Imaging following bariatric surgery: roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and sleeve gastrectomy

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography

PURPOSE

To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures.

METHODS

Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators.

RESULTS

In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4 mm, RGA 1.6 ± 0.5 mm, and GEA 1.7 ± 0.4 mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans.

CONCLUSION

In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

Gastrojejunostomy junction perforation resulting from Dobhoff tube insertion in a patient with a history of Roux-en-Y surgery: a case report

BACKGROUND

Gastrojejunostomy junction perforation is a rare yet critical complication associated with enteral tube placement, presenting unique challenges in patients with a history of Roux-en-Y gastric bypass surgery.

CASE PRESENTATION

A 63-year-old white female with a complex medical history, including heart failure, atrial fibrillation, stage 4 chronic kidney disease, and prior Roux-en-Y gastric bypass surgery in 2015, experienced a significant decline in her health. She was discharged to a skilled nursing facility after a fall but deteriorated rapidly in the 2 weeks before admission. She presented with symptoms of failure to thrive, abdominal/back pain, inability to eat or drink, constipation, and stool incontinence. Lab tests showed anemia, electrolyte imbalances, and acute kidney injury. Imaging confirmed Roux-en-Y gastric bypass anatomy and a small hiatal hernia. Despite treatment attempts, her condition worsened. Nutrition discussions led to a temporary Dobhoff tube placement, considering her Roux-en-Y gastric bypass history, with plans for a gastrostomy tube. However, Dobhoff tube placement posed challenges, and imaging later revealed perforation near the gastrojejunostomy junction. After consulting with the family, the decision was made to transition the patient to comfort care due to her overall condition. Yearly education of staff about Roux-en-Y gastric bypass anatomy and updated Dobhoff placement protocol was implemented with physician oversight. Further imaging protocol in a patient who had had a Roux-en-Y gastric bypass was updated to include fluoroscopic guidance when endoscopic placement was unavailable.

CONCLUSIONS

This case highlights the intricacies of managing patients with Roux-en-Y gastric bypass history and underscores the need for meticulous planning and consideration of anatomical variations when performing procedures involving the gastrointestinal tract and the importance of involving multiple healthcare disciplines in complex decision-making and preventive measures to enhance patient safety in similar cases.

Cardiothoracic Medical Devices - A Pictorial Review

The rapid advancement of medical technology has introduced a plethora of innovative devices designed for use within the thoracic cavity. Familiarity with the characteristic imaging features of these devices, their purpose and desired positioning is crucial for radiologists to identify them promptly and accurately assess any associated complications. This pictorial review provides a comprehensive overview of the radiologic findings associated with various new chest devices, aiming to equip radiologists with the knowledge required for effective clinical management.

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.

Association of body composition with postoperative complications after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

OBJECTIVE

To evaluate predictive values of body composition parameters measured from preoperative CT/MRIs for postoperative complications after laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) in patients with obesity.

METHODS

In this retrospective case-control study, patients performing abdominal CT/MRIs within one month before and developing 30-day complications after bariatric procedures were matched for age, sex, and type of surgery with patients without complications (1/3 ratio, respectively). Complications were determined by documentation in the medical record. Two readers blindly segmented the total abdominal muscle area (TAMA) and visceral fat area (VFA) using predetermined thresholds for the Hounsfield unit (HU) on unenhanced CT and the signal intensity (SI) on T1-weighted MRI at the L3 vertebral level. Visceral obesity (VO) was defined as VFA > 136 cm² in males and > 95 cm² in females. These measures, along with perioperative variables, were compared. Multivariate logistic regression analyses were performed.

RESULTS

Of 145 included patients, 36 had postoperative complications. No significant differences between LSG and LRYGB were present regarding complications and VO. Hypertension (p = 0.022), impaired lung function (p = 0.018), American Society of Anesthesiologists (ASA) grade (p = 0.046), VO (p = 0.021), and VFA/TAMA ratio (p < 0.0001) were associated with postoperative complications in the univariate logistic analysis; the VFA/TAMA ratio was the only independent predictor in multivariate analyses (OR 2.01, 95% CI 1.37-2.93, p < 0.001).

CONCLUSION

The VFA/TAMA ratio provides important perioperative information in predicting patients who are likely to develop postoperative complications undergoing bariatric 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.

Simultaneous Winslow and Petersen’s Hernias after a Roux-en-Y Gastric Bypass Causing Bowel Obstruction: Laparoscopic Management and Review of the Literature

Internal hernias after Roux-en-Y gastric bypass are one of the most common complications in bariatric surgery leading to hospital readmissions with or without surgery. Due to the insidious and non-specific clinical presentation combined with difficult radiological identification, internal hernias remain a diagnostic and therapeutic challenge. Delay in diagnosis and treatment can lead to severe morbidity and mortality. We report the case of a patient presenting an unusual intestinal obstruction due to two simultaneous and distinct internals hernias affecting the Petersen’s defect and the foramen of Winslow 4 years after a laparoscopic gastric bypass. A 41-year-old female patient with a history of robotic laparoscopic Roux-en-Y gastric bypass presented with proximal small bowel obstruction symptoms and epigastric pain. Computed tomography showed two simultaneous internal hernias, one affecting the Petersen’s defect and the other affecting the foramen of Winslow with an incarcerated transverse colon. We performed an explorative laparoscopy to reduce both hernias and, after an assessment of bowel viability by indocyanine green angiography, we closed both defects with interrupted non-absorbable sutures to prevent recurrence. The follow-up of more than 1 year has been uneventful. In the cases of obstruction and hospital admission after gastric bypass, we suggest that patients undergo a computed tomography directly after the initial examination. Internal hernia diagnosis is often delicate and requires surgical exploration since bowel strangulation can lead to dramatic outcomes. The operation can be safely done laparoscopically, and all internal hernia defects should be repaired with non-absorbable sutures.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (&gt; 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding

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Although most complications following LAGB are confined to the stomach and port site, some may envolve the entire bowel causing extensive damage.

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One must be wary of the presentation of long term complications, as it may initially present as an unrelated pathology, such as acute pancreatitis.

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Long term complications may be asymptomatic for years despite extensice damage, including multiple contained perforations.

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The surgical procedure performed to treat long term complications should be planned and performed by physicians experienced in foregut surgery.

Introduction

Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported.

Presentation of case

A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum.

Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21.

Discussion

Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature.

Conclusion

Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

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.

The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon's point of view

BACKGROUND

The number of bariatric procedures is increasing worldwide. No consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available. The aim of this study is to investigate by a web survey how an emergency surgeon approaches this unique group of patients in an emergency medical scenario and to report their personal experience.

METHOD

An international web survey was sent to 197 emergency surgeons with the aim to collect data about emergency surgeons' experience in the management of patients admitted in the emergency department for acute abdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiple choice and open) questions and approved by a steering committee.

RESULTS

One hundred seventeen international emergency surgeons decided to join the project and answered to the web survey with a response rate of 59.39%.

CONCLUSIONS

The aim of this WSES web survey was to highlight the current management of patients previously submitted to bariatric surgical procedures by ES. Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon. In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration for bariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first 12-24 h, to have good outcomes and decrease morbidity rate.

Imaging of Abdominal Postoperative Complications

We present a case-based review of abdominal postoperative complications, organized by organ system affected, including wound/superficial, hepatobiliary, pancreatic, gastrointestinal, genitourinary, and vascular complications. Both general complications and specific considerations for certain types of operations are described, as well as potential pitfalls that can be confused with complications. Representative cases are shown using all relevant imaging modalities, including CT, fluoroscopy, ultrasound, MRI, and nuclear medicine. Management options are also described, highlighting those that require radiologist input or intervention.