Laparoscopic Gastric Banding Radiological Evaluation

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Laparoscopic Gastric BandingRadiological
Evaluation
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What is a Lap-Band?

• A restrictive gastric banding procedure was first
  introduced in 1983
• made adjustable in 1986
• made available laparoscopically in the early
  1990s
• silicone band around upper stomach to create
  small gastric pouch and narrow stoma that
  communicates with remainder of stomach

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LAGB

• silicone band has adjustable inner balloon cuff
  and subcutaneous injection reservoir sutured to
  anterior rectus sheath
• pouch volume created typically 15 cm3
• initial stomal size approx. 12 mm diameter
• LAGB can adjust to the patients situation
  without need for additional surgery
• inner balloon inflated to maximal volume of 5
  cm3, and ideal stomal size is 3 to 5 mm

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• Routine early postoperative UGI evaluation after
  LAGB to assess for extraluminal leak or
  obstruction
• placement of the band, pouch size, and stoma size
  may be assessed
• From Obesity Surgery, 13, 901-908 Because of the
  difficulty that obese patients have in changing
  position, we always used the upright position,
  except for performing plain abdominal film
  (supine position), or evaluating gastric
  integrity on the first postoperative day (left
  lateral decubitus), or for checking any device
  leakage (supine position).

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Initial Early post-op UGI

• Initial supine scout to locate band, port and
  tubing, assure contiguity and position
• Straight AP or slightly RPO to move fundus to
  left then move to place band in profile
• First check for leak, then give barium and watch
  for small gastric pouch, small stoma, filling of
  stomach
• May be mild delay in esophageal emptying,
  especially in early post-op
• One study reported 45 degree positioning (RSNA)

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Adjusting the stoma

• Adjustments usually performed 6 weeks post-op,
  once edema has resolved
• With Lap-Band system, stoma size decreased by 0.5
  mm following addition of 0.4 cm3 of saline
• Center of port localized at fluoroscopy in supine
  position
• Radiopaque marker placed, skin prepped with
  antiseptic, local anesthesia
• 20- to 22-gauge noncoring, deflected-tip needle
  to access the port

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Early complications

• Early complications are rare
• Gastroesophageal perforation in lt0.5
• Improper positioning at surgery/post-op slippage
  requiring repositioning less than 1
• Acute stomal obstruction 1.4
• Early dysphagia in up to 14
• Regurgitation and pouch esophageal reflux are
  common until dietary habits change

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Late complications

• Most common long-term complications pouch
  dilatation (25) and slippage (24) of gastric
  band
• Other significant late complications include
• intragastric band migration or erosion
• acute obstruction
• device-related complications resulting in leakage
  of saline from the system or infection
• Gastric necrosis- rare complication of LAGB
  (lt0.3) due to slippage with strangulation

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Clinical Radiology (2004) 59, 227236
(a) A 39-year-old woman during fluoroscopy
showing eccentric pouch (arrowheads) dilatation
due to posterior band slippage. Note the abnormal
band orientation (arrows). (b) After surgery the
normal orientation of the band has been
reconstituted with a small proximal neostomach.
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10 mos later
Initial postop
1 mo later-no intervention
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References

• Clinical Radiology (2004) 59, 227236
• Radiol Clin N Am 45 (2007) 261274
• Obesity Surgery, 13, 901-908
• Radiology 2000 216389394
• Eur Radiol. (2001) 11 417-21
• Videos courtesy of Mark Wulkan