Gastrocolic fistula: a rare complication of gastric banding

Clinical History

Female patient, 42-years-old, underwent gastric banding 3 years before, had the gastric band extracted 1 year before because of complete intragastric migration.
Now complains of dyspepsia, weight loss, halitosis, gastroesophageal reflux and frequent diarrhoea.
Physical examination revealed no significant alterations.

Imaging Findings

The oesophago-gastro-duodenal barium study found early passage of contrast material into the splenic angle of the colon, with evidence of a gastrocolic fistula.
The fistula presents itself in the place of origin of the normal positioned band.
These findings were corroborated by findings of CT with oral and IV contrast and endoscopy.

Discussion

Background and clinical perspective

Morbid obesity is a major problem in the modern society.

A surgical approach may be required to treat or prevent associated morbidities.

Gastric banding forms a significant and necessary component in the management pathway of these patients, allowing a healthy and consistent loss of weight.

Gastric banding was introduced in an attempt to provide a low-invasive surgical procedure that could effectively provide the weight loss that these patients require [1].

Imaging perspective

The pouch should have a volume of about 20 ml and the stoma a width of about 3-4 mm in order to provide the feeling of satiety necessary to allow adequate weight loss. The band is placed about 2-3 cm from the gastro-oesophageal junction [2].

The procedure has complications that are divided in early (band misplacement, perforation and early slippage) and late complications (pouch dilatation, migration, disconnection, slippage, necrosis, erosion of the gastric wall and oesophageal dysmotility) [3, 4].

Perforation
Usually due to preoperative trauma of the stomach or esophagus.

Early slippage
Usually in low-positioned bands.
Pouch progressive concentric dilatation is noted.

Pouch dilatation
Concentric pouch dilatation is the result of a functional stenosis of the band stoma and pre-stenotic dilatation. Causes of functional stenosis include a too tight fastening of the band, chronic inflammation or nutritional overload.

Migration
Complete or incomplete penetration of the gastric band into the gastric lumen is a rarely observed but severe complication of gastric banding. Band penetration is likely to be caused by a chronic inflammatory process leading to the erosion of an intra-operatively damaged gastric wall.

Disconnection
Disconnection of the catheter may occur at the port or at the connection between the distal and proximal catheter.

Slippage

Slippage is frequently associated with patient's non-compliance with the appropriate dietary restrictions, especially with bulimic episodes followed by frequent vomiting that displaces the band.
The following complications are associated:
Pouch dilation, gastric outlet obstruction, gastric volvulus, gastric infarction, transmural gastric band migration.

Necrosis, erosion of the gastric wall
It is typically a late complication due to pressure ischemia and necrosis of the gastric wall by the band.

Esophageal dysmotility

A gastrocolic fistula is likely to be caused by a chronic inflammatory process leading to the erosion of an intra-operatively damaged gastric wall with or without band migration.

Outcome
The patient underwent surgery and is now without morbidities.

Differential Diagnosis List

Final Diagnosis

Gastrocolic fistula

URL:	https://eurorad.org/case/9629
DOI:	10.1594/EURORAD/CASE.9629
ISSN:	1563-4086