Lap band intragastric erosion

Clinical History

Female patient, 35 years old, underwent a gastric lap band placement in 2007. Symptoms of nausea and vomiting in the past 2 years.

Imaging Findings

Upper GI tract fluoroscopic examination:
The scout image reveals a minor deviation of the lap band from the midline and a phi angle of 53.5º, which is still within the normal range but approaching the upper limit (phi angle must be between 4º and 58º) (Fig. 1). After contrast ingestion, the contrast material is seen surrounding the lap band, especially its right side, instead of passing through the stoma (Fig. 2). These findings are suggestive of an intragastric band position.

Abdominal CT:
The gastric band is in an intragastric position, confirming the intragastric erosion/migration. It is difficult to diagnose a complete or incomplete migration accurately with CT. There are no signs of complications (Fig. 3 and 4).

Discussion

Background:
The most common complications after laparoscopic adjustable gastric banding include pouch dilatation, band slippage, and port complications. As the results of long-term follow-up have become available, a new complication has appeared: intragastric band erosion, in which the silicone ring erodes the gastric wall and, in some patients, migrates into the stomach lumen [1].
Lap band erosion into the gastric lumen is a late and rare complication, occurring in less than 2% of patients [2].
This complication may result from high pressures generated by the inflated band, with pressure necrosis of the adjacent gastric wall and subsequent erosion of the band into the lumen [2].

Clinical Perspective:
Intragastric band erosion can be a chronic and insidious process, with nearly half of patients being asymptomatic. Patients may present with vague epigastric pain, cessation of weight loss, vomiting, haematemesis, or turbid fluid may have been aspirated from the port due to recurrent port-site infections [3].
Usually the erosion is incomplete, but occasionally total erosion occurs. In these cases, the band can migrate distally and become lodged in the gastric antrum, duodenum, or proximal jejunum, causing mechanical obstruction. Rarely, migration can occur into the gastroesophageal junction [2].

Imaging Perspective:
On barium studies, intraluminal band erosion can be seen by the passing of contrast around the intraluminal portion of the band, or around all sides of the band in case of complete erosion [4]. This radiologic appearance is pathognomonic. However, in its early stages, no abnormality may be seen [1].
If symptoms suggest intraabdominal abscess or open perforation, CT should be used to assess the presence of perigastric abscess or extravisceral air associated with the erosion. When erosion is incomplete, it is especially difficult to detect. A review of multiplanar images can be helpful for identifying sites of gastric erosion [3].
The final diagnosis is made by endoscopic study [3].

Outcome:
The appropriate treatment of intragastric band erosion is still controversial, including endoscopic follow-up in asymptomatic patients, endoscopically assisted removal of the band, or laparoscopic band removal [1].
At this time, this patient has an endoscopy scheduled to program its removal.

Take Home Message, Teaching Points:
Intragastric lap band erosion is a major and late complication after band placement.
Its prevalence is underestimated since it is asymptomatic for years in half of the cases.
The diagnosis is mainly done by endoscopic studies, however, the radiologic appearance in barium studies is pathognomonic.
CT should be used if there is any suspicion of complications (abscess or perforation).

Differential Diagnosis List

Final Diagnosis

Lap band intragastric erosion

URL:	https://www.eurorad.org/case/12751
DOI:	10.1594/EURORAD/CASE.12751
ISSN:	1563-4086