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Trac J, Balas M, Gee D, Hutter MM, Jung JJ. Does routine upper gastrointestinal swallow study after metabolic and bariatric surgery lead to earlier diagnosis of leak? Surg Obes Relat Dis 2024; 20:767-773. [PMID: 38570283 DOI: 10.1016/j.soard.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/14/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND It is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery. OBJECTIVE To investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak. SETTING MBSAQIP-accredited hospitals in the United States and Canada. METHODS We conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n = 82,510) and sleeve gastrectomy (SG) (n = 283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine versus no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak. RESULTS In our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, P = .9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, P = .06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI .8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%). CONCLUSIONS Routine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.
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Affiliation(s)
- Jessica Trac
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Denise Gee
- Division of General and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew M Hutter
- Division of General and Oncologic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - James J Jung
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Duke University, Durham, North Carolina.
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Dayma K, David A, Omer A, Abdel-Dayam H, Tawil A, Socci N, Ahmed L, Gilet A, Haddad D. Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility. Obes Surg 2024; 34:1552-1560. [PMID: 38564172 DOI: 10.1007/s11695-024-07125-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.
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Affiliation(s)
- Ketan Dayma
- Department of Radiology, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Aruna David
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Adil Omer
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Haneen Abdel-Dayam
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Anan Tawil
- Department of Surgery, Harlem Hospital Center, New York, NY, 10037, USA
| | - Nicholas Socci
- Department of Bioinformatics, Memorial Sloan-Kettering Cancer Center, New York, NY, 10021, USA
| | - Leaque Ahmed
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Anthony Gilet
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
- Department of Radiology, Westchester Medical Center, Westchester, NY, 10595, USA
| | - Dana Haddad
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA.
- School of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates.
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Houlder K, Mocanu V, Verhoeff K, Marcil G, Birch DW, Karmali S, Switzer NJ. Trends, Outcomes, and Impact of Early Discharge Following Bariatric Surgery: a Retrospective MBSAQIP Analysis of 748,955 Patients. Obes Surg 2022; 32:2572-2581. [PMID: 35619047 DOI: 10.1007/s11695-022-06108-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/08/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Decreasing the length of stay following bariatric surgery can reduce pressure on hospitals and surgical costs and increase patient satisfaction. We examine trends in length of hospital stay following bariatric surgery and in post-operative complications. METHODS AND PROCEDURES The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to compile patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Patients were categorized into either early discharge (within one day of surgery) or late discharge, and patient and non-patient factors were compared between the two groups. A multivariable logistic regression was carried out to determine predictive factors for early discharge. RESULTS We evaluated 748,955 patients, with 399,918 (53%) being discharged early. Patients discharged early were younger and had fewer associated medical problems. The rate of early discharge increased between 2015 and 2019 (42.1% in 2015 vs 62.0% in 2019), while complication rates decreased or were unchanged. Multivariable analysis revealed lower ASA classification (OR 1.07; CI 1.06-1.09; p < 0.0001) and operative year (2019 vs. 2015 OR 2.26; CI 2.22-2.29; p < 0.0001) to be independently associated with early discharge. Several factors including undergoing RYGB (OR 0.44 CI 0.44-0.45; p < 0.0001), and dialysis dependence (OR 0.50; CI 0.45-0.55; p < 0.0001) among others, were associated with reduced early discharge likelihood. CONCLUSIONS There is a trend in bariatric surgery towards the practice of early discharge, which is safe for patients. Further work is needed to develop a set of criteria to determine which patients are best suited for this practice.
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Affiliation(s)
- Kieryn Houlder
- Faculty of Medicine and Dentistry, University of Alberta, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, Canada.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Gabriel Marcil
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Daniel W Birch
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Samuels N, Wesley S, Williams K, Yan F, Smith R, Nguyen J, Udobi K, Sola R. Contrast study after gastric repair: a review of incidence, outcomes and risk factors at an adult level 1 trauma center. Eur J Trauma Emerg Surg 2022; 48:4143-4147. [PMID: 35366067 DOI: 10.1007/s00068-022-01949-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The role of contrast study after traumatic gastric repair, continues to be controversial. To that end, we aim to review the incidence, outcomes, and risk factors of patients undergoing contrast study after traumatic gastric repair. METHODS This was a retrospective review of all trauma patients admitted to a level 1 trauma center that sustained gastric injuries with subsequent repair between 2011 and 2018. Demographics, surgical interventions, complications, and clinical outcomes were evaluated. Statistical analysis included Chi-square/Fisher exact univariate analysis and multivariate logistic regression analysis with a 5% significance level. RESULTS A total of 233 patients received a gastric repair, of whom 49 (21%) had a contrast study performed. Out of 49 patients with a contrast study, one was found to have a gastric leak. Mean time to contrast study was 6.3 ± 2.7 days. There was no statistically significant difference in post-operative complications between non-contrast and contrast study groups. Multivariate logistic regression analysis demonstrated a lack of statistical significance in clinical risk factors that would lead to obtaining a contrast study. CONCLUSION Gastric leak after repair is rare and there is no statistically significant difference in clinical outcomes when comparing patients who underwent contrast study to those who did not. Routine contrast study after traumatic gastric repair may not be necessary and further evidence is warranted to determine the risk factors for a selective contrast study.
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Affiliation(s)
- Nicolai Samuels
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Sarah Wesley
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Keyonna Williams
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Fengxia Yan
- Department of Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Randi Smith
- Department of Surgery, Emory School of Medicine, 69 Jesse Hill Jr. Dr. SE, 102, Atlanta, GA, 30303, USA
| | - Jonathan Nguyen
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Kahdi Udobi
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Richard Sola
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA.
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Knight J, Krishnaraj A. Utility of 3-Week Follow-Up of Upper Gastrointestinal Study in Asymptomatic Patients Following Laparoscopic Sleeve Gastrectomy. Curr Probl Diagn Radiol 2020; 49:260-265. [DOI: 10.1067/j.cpradiol.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/23/2019] [Accepted: 05/07/2019] [Indexed: 01/19/2023]
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Vilallonga R, Pereira-Cunill JL, Morales-Conde S, Alarcón I, Breton I, Domínguez-Adame E, Ferrer JV, Ruiz-de-Gordejuela AG, Goday A, Lecube A, García-Almenta EM, Rubio MÁ, Tinahones FJ, García-Luna PP. A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity. Obes Surg 2020; 29:3842-3853. [PMID: 31342249 DOI: 10.1007/s11695-019-04043-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO). METHOD The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies. RESULTS Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76). CONCLUSION In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.
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Affiliation(s)
- R Vilallonga
- Endocrine, metabolic and bariatric Unit, General Surgery Department, Hospital Vall d'Hebron, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - J L Pereira-Cunill
- Clinical Nutritión Unit, Endocrinology and Nutrition Service, University Hospital "Virgen del Rocío", Seville, Spain
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital "Virgen del Rocío", Hospital Quironsalud Sagrado Corazón, University of Sevilla, Sevilla, Spain
| | - I Alarcón
- Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital "Virgen del Rocío", Hospital Quironsalud Sagrado Corazón, University of Sevilla, Sevilla, Spain
| | - I Breton
- Unidad de Nutrición Clínica y Dietética del Servicio de Endocrinología y Nutrición del Hospital Gregorio Marañón, Madrid, Spain
| | - E Domínguez-Adame
- UGC Cirugía General y Aparato Digestivo, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | | | - A Garcia Ruiz-de-Gordejuela
- Endocrine, metabolic and bariatric Unit, General Surgery Department, Hospital Vall d'Hebron, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Goday
- Servicio de Endocrinología, Hospital del Mar de Barcelona, Departament de Medicina, CIBERobn, ISCIII, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Lecube
- Servicio deEndocrinología y Nutrición, Hospital Universitari Arnau de Vilanova de Lleida, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida (UdL), Avda. Rovira Roure, 80 25198, Lleida, Spain
| | - E Martín García-Almenta
- Unidad Cirugía Esófago-Gástrica, Metabólica y Bariátrica, Hospital Clínico San Carlos, Madrid, Spain
| | - M Á Rubio
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Idissc, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - F J Tinahones
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario Virgen de Victoria de Malaga, Málaga, Spain
| | - P P García-Luna
- Unidad de Nutrición Clínica y de la Unidad de Obesidad Mórbida (Unidad de Gestión de Endocrinología y Nutrición, UGEN), Hospital Universitario Virgen del Rocío, Seville, Spain
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Early Routine Upper Gastrointestinal Contrast Study Following Bariatric Surgery: an Indispensable Postoperative Care or a Medicolegal Heritage? Obes Surg 2020; 29:1995-1998. [PMID: 30945153 DOI: 10.1007/s11695-019-03850-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.
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Musella M, Cantoni V, Green R, Acampa W, Velotti N, Maietta P, Cuocolo A. Efficacy of Postoperative Upper Gastrointestinal Series (UGI) and Computed Tomography (CT) Scan in Bariatric Surgery: a Meta-analysis on 7516 Patients. Obes Surg 2019. [PMID: 29516397 DOI: 10.1007/s11695-018-3172-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND To demonstrate the lack of utility and efficacy of routine early postoperative upper gastrointestinal study (UGI) in obese patients undergoing bariatric surgery and to show the higher efficacy of CT scan in cases of clinical suspicion of a leakage, a meta-analysis was performed. MATERIALS AND METHODS A literature search including articles published in last 18 years was performed. For both UGI and CT scan, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A first analysis considered overall patients, and a second analysis considered only symptomatic patients. RESULTS Starting from 1233 eligible citations, 18 articles, including 7516 patients, were left. The pooled sensitivity was 54% for UGI (95% CI 34-74) with a high heterogeneity (I2 = 99.8%, p < .001), whereas CT scan showed a pooled sensitivity of 91% (95% CI 89-93) significantly higher than sensitivity of UGI series (p < 0.01), with a high heterogeneity (I2 = 98.9%, p < .001). In symptomatic patients the pooled sensitivity of UGI series was significantly lower than sensitivity of CT scan [49% (95% CI 31-68) vs 94% (95% CI 92-96), p < 0.01]. PPV showed a significant difference between UGI series and CT scan (54 vs 100%, p < 0.01). Specificity for UGI series was 98.6%, and specificity for CT scan was 99.7% (p = ns); the mean NPV was 96 and 98% for UGI series and CT scan (p = ns). CONCLUSIONS According to our results, a CT scan triggered by clinical suspicion must be considered the first-line procedure to detect a postoperative leak following primary sleeve gastrectomy or Roux-en-Y gastric bypass.
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Affiliation(s)
- Mario Musella
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy.
| | - Valeria Cantoni
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Roberta Green
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Wanda Acampa
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Nunzio Velotti
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Paola Maietta
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Alberto Cuocolo
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
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Timsit G, Johanet H. Medico-legal claims in bariatric surgery in France between 2010 and 2015. J Visc Surg 2019; 156 Suppl 1:S51-S55. [DOI: 10.1016/j.jviscsurg.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tankel J, Rotem R, Wiess J, Mintz A, Spira RM. Routine Early Fluoroscopy and Clinical Observations Following Laparoscopic Roux-En-Y Gastric Bypass for Obesity Fail to Predict Subsequent Anastomotic Leakage. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Choi Y. Comment on: diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery. Surg Obes Relat Dis 2018; 14:1318. [PMID: 30005864 DOI: 10.1016/j.soard.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Yong Choi
- Minimally Invasive and Bariatric Surgeon, Baylor St. Luke's Medical, CHI-St. Luke's the Woodlands Hospital, The Woodlands, Texas
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12
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Ribeiro IB, Gestic MA, Utrini MP, Chaim FDM, Chaim EA, Cazzo E. DRAIN AMYLASE LEVELS MAY INDICATE GASTROJEJUNOSTOMY LEAKS AFTER ROUX-EN-Y GASTRIC BYPASS. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:66-72. [PMID: 29561980 DOI: 10.1590/s0004-2803.201800000-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although the incidence of leaks after Roux-en-Y gastric bypass (RYGB) significantly decreased over time, their detection still remains challenging. OBJECTIVE This study aimed to determine the usefulness of drain amylase levels to detect leaks after RYGB. METHODS This is a population-based study which enrolled 170 individuals who underwent RYGB. Drain amylase levels were determined on the first and fourth postoperative days. Two thresholds were evaluated: three times higher than the serum levels (parameter I) and higher than 250 IU/L (parameter II). The main outcomes evaluated were perioperative morbidity, the occurrence of leaks, 30-day readmissions and reoperations, hospital stay, and mortality. RESULTS Considering the parameter I, high drain amylase levels were significantly associated with leaks (12.5% vs 0; P<0.00001). Considering the parameter II, high drain amylase levels were significantly associated with longer hospital stay (8±5.7 vs 4.5±1.3 days; P=0.00032), 30-day reoperations (50% vs 3%; P=0.000285), and leaks (50% vs 0; P<0.00001). The parameter I presented a sensitivity of 100% and specificity of 95.9%, whereas the parameter II presented a sensitivity of 100% and a specificity of 99.4%. CONCLUSION The determination of drain amylase levels after RYGB was a significant indicator of leaks, hospital stay, and 30-day reoperations. This finding reinforces the importance of abdominal drainage in the RYGB within this context.
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Affiliation(s)
- Igor Braga Ribeiro
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Martinho Antonio Gestic
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Murillo Pimentel Utrini
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Felipe David Mendonça Chaim
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Elinton Adami Chaim
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Everton Cazzo
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
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Terterov D, Leung PHY, Twells LK, Gregory DM, Smith C, Boone D, Pace D. The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks. Can J Surg 2017; 60:335-341. [PMID: 28742012 DOI: 10.1503/cjs.015216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.
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Affiliation(s)
- Dimitry Terterov
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Philemon Ho-Yan Leung
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Laurie K Twells
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Deborah M Gregory
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Chris Smith
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Darrell Boone
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - David Pace
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
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14
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Poris S, Fontaine A, Glener J, Kubovec S, Veldhuis P, Du Y, Pepe J, Eubanks S. Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation. Surg Endosc 2017; 32:400-404. [PMID: 28664428 DOI: 10.1007/s00464-017-5695-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/22/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no guidelines on the routine or selective use of contrast upper gastrointestinal series (UGI) after omental patch repair (OPR) of a gastric (GP) or duodenal perforation (DP). This study aims to elucidate whether the use of selective versus routine contrast study will lead to worse clinical outcomes. METHODS A retrospective analysis of 115 (n = 115) patients with OPR of GP or DP was performed. Data were obtained from seven Florida Hospital campuses. Patients aged 18 and older from 2006 to 2016 were identified by ICD9 billing information. Patients were divided into two groups: UGI and no UGI. The UGI group was subdivided into selective versus routine. A selective UGI was defined as one or more of the following after post-operative day 3: WBC >12,000, peritonitis, fever >100.4 F, tachycardia >110 bpm on three or more assessments, and any UGI performed after POD 7. Perioperative symptoms, perforation location, size, abdominal contamination, laparoscopic or open, leak detection, length of stay, mortality, and reoperation within 2 weeks were also examined. RESULTS No differences between the UGI group and non-UGI group relating to preoperative symptoms, leak detection, death, and reoperation rate were revealed. Differences in length of stay were found to be statistically significant with the UGI group and non-UGI at a median of 15.5 and 8 days, respectively. In the UGI subgroup, 20 of the 29 patients received selective studies. There were no statistical differences identified in leak detection, death, and reoperation. CONCLUSIONS Rates of leak detection, reoperation, and death in patients with GP or DP repaired with omental patch utilizing an UGI study were not statistically significant. An increased length of stay was observed within the UGI group. There was no advantage demonstrated between a selective versus routine UGI; therefore, the use of selective UGI should be based upon clinical indications.
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Affiliation(s)
- Stephenie Poris
- Institute for Surgical Advancement, Florida Hospital Orlando, 2415 N Orange Ave, #400, Orlando, FL, 32804, USA.
| | - Andrew Fontaine
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Julie Glener
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Stacey Kubovec
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Paula Veldhuis
- Institute for Surgical Advancement, Florida Hospital Orlando, 2415 N Orange Ave, #400, Orlando, FL, 32804, USA
| | - Yuan Du
- Institute for Surgical Advancement, Florida Hospital Orlando, 2415 N Orange Ave, #400, Orlando, FL, 32804, USA
| | - Julie Pepe
- Institute for Surgical Advancement, Florida Hospital Orlando, 2415 N Orange Ave, #400, Orlando, FL, 32804, USA
| | - Steve Eubanks
- Institute for Surgical Advancement, Florida Hospital Orlando, 2415 N Orange Ave, #400, Orlando, FL, 32804, USA
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15
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Consalvo V, Salsano V, Sarno G. Intraoperative iodinated contrast swallow with CT-scan delayed control for detection of early complications in laparoscopic gastric bypass: A case series of 260 cases. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Xu T, Rosculet N, Steele K, Auster M. Comparison of upper gastrointestinal fluoroscopy versus computed tomography for evaluation of post-operative leak in a bariatric surgery patient. BJR Case Rep 2016; 3:20160076. [PMID: 30363346 PMCID: PMC6159306 DOI: 10.1259/bjrcr.20160076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 01/11/2023] Open
Abstract
Bariatric surgery patients commonly undergo post-operative fluoroscopic evaluation for complications, including leaks, in order to progress with oral intake and recovery. As one of the most severe and potentially life-threatening complications, leaks occur in as many as 5% of bariatric surgery patients. Several characteristics of these patients complicate the detection of leaks, including large body habitus and limited mobility. The early detection of leaks can lead to significant reductions in morbidity and mortality in bariatric surgery patients. In a retrospective case series of 619 patients, of whom 20 had experienced a leak, CT scan had a sensitivity of 95% and specificity of 100%, while upper gastrointestinal (UGI) evaluation had an inferior sensitivity of 79% and specificity of 95%. In addition to greater sensitivity and specificity, CT scan can identify other complications, such as abscesses and bowel obstructions. Also, UGI evaluation is notably more dependent on patient and technologist compliance, resulting in suboptimal examinations. UGI, on the other hand, may help further define the size and more precise location of the leak, but typically cannot be performed until the following day if the patient becomes symptomatic at night. We propose that CT evaluation, used in combination with UGI, may increase the overall sensitivity of detecting a leak, thereby improving patient outcomes and decreasing hospital utilization.
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Affiliation(s)
- Tim Xu
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Kimberley Steele
- Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Martin Auster
- Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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17
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Controversies and Pitfalls of Imaging Patients Postoperative Bariatric Surgery. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0152-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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18
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Musella M, Milone M, Bianco P, Maietta P, Galloro G. Acute Leaks Following Laparoscopic Sleeve Gastrectomy: Early Surgical Repair According to a Management Algorithm. J Laparoendosc Adv Surg Tech A 2016; 26:85-91. [PMID: 26671482 DOI: 10.1089/lap.2015.0343] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Mario Musella
- General Surgery, Advanced Biomedical Sciences Department, “Federico II” University, Naples, Italy
| | - Marco Milone
- General Surgery, Advanced Biomedical Sciences Department, “Federico II” University, Naples, Italy
| | - Paolo Bianco
- General Surgery, Advanced Biomedical Sciences Department, “Federico II” University, Naples, Italy
| | - Paola Maietta
- General Surgery, Advanced Biomedical Sciences Department, “Federico II” University, Naples, Italy
| | - Giuseppe Galloro
- Surgical Endoscopy, Clinical Medicine and Surgery Department, “Federico II” University, Naples, Italy
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19
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Rawlins L, Penn R, Schirmer B, Hallowell P. Accuracy of routine postoperative swallow study in predicting leak or obstruction after gastric bypass. Surg Obes Relat Dis 2014; 11:1-4. [PMID: 25553886 DOI: 10.1016/j.soard.2014.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 04/29/2014] [Accepted: 07/27/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Many bariatric surgeons use a routine postoperative day 1 swallow study after Roux-en-Y gastric bypass to rule out leak or obstruction. The authors' practice adheres to this dictum, but the aim of this study was to determine how accurate this testing is in properly predicting complications. METHODS A retrospective chart review of all patients undergoing gastric bypass in the past 5 years (2008-2012) was performed; the results of their swallow study was examined and compared with their actual clinical outcome within 30 days of operation. RESULTS The records of 501 patients were reviewed, and there were 15 leaks and 29 obstructions for a total prevalence rate of 9%. When the swallow study was negative, 33 complications were missed and 433 reports were correct. When the swallow study was positive, only 11 complications were correctly identified and 24 of the reports were false positive. The sensitivity of the test was only 25%. The positive predictive value was only 31%. The result of the swallow study was incorrect 12% of the time. CONCLUSION Routine postoperative swallow study after gastric bypass was a poor method of accurately detecting clinically significant obstruction or leak. This test may be unnecessary for all patients and might best be used when clinically indicated.
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Affiliation(s)
- Logan Rawlins
- Department of Surgery, University of Virginia, Charlottesville, Virginia.
| | - Rachel Penn
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Bruce Schirmer
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Pete Hallowell
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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20
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Quartararo G, Facchiano E, Scaringi S, Liscia G, Lucchese M. Upper Gastrointestinal Series after Roux-en-Y Gastric Bypass for Morbid Obesity: Effectiveness in Leakage Detection. a Systematic Review of the Literature. Obes Surg 2014; 24:1096-101. [DOI: 10.1007/s11695-014-1263-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Abstract
Obesity has been steadily increasing over the last three decades and is one of the leading causes of increased health costs due to its associated comorbidities. Unfortunately, conservative treatment including lifestyle changes did not achieve the desired results. Bariatric surgery, on the other hand, has emerged as an effective and safe treatment for obesity and its related comorbidities such as type 2 diabetes. Much time has passed since the first Roux-en-Y gastric bypass was performed in the 1960s, and the operation technique has since evolved. New variations such as the distal gastric bypass as well as the omega loop bypass have been developed. Today, the laparoscopic gastric bypass is still the most widely applied bariatric operation technique, followed by laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. The refinement of the surgical technique and the introduction of laparoscopy have resulted in low perioperative morbidity and mortality after gastric bypass surgery. In this article, we will be discussing the history of gastric bypass surgery as well as presenting current data on excessive weight loss and resolution of comorbidities with a focus on diabetes. We will be looking into newer techniques such as omega loop bypass and their efficacy compared to the standard gastric bypass. Furthermore, we will be addressing the most important early and long-term complications, their diagnostic strategies as well as their management.
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Affiliation(s)
- Larissa Vines
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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22
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The Utility of Routine Postoperative Upper Gastrointestinal Swallow Studies Following Laparoscopic Sleeve Gastrectomy. Obes Surg 2014; 24:1415-9. [DOI: 10.1007/s11695-014-1243-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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23
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Hirst NA, Tiernan JP, Millner PA, Jayne DG. Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Colorectal Dis 2014; 16:95-109. [PMID: 23992097 DOI: 10.1111/codi.12411] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
AIM Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage. METHOD A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing. RESULTS Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications. CONCLUSION Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.
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Affiliation(s)
- N A Hirst
- Section of Translational Anaesthesia and Surgical Sciences, Leeds Institute of Molecular Medicine, St James's University Hospital, Leeds, UK
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24
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The role of drainage after Roux-en-Y gastric bypass for morbid obesity: a systematic review. Surg Obes Relat Dis 2013; 10:171-6. [PMID: 24355318 DOI: 10.1016/j.soard.2013.09.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/14/2013] [Accepted: 09/09/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). METHODS An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. RESULTS Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. CONCLUSION Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.
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25
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Subhani M, Rizvon K, Mustacchia P. Endoscopic Evaluation of Symptomatic Patients following Bariatric Surgery: A Literature Review. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2012; 2012:753472. [PMID: 22665965 PMCID: PMC3361154 DOI: 10.1155/2012/753472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 03/11/2012] [Indexed: 01/04/2023]
Abstract
Obesity is an epidemic in our society, and rates continue to rise, along with comorbid conditions associated with obesity. Unfortunately, obesity remains refractory to behavioral and drug therapy but has shown response to bariatric surgery. Not only can long-term weight loss be achieved, but a majority of patients have also shown improvement of the comorbid conditions associated with obesity. A rise in the use of surgical therapy for management of obesity presents a challenge with an increased number of patients with problems after bariatric surgery. It is important to be familiar with symptoms following bariatric surgery, such as nausea/vomiting, abdominal pain, dysphagia, and upper gastrointestinal bleeding and to utilize appropriate available tests for upper gastrointestinal tract pathology in the postoperative period.
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Affiliation(s)
- Miral Subhani
- Department of Gastroenterology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA
| | - Kaleem Rizvon
- Department of Gastroenterology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA
| | - Paul Mustacchia
- Department of Gastroenterology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA
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