Accuracy of routine postoperative swallow study in predicting leak or obstruction after gastric bypass

Computed tomography as primary postoperative follow-up after laparoscopic Roux-en-Y gastric bypass

AIM

To evaluate upper abdominal computed tomography (CT) scan as primary follow-up after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

This prospective study was approved by the Ethical Committee of the State of Zurich, and informed consent was obtained from all patients. Sixty-one patients who underwent LRYGB received upper abdominal CT on postoperative day 1, with the following scan parameters: 0.6 mm collimation, 1.2 mm pitch, CareKV with reference 120 mAs and 120 kV, and 0.5 s rotation time. Diluted water-soluble radiographic contrast-medium (50 mL) was administered to achieve gastric pouch distension without movement of the patient. 3D images were evaluated to assess postoperative complications and the radiation dose received was analysed.

RESULTS

From the 70 patients initially enrolled in the study, 9 were excluded from analysis upon the intraoperative decision to perform a sleeve gastrectomy and not a LRYGB. In all of the 61 patients who were included in the analysis, CT was feasible and there were no instances of aspiration or vomiting. In 7 patients, two upper abdominal scans were necessary as the pouch was not distended by contrast medium in the first acquisition. Radiologically, no leak and no relevant stenosis were found on the first postoperative day. These early postoperative CT findings were consistent with the findings at clinical follow-up 6 wk postoperatively, with no leaks, stenosis or obstructions being diagnosed. The average total dose length product in CT was 536.6 mGycm resulting in an average effective dose of 7.8 mSv. The most common surgical complication, superficial surgical site infections (n = 4), always occurred at the upper left trocar site, where the circular stapler had been introduced.

CONCLUSION

Early LRYGB postoperative multislice spiral CT scan is feasible, with low morbidity, and provides more accurate anatomical information than standard upper gastrointestinal contrast study.

Comparison of Imaging Modalities for Detecting Complications in Bariatric Surgery

PURPOSE

The purpose of this study is to evaluate the results of routine fluoroscopic swallowing study (FSS) imaging 24 h after surgery and computed tomography (CT) on demand based on clinical data, in diagnosing complications after bariatric surgery.

MATERIAL AND METHODS

This retrospective study includes 9386 patients that underwent bariatric surgery. A total of 3241 (34.53%) patients underwent FSS imaging following the surgical procedure, and 106 (1.13%) patients underwent CT.

RESULTS

Sleeve gastrectomy was performed in 8093 patients (75.81%), gastric bypass was performed in 1281 patients (12%), duodenal switch or biliopancreatic diversion was performed in 12 patients (0.11%), and gastric banding was performed in 1289 patients (12.07%), which were excluded from the study as no imaging modality was used in any of these patients. The sensitivity for FSS was 71.43% and the specificity was 99.85%. An analysis of disease prevalence revealed a value of 0.43% with a positive predictive value of 66.67%. The sensitivity for CT was 71.42% and the specificity was 98%. A disease prevalence analysis revealed a value of 6.60% with a positive predictive value of 83.33%. A comparison of the two modalities showed that FSS has higher specificity values (p < 0.02) and a higher accuracy (p < 0.0001) than CT.

CONCLUSION

CT and FSS have a similar sensitivity for diagnosing complications after bariatric surgery. However, the specificity and accuracy of FSS are superior to that of CT. This study was approved by the instructional ethics committee (Helsinki board) and was registered on the National Institutes of Health ( ClinicalTrials.gov ) web site with identifier NCT02813122.

The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks

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.

Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation

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.