper gastric pouchdilatation occurs, and the pouch is usually pos-terior and inferior in posterior slippage (Fig. 8)and anterior and superior in anterior slippage(Fig. 9). Severe band slippage can be compli-cated by bleeding, gastric volvulus (Fig. 10),infarction, and perforation. In these cases pa-tients have abdominal pain and signs of perito-nitis. In our series of 125 patients with bandslippage, the band was removed in 70 (56%) ofthe patients, whereas in 55 (44%) of the pa-tients, the band was repositioned or replacedimmediately and successfully.

Acute Gastric PerforationGastric perforation occurs in 0.1–0.8% of

cases [5, 6, 9, 10, 12], has an extremely vari-able clinical presentation, and can lead to life-threatening sepsis. Patients usually presentsoon after surgery with fever and abdominalpain or with less specific signs of sepsis, suchas tachycardia and anxiety. Patients with sus-pected gastric perforation should be evaluatedwith CT, which may depict the perforationand abscess. CT findings indicative of perfo-ration include free or loculated extraluminalair and extraluminal contrast material with in-filtration of the mesenteric fat (Fig. 11). CTalso shows intraabdominal fluid collectionsand abscesses and enables guided drainage,obviating difficult surgery (Fig. 12).

Band Erosion and Chronic Gastric PerforationChronic gastric perforation can be caused

by transmural band erosion [6] and occurs in1–3% of patients [3, 7, 8, 13, 14]. The ero-sion can be the result of continuous pressureof the band against the gastric wall, faultysurgical technique, and abuse of nonsteroi-dal antiinflammatory drugs. The time fromprimary operation to diagnosis of band ero-sion in our series ranged from 3 weeks to 45months (mean, 19 months). Patients maypresent with chronic infection of the port site(40% of our patients), weight gain (12%),hematemesis, and sometimes peritonitis orsubphrenic abscess due to leak of stomachcontents or of saline solution from theport–band system. At radiography and CT,contrast material may be visualized aroundthe intragastric part of the band (Fig. 13).Urgent surgery is usually performed.

Port and Band ComplicationsPort and band complications are reported

in 0–7% of cases [4, 7, 8, 14] and includemalfunction of the catheter, the port–cathe-ter connection, and the catheter–band con-nection. Ninety-one (7.1%) of 1,272 patientsavailable for a mean follow-up period of 37months had port complications, and 103(8.1%) of the patients needed remedial oper-ations. Sixty-two patients had system leaks,19 had infectious problems, and 10 had mis-cellaneous problems that led to the correc-tive operation. Band removal was needed byonly six patients (0.5%) and band replace-ment by one patient.

Patients with port and band complicationspresent with decreasing weight loss and re-port no change in ability to eat after the pro-cedure. Port and band complications may bediagnosed on plain radiography or with in-jection of 5 mL of nonionic contrast materialinto the band through the subcutaneous port(portogram). In band disconnection (Fig. 14)and in cases of leakage, contrast material canbe seen leaking from the port–catheter con-nection (Fig. 15) or from the catheter–gastricband connection (Fig. 16). The band also caninflate in a nonuniform manner (Fig. 17),causing ineffective narrowing of the stomachby the band. A leaking band or a discon-nected port must be surgically removed andreplaced. The subcutaneous port can becomeinfected, and an abscess can form. Becauseof the body habitus of the patients, subcuta-neous infection can be difficult to diagnose,and CT or sonography may be needed for di-agnosis (Fig. 18).

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474 AJR:188, February 2007

SummaryWith the increasing prevalence of morbid

obesity, laparoscopic adjustable gastric band-ing surgery has evolved to be a leading surgi-cal technique. Radiologists need to be famil-iar with the postoperative normal anatomicfeatures and with the imaging findings ofpostoperative complications.

References1. Consensus Development Conference Panel. Gas-

trointestinal surgery for severe obesity. Ann Intern

Med 1991; 115:956–961

2. O’Brien PE, Brown WA, Smith A, McMurrick PJ,

Stephens M. Prospective study of laparoscopically

placed, adjustable gastric band in the treatment of

morbid obesity. Br J Surg 1999; 85:113–118

3. Evans JD, Scott MH, Brown AS, et al. Laparoscopic

adjustable gastric banding for the treatment of mor-

bid obesity. Am J Surg 2002; 184:97–102

4. 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

5. Hainaux B, Coppens E, Sattari A, et al. Laparo-

scopic adjustable silicone gastric banding: radio-

logical appearances of a new surgical treatment for

morbid obesity. Abdom Imaging 1999; 24:533–537

6. Zinzindohoue F, Chevallier JM, Douard R, et al.

Laparoscopic gastric banding: a minimally invasive

surgical treatment for morbid obesity—prospective

study of 500 consecutive patients. Ann Surg 2003;

237:1–9

7. O’Brien PE, Dixon JB. Lap-band: outcomes and re-

sults. J Laparoendosc Adv Surg Tech A 2003;

13:265–270

8. O’Brien PE, Dixon JB, Brown W, et al. The laparo-

scopic adjustable gastric band (Lap-Band): a prospec-

tive study of medium-term effects on weight, health

and quality of life. Obes Surg 2002; 12:652–660

9. Weiner R, Blanco-Engert R, Weiner S, et al. Out-

come after laparoscopic adjustable gastric banding:

8 years experience. Obes Surg 2003; 13:427–434

10. Favretti F, Cadiere GB, Segato G et al. Laparo-

scopic adjustable silicone gastric banding (Lap-

Band): how to avoid complications. Obes Surg

1997; 7:352–358

11. Wiesner W, Weber M, Hauser RS, Hauser M,

Schoeb O. Anterior versus posterior slippage: two

different types of eccentric pouch dilatation in pa-

tients with adjustable laparoscopic gastric banding.

Dig Surg 2001; 18:182–187

12. De Luca M, De Werra C, Formato A, et al. Laparo-

tomic vs laparoscopic lap-band: 4-year results with

early and intermediate complications. Obes Surg

2000; 10:266–268

13. Abu-Abeid S, Keidar A, Gavert N, Blanc A, Szold

A. The clinical spectrum of band erosion after lap-

aroscopic adjustable silicone gastric banding for

morbid obesity. Surg Endosc 2003; 17:861–863

14. Wiesner W, Schob O, Hauser RS, et al. Adjust-

able laparoscopic gastric banding in patients with

morbid obesity: radiographic management, re-

sults, and postoperative complications. Radiol-

ogy 2000; 216:389–394

A B

Fig. 1—Laparoscopic adjustable gastric banding device.A, Photograph shows adjustable band with inflatable sleeve (black arrow) connected through catheter to subcutaneous port (white arrow).B, Unenhanced abdominal radiograph shows inflatable sleeve (black arrow) connected through catheter to subcutaneous port (white arrow).

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A B

Fig. 2—56-year-old woman with normal anatomic findings after laparoscopic adjustable gastric banding.A, Esophagogram shows contrast material passing through esophagus (E) and stoma into stomach (S). Band (arrow) is properly located.B, Axial CT section at level of band (arrow) shows small gastric pouch (GP) and contrast material in stomach.

A B

Fig. 3—26-year-old woman with acute stomal stenosis 7 months after laparoscopic adjustable gastric banding surgery. Symptom was recurrent vomiting that increased in severity.A, Esophagogram shows dilated upper pouch (P) and minute passage of contrast material through narrow stoma (arrow).B, Esophagogram after band deflation shows normal passage of contrast material (arrow) from esophagus (E) to stomach (S).

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).

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).

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.

A B

Fig. 8—42-year-old woman with posterior band slippage 8 months after surgery. Symptoms were recurrent vomiting, abdominal pain, regurgita-tion, and chronic cough due to recurrent aspiration.A, Esophagogram shows posterior slippage of prox-imal pouch (P) inferior in relation to vertically mal-positioned band (arrow). E = esophagus.B, Coronal multiplanar CT reconstruction shows band (arrow) has slipped from its normal position immediately below gas-troesophageal 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.

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.

A B

Fig. 11—51-year-old man with band perforation and peritonitis 2 weeks after surgery. Symptoms were fever and abdominal pain.A, 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.B, 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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A B

Fig. 12—46-year-old man with large left subphrenic abscess managed with CT-guided abdominal abscess drainage.A, Axial CT scan at level of gastric band (arrow) shows large perisplenic fluid collection (C). S = stomach, SP = spleen.B, 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.

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.

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).

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.

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.

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).