Radiological imaging of the GI tract after bariatric surgery

Is the Resected Gastric Volume Effective in the Complication of Laparoscopic Sleeve Gastrectomy?

BACKGROUND

To determine the relationship between the resected gastric volume (RGV) and the results of laparoscopic sleeve gastrectomy (LSG).

METHODS

The study included 333 patients with LSG. Patients were divided into 4 groups according to RGV: 600 to 999 cm as Group 1, 1000 to 1499 cm as Group 2, 1500 to 1999 cm as Group 3, and ≥2000 cm consists the Group 4. Prospectively collected data at first month, sixth month, and at first year were retrospectively reviewed. The percentage of the reduction in body mass index and the excess weight loss and remission of comorbid diseases were recorded.

RESULTS

Preoperative demographic data were similar within groups. No statistically significant difference was observed between the groups in terms of the changes in excess weight loss. The major complication rates were highest in Group 4 and the difference between the groups was statistically significant (P=0.012).

CONCLUSIONS

The results of this study showed that different RGV do not affect the results of LSG, furthermore in patients with RGV ≥2000 cm, surgeons should be careful for major complications.

Diagnosis of gastrogastric fistula on computed tomography: a quantitative approach

OBJECTIVE

To determine if the attenuation of contrast material in the excluded stomach compared with the gastric pouch is helpful in diagnosing gastrogastric (GG) fistula.

MATERIALS AND METHODS

In a retrospective study, 13 CT scans in 12 patients (age 43.2 ± 9.2, 10 females) who had undergone Roux-en-Y gastric bypass and who had oral contrast in both the gastric pouch and excluded stomach were qualitatively and quantitatively evaluated for GG fistula by two radiologists, using upper GI series (UGI) as the gold standard. Quantitative analysis was performed by computing the relative attenuation (RA) ratio (HU in excluded stomach/HU in gastric pouch). Statistical analysis was performed to determine if the RA ratio values correlated with the UGI findings of GG fistula.

RESULTS

46.2% (6/13) of UGI studies demonstrated a GG fistula. Statistical analysis demonstrated a significant difference in RA ratio (P < 0.05) between the fistula group (1.12 ± 0.29) and the reflux group (0.56 ± 0.19). A receiver operating characteristic analysis identified an RA ratio of 0.8 that maximized sensitivity (100%), at the expense of specificity (78.6%), for diagnosing GG fistula. In contrast, the initial qualitative evaluation for GG fistula yielded a lower sensitivity (45.8%) and a higher specificity (89.2%). After taking RA ratios into account, radiologists' final conclusions achieved higher sensitivity (58.3%) and specificity (100%).

CONCLUSION

The relative attenuation ratio of oral contrast in the excluded stomach versus the gastric pouch can be a reliable tool in differentiating GG fistula from oral contrast reflux up the biliopancreatic limb on CT.

Changes in Gastric Volume and Their Implications for Weight Loss after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a relatively new surgical technique for the treatment of morbid obesity. It is unclear whether the volume of the gastric remnant can expand after surgery as a result of intraluminal pressure maintained over time. If this were the case, the increased volume could affect weight loss and the improvement in comorbidities. This study aims to assess the evolution of residual gastric volume (RGV) during the first year after LSG and its relationship with weight loss.

MATERIAL AND METHODS

We conducted a prospective study of 112 patients who underwent LSG from February 2009 to December 2013. In order to measure the RGV after surgery, all patients were evaluated radiologically by an esophagogastroduodenal (EGD) transit at 1 and 12 postoperative months.

RESULTS

All patients showed a significant reduction in BMI compared with the preoperative measurement (33.48 ± 5.78 vs. 50.54 ± 6.69 kg/m²; p < 0.001). Increased RGV was observed when comparing the results obtained by EGD transit at 1 (68.39 ± 25.89 cm³) and 12 postoperative months (122.58 ± 38.76 cm³; p < 0.001). There was no association between increase in gastric volume and weight loss at 1-year follow-up (r = 0.01; p = 0.910).

CONCLUSIONS

The volume of the gastric remnant increased significantly during the first year after LSG. However, this increase was not associated with weight loss. Further prospective research with longer follow-up periods is needed to confirm or contrast the present results.

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.

Residual gastric volume estimated with a new radiological volumetric model: relationship with weight loss after laparoscopic sleeve gastrectomy

BACKGROUND

The volume of the gastric reservoir appears crucial to explain the success of laparoscopic sleeve gastrectomy (LSG) in the treatment of morbid obesity. The aims of this study were to describe a new, easy model to estimate gastric reservoir volume after LSG; to evaluate the volumetric changes 1 year after surgery; and to analyze their relationship with weight loss.

METHODS

This is a prospective observational study of all patients undergoing LSG in the Department of Surgery at our institution. The gastric reservoir was evaluated radiologically considering the image as a complex geometrical shape with two components: a cylinder (gastric body) and a truncated cone (antrum). Radiologic assessment using this new model was performed at 1 and 12 months after surgery. Moreover, body mass index and percentage of excess weight loss (%EWL) were evaluated at 3, 6, 12, and 18 months after LSG.

RESULTS

Forty-five patients (34 F/11 M) with a mean age of 46.9 years were included. A significant increase in total gastric reservoir volume (124.8 ± 58.7 and 188.6 ± 76.4 mL at 1 and 12 months, respectively; p = 0.001) was observed. No statistically significant differences were observed comparing volume of the two components at the two time points. The %EWL at 18 months was inversely correlated with reservoir volume changes at 12 months after LSG (p = 0.006).

CONCLUSIONS

We describe an easy volumetric model to estimate the size of the gastric reservoir after LSG. Moreover, a direct relationship between an increase in gastric reservoir volume and a lower weight loss after surgery was documented.

Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

Routine drainage is not necessary after laparoscopic gastric bypass

INTRODUCTION

Routine intra-abdominal drainage has been recommended for detecting surgical complications, such as anastomotic leaks or intra-abdominal hemorrhage, after laparoscopic gastric bypass for morbid obesity. The aim of this study was to determine whether routine drainage after laparoscopic gastric bypass is indeed necessary.

METHODS

Patients undergoing laparoscopic gastric bypass with intra-abdominal drainage (D-group) were compared with those without drainage (N-group) in a retrospective study. The main outcome measures were postoperative course and complications.

RESULTS

No differences were observed in the postoperative complications. Both groups had one major complication of leakage (1/90, 1.1%). Minor complications occurred in six D-group patients (6/90, 6.7%) and eight N-group patients (8/90, 8.9%) (P=0.578). No difference was observed in postoperative analgesic dose usage (mean ± SD: 63 ± 37 mg vs 60 ± 31 mg; P=0.963) or length of stay hospital (5.2 ± 2.6 d vs 4.7 ± 1.8 d; P=0.135). However, the N-group had a shorter time to flatus passage compared to the D-group (1.6 ± 0.7 d vs 1.2 ± 0.5 d; P=0.006).

CONCLUSION

Routine abdominal drainage is not necessary after a successful laparoscopic gastric bypass for morbidly obese patients. Drainage omission may contribute to a quicker recovery without additional surgical complications.

3D gastric computed tomography as a new imaging in patients with failure or complication after bariatric surgery

The number of bariatric operations performed each year is increasing. As a result, a rising number of patients in possible need for revisional surgery are referred to bariatric surgeons. But the standard methods of evaluation are often insufficient, and the best strategy remains difficult to choose. In our centre, we have developed 3D gastric computed tomography with air (3D-GCT). The aim of this pilot study was to assess the usefulness of this new image modality as an aid in the decision-making process in patients with failure or complications after bariatric surgery. Twenty patients referred for failure or complications after various bariatric procedures were included in the study. 3D-GCT was performed on a multidetector CT scanner after absorption of effervescent salt diluted in 10 ml of water and IV injection of butylscopolamine. Thin-slice data were transferred to a dedicated 3D workstation creating three-dimensional volume-rendering images of the oesophagus, gastric cavities and anastomoses. The volume of the gastric pouches and the diameter of stoma or anastomoses were measured. No failure or complications were observed. In all patients, 3D-GCT resulted in very impressive precise 3D images of post-surgical anatomy of the stomach. Imaging findings allowed us to identify or to eliminate the common complications of each procedure with a good accuracy, resulting in an aid to choose the best strategy in each patient. In conclusion, our pilot study suggests that 3D-GCT is useful as a decision-making aid in patients with failure or complications after bariatric surgery.