Multidetector CT imaging of bariatric surgical complications: a pictorial review

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.

Post-laparoscopic sleeve gastrectomy with splenic abscess: Case report

INTRODUCTION AND IMPORTANCE

One of the complications of laparoscopic sleeve gastrectomy (LSG) is a splenic abscess, considered a rare complication. As it is rare, it is a challenge to diagnose.

CASE PRESENTATION

In this case, a 62-year-old male patient who underwent LSG returned after three weeks with abdominal pain and fever. CLINICAL DISCUSSION: leak, Infection, spleen infarction These seemed like common complications, such as leaking from the stapler line, but the CT findings indicated a splenic abscess. The primary explanation for such an abscess is unclear in our case as the other reported cases were with the hypothesis of the late leak. A different treatment approach, laparoscopic exploration with incision and drainage, is the preferred option for this patient.

CONCLUSION

rare complications can be a challenge and how to manage them can be different from the standard to help the patient.

The incremental value of multislice CT in diagnosis of late bariatric surgery complications

Background

Bariatric surgery has become a widely accepted treatment option among the population for obesity management. Nevertheless, different complications may still be encountered during the late post-operative period. Our prospective cross-sectional study aimed to show the incremental value of multislice CT for diagnosis of such complications.

Results

Within the included twenty patients who underwent multislice CT of upper abdomen, gastric pouch dilatation causing recurrent weight gain was the commonest complication detected in 70% of the studied patients and was found mainly after sleeve gastrectomy in whom mean gastric pouch volume was 248.4 ml. Gastric stricture, gastric herniation through plication suture, hiatus hernia and incisional hernia were less commonly encountered complications.

Conclusion

Multislice CT is a useful non-invasive imaging modality for detection of late bariatric surgery complications.

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.

The Jejunojejunostomy: an Achilles Heel of the Roux-en-Y Gastric Bypass Construction

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) has for long been the gold standard technique in bariatric surgery, especially in the Scandinavian countries. In a tertiary hospital setting, we observed an increasing number of patients with postprandial abdominal pain and nausea, often associated with complex hypoglycemia.

OBJECTIVES

The present study aimed to characterize the clinical patterns, patient characteristics, and clinical outcomes after surgical revision of dysfunctional RYGB at Sahlgrenska University Hospital in Gothenburg, Sweden.

METHODS

This cohort study included patients with RYGB who underwent revision of the jejunojejunostomy (JJ) after 2013. Information was obtained by reviewing medical records and performing complementary interviews.

RESULTS

Laparoscopic revisional surgery was performed in 115 cases with either adhesiolysis or total revision of the JJ (mean age 41 years, range 19-67 years; 90% women). The median time to assessment after the last revision was 33 months (range 12-75 months). Forty-four (38%) patients reported that they were symptom-free long-term after the intervention, and 32 (28%) patients experienced an improvement in the symptoms that were the indication for revision. However, 31 (27%) patients reported no long-term improvement, and half of them (n = 16) subsequently had a reversal of the anatomy. Eight (7%) patients were lost to follow-up.

CONCLUSIONS

Dysfunction of the JJ appears to be a relatively common cause of postprandial pain and nausea after ante-colic/ante-gastric RYGB. Most patients with symptoms of dysfunction experienced partial or total relief following revisional surgery, but a substantial minority had persistent problems, with one in five eventually undergoing reversal of the anatomy.

Splenic Abscess Following Sleeve Gastrectomy: A Systematic Review of Clinical Presentation and Management Methods

BACKGROUND

Splenic abscess is a rare complication following sleeve gastrectomy.

METHODS

We performed a systematic review to clarify its clinical significance, presentation, and management. PubMed, Embase, MEDLINE, Google Scholar, and the Cochrane Library were searched up to the 19th of July 2020. A total of 18 patients were included, of which 11 were female and 7 were male. The mean age was 34.1 ± 12.3 years, and the mean body mass index was 45.8 ± 7.6 kg/m². Type 2 diabetes mellitus was reported in 11.1% of patients and hypertension in 22.2%. Fever was the most common presenting symptom seen in 17 (94.4%) patients, followed by abdominal pain in 10 (55.6%). The mean duration from surgery to presentation was 98.6 ± 132.7 days (range 10-547 days). Computed tomography was used for investigations in 17/18 (94.4%) patients. Seven patients had reported leak, three reported bleeding, and 2 reported pleural effusion. Thirteen patients had unilocular abscess. All patients were treated with antibiotics. Four patients needed total parenteral nutrition, and three were given proton pump inhibitor. In total, 11 patients needed percutaneous drainage as a part of treatment and 11 patients needed total splenectomy and 1 needed partial splenectomy.

CONCLUSION

Splenic abscess following sleeve gastrectomy is a rare identity. The etiology of formation of splenic abscess needs further studies. A computed tomography of the abdomen with contrast is the preferred diagnostic tool. There is no gold standard treatment for splenic abscess.

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.

Diagnostic imaging in the diagnosis of acute complications of bariatric surgery

PURPOSE

The aim of study is to identify the frequency of acute complications and imaging findings at gastro-intestinal transit (GI) and computerised tomography (CT) in a group of obese patients who developed clinical suspicion of acute complications (painful and meteoric abdomen, nausea, vomiting, fever, intestinal blockage) in post bariatric surgery.

MATERIAL AND METHODS

We retrospectively review 954 obese patients who underwent bariatric surgery between 2013 and 2019. The study included 72 patients who developed clinical suspicion of acute complications (painful and meteoric abdomen, nausea, vomiting, fever, intestinal blockage) within 6 days of bariatric surgery of sleeve gastrectomy, gastric banding, gastric bypass with Roux loop confirmed by CT, and who underwent a gastrointestinal transit before the CT examination.

RESULTS

GI exam allowed visualisation of 58% of complications. Analysing the data for each surgical technique, 46 post-operative complications were found involve gastric banding. The most frequent was bandage migration (26 cases, 56 %), identified in all cases at GI transit and then confirmed on CT.

CONCLUSIONS

The study suggests that CT should be used to clarify all doubtful or clinically discordant GI transit exam results. The participation of a radiologist in qualification and post-operative evaluation is important for bariatric surgery patients.

Review and pictorial essay on complications of bariatric surgery

Obesity is a chronic disease characterized by excess fat in the body and a real public health problem. Bariatric surgery, in recent decades, has gained space in its treatment due to the efficiency obtained in weight loss and significant reduction of the related comorbidities. The most commonly performed bariatric procedures include Roux-en-Y gastric bypass, adjustable gastric band, and laparoscopic sleeve gastrectomy. Possible complications described include fistulas, dehiscence, marginal ulcers, intestinal obstruction, internal hernias, and anastomotic stenosis. These complications may have unfavorable clinical outcomes since symptoms are often nonspecific. Abdominal computed tomography (CT) is an important tool in the evaluation of postoperative complications, both in the immediate and late postoperative status of patients undergoing such a procedure. We analyzed the most illustrative tomographic findings of the different complications after reducing gastroplasty in 203 patients without distinction of age or gender. Correct interpretation requires radiologists to understand the surgical technique since postoperative anatomy and surgery-specific complications may be obstacles to proper interpretation.

Computed Tomography-based Diagnosis of Post-laparoscopic Sleeve Gastrectomy Gastric Leak

Objective:

Gastric leak post-laparoscopic sleeve gastrectomy may appear as a variety of computed tomography (CT) findings. We aimed to review the various CT findings sensitivity and specificity in confirmed cases of gastric leak.

Materials and Methods:

A retrospective review was performed for all patients who underwent sleeve gastrectomy, CT, and endoscopy for suspected leak between 2011 and 2018. All patients with positive CT findings for gastric leak were included in the study.

Results:

A total of 152 consecutive patients underwent CT for suspected post-sleeve gastrectomy gastric leak. Out of 152 patients, 88 had positive CT findings for gastric leak and underwent endoscopy. The CT findings sensitivity and specificity of perigastric collection without oral contrast leak were 61% and 88.8%, oral contrast leak were 28% and 100%, and gas leak were 10% and 77.7%, respectively.

Conclusions:

Perigastric fluid collection without contrast leak and with variable wall enhancement and gas content is the most common CT findings of post-sleeve gastrectomy gastric leak. Among various CT findings, it exhibits good diagnostic accuracy with 61% sensitivity and 88.8% specificity.

Abdominal viscus penetration by laparoscopic-adjustable gastric band tubing: case report and review

Laparoscopic-adjustable gastric band (LAGB) complications are increasingly recognised as follow-up time increases. These are most commonly related to the gastric band or port site, but complications of the connecting tubing are also reported. We present a case of LAGB tubing penetration through the transverse colon causing abdominal sepsis in a complex surgical abdomen and review prior published cases of abdominal viscus penetration by LAGB tubing. Like complications involving all LAGB components, these often present with non-specific abdominal signs and symptoms and undergo abdominal CT as an early investigation. This makes knowledge of normal and pathological imaging features of LAGB components important in radiology practice.

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure

Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

Gastric and colonic erosion caused by laparoscopic gastric band: a case report

Laparoscopic adjustable gastric banding is commonly used to treat obesity. It rarely results in complications, one of which is gastrointestinal erosion. Simultaneous erosion of the stomach and colon is a rare finding that has been documented in only a few case reports. We present a 62-year-old female with abdominal pain, nausea, and hematochezia. She was found to have simultaneous gastric and colonic erosion identified on CT scan. Imaging findings were confirmed and device was removed during surgery.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.