Gastrointestinal devices: common and uncommon foreign bodies

Devices for the gastrointestinal tract are widely available and constantly advancing with less invasive techniques. They play a crucial role in diagnostic and therapeutic interventions and are commonly placed by interventional radiologists, gastroenterologists, and surgeons. These devices frequently appear in imaging studies, which verify their proper placement, identify any complications, or may be incidentally detected. Radiologists must be able to identify these devices at imaging and understand their intended purpose to assess their efficacy, detect complications such as incorrect positioning, and avoid misinterpreting them as abnormalities. Furthermore, many patients with these devices may require MRI, making assessing compatibility essential for safe patient care. This review seeks to provide a succinct and practical handbook for radiologists regarding both common and uncommon gastrointestinal devices. In addition to textual descriptions of clinical indications, imaging findings, complications, and MRI compatibility, the review incorporates a summary table as a quick reference point for key information and illustrative images for each device.

Up-to-date review into the evolving world of bariatric interventions: a guide for radiologists

Obesity is a worldwide health concern leading to several chronic health problems and comorbidities. Its treatment requires a multidisciplinary approach where lifestyle changes are fundamental. Additionally, in the past decade, the use of different surgical procedures of various levels of complexity has grown, with the objective of reducing the gastric capacity, creating diversions, or a combination of both. The aim of this article is to review and illustrate the major types of bariatric surgical techniques, their normal post-surgical anatomy, and the possible associated complications, to aid the radiologist in their assessment and timely diagnosis.

Bariatric Surgery Emergencies in Acute Care Surgery

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Common, Less Common, and Unexpected Complications after Bariatric Surgery: A Pictorial Essay

Bariatric surgery has demonstrated a higher rate of success than other nonsurgical treatments in selected patients with obesity; however, like all medical procedures, postoperative complications may occur, ranging between 2 and 10% and, although rare, they can be life threatening. Complications may be unspecific (any surgery-related complications) or specific (linked to the specific surgical procedure) and can be distinguished as common, less common, and unexpected. According to the onset, they may be acute, when occurring in the first 30 days after surgery, or chronic, with a presentation after 30 days from the procedure. The aim of this pictorial essay is to review the radiological aspects of surgical techniques usually performed and the possible complications, in order to make radiologists more confident with the postsurgical anatomy and with the normal and abnormal imaging findings.

Perigastric Abscess Resection During Roux-en-Y Bypass Surgery After Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) has a low rate of perioperative morbidity and mortality, while long-term complications are not rare. band erosion may be insidious and the patient may be asymptomatic. We present an unusual case of a 51-year-old patient who developed an intra-abdominal abscess after LAGB and required a resectional Roux-en-Y gastric bypass procedure. The patient's perioperative course was uneventful.  Removal of the abscess with partial gastrectomy and completion of a RYGB was safe and feasible.

Efficacy and Mechanisms of Gastric Volume-Restriction Bariatric Devices

Obesity is a chronic disease that affects over 795 million people worldwide. Bariatric surgery is an effective therapy to combat the epidemic of clinically severe obesity, but it is only performed in a very small proportion of patients because of the limited surgical indications, the irreversibility of the procedure, and the potential postoperative complications. As an alternative to bariatric surgery, numerous medical devices have been developed for the treatment of morbid obesity and obesity-related disorders. Most devices target restriction of the stomach, but the mechanism of action is likely more than just mechanical restriction. The objective of this review is to integrate the underlying mechanisms of gastric restrictive bariatric devices in obesity and comorbidities. We call attention to the need for future studies on potential mechanisms to shed light on how current gastric volume-restriction bariatric devices function and how future devices and treatments can be further improved to combat the epidemic of obesity.

Multimodality imaging of adult gastric emergencies: A pictorial review

Acute gastric emergencies require urgent surgical or nonsurgical intervention because they are associated with high morbidity and mortality. Imaging plays an important role in diagnosis since the clinical symptoms are often nonspecific and radiologist may be the first one to suggest a diagnosis as the imaging findings are often characteristic. The purpose of this article is to provide a comprehensive review of multimodality imaging (plain radiograph, fluoroscopy, and computed tomography) of various life threatening gastric emergencies.

Role of Imaging in Bariatric Surgery: A Review of the Various Surgical Techniques and Their Complications

According to the World Health Organization, obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese. Bariatric surgery is being increasingly used as a form of treatment, particularly in those patients where lifestyle modifications are deemed insufficient. With the role of radiologists transitioning from a medical to a surgical evaluation in obesity, it is becoming increasingly important to familiarize oneself with the various imaging techniques used in the preoperative and postsurgical evaluation in such cases. This article aims to review the various surgeries performed, their normal imaging appearance, and the various complications that could be encountered.

Weighing in on heart failure: the potential impact of bariatric surgery

Obesity is a growing worldwide epidemic with significant economic burden that carries with it impacts on every physiologic system including the cardiovascular system. Specifically, the risk of heart failure has been shown to increase dramatically in obese individuals. The purpose of this review is to provide background on the individual burdens of heart failure and obesity, followed by exploring proposed physiologic mechanisms that interconnect these conditions, and furthermore introduce treatment strategies for weight loss focusing on bariatric surgery. Review of the existing literature on patients with obesity and heart failure who have undergone bariatric surgery is presented, compared, and contrasted.

Abdominal and pelvic radiographs of medical devices and materials-Part 1: gastrointestinal and vascular devices and materials

When compared with chest radiographs, medical devices of the abdomen and pelvis are less frequently seen. However, with recent advances in technology the interpreting radiologists are seeing more medical objects on these radiographs. The identification of these devices and materials are crucial for not only enabling the radiologist to understand the underlying background pathology but also for evaluating any related complications. An online survey of literature showed our review article to be the most detailed. In this first part of our two-part series, we discuss about the various gastrointestinal and vascular devices and materials seen on abdominal and pelvic radiographs.

A review of commonly performed bariatric surgeries: Imaging features and its complications

Obesity is a disease that has achieved the level that can be considered an epidemic. According to the National Center for Health Statistics data, the prevalence of obesity has increased from 30.5% in 1999-2000 to 42.4% in 2017-2018. During the same period, severe obesity has increased from 4.7% to 9.2%. With the growing prevalence of obesity, related conditions such as coronary artery disease, diabetes, and strokes have also become more prevalent. In the past few years, the need for bariatric surgeries such as laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric banding has increased considerably. With an increasing number of bariatric surgeries, multiple postoperative complications have become common. In this review, we have attempted to describe normal postsurgical anatomical findings after bariatric surgeries and pictorial review of a few common postoperative complications.

Imaging of acute gastric emergencies: a case-based review

The stomach is one of the most frequently imaged organs in the body with dedicated and incidental inclusion in chest imaging modalities. Gastric emergencies often present clinically with non-specific abdominal, nausea, and vomiting. As such, imaging plays a critical role in early identification and treatment of a myriad of gastric emergencies. The goal of this paper is to showcase gastric emergencies as they appear on multimodality imaging.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Eroded adjustable gastric band migration causing gastric obstruction and perforation in a pregnant lady

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Laparoscopic adjustable gastric banding (LAGB) was considered as one of the most effective management for morbid obesity, with outstanding long-term results on weight loss, comorbidities, and quality of life.

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Reported complications of LAGB include erosion, infection, migration, obstruction, and rarely ischemia.

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We report a case of pregnant woman who underwent LAGB 12 years ago diagnosed as gastric obstruction and perforation that was managed by central gastrectomy with gastro-gastrostomy.

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We encourage the bariatric surgeons to be attentive LAGB complications among women planning for pregnancy.

Background

The laparoscopic adjustable gastric band is the least invasive bariatric surgery, which has the advantage of preserving the anatomy of the gastrointestinal tract. In the last two decades, the laparoscopic adjustable gastric band (LAGB) has largely been replaced by other surgical techniques for weight loss because of its high inseparable complications. Although a popular surgical technique at the time of its introduction in 1993, LAGB nowadays reports for not more than 5.5% of all bariatric procedures. The estimated overall long term complication rates of LAGB are ranging from 0.1% to 28%.

Objective

In this report, we review one of the cases that are considered as an anecdotic event that might follow one of the bariatric procedures.

Methods

We reported a pregnant lady who undergoes gastric banding 12 years ago. presented with progressively increasing colicky epigastric pain, nausea, and vomiting. The investigations show gastric obstruction and perforation secondary to eroded gastric band and migration.

Results

The management was completed by the elimination of the gastric band proceed with central gastrectomy plus gastro-gastrostomy with an excellent outcome for the patient and her baby.

Conclusion

This case highlights an absolutely rare serial complication, that may happen even when the patient presents with a vague complaint. Intraoperative findings can determine the way of management to achieve suitable results. Lastly; we encourage the young Women who underwent or planning for bariatric surgery to do a careful follow-up.

Laparoscopic mini/one anastomosis gastric bypass: anatomic features, imaging, efficacy and postoperative complications

Laparoscopic mini/one anastomosis gastric bypass (MGB/OAGB) is an increasingly used bariatric surgical procedure. This surgical technique is effective in terms of both weight loss and the resolution of comorbidities, but it is not without complications. To report our experience in MGB/OAGB, assessing comorbidities and complications, and to illustrate post-surgical anatomy and radiological appearance of complications, a single-centre retrospective study of 953 patients undergoing MGB/OAGB between January 2005 and September 2018 was done. The inclusion criteria: body mass index (BMI) of 40 kg/m² or higher or BMI between 35 and 40 kg/m² with significant comorbidities not responsive to medical therapies. In the postoperative period, all patients were evaluated with clinical and laboratory tests and radiological examinations (upper gastrointestinal series, computed tomography and magnetic resonance imaging). Median weight was 126.69 kg and mean BMI was 49.4 kg/m². Regarding comorbidities, 37.2%, 52.8%, 46.7% and 43.2% of patients presented with preoperatively diagnosed type 2 diabetes mellitus (T2DM), hypertensive disease, dyslipidaemia and obstructive sleep apnoea syndrome (OSAS), respectively. Median excess weight loss at 6, 12, 24 and 60 months after surgery was 33.45%, 53.81%, 68.75% and 68.80%, respectively. The remission of comorbidities was 91.4% for T2DM, 93.7% for hypertensive disease, 90.3% for dyslipidemia and 93.4% for OSAS. Early and late complication rates identified with radiological examinations were 1.5% and 1.6%, respectively. MGB/OAGB was effective for weight loss and comorbidities remission. Complications occurred at lower rate than with other surgical procedures were identified with imaging; CT was the main radiological technique.

Medical Devices of the Abdomen and Pelvis and Their Complications: A Radiologic Atlas

의료기구들이 발달하면서 복부 및 골반 내에 이식되거나 거치되는 의료기구들이 다양해졌다. 흔하게 사용되는 기구들의 영상의학 소견은 영상의학과 의사들에게 매우 익숙하지만, 상대적으로 사용 빈도가 낮거나 새로운 형태의 기구들의 영상의학 소견은 잘 알려져 있지 않다. 또한 환자에 대한 임상정보가 제한적일 경우 이런 새로운 형태의 의료기구들은 잘못 해석되거나 놓치기 쉽다. 그러므로 복부 및 골반 내 의료기구들의 영상의학 소견을 인지하는 것은 기구들의 올바른 위치를 평가하고, 이와 관련된 합병증을 평가하는데 있어 매우 중요하다. 본 논문에서는 다양한 복부 및 골반 내 의료기구들과 이와 관련된 합병증의 영상의학 소견을 소개하고자 한다.

Laparoscopic adjustable gastric banding migration: an early approach for a late complication

AIM

Laparoscopic adjustable gastric banding (LAGB) migration is an uncommon late complication after bariatric surgery. It usually presents with an unexplained weight increase or without any symptom. Current guidelines do not establish the timing of a clear endoscopic follow-up to prevent and/or to treat this kind of complication.

PATIENTS AND METHODS

Long-term follow-up was performed in 217 patients with LAGB (37 underwent surgery in other bariatric centers). At the endoscopic check, 3 patients presented banding erosion respectively 7, 9 and 11 years after surgery. In all three cases the patients, lost at the follow-up in their bariatric centers, had weight gain. During the endoscopy was treated just one patient because of the advanced migration. For the other patients, with a minimal migration, the choice was to perform an endoscopic surveillance every 4 months.

DISCUSSION

Removal of eroded gastric banding with common endoscopic devices is feasible, safe, and effective.

CONCLUSION

With our experience we suggest to perform planned endoscopy at least within 2 years in order to guarantee the early diagnosis and managing of gastric banding erosion.

ARTIFACTS AFFECTING DUAL-ENERGY X-RAY ABSORPTIOMETRY MEASUREMENTS

OBJECTIVE

To present 3 cases in which the presence of artifacts altered the dual-energy X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) in the lumbar field.

METHODS

Clinical presentation and literature review.

RESULTS

The first patient was a 49-year-old premenopausal woman with a spinal cord stimulator implanted in her lumbar spine. The implant increased the measured BMD in the lumbar region from osteopenia to normal range. The second patient was a 56-year-old man who had a DXA scan after he was administered oral and intravenous iodine-based contrast earlier the same day. The oral contrast in the patient's colon created a dense artifact, which overlapped the lumbar spine and adjacent soft tissue. The effect almost changed his DXA diagnosis from osteoporosis to osteopenia. The third patient was a 64-year-old woman who had undergone laparoscopic adjustable gastric banding (LAGB). A part of the LAGB system adjacent to lumbar vertebra 3 was mistakenly included as part of the vertebrae by the DXA scanner, causing an increase in the measured BMD.

CONCLUSION

There are numerous artifacts that can alter DXA BMD measurement. It is important for providers who interpret DXA scans to be familiar with the potential effects of artifacts and how to adjust for their presence, since erroneous measurements can lead to incorrect decisions regarding treatment and follow-up.

Gastric Banding: Complications Identified by CT

PURPOSE

Laparoscopic adjustable gastric banding (LAGB) used to be a common procedure at the turn of the century and is still frequently encountered on CT scans in common clinical practice. Our aim is to present the frequency and spectrum of complication associated with LAGB, as observed in CT.

MATERIALS AND METHODS

After approval of our institutional review board, a retrospective search for LAGB in CT interpretations using the term "band" between December 2011 and April 2017 was conducted. CT scans were reviewed to identify complications. The findings were divided into two groups: symptomatic, in which the complications caused acute symptoms for which CT scans were conducted, and incidental, in which complications were incidentally identified. The frequency of complications was calculated.

RESULTS

We identified 160 patients who underwent LAGB and performed a CT scan. Complications were identified in 69/160 (43.1%) patients, with a total of 83 findings: 47/160 (29.4%) esophageal dilatation, 13/160 (8.2%) pulmonary complications, 6/160 (3.8%) abdominal abscesses, 5/160 (3.1%) small bowel obstructions, 4/160 (2.5%) intragastric band erosions, 4/160 (2.5%) tube disconnections, 3/160 (1.9%) port site and tube course infections, and 1/160 (0.6%) small pouch bezoars. When compared with patients' referral notes, 38/83 (45.8%) of the findings were associated with acute symptoms, whereas 45/83 (54.2%) of the findings were incidental. Eighteen percent of the incidental complications were clinically important.

CONCLUSION

Complications were found in 43% of CT scans of patients who underwent LAGB; less than half of the findings were symptomatic. Some of the incidentally identified complications had substantial clinical importance.

Laparoscopic adjustable gastric band erosion with intragastric band migration: A rare but serious complication

Although laparoscopic adjustable gastric banding is considered the most minimally invasive surgical technique for the treatment of morbid obesity, the procedure has a reported overall complication rate of up to 26%. Among the various complications, gastric band erosion with intragastric band migration is the most worrisome because of the risk of subsequent obstruction, peritonitis, and sepsis. Therefore, prompt and accurate diagnosis is crucial during imaging evaluation of these patients in the late postoperative setting. In this article, we report a case of a 47-year-old woman with a gastric band that had eroded into the gastric wall with intragastric migration demonstrating classic findings on fluoroscopic and computed tomography imaging.

Gastropericardial Fistula as a Late Complication of Laparoscopic Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) is a bariatric procedure that is being performed with increasing frequency as an alternative management option for morbid obesity. Several common complications have been reported including gastric band slippage and associated pouch dilatation, intragastric erosion of the band, gastric wall perforation, and abscess formation. We present a case of gastropericardial fistula occurring nine years after an LAGB. There have been no previous documented cases of the complication after this procedure.

MDCT imaging of the stomach: advances and applications

The stomach may be involved by a myriad of pathologies ranging from benign aetiologies like inflammation to malignant aetiologies like carcinoma or lymphoma. Multidetector CT (MDCT) of the stomach is the first-line imaging for patients with suspected gastric pathologies. Conventionally, CT imaging had the advantage of simultaneous detection of the mural and extramural disease extent, but advances in MDCT have allowed mucosal assessment by virtual endoscopy (VE). Also, better three-dimensional (3D) post-processing techniques have enabled more robust and accurate pre-operative planning in patients undergoing gastrectomy and even predict the response to surgery for patients undergoing laparoscopic sleeve gastrectomy for weight loss. The ability of CT to obtain stomach volume (for bariatric surgery patients) and 3D VE images depends on various patient and protocol factors that are important for a radiologist to understand. We review the appropriate CT imaging protocol in the patients with suspected gastric pathologies and highlight the imaging pearls of various gastric pathologies on CT and VE.

CT of gastro-duodenal obstruction

Gastro-duodenal obstruction encompasses a spectrum of benign and malignant disease. Historically, chronic peptic ulcer disease was the main cause of gastro-duodenal obstruction, whereas now malignant cause with gastric carcinomas for gastric obstruction and pancreatic tumors for duodenal obstruction predominate. This paper reviews the role of CT in diagnosing gastro-duodenal obstruction, its level, its cause by identifying intraluminal, parietal, or extrinsic process, and the presence of complication.

Multidetector CT imaging of bariatric surgical complications: a pictorial review

The prevalence of obesity is increasing, along with the number of bariatric surgical procedures performed to treat obesity. Laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic gastric banding (GB) comprise the vast majority of procedures with SG now the dominant procedure in the USA. Although multidetector computed tomography (MDCT) is not always the examination of choice for a particular suspected complication, many of these patients present with non-specific abdominal symptoms and undergo MDCT evaluation as an initial diagnostic test. This pictorial essay will review and discuss the normal post-surgical bariatric appearance on MDCT, and the appearance of common and uncommon complications associated with the common bariatric procedures on MDCT with correlative imaging. SG complications include leak/abscess, hemorrhage, splenic injury, and portomesenteric thrombosis. RYGB complications include leak/abscess, gastrogastric fistula, small bowel obstruction, internal hernia, and intussusception. Although GB is waning in popularity, radiologists continue to see the legacy of these patients and complications include gastric prolapse, band erosion, and port/tubing mechanical failures. Awareness of the characteristic findings of bariatric complications on MDCT is critical, allowing for earlier recognition and prompt intervention.

MRI of the stomach: a pictorial review with a focus on oncological applications and gastric motility

The purpose of this pictorial review is to demonstrate gastric pathology seen on magnetic resonance imaging (MRI) and discuss the essential MRI sequences for the evaluation of benign and malignant gastric pathologies. Common tumors of the stomach, polyposis syndromes, iatrogenic conditions, as well as other conditions of the stomach will be reviewed. The utility of MRI in the evaluation of patients with gastric malignancies and disorders of gastric motility will also be discussed.

Cross-sectional imaging, with surgical correlation, of patients presenting with complications after remote bariatric surgery without bowel obstruction

Both restrictive and malabsorptive types of bariatric surgery may be associated with short- and long-term complications. The lack of small bowel obstruction is not necessarily indicative of a normal study, as a variety of non-obstructed complications exist. These include stenosis at the gastrojejunostomy, leaks, abscesses, hemorrhage, internal hernias, and gastric band erosions. Radiologists should be familiar with these complications for early diagnosis and intervention before symptoms become life threatening. An understanding of the intraoperative appearances of these complications may improve imaging descriptions and add value to radiological consults for surgeons. This review provides surgical correlations to the imaging features of post-bariatric complications without obstruction of the bowel.

A Challenging Misleading Diagnosis in a Patient with Suspicion of Gastric Banding Slippage and Strangulation: Diagnosis and Laparoscopic Treatment

A 51-year-old female (height 160 cm, weight 89 kg, BMI 34.8) presented at the emergency department complaining of sudden onset of sharp abdominal pain in the epigastrium, colicky in nature, dysphagia, nausea, and repeated retching with non-productive vomiting. She has had an adjustable gastric banding implanted laparoscopically 11 years earlier. Since then, she reported to have had only a moderate weight loss (initial BMI 44), although she was closely followed up and the reservoir properly filled by her obesity surgeon. A gastrografin was performed and showed no clear signs of slippage of the gastric band nor of gastric strangulation/ischemia. Nonetheless, the passage of the contrast through esophagogastric junction was slightly slow and restricted suggesting a moderate stenosis from the band. Two cubic centimeters of saline were aspirated from the reservoir to loosen the gastric band. However, on the following minutes, no significant relief of the sharp pain was observed. NSAIDS and morphine were repeatedly given without significant pain relief, and after a few hours, the pain was more intense and diffused to the upper abdomen. I.V. contract CT scan showed a large amount of free fluid, with severe small bowel distension and suspected volvulus and a transition point at the port site of the reservoir, suggesting a strangulated incisional hernia on this site and/or strangulating band adhesion. Urgent surgery was planned, and a laparoscopic approach was chosen. A large amount of free bloody fluid was found, and a long segment of small bowel was twisted around a strangulating band adhesion on the port site of the reservoir, incarcerated within an incisional hernia on the same port site. The strangulating band was cut, and the strangulated bowel was released. Gradual reversion of bowel ischemia was observed, and the gastric banding was removed according to the patient's preoperative request.

Imaging of complications of common bariatric surgical procedures

Several techniques for the surgical management of obesity are available to bariatric surgeons. These interventions are performed more frequently with worsening of the obesity epidemic. Radiologists should be familiar with the surgical techniques, normal postoperative appearances, and potential complications for which imaging may be employed to establish a diagnosis to optimize patient care.