1. Restricting Appetites: Common and Unusual Post-operative Complications for Gastric Bands
S Tincey1, A Hadjivassiliou1, A Tavare1, P Sufi2,
M Steward1
Department of Radiology1 and Bariatric & Upper GI Surgery2,
Whittington Hospital, London

2. Background
Obesity has become an epidemic in the western world and is associated with high morbidity and mortality (1).
Obesity is defined with the Body Mass Index (BMI) as follows:
Overweight BMI kg/m2
Obesity BMI kg/m2
Morbid obesity BMI >35 – 40 kg/m2

3. Background
Treatment options for obesity include behavioural, medical and surgical
Surgery provides the most reliable longterm solution
Laparoscopic gastric band insertion is commonly performed for the management of morbid obesity (4)

4. Procedure
Gastric banding works by promoting early satiety leading to reduced oral intake and subsequent weight loss (2)
An adjustable silicon band is used. This is placed approximately 2 cm distal to the gastro-oesophageal junction
The stomach is subsequently divided into two pouches
The proximal pouch is smaller ~15-20 mls
Band paper 1

5. Procedure
The stoma of the band should be ~3-4 mm in width to allow emptying of gastric pouch contents in 15 – 20 minutes
Stitches are placed on the gastric serosa joining the anterior portion of the distal stomach with the small proximal pouch to minimise risk of slippage
The band is then connected with an anterior abdominal wall implantable port via a tube
Band paper 1

6. Procedure
The port is used to adjust the stoma of the gastric band by either inserting or removing saline. This is performed under fluoroscopic guidance
Adjustment of the band is guided by the patient’s weight loss and symptoms

7. Normal band position
The band is positioned within the proximal stomach approximately 2 cm from the gastro-oesophageal junction
The band should have an oblique orientation (~45 degrees) with its lateral aspect lying more superiorly than its medial aspect
(WHL 181)

8. Normal band position ~45°
Figure 1: Normal band position and orientation (red arrow) as seen on fluoroscopy (a). Oral contrast is seen to pass freely beyond the band with normal stomal width (orange arrow) and no upstream oesophageal dilatation (b).

9. Normal band position
Figure 2: Contrast enhanced coronal MDCT showing radio-opaque band in its normal position (red arrows).

10. Complications Common Uncommon
Alternatively complications can be classified as early and late complications

11. Complications
Table 1: Complications of gastric band surgery (3)

12. Complications
Common:
Slippage
Port breakage
Infection

13. Slippage
Slippage implies herniation of gastric parts through the band. There are different types:
Anterior
Occurs in patients with gastroesophageal band and weakened stabilising sutures. The band rotates clockwise
Posterior
Occurs in patients with retrogastric band placement (no longer performed). The band is displaced in a counter clockwise direction
Band paper 1

14. Slippage
Figure 3: Patient presented with vomiting and intolerance of solids and liquids. Abnormally positioned gastric band (red arrow) lying horizontally (180 °) was identified on fluoroscopy. No contrast is seen distal to the band. Note the overhanging edge of the stomach (blue arrow). This patient went on to have band deflation under fluoroscopic guidance and surgical referral.

15. Slippage
Figure 4: A slipped horizontal gastric band (red arrow) on fluoroscopy. Note that in this patient the distal stomach is opacified (green arrow) illustrating that there is still passage of contrast distal to the band.

16. Slippage and Stricture
IS THIS IMAGE LABELLED CORRECTLY? WHERE IS THE STRICTURE??
Figure 5: Fluoroscopy image of patient with slipped band (band not present on this image) which was subsequently removed but had stricture formation at the site of chronically slipped band (red arrow).

17. Slippage
Figure 6: Patient with a slipped band on post contrast enhanced MDCT. Note the abnormal band orientation (red arrow) where the lateral edge is inferior to the medial portion. Note the proximal stomach dilatation with overhanging edges of the stomach (yellow arrow).

18. Slippage
Figure 7: Fluoroscopy image of horizontally lying band (red arrow) and secondary oesophageal dilatation (blue arrows).

19. Oesophageal dilatation
Figure 8: Patient with oesophageal dilatation (green arrow). Tertiary contractions (orange arrows) were also seen in keeping with oesophageal dysmotility. Gastric band (red arrow).

20. Oesophageal dilatation intervention
Figure 9: Patient with previously demonstrated oesophageal dilatation on fluoroscopy. The band (red arrow) was deflated via aspiration. This is done by puncturing the port (blue arrow) with a needle (green arrow) under fluoroscopic guidance.

21. Infection
Figure 10: Patient presented with sepsis. Contrast enhanced coronal MDCT shows evidence of low attenuation and fat stranding (blue arrow) around the port site in keeping with infection.

22. Complications
Uncommon:
Erosion
Tube kink
Stricture

23. Band Erosion
Figure 11: Post contrast enhanced coronal MDCT. Intramural gas locules (green arrow) indicating microperforation at an early stage in the development of erosion. These findings are in keeping with the band (red arrow) eroding into the gastric lumen, confirmed at endoscopy.

24. Tubing Erosion Bladder
Figure 12: Coronal MDCT shows tubing seen to be abnormally straightened, extending into the pelvis (red arrow) and eroding through the bladder wall (yellow arrow).

25. Tube Kink
Figure 13: Fluoroscopy image: Kink demonstrated within the tubing (orange arrow) connecting the gastric band (not included in this image) to the anterior abdominal wall implantable port (green arrow). The band was unable to be filled and tubing required surgical manipulation.

26. Conclusion Obesity is associated with high morbidity and mortality
Laparoscopic gastric band insertion is a minimally invasive procedure performed to promote weight loss
There are common and uncommon complications of gastric bands
Identifying these on imaging is crucial for patient management

27. References
Imaging of bariatric surgery: normal anatomy and postoperative complications. Levine M, Carucci R. Radiology Feb;270(2):327-41
Radiographic imaging of the normal anatomy and complications after gastric banding. H Prosch, R Tscherney, S Kriwanek, D Tscholakoff. Br J Radiol Sep;81(969):753-7.
Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guide. Eid I, Birch, D, Sharma A, Sherman, V, Karmali S. Can J Surg. Feb 2011; 54(1): 61–66.
Laparoscopic adjustable gastric banding: What radiologists need to know. Sonavane et al. Radiographics July – August 2012 , Volume 32, Issue 4