Radiology of the Laparoscopic Roux-en-Y Gastric Bypass Procedure: Conceptualization and Precise Interpretation of Results

A Rare Case of a Petersen's Hernia During Pregnancy After Roux-en-Y Gastric Bypass

Obesity is an escalating problem worldwide and is associated with increased adverse maternal and perinatal outcomes in pregnancy. Bariatric surgery offers women an effective method of sustained weight loss, with patients often less likely to develop obesity-related comorbidities in pregnancy, including hypertension and gestational diabetes. However, despite beneficial effects, previous bariatric surgery can also predispose pregnant patients to developing internal hernias. We present a rare case of a Petersen's hernia diagnosed in a patient with a previous Roux-en-Y gastric bypass procedure during her third trimester.

Chylous Ascites Pointing Toward an Internal Hernia in the Setting of Roux-en-Y Gastric Bypass: A Case Report

Chylous ascites is a rare but significant complication of a variety of surgical procedures. It is an uncommon complication of laparoscopic Roux-en-Y gastric bypass (LRGYB). The underlying etiology is assumed to be an internal hernia, in which the hernia causes lymphatic channel engorgement and lymphatic extravasation. We present the case of a 34-year-old male who had a history of LRGYB a year back and had been experiencing gradually worsening, colicky abdominal pain radiating to the right flank for the last 24 hours. Laparoscopic exploration revealed chylous ascites due to internal herniation owing to the complication of LRYGB. Classic signs of internal hernias such as mesenteric swirl were absent on the computed tomography scan of the abdomen.

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.

Imaging Postoperative Abdominal Hernias: A Review with a Clinical Perspective

Postoperative internal hernia is a challenging but critical diagnosis in postoperative patients presenting with acute abdomen. Postoperative internal hernias are increasingly being recognized after Roux-en-Y gastric bypass (RYGB) and bariatric surgeries. These internal hernias have a high risk of closed-loop obstruction and bowel ischemia; therefore, prompt recognition is necessary. Computed tomography (CT) is the imaging modality of choice in cases of postoperative acute abdomen. Understanding the types of postoperative internal hernia and their common imaging features on CT is crucial for the abdominal radiologist. Postoperative external hernias are usually a result of defect or weakness of the abdominal wall created because of the surgery. CT helps in the detection, delineation, diagnosis of complications, and surgical planning of an external hernia. In this article, the anatomy, pathophysiology, and CT features of common postoperative hernias are discussed. Afterreading this review, the readers should be able to (1) enumerate the common postoperative internal and external abdominal hernias, (2) explain the pathophysiology and surgical anatomy of Roux-en-Y gastric bypass-related hernia, (3) identify the common imaging features of postoperative hernia, and (4) diagnose the complications of postoperative hernias.

Role of CT imaging in discriminating internal hernia from aspecific abdominal pain following Roux-en-Y gastric bypass: a single high-volume centre experience

Internal hernia (IH) represents a delayed complication of the laparoscopic Roux-en-Y gastric bypass (LRYGB) and it is historically difficult to identify preoperatively. Numerous CT signs were considered suggestive of IH but none of them is pathognomonic. In this study, we aim to evaluate the accuracy of CT in diagnosing IH, differentiating from non-specific abdominal pain. This can lead to a way of personalized medicine and improve the outcome of anti-obesity treatments. We retrospectively reviewed CT scans of 50 patients previously subjected to LRYGB procedure, with a clinical suspicion of IH. 3 groups of patients were identified: IH group (21 patients with a surgical confirmed IH), negative group (12 patients in whom IH was not confirmed at surgery), and control group (17 patients who were not surgically explored because of low/no suspicion of IH). We divided CT signs into three groups: "bowel loop signs", "vessel signs", and "venous congestion/stasis signs". The accuracy of CT in detecting IH was tested by comparing each sign, either individually or in combination, with the surgical findings. Statistical analysis showed that "vessel signs" (swirl sign, superior mesenteric vein beaking, mesenteric arteries, and veins branches inversion) present the highest distribution in patients with IH demonstrated at surgery, with a higher accuracy in case of simultaneous presence of two or three signs. CT imaging is highly accurate in diagnosing IH. Despite no single sign being pathognomonic, the combination of two or more signs, especially among the "vessels signs", can suggest the IH, even in pauci-symptomatic patients.

Value of contrast-enhanced multidetector computed tomography in imaging of symptomatic patients after laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy

Background

To assess the role of contrast-enhanced multidetector computed tomography (MDCT) in the assessment of symptomatic patients following laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Results

We reviewed the studies of 129 cases and found complications in 113 patients: 55 early complications and 48 late complications. All of these complications were diagnosed with intravenous contrast-enhanced MDCT. Statistically significant difference was found between UGIS and MDCT in the diagnosis of many cases.

Conclusion

The rate of complications in bariatric surgery is high and the associated mortality is not negligible. The interpreting radiologists should know the normal postoperative findings and be aware of possible complications.

Petersen's Hernia after Esophagectomy With Antesternal Jejunal Reconstruction: Case Report

Petersen's hernia after esophagectomy is quite rare. The patient was a 75-year-old man who had undergone esophagectomy via right thoracotomy and reconstruction with a jejunal loop by the antesternal route in 2014. In March 2015, severe acute abdominal pain occurred the next day. A contrast-enhanced abdominal computed tomography scan revealed a diffuse low density area in the abdominal cavity and partial dilatation of the small intestine with torsion of the superior mesenteric artery. The patient underwent emergency laparotomy, revealing chyle-like ascites and pallor of almost the entire small intestine due to circulatory impairment because of strangulation after herniation through Petersen's defect. After strangulation was relieved, the color and motility of the small intestine recovered rapidly. Then we closed the defect between the jejunal pedicle and the transverse mesocolon. This is the first English report showing Petersen's hernia after esophagectomy.

Internal Hernia in Pregnant Woman after Roux-en-Y Gastric Bypass Surgery

Laparoscopic Roux-en-Y gastric bypass has become the most common obesity surgery procedure worldwide over the last two decades. Many patients undergoing the procedure are women of reproductive age. This carries a risk for developing gastric bypass-related complications during pregnancy. One of the potentially serious risks is an internal hernia. We present a patient in the third trimester of pregnancy with an internal hernia following a laparoscopic Roux-en-Y gastric bypass for morbid obesity. We discuss the importance of computed tomography (CT) in the diagnosis of an internal hernia and review key CT findings including compression of the superior mesenteric vein, which proved to be crucial in diagnosing the internal hernia in this patient.

Percutaneous gastric remnant gastrostomy following Roux-en-Y gastric bypass surgery: a single tertiary center's 13-year experience

PURPOSE

The purpose of the study is to evaluate the indications, techniques, and outcomes for percutaneous gastrostomy placement in the gastric remnant following Roux-en-Y gastric bypass (RYGB) in bariatric patients.

MATERIALS AND METHODS

Retrospective chart review and summary statistical analysis was performed on all RYGB patients that underwent attempted percutaneous remnant gastrostomy placement at our institution between April 2003 and November 2016.

RESULTS

A total of 38 patients post-RYGB who underwent gastric remnant gastrostomy placement were identified, 32 women and 6 men, in which a total of 41 procedures were attempted. Technical success was achieved in 39 of the 41 cases (95%). Indications for the procedure were delayed gastric remnant emptying/biliopancreatic limb obstruction (n = 8), malnutrition related to RYGB (n = 17), nutritional support for conditions unrelated to RYGB (n = 15), and access for endoscopic retrograde cholangiopancreatography (ERCP, n = 1). Insufflation of the gastric remnant was performed via a clear window (n = 35), transhepatic (n = 5), and transjejunal (n = 1) routes. Five complications were encountered. The four major complications (9.8%) included early tube dislodgement with peritonitis, early tube dislodgement requiring repeat intervention, intractable pain, and upper gastrointestinal bleeding. A single minor complication occurred (2.4%), cellulitis.

CONCLUSION

Patients with a history of RYGB present a technical challenge for excluded gastric remnant gastrostomy placement. As the RYGB population increases and ages, obtaining and maintaining access to the gastric remnant is likely to become an important part of interventional radiology's role in the management of the bariatric patient.

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.

Studying the complications of bariatric surgery with intravenous contrast-enhanced multidetector computed tomography

OBJECTIVE

To review the complications of bariatric surgery and their diagnosis with intravenous contrast-enhanced multidetector computed tomography (MDCT).

MATERIAL AND METHODS

We retrospectively studied all patients who underwent gastric bypass or sleeve gastrectomy at our center during 2013 or 2014. We classified complications into early complications (appearing within 30 days of the intervention) and late complications.

RESULTS

We reviewed 155 cases and found 24 complications in 22 patients: 16 early complications (7 intraperitoneal hematomas, 5 anastomotic dehiscences, 2 intestinal obstructions, and 2 external hernias) and 8 late complications (3 internal hernias, 3 intestinal perforations, and 2 marginal ulcers). Two patients died. All of these complications were diagnosed with intravenous contrast-enhanced MDCT, except one, which required a barium transit study.

CONCLUSION

The rate of complications in bariatric surgery is high and the associated mortality is not negligible. Radiologists need to know the normal findings in these patients so they can quickly identify possible complications, most of which can be diagnosed with intravenous contrast-enhanced MDCT.

Gastric infarction following gastric bypass surgery

Gastric infarction is an extremely rare occurrence owing to the stomach's extensive vascular supply. We report an unusual case of gastric infarction following gastric bypass surgery. We describe the imaging findings and discuss possible causes of this condition.

MRI of the stomach: a pictorial review with a focus on oncological applications and gastric motility

The purpose of this pictorial review is to demonstrate gastric pathology seen on magnetic resonance imaging (MRI) and discuss the essential MRI sequences for the evaluation of benign and malignant gastric pathologies. Common tumors of the stomach, polyposis syndromes, iatrogenic conditions, as well as other conditions of the stomach will be reviewed. The utility of MRI in the evaluation of patients with gastric malignancies and disorders of gastric motility will also be discussed.

Relationship between gastric pouch and weight loss after laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is considered safe and effective even as conversion procedure after primary bariatric operations. The correlation between gastric pouch volumes and patients weight loss remains unclear.

METHODS

To assess a correlation between the gastric remnant size and the weight loss, we reviewed 49 consecutive barium swallow UGS performed at our institute from August 2012 through May 2014 in LSG patients with symptoms and/or unsatisfactory weight loss. The anteroposterior (AP), laterolateral (LL) and vertical (CC) diameters of the gastric pouch were measured to calculate the volume by the formula of the ellipsoid (AP × LL × CC × 0.5). Patients were divided in two groups: group 1 without gastric pouch (n = 36) and group 2 with gastric pouch (n = 13). Correlation between pouch volume and weight loss data was calculated with t Student's and Fisher tests to compare the percent excess body mass index (BMI) and percent excess body mass loss (EBL) between two groups, and P < 0.05 was considered statistically significant.

RESULTS

The mean percent EBL was 26.54 ± 11.02 and 27.12 ± 12.35 kg/m(2) in groups with and without pouch, respectively. The mean volume of the pouch after LSG was 17.13 ± 21.56 mm(3). Pouch volume, when present, was not significantly correlated to weight loss (P = 0.88 95% CI, CL 19.88-33.20 group 2; CL 22.94-31.30 group 1).

CONCLUSIONS

No statistical correlation was found between the volume of the gastric pouch and weight loss (percent EBL) after LSG in symptomatic or with unsatisfactory weight loss patients.

Common postoperative findings unique to laparoscopic surgery

The interpretation of images obtained in patients who have recently undergone abdominal or pelvic surgery is challenging, in part because procedures that were previously performed with open surgical techniques are increasingly being performed with minimally invasive (laparoscopic) techniques. Thus, it is important to be familiar with the normal approach used for laparoscopic surgeries. The authors describe the indications for various laparoscopic surgical procedures (eg, cholecystectomy, appendectomy, hernia repair) as well as normal postoperative findings. For example, port site hernias are more commonly encountered in patients with trocar sites greater than 10 mm and occur at classic entry sites (eg, the periumbilical region). Similarly, preperitoneal air can be encountered postoperatively, often secondary to trocar dislodgement during difficult entry or positioning. In addition, intraperitoneal placement of mesh during commonly performed ventral or incisional hernia repairs typically leads to postoperative seroma formation. Familiarity with normal findings after commonly performed laparoscopic surgical procedures in the abdomen and pelvis allows accurate diagnosis of common complications and avoidance of diagnostic pitfalls.

Case review and consideration for imaging and work evaluation of the pregnant bariatric patient

BACKGROUND

There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB.

METHODS

After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress.

RESULTS

Five patients were identified. Patient age ranged from 22-34 years (mean 28.4). Gestational age ranged from 9-31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m(2). Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks.

CONCLUSIONS

Pregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

Imaging of complications of common bariatric surgical procedures

Several techniques for the surgical management of obesity are available to bariatric surgeons. These interventions are performed more frequently with worsening of the obesity epidemic. Radiologists should be familiar with the surgical techniques, normal postoperative appearances, and potential complications for which imaging may be employed to establish a diagnosis to optimize patient care.

Imaging of bariatric surgery: normal anatomy and postoperative complications

Obesity is a disease that has reached epidemic proportions in the United States and around the world. During the past 2 decades, bariatric surgery has become an increasingly popular form of treatment for morbid obesity. The most common bariatric procedures performed include laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy. Fluoroscopic upper gastrointestinal examinations and abdominal computed tomography (CT) are the major imaging tests used to evaluate patients after these various forms of bariatric surgery. The purpose of this article is to present the surgical anatomy and normal imaging findings and postoperative complications for these bariatric procedures at fluoroscopic examinations and CT. Complications after Roux-en-Y gastric bypass include anastomotic leaks and strictures, marginal ulcers, jejunal ischemia, small bowel obstruction, internal hernias, intussusception, and recurrent weight gain. Complications after laparoscopic adjustable gastric banding include stomal stenosis, malpositioned bands, pouch dilation, band slippage, perforation, gastric volvulus, intraluminal band erosion, and port- and band-related problems. Finally, complications after sleeve gastrectomy include postoperative leaks and strictures, gastric dilation, and gastroesophageal reflux. The imaging features of these various complications of bariatric surgery are discussed and illustrated.

[Laparoscopic gastric bypass: computed tomography appearance of common postoperative changes and complications]

Laparoscopic Roux-en-Y bypass is being increasingly used for weight reduction in patients with morbid obesity. Unfortunately, some complications can occur after this procedure, the most frequent being intestinal obstruction (due to stenosis of the anastomosis at the distal end of the loop, internal hernias, bands, and adhesions), anastomotic leaks, and bleeding. This article provides basic knowledge about the surgical technique and its correlation with the common postoperative changes with the aim of facilitating the interpretation of CT findings and the identification of postoperative complications in these patients.

Imaging of patients treated with bariatric surgery

Over the past few years, obesity has become a major clinical and population concern in the majority of developed countries. Obesity leads to significant systemic disorders, such as hypertension, hypercholesterolemia, hypertriglyceridemia and insulin resistance, and also increases the risk of developing cardiovascular diseases (ischemic heart disease, ischemic stroke), metabolic diseases (type 2 diabetes), certain types of cancer, and degenerative bone disorders (osteoarthritis). Health hazards associated with epidemic of obesity and potential benefits of weight loss have spurred interest in new treatment methods. Bariatric surgical procedures constitute a recognized alternative in cases where conservative management of obesity fails. Several bariatric operations can be distinguished: restrictive procedures, such as adjustable gastric band (AGB) and vertical banded gastroplasty (VBG); predominantly malabsorptive procedures, such as biliopancreatic diversion (BPD), and a combination of both methods, such as Roux-en-Y gastric bypass. The adverse consequences of surgical treatment of obesity include i.a.: intestinal anastomotic leakage, impaired intestinal permeability and internal hernia, dilatation of the stomach, gastrointestinal anastomotic stenosis, marginal ulceration, incisional hernia. Basic knowledge of procedures in the surgical treatment of obesity is of vital importance for the radiologist during evaluation of upper gastrointestinal tract in the early and late postoperative period, allowing correct interpretation of acquired images as well as recognition of typical complications.

Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature

INTRODUCTION

Gastric bypass surgery is the most common obesity surgery procedure in women. Decreased weight loss favors fertility and leads to pregnancy sometimes just months after surgery, raising the risk of developing gastric bypass-related complications during pregnancy, including the formation of internal hernias.

PRESENTATION OF CASE

The first patient presented at 37 weeks of gestation with abdominal pain, nausea and vomiting. X-ray revealed multiple air-fluid levels and absence of gas in colon. She underwent a cesarean section and exploratory laparotomy without complications. A Petersen's space internal hernia was found. The second patient presented at 25 weeks of gestation with abdominal pain and nausea. X-ray revealed multiple air-fluid levels and a "U-shaped" intestinal loop. She underwent exploratory laparotomy with reduction of an internal hernia also in Petersen's space.

DISCUSSION

Pregnant patients with internal hernias after gastric bypass are usually of young age and with a several-day history of abdominal pain. Surgical exploration is safe and should not be delayed. The literature review showed that maternal death (9%) and fetal death (13.6%) rates are considerably high.

CONCLUSION

The possibility of an internal hernia should always be considered in pregnant women with history of gastric bypass who present with abdominal pain, in order to prevent catastrophic outcomes such as maternal and/or fetal death.

A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review

The post-operative abdomen can be challenging and knowledge of normal post-operative anatomy is important for diagnosing complications. The aim of this pictorial essay is to describe a few selected common, major gastrointestinal surgeries, their clinical indications and depict their normal post-operative computed tomography (CT) appearance. This essay provides some clues to identify the surgeries, which can be helpful especially when surgical history is lacking: recognition of the organ(s) involved, determination of what was resected and familiarity with the type of anastomoses used.

The four different types of internal hernia occurring after laparascopic Roux-en-Y gastric bypass performed for morbid obesity: are there any multidetector computed tomography (MDCT) features permitting their distinction?

BACKGROUND

Four different types of internal hernias (IH) are known to occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP) performed for morbid obesity. We evaluate multidetector row helical computed tomography (MDCT) features for their differentiation.

METHODS

From a prospectively collected database including 349 patients with LRYGBP, 34 acutely symptomatic patients (28 women, mean age 32.6), operated on for IH immediately after undergoing MDCT, were selected. Surgery confirmed 4 (11.6%) patients with transmesocolic, 10 (29.4%) with Petersen's, 15 (44.2%) with mesojejunal, and 5 (14.8%) with jejunojejunal IH. In consensus, 2 radiologists analyzed 13 MDCT features to distinguish the four types of IH. Statistical significance was calculated (p<0.05, Fisher's exact test, chi-square test).

RESULTS

MDCT features of small bowel obstruction (SBO) (n=25, 73.5%), volvulus (n=22, 64.7%), or a cluster of small bowel loops (SBL) (n=27, 79.4%) were inconsistently present and overlapped between the four IH. The following features allowed for IH differentiation: left upper quadrant clustered small bowel loops (p<0.0001) and a mesocolic hernial orifice (p=0.0003) suggested transmesocolic IH. SBL abutting onto the left abdominal wall (p=0.0021) and left abdominal shift of the superior mesenteric vessels (SMV) (p=0.0045) suggested Petersen's hernia. The SMV predominantly shifted towards the right anterior abdominal wall in mesojejunal hernia (p=0.0033). Location of the hernial orifice near the distal anastomosis (p=0.0431) and jejunojejunal suture widening (p=0.0005) indicated jejunojejunal hernia.

CONCLUSIONS

None of the four IH seems associated with a higher risk of SBO. Certain MDCT features, such as the position of clustered SBL and hernial orifice, help distinguish between the four IH and may permit straightforward surgery.

[Bariatric surgery and associated complications: radiological imaging]

Obesity is an increasing problem faced by the healthcare system. In managing obesity, bariatric surgery is becoming more important with evidence showing a reduction in long-term morbidity and mortality. There are special challenges faced by the radiology department in providing an imaging service for this population of patients, from technical requirements through to the interpretation of post-surgical images. This article provides an overview of the most frequently performed procedures, normal postoperative imaging findings and the appearance of common complications.

Imaging in bariatric surgery: service set-up, post-operative anatomy and complications

Obesity is an increasingly prevalent and costly problem faced by the healthcare system. The role of bariatric surgery in managing obesity has also increased with evidence showing a reduction in long-term morbidity and mortality. There are unique challenges faced by the radiology department in providing an imaging service for this population of patients, from technical and staffing requirements through to the interpretation of challenging post-surgical images. We describe these challenges and provide an overview of the most frequently performed procedures, normal post-operative imaging findings and the appearance of common complications.

Radiological imaging of the GI tract after bariatric surgery

BACKGROUND

Obesity is becoming epidemic in proportion and is leading to considerable morbidity and mortality in the community. Bariatric surgery offers one tested solution to sustained weight loss and comorbidity reduction. However, it is associated with a significant number of complications.

OBJECTIVE

The objective of this article is to review the utility of radiological techniques in the diagnosis of surgical complications after bariatric surgery.

DESIGN

Literature-based review and pictorial illustration in the use of imaging techniques in the diagnosis of complications after bariatric surgery.

CONCLUSIONS

Radiology plays a critical role in the diagnosis of complications after bariatric surgery. Upper GI contrast study and CT are the most commonly used imaging modalities in this regard. They are complementary in their diagnostic abilities and should be used in concert for the complete evaluation of symptomatic patients. All other radiological imaging modalities are also used in the diagnosis of complications after bariatric surgery, but much less commonly.

Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass surgery

PURPOSE

The purpose of this study was to review the etiology and computed tomography (CT) findings of small-bowel obstruction (SBO) in patients who have undergone bariatric laparoscopic Roux-en-Y gastric bypass (LGBP) surgery.

MATERIALS AND METHODS

Prospectively entered data from a surgical database of 835 consecutive patients who underwent antecolic-antegastric LGBP for morbid obesity from June 1999 to April 2005 in a single institution were retrospectively reviewed. A total of 42 cases of bowel obstruction were observed in 41 patients. Surgical proof was available in 38 cases, and 4 cases had characteristic imaging features and/or clinical follow-up. Seventeen CT scans were reviewed to determine cause and level of obstruction, and this was correlated with surgical findings and clinical follow-up.

RESULTS

Internal hernia was the most common (13 cases) and also the most frequently missed etiology of SBO on CT scans, with the diagnosis being made prospectively in only 2 of 6 cases, in which CT was done. Adhesions, ventral hernia, postoperative ileus, and jejunojejunal (JJ) anastomotic strictures, in that order, were the other commonly observed etiologies for SBO, with 11, 7, 5, and 4 cases, respectively. Some causes of SBO post-LGBP (JJ anastomotic stricture and postoperative ileus) developed relatively early, whereas others (internal hernia) tended to develop later or had a bimodal distribution (adhesions and ventral hernia). Fifteen (36%) of 42 cases had SBO at or near the level of jejunojejunostomy site; causes included internal hernia (5 cases), adhesions/kinking of small bowel (5 cases), JJ anastomotic stricture (4 cases), and JJ intussusception (1 case).

CONCLUSION

The time interval between LGBP and development of SBO might provide a useful clinical clue to its etiology. The JJ level is an important location for SBO post-LGBP because of a variety of causes, and special attention must be paid to this site at imaging of post-LGBP patients.

A case study from the advanced bariatric life support initiative: pulmonary embolism after laparoscopic gastric bypass

Pulmonary embolism is the leading cause of death after bariatric surgery and represents one of the many potential life-threatening conditions after bariatric surgery. The Advanced Bariatric Life Support (ABLS) initiative was developed to teach practising bariatric surgeons, emergency physicians, and allied health professionals the need for accurate and timely diagnosis and management of life-threatening bariatric surgery complications. This case study was derived from the ABLS file and discusses the difficulty in differentiating between two major complications after gastric bypass--pulmonary embolism vs leak. Accurate diagnosis and expeditious treatment are of utmost importance to prevent death associated with these serious bariatric surgical complications.

Laparoscopic Remnant Gastrectomy: A Novel Approach to Gastrogastric Fistula after Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND

Gastrogastric fistula (GGF) is a relatively rare and devastating complication after divided Roux-en-Y gastric bypass (RYGB) for morbid obesity. The aim of this study was to review laparoscopic remnant gastrectomy (LRG) as a novel treatment option for this complication.

STUDY DESIGN

After IRB approval, we retrospectively reviewed data from all patients who underwent bariatric surgery at Cleveland Clinic Florida and from all patients who were diagnosed with GGF as a complication of RYGB, between January 2000 and March 2005. Data collected included demographics, body weight, symptoms, initial diagnostic method, indications for LRG, and postoperative complications.

RESULTS

Of 1,400 patients who had undergone RYGB in our institution during the study period, 21 patients (1.5%) were diagnosed with GGF; 4 more patients who were admitted with GGF after RYGB underwent the initial operation at another institution. Of these, 15 patients underwent LRG. Indications for surgical treatment were intractable epigastric pain (10 of 15), upper gastrointestinal bleeding (2 of 15), intolerance of soft diet (2 of 15), and weight regain (1 of 15). Mean hospital length of stay after the procedure was 4.7 days. There was no mortality, and there was no recurrence of GGF during the followup period.

CONCLUSIONS

LRG appears to be a safe and effective surgical procedure for selective patients with GGF after RYGB.