Imaging of patients treated with bariatric surgery

Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations

In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.

Sleeve Gastrectomy Is the Most Common Cause of Gastroesophageal Reflux Disease in Comparison with Other Bariatric Operations

INTRODUCTION

Gastroesophageal reflux disease (GERD) is one of the complications of bariatric operations that might affect the quality of life. We aim to perform a retrospective cohort study to determine the incidence of symptomatic GERD following different types of bariatric surgery and which operations are considered a contraindication of GERD. Besides, we are attempting to identify the risk factors of GERD after bariatric surgery.

METHODS

Medical records of 729 patients who had undergone bariatric operations between January 2010 and June 2019 at the Shamir (Assaf Harofeh) Medical Center were reviewed.

RESULTS

There was a significant difference between the type of bariatric procedure and the incidence of GERD symptoms after the operation. The incidence of symptomatic GERD in patients who underwent sleeve gastrectomy (SG) was 39.9% (p = 0.0131). This was significantly higher compared to 16.4% following Roux-en-Y gastric bypass, 23.4% following laparoscopic adjustable gastric band, and 11% following one anastomosis gastric bypass. 113 patients out of 718 had a positive swallow test, and of these patients, 71 developed GERD symptoms postoperatively without correlation to the degree of reflux at the swallow test but with statistically significant correlation to the type of operation especially for SG (p value < 0.001), and to our knowledge, this was never reported in the literature.

CONCLUSION

SG is a good bariatric procedure option but should be considered carefully in asymptomatic patients with reflux at contrast swallow study and symptomatic GERD patients preoperatively because of high levels of symptomatic GERD postoperatively. Asymptomatic reflux at contrast swallow study preoperatively could be considered a risk factor for GERD after the operation. More studies are needed to be performed on this subject with the addition of postoperative contrast swallow test and pH monitoring preoperatively and postoperatively.

Role of imaging in assessment and detection of complications after bariatric surgery

Background

Bariatric surgery is performed to control morbid obesity secondary to failed medical approaches. Practical knowledge of post-surgical anatomy allows accurate interpretation of imaging findings related to normal post-surgical anatomy and common post-surgical complications.

The purpose of this study was to highlight the role of imaging in the assessment and detection of complications after bariatric surgery.

Results

This prospective study included 49 patients who had bariatric surgery. Sleeve gastrectomy was the most common bariatric surgery. The leak was the commonest complication (12%). The sensitivity of upper GI series for diagnosis of post-operative complication after bariatric surgery was 70% and specificity 94% while the sensitivity of CT study was 95% and specificity 95%.

Conclusion

CT has a golden role in the diagnosis of post-operative complications. Both post-contrast CT and upper GI series should be used in diagnosing complications following bariatric surgery. US is useful for diagnosis of a superficial problem.

Contemporary follow-up imaging after endovascular repair of lower extremity atherosclerotic lesions

Atherosclerotic disease is currently one of the most important problems of modern medicine because it is a leading cause of increased morbidity, morbidity and mortality, and disability in the Western World. Atherosclerosis of the lower limbs (peripheral arterial disease – PAD) significantly affects the quality of life and in a considerable proportion of patients is a cause of disability. Radical treatment of PAD, both surgical and endovascular, aims at revascularisation of ischaemic tissues distal to obstructed arteries. Surveillance imaging is an important part of patient management after endovascular repair of PAD. Apart from availability and contraindications, challenges of imaging include calcifications, flow dynamics, and stent-related artefacts. The aim of this paper was to review the current literature on imaging methods for follow-up after endovascular repair of atherosclerotic lesions, with special attention paid to novel techniques. As a non-invasive modality, ultrasound is still the first-line examination, but computed tomography angiography remains a current state-of-the art technique for follow-up. However, since current imaging recommendations seem not to adhere to contemporary imaging possibilities, more attention should be paid to recent improvements in magnetic resonance angiography technology.

High-fat Diet Accelerates Intestinal Tumorigenesis Through Disrupting Intestinal Cell Membrane Integrity

Background:

Excess energy supply induces chronic low-grade inflammation in association with oxidative stress in various tissues including intestinal epithelium. The objective of this study was to investigate the effect of high-fat diet (HFD) on intestinal cell membrane integrity and intestinal tumorigenesis in Apc^Min/+ mice.

Methods:

Mice were fed with either normal diet (ND) or HFD for 12 weeks. The number of intestinal tumors were counted and biomarkers of endotoxemia, oxidative stress, and inflammation were determined. Changes in intestinal integrity was measured by fluorescein isothiocyanate (FITC)-dextran penetration and membrane gap junction protein expression.

Results:

HFD group had significantly higher number of tumors compared to ND group (P < 0.05). Blood total antioxidant capacity was lower in HFD group, while colonic 8-hydroxy-2′-deoxyguanosine level, a marker of oxidative damage, was higher in HFD group compared to that of ND group (P < 0.05). The penetration of FITC-dextran was substantially increased in HFD group (P < 0.05) while the expressions of membrane gap junction proteins including zonula occludens-1, claudin-1, and occludin were lower in HFD group (P < 0.05) compared to those in ND group. Serum concentration of lipopolysaccharide (LPS) receptor (CD14) and colonic toll-like receptor 4 (a LPS receptor) mRNA expression were significantly higher in HFD group than in ND group (P < 0.05), suggesting that significant endotoxemia may occur in HFD group due to the increased membrane permeability. Serum interleukin-6 concentration and myeloperoxidase activity were also higher in HFD group compared to those of ND group (P < 0.05).

Conclusions:

HFD increases oxidative stress disrupting intestinal gap junction proteins, thereby accelerating membrane permeability endotoxemia, inflammation, and intestinal tumorigenesis.

Obese patients and radiography literature: what do we know about a big issue?

Obesity is a global health issue with obese patients requiring specialised diagnosis, treatment and care through the health service. The practical and social difficulties associated with medical imaging of obese patients are an increasingly common problem and it is currently unknown how student and qualified radiographers perceive and respond to these challenges. By better understanding challenges presented in providing quality imaging and care of imaging obese patients, education for both qualified and student radiographers can be enhanced. Radiographers are heavily reliant on visual and tactile senses to locate the position of anatomical structures for diagnostic imaging and determine radiation exposure through a delicate consideration of dose, image quality and anatomical attenuation. However, obese patients require modifications to routine radiographic practice in terms of movement/assisted positioning, equipment capabilities to take increased weight or coverage. These patients may also be subject to compromised radiological diagnosis through poor visualisation of structures. In this paper, the professional and educational literature was narratively reviewed to assess gaps in the evidence base related to the skill and care knowledge for obese patients. Literature was sourced relating to discrete radiographic considerations such as the technical factors of imaging obese patients, exposure and the impact of obesity on imaging departments’ service provisions. The recent literature (post-2000 to coincide with the sharp increase in global obesity) on the perceptions of health professionals and student health practitioners has also been explored because there are no specific radiographer studies to report. By understanding the research in similar fields, we may identify what common attitudes qualified and student radiographer's hold and what challenges, technical and care related, can be prepared for.