Laparoscopic Gastric Banding Radiological Evaluation

1. Laparoscopic Gastric BandingRadiological Evaluation

2. 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

3. 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 patient’s situation without need for additional surgery • inner balloon inflated to maximal volume of 5 cm3, and ideal stomal size is 3 to 5 mm

9. 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).”

10. 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)

15. 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

17. Early complications • Early complications are rare • Gastroesophageal perforation in <0.5% • 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

18. 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 (<0.3%) due to slippage with strangulation

20. Clinical Radiology (2004) 59, 227–236 (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.

21. 10 mos later Initial postop 1 mo later-no intervention

28. References • Clinical Radiology (2004) 59, 227–236 • Radiol Clin N Am 45 (2007) 261–274 • Obesity Surgery, 13, 901-908 • Radiology 2000; 216:389–394 • Eur Radiol. (2001) 11: 417-21 • Videos courtesy of Mark Wulkan