Gastric banding: What radiologists need to know

Transcription

1 Gastric banding: What radiologists need to know Poster No.: C-1606 Congress: ECR 2010 Type: Educational Exhibit Topic: GI Tract Authors: D. V. Thomas, G. Finch; Northampton/UK Keywords: Laparoscopic gastric banding, Radiology, Complications DOI: /ecr2010/C-1606 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

2 Learning objectives Brief review of the relevant features of laparoscopic gastric band surgery, the role of a radiologist and the imaging features that one might encounter. Background The prevalence of obesity is increasing worldwide and in particular in the Western world. Methods of controlling obesity amongst others include behavioural changes; weight loss programmes with diet control and regular physical activity; drug treatment and bariatric surgery. As per the NICE guidelines for Obesity (CG CG43NICEGuideline.pdf ) - Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled: - they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight - all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months - the person has been receiving or will receive intensive management in a specialist obesity service - the person is generally fit for anaesthesia and surgery - the person commits to the need for long-term follow-up. Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate. Amongst others, the popular bariatric surgical options are Laparoscopic gastric banding Gastric bypass Sleeve gastrectomy Gastric balloon (temporary) Page 2 of 22

3 Imaging findings OR Procedure details Laparoscopic gastric banding (LAGB) is a restrictive procedure in which an adjustable band is placed laparoscopically around the proximal stomach about 2-3cm from the gastro-oesophageal junction. The band is connected to a sub-cutaneous port via a tube. The band is filled or de-filled by injecting or aspirating fluid (usually saline) from the port. Types of Bands There are different types of gastric bands, the common ones being the Swedish Adjustable Gastric Band (SAGB)(also known as the Realize-Band in the USA), Lap-Band, Heliogast, Midband etc. The capacity varies between different bands and sizes. SAG Band Page 3 of 22

4 Fig.: SAG/ Realize Band References: Ethicon Endosurgery Inc. Diagramatic illustration of a gastric band Fig. References: uptodate.com Parts of an LAGB Page 4 of 22

5 An LAGB system typically consists of a subcutaneous port (sometimes with sutures/ fixators), a connecting tube and the band itself. Fig.: Parts of an LAGB as shown by a bandogram with contrast within the system. References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Role of the Radiologist Page 5 of 22

6 Whilst most patients would be managed by the surgeon, the assistance of a radiologist is often required in the evaluation and follow-up of such patients. For example in Contrast imaging of the oesophagus and gastric pouch is useful to evaluate for potential complications. Help with difficult port access. Performing bandograms to evaluate for leaks within the system. Accessing the port The Huber needle is a non-coring needle which is recommended for use in ports to minimise the damage caused to the port by repeated punctures. The port may be accessed blindly by feel, by ultrasound guidance or by fluoroscopic guidance. USS and fluroscopy are particularly useful in cases where the port is tilted. Strict asepsis should be adhered to to prevent any possibility of infection. Page 6 of 22

7 Fig.: Fluoroscopic access. Huber needle in the port. Gastric band also seen. Page 7 of 22

8 References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Fig.: USS scan of the subcutaneous port, the metallic undersurface is also visualised. References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Band adjustments Instillation of saline will increase the band diameter and thereby produce restriction (and vice versa). The ideal size of the stoma through the band should be about 3-4mm. Appearances on a barium swallow Page 8 of 22

9 Fig.: Gastric band with early pouch dilatation References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Gastric band on CT Page 9 of 22

10 Fig.: Inflated gastric band on CT References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Complications These can be broadly classed as early or late. Early complications - These include band malposition and gastric perforation. These can be identified by a radiologist by performing a contrast swallow. Late complications - Some of the late complications are Pouch dilatation, Oesophageal dilatation, Gastric erosion/penetration, Tube leak, System disconnection etc. Page 10 of 22

11 1. Pouch dilatation - This may occur due to a variety of factors. The types of pouch dilatation are Acute dilatation, Chronic dilatation or Eccentric pouch dilatation. Acute pouch dilatation - This may occur if the band is too tight. This is concentric and is relieved by defilling the band. Page 11 of 22

12 Fig.: Acute Pouch Dilatation References: Wiesner W et al. Radiology 2000;216: Chronic pouch dilatation - This may occur due to chronic overdistension and is managed by a defill and nutritional advice prior to attempting refills again. Page 12 of 22

13 Fig.: Chronic dilatation References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Page 13 of 22

14 Eccentric pouch dilatation / Slippage - this occurs with band slippage and may be anterior, posterior or both. This is now a rare complication due to a change in technique of band placement. Band placement is now suprabursal (without penetrating the lesser sac). This complication is usually remedied by band replacement. Fig.: Band slippage with partial gastric volvulus and excessive pouch dilatation. Page 14 of 22

15 References: Wiesner W et al. Radiology 2000;216: Tube leak This may occur due to mechanical failure of the tube or by inadvertant tube puncture. This is treated by replacing the connecting tube. Page 15 of 22

16 Fig.: Bandogram showing leak from the tube. References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM 3. Port tilting / flipping Page 16 of 22

17 This is easily visualised on USS or fluroscopy. Access is by USS or fluoroscopy with angulation of the tube. The port may be straightened temporarily for access by using a second needle (Thomas method). If it is not possible to access the port (such as if it flips upside down), then it needs to be resited. Fig.: Port tilted References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Page 17 of 22

18 Fig.: Port straightened with one needle on the fixator. The port is now accessible with a second Huber needle (Thomas method). References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM Page 18 of 22

19 Fig.: Port access after being straightened (Thomas method) References: D. V. Thomas; Dept of Radiology, Northampton General Hospital, Northampton, UNITED KINGDOM 4. System disconnection This may occur by excessive manipulation or by trauma. This is treated depending on the site of disconnection. Page 19 of 22

20 Fig.: System disconnection due to blunt trauma References: Wiesner W et al. Radiology 2000;216: Band penetration/perforation This occurs by band erosion into the stomach and requires band removal and repair. Page 20 of 22

21 Fig.: Band penetration References: Wiesner W et al. Radiology 2000;216: Conclusion Page 21 of 22

22 Laparoscopic gastric banding is an increasingly popular form of bariatric surgery in the management of obesity. Radiologists have an important role to play in the management of such patients and should be active participants in the bariatric surgery multi-disciplinary team. Personal Information Dr Davis V Thomas - I am a vascular interventional radiologist based in Northampton, UK. I can be contacted by at - davis.thomas@ngh.nhs.uk. Mr Guy Finch - I am a surgeon with a sub-speciality interest in Laparoscopic, upper gastro-intestinal and bariatric surgery. I can be contacted by at guy.finch@ngh.nhs.uk References References and further reading 1. NICE guidelines for Obesity (CG43) 2. Adjustable Laparoscopic Gastric Banding in Patients with Morbid Obesity: Radiographic Management, Results, and Postoperative ComplicationsWalter Wiesner, Othmar Schob, Renward S Hauser, Markus Hauser Radiographical imaging of the normal anatomy and complications after gastric banding H Prosch, R Tscherney, S Kriwanek, D Tscholakoff Page 22 of 22