Esophageal function following Livaditis repair of long gap esophageal atresia

Proximal pouch esophagomyotomy (Livaditis) allows for repair of long gap esophageal atresia (EA). Postoperative esophageal functional studies in these patients are lacking. Six such infants were followed for up to 42 months. Esophageal function was assessed clinically and by barium swallow, manometry, 24 hr pH monitoring, esophagoscopy, and biopsy. Operative complications included two minor anastomotic leaks and two asymptomatic diverticula at the myotomy site. All patients had dysmotility on barium swallow. Gastroesophageal reflux (GER) was seen in four. Manometry showed a variable aperistaltic segment in each infant but lower esophageal sphincter pressures and relaxation were retained. Twenty-four hour pH monitoring showed an increase in frequency and duration of GER. All four patients biopsied had esophagitis. Five of the six patients showed normal growth velocity. Livaditis modified repair of EA was not associated with significant surgical complications. Esophageal motility showed abnormalities similar to those reported after the standard repair of EA. Myotomy did not adversely affect the esophageal function.     

Routine postoperative upper gastroesophageal imaging is unnecessary after laparoscopic Roux-en-Y gastric bypass

Routine early postoperative upper gastroesophageal imaging (UGI) is often used in laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures to confirm anastomotic patency and to exclude leaks. The aim of our study was to assess the usefulness of this practice. From January 2003 to November 2004, 322 LRYGB cases were performed using linear staplers for the gastrojejunostomy and jejuno-jejunostomy anastomoses. As part of our protocol, all patients received a Gastrograffin (Mallinkrodt, Inc., St Louis, Missouri) UGI on postoperative Day 1. The same radiological techniques were used and the same radiological team reviewed all films. Abnormal films were identified. In addition, patient demographics, time to discharge, and complications were collected and analyzed in a prospective database. There were no anastomotic leaks or obstructions. However, 42 of 322 (13%) studies demonstrated delayed gastric emptying. There were no statistically significant differences between patients with normal and delayed UGI studies. Routine UGI studies did not contribute significantly to patient care, and its routine use was subsequently abandoned.     

The Utility of Contrast Studies and Drains in the Management of Patients after Roux-en-Y Gastric Bypass

Background: The role of routine post-operative contrast examination (UGI) and drainage of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGBP) is controversial.The authors determined if early routine post-operative UGI detects occult anastomotic leaks, thereby altering treatment and withholding early feeding. Methods: Prospective data on 100 consecutive patients who underwent RYGBP from September 1998 to September 2000 was reviewed. Closed suction drains were routinely used. Within 36 hr postoperatively, all patients underwent UGI to evaluate the gastrojejunostomy. Patients were given liquids if the UGI showed no leak, and drains were removed 24 hr later. A blinded radiologist reviewed all the UGI. Results: 87 women and 13 men underwent 75 open and 25 laparoscopic RYGBP. BMI was 52.0 kg/m². 3 patients whose UGI showed a leak were treated nonoperatively with antibiotics, maintenance of drains, nasogastric tube and NPO. 2 of those patients developed purulent drainage within 24 hr after the UGI. None of the three patients required reoperation. 4 UGI were not available for the blinded reviewer who graded the remaining as satisfactory (94) and unsatisfactory (2). This reviewer disputed a leak in 1 of 3 previously reported leaks and reported a leak in a previously negative study. The latter patient subsequently required surgery for an uncontrolled leak. Conclusions: UGI can be used to withhold early oral intake in patients with radiographic leaks that would otherwise progress to clinically significant leaks. Surgical drains facilitate the non-operative management of such anastomotic leaks. Planned early UGI and surgical drains minimize the morbidity of anastomotic leaks after bariatric surgery.     

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

Background The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB. Methods All patients who underwent LRYGB at the authors’ institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated. Results This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%). Conclusions According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.     

The Utility of Routine Postoperative Upper Gastrointestinal Swallow Studies Following Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has grown in popularity in recent years for the treatment of morbid obesity. Controversy exists regarding the usefulness of upper gastrointestinal (UGI) swallow studies on the first postoperative day in detecting possible complications. The aim of our study was to determine the efficacy and cost benefit of routine UGI studies on the first postoperative day following LSG. We retrospectively reviewed the hospital’s records to identify patients who underwent LSG between January 2012 and June 2013. All patients had iodine-based contrast swallow study on the first postoperative day. Reports from all imaging studies and medical files were retrospectively reviewed, and complications were recorded. The Institutional Review Board waived the requirement for informed consent. During the study period, 722 patients underwent LSG. Mean BMI was 43 kg/m² (range 25–70). Of the 722 UGI studies, 721 were normal. The 1 abnormal study showed complete obstruction due to an incarcerated hiatal hernia. Five patients presented with a leak (0.7 %). UGI swallow studies failed to detect any of the leaks resulting in a sensitivity of 0 %. All leaks were apparent on computed tomography (CT) scans on postoperative days 2, 5, 7, 23, and 90. The total cost of the UGI swallow studies was $180,500. Performing routine UGI studies on the first postoperative day following LSG is clearly not cost beneficial. UGI contrast studies are not efficient to screen for suture line leaks. We recommend obtaining a CT scan when there is clinical suspicion for a complication.     

Development of a true primary repair for the full spectrum of esophageal atresia.

OBJECTIVE: To determine whether or not a true primary repair, without myotomies and with the gastroesophageal junction below the diaphragm, can be accomplished across the esophageal atresia (EA) spectrum. Our hypothesis is that the esophageal anastomosis can withstand significant tension. The consequences, particularly for those patients with a very long gap atresia, were assessed. SUMMARY OF BACKGROUND DATA: Difficulties arise roughly in proportion to the size of the gap between esophageal segments. Reported surgical complications remain frequent, and particularly at the far end of the EA spectrum, not all children are left with a satisfactorily functioning esophagus or esophageal substitute. METHODS: The outcomes of all infants who had a true primary repair of EA from 1976-1997 were determined. Surgically, the methods used to achieve a reliable true primary repair were expanded to accomplish this, even for a very long gap EA. RESULTS: From 1976-97, 70 infants with or without associated tracheoesophageal fistula (TEF) had primary repairs performed with no surgery-related deaths and 11% later deaths. No interpositions were performed since 1983. There were no discernible anastomotic leaks and one late recurrent TEF related to the early use of balloon dilation. Ten infants had gaps of 5.0-6.8 cm and, among these, four had gaps of 5.5-6.8 cm that could not be pulled together initially. Traction sutures in the esophageal ends, however, produced sufficient lengthening within 6-10 days for a true primary repair. Very long gap repairs produced more reflux (10 of 10 required a fundoplication versus 24 of 70 overall) and more dilations to relieve strictures. Two infants underwent stricture resection with no recurrence. On follow-up, all patients over 2 years of age were eating well or satisfactorily, and none had a gastrostomy tube. CONCLUSIONS: (1) The esophageal anastomosis can withstand considerable tension and allows a reliable true primary repair for the full EA spectrum. (2) Growth is rapid and traction sutures will produce significant esophageal lengthening within days. (3) With increasing tension, gastroesophageal reflux (GER) and strictures are more common; however, both are treatable. Follow-up reveals the benefits of true primary repair over other solutions.     

The utility of routine postoperative upper GI series following laparoscopic gastric bypass

Background Routine upper gastrointestinal (UGI) studies following laparoscopic Roux-en-Y gastric bypass (LRYGBP) have the potential advantage of early identification of anastomotic complications. The aim of our study was to evaluate the efficacy of routine postoperative UGI and its relationship to clinical outcomes. Methods Over a three-year period, 516 patients underwent LRYGBP followed by routine postoperative UGI studies. Data were collected on the results of the UGI, clinical parameters, and patient outcomes. Study groups were composed of patients with a normal UGI (Group I, n = 455), abnormal UGI not requiring further intervention (Group II, n = 36), and abnormal UGI requiring further intervention (Group III, n =25). Statistical significance was set at α= 0.05 level for all analyses. Results The three study groups were not statistically different in mean age (42 years) or body mass index (BMI) (45) and were predominantly female (90%). Most patients had an uneventful postoperative course. Anastomotic complications (gastrojejunostomy and jejunojejunostomy) were uncommon (1.3%). The sensitivity of the UGI for anastomotic leak in this study was low (33%). However, all patients with alimentary limb obstruction (n = 3) had UGI evidence of this complication. Of the 516 UGI reports, there were only 25 (4.8%, Group III) that were abnormal and required some form of intervention ranging from serial imaging (84%) to reoperation (16%). Of the various clinical parameters examined, the patients in Group III demonstrated a significantly higher prevalence of fever (p < 0.001), tachycardia (p < 0.01), vomiting (p < 0.001), and postoperative day 1 leukocytosis (p < 0.005). Conclusions Our data suggest that routine UGI after LRYGBP has limited utility as it may result in unnecessary intervention based on false-positive results or a delay in treatment based on false-negative results. We advocate selective UGI imaging following LRYGBP based on the patient’s clinical factors, particularly fever and tachycardia. Poster presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Las Vegas, Nevada, April 2007     

Selective approach to use of upper gastroesophageal imaging study after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Many institutions routinely perform upper gastroesophageal imaging (UGI) studies on their laparoscopic Roux-en-Y gastric bypass (LRYGB) patients after surgery. We had routinely studied our patients with UGI on postoperative day 1 to rule out an anastomotic leak or obstruction, until recently when we abandoned this practice. As previously reported, we found that routine UGI did not contribute significantly to patient care. The purpose of this study was to determine whether patient outcomes were affected by this change in protocol. METHODS: From March 2004 to September 2005, 508 LRYGB cases were performed at our institution. Linear cutting staplers were used to create both the gastrojejunostomy and the jejunojejunostomy. In each case, the Roux limb was brought up in an antecolic, antegastric configuration. Before changing our protocol, 194 LRYGB cases were performed, and each patient underwent a routine UGI study (group 1). After abandoning this practice, 314 LRYGB cases were performed (group 2), and an UGI study was obtained only if clinical indicators (e.g., tachypnea, tachycardia, nausea, vomiting, low urine output, and/or abdominal pain) were present. The patient demographics, including gender, age, body mass index, length of hospital stay, and complications were recorded in our bariatric database and reviewed retrospectively. RESULTS: A postoperative UGI study was obtained in 204 patients--in 194 patients routinely (group 1) and in 10 patients because of clinical indications (group 2). No obstructions or leaks were found in any of these 204 patients. In group 2, 304 patients were discharged without an UGI series and did well without any leak or obstruction, except for 1 patient who returned 3 months postoperatively with a stricture at his jejunojejunostomy. No statistically significant differences were found between the 2 groups. CONCLUSION: The results of our study have shown that routine UGI studies after LRYGB do not contribute significantly to postoperative patient care at our institution. We now perform them selectively according to clinical indications, without this change adversely affecting our clinical outcomes.     

Routine postoperative upper gastrointestinal series after Roux-en-Y gastric bypass: determination of whether it is necessary

OBJECTIVE: To evaluate the clinical utility of the routine use of postoperative barium swallow to diagnose postoperative complications in patients undergoing open or laparoscopic Roux-en-Y gastric bypass. DESIGN: A total of 417 consecutive patients undergoing Roux-en-Y gastric bypass at our institution between January 1, 2001, and December 31, 2002, were included. We performed 341 open procedures and 76 laparoscopic gastric bypasses. All patients received a limited postoperative fluoroscopic upper gastrointestinal series, except for the patients who exceeded the weight limitation of the radiologic equipment. Radiologic findings of anastomotic complications were anastomotic leak, delayed gastric emptying, gastric outlet obstruction, and gastrogastric fistula. We evaluated clinical signs and symptoms to obtain a list of criteria suggesting these complications. Patients were stratified into 2 groups: those with and those without radiographic anastomotic complications. Clinical and radiologic criteria were compared using univariate and multivariate logistic regression analysis. RESULTS: We noted 42 radiologic abnormalities during a routine postoperative barium swallow evaluation. Among our 417 patients, we documented 12 leaks (2.9%), 19 cases of delayed gastric emptying (4.6%), 4 gastric outlet obstructions (1.0%), and 7 gastrogastric fistulas (1.7%). The combination of fever, tachycardia, and tachypnea was the most specific indicator of a leak, at 0.99 (95% confidence limit, 0.99, 1.01). Nausea with vomiting was the most predictive indicator of delayed gastric emptying and gastric outlet obstruction, with a specificity of 0.99 (95% confidence limit, 0.98, 0.99) and 0.97 (95% confidence limit, 0.96, 0.99), respectively. CONCLUSIONS: Postoperative complications after Roux-en-Y gastric bypass surgery are predictable based on the patient's symptoms. The use of routine postoperative fluoroscopic upper gastrointestinal series is unnecessary in asymptomatic patients.     

Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary

Background

Laparoscopic sleeve gastrectomy has gained popularity among bariatric surgeons. The purpose of this study was to evaluate the usefulness of early upper gastrointestinal (UGI) contrast studies in the detection of postoperative complications.

Methods

Radiographic reports were reviewed from April 2006 to January 2013. During that time, 161 patients underwent laparoscopic sleeve gastrectomy. All patients were submitted to UGI examination on postoperative day (POD) 1.

Results

Among the 161 patients who underwent UGI, no contrast leaks were found on POD 1. Three patients (1.9%) developed stapler line leaks near the gastroesophageal junction, which were diagnosed on PODs 3, 4, and 10. Gastroesophageal reflux in 5 patients (3.1%) and delayed gastroesophageal transit in 10 patients (6.2%) were detected.

Conclusions

The results of this study show that UGI series on POD 1 cannot assess the integrity of the gastric remnant. Early UGI series are not required as routine procedures in all operated patients. Computed tomographic swallow studies should be performed in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain, or fever.     

Repair of esophageal atresia with tracheoesophageal fistula via thoracotomy: a contemporary series

Background

A recent series detailing thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) reported lower complication rates compared with historic controls. This study provides a contemporary cohort of patients repaired via thoracotomy for comparison with the recent large multi-institutional thoracoscopic series.

Methods

Records of patients with EA/TEF between 1993 and 2008 were reviewed. Attention was focused on demographics and complications including anastomotic leak, recurrent fistulae, stricture formation, and need for fundoplication.

Results

Seventy-two patients underwent repair of EA/TEF via thoracotomy. Complication rates in the current series compared with the thoracoscopic series were anastomotic leak, 2.7% versus 7.6%; recurrent fistulae, 2.7% versus 1.9%; stricture, 5.5% versus 3.8%; and need for fundoplication, 12% versus 24%. Differences in complication rates did not reach statistical significance. Two children in this cohort developed mild scoliosis attributed to congenital vertebral anomalies, neither of whom required intervention.

Conclusions

Thoracoscopic repair of EA/TEF yielded complication rates similar to this contemporary series; however, trends toward increased anastomotic leaks and greater need for fundoplication were noted. No musculoskeletal sequelae were directly attributable to thoracotomy.     

Cost and validity of early postoperative contrast swallow after laparoscopic adjustable gastric banding

BackgroundTo assess the validity and cost of early routine upper gastrointestinal (UGI) studies after laparoscopic adjustable gastric banding (LAGB) at a university hospital in the United States. Today, although there is widespread use of LAGB, and it is considered a safe procedure, it also can result in some specific early complications. In most centers, an UGI series after bariatric surgery is performed to rule out these potentially dangerous complications.MethodsFrom March 2006 to July 2010, 183 LAGB procedures were performed by a single surgeon. All data were collected prospectively in a computerized database and reviewed retrospectively. The patients underwent water-soluble UGI studies during the early postoperative phase (2–24 h) to exclude gastrointestinal perforation, obstruction, and gastric band malposition.ResultsNo intraoperative complications occurred. One conversion to an open procedure was required because of massive adhesions. A total of 21 postoperative complications (11.5%) occurred. None of the 183 patients who underwent an early UGI series experienced leakage, gastric band malposition, or slippage. The only radiologic abnormality was a stomal obstruction (.5%) requiring reoperation. The total cost for the 183 UGI studies was $54,900. The mean hospital stay was .5 day (range .1–5.6). Approximately 90% of patients were discharged within the first 24 hours.ConclusionThe fear of acute perforation or obstruction has been the rationale for obtaining UGI studies after LAGB. We found this to be expensive and of limited value in an experienced center and have created a decisional algorithm to determine when its use is appropriate for symptomatic patients.     

The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia

ObjectiveThe aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia.MethodsData from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed.ResultsAmong the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different (P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different (P = .0015).ConclusionsPostoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia.     

The effect of tube gastrostomy on gastroesophageal reflux in patients with esophageal atresia

Gastroesophageal reflux (GER) occurs frequently in infants with esophageal atresia (EA). The definitive management is primary repair and often includes tube gastrostomy. The recent finding of lower esophageal sphincter (LES) pressure changes with tube gastrostomy suggests that GER might be related to gastrostomy rather than EA per se. To evaluate this thesis, two populations of patients from different children's hospitals were reviewed: EA with and without routine gastrostomy. The two populations were similar with respect to number of infants, associated anomalies, distribution in the Waterston classification, morbidity, and mortality. One hundred sixteen patients were studied. Of the 66 survivors who underwent gastrostomy and repair of EA, 30 were found to have GER (45.5%) and 12 required fundoplication (18.2%). Of 31 surviving patients who underwent repair of EA without gastrostomy, 11 had GER (35.5%) and four required fundoplication (12.9%). These data suggest that tube gastrostomy does not significantly contribute to the GER associated with EA.     

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: lessons learned

OBJECTIVE: Repair of esophageal atresia and tracheoesophageal fistula has traditionally been performed via thoracotomy. This study aims to evaluate the feasibility and pitfalls of the thoracoscopic approach. MATERIALS AND METHODS: Six consecutive patients with type C tracheoesophageal fistulae underwent thoracoscopic repair. The operation was approached through the right chest using a three-trocar technique (two 5-mm and one 3-mm) with the patient placed in a three-quarter prone position. Patient characteristics, operative time, duration of narcotic usage, conversion factors, postoperative complications, and long-term follow-up were recorded. RESULTS: Five of six patients were successfully operated on thoracoscopically. The average operative time was 143 minutes (range, 75-215 minutes) with repair of long-gap defects requiring significantly longer times than short-gap defects (200 vs. 129 minutes, P < 0.05). There were no intraoperative complications. Mean duration of narcotic use was 52 hours (range, 24-72 hours). There were no anastomotic leaks. One patient developed an anastomotic stricture at the third postoperative week, which resolved with two dilations. One patient died on the first postoperative day from respiratory failure. CONCLUSION: Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula is feasible, but is technically challenging. Long-gap defects require more extensive dissection and difficult anastomosis, and are therefore associated with longer operative times. More data are needed for further evaluation of this approach.     

Utility of Routine Versus Selective Upper Gastrointestinal Series to Detect Anastomotic Leaks After Laparoscopic Gastric Bypass

Background  

In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB.     

The effect of azygos vein preservation on postoperative complications after esophageal atresia repair: Results from the Turkish Esophageal Atresia Registry

AimPreservation of the azygos vein (AV) maintains normal venous drainage of the mediastinum and decreases postoperative congestion. The modification of esophageal atresia (EA) repair by preserving AV may prevent postoperative complications and may lead to better outcomes. The data from the Turkish Esophageal Atresia Registry (TEAR) were evaluated to define the effect of AV preservation on postoperative complications of patients with EA.MethodsData from TEAR for a period of five years were evaluated. Patients were enrolled into two groups according to the preservation of AV. Patients with divided (DAV) and preserved AV (PAV) were evaluated for demographic and operative features and postoperative complications for the first year of life. The DAV and PAV groups were compared according to the postoperative complications, such as fistula recanalization, symptomatic strictures, anastomotic leaks, total number of esophageal dilatations, and anti-reflux surgery. In addition, respiratory problems, which required treatment, were compared between groups.ResultsAmong 502 registered patients; the data from 315 patients with the information of AV ligation were included. The male female ratio of DAV (n = 271) and PAV (n = 44) groups were 150:121 and 21:23, respectively (p > 0.05). The mean body weight, height, gestational age, and associated anomalies were similar in both groups (p > 0.05). The esophageal repair with thoracotomy was significantly higher in DAV group, when compared to the PAV group (p < 0.05). The rates of primary anastomosis and tensioned anastomosis were similar in both groups (p > 0.05). There was no difference between DAV and PAV groups for anastomotic leaks, symptomatic anastomotic strictures, fistula recanalization, and the requirement for anti-reflux surgery (p > 0.05). The rate of respiratory problems, which required treatment, was significantly higher in the DAV group (p < 0.05)ConclusionThe data in the TEAR demonstrated that preserving the AV during EA repair led to no significant advantage on postoperative complications, with exception of respiratory problems. AV should be preserved as much as possible to maintain a normal mediastinal anatomy and to avoid respiratory complications.     

Routine Upper Gastrointestinal Gastrografin® Swallow after Laparoscopic Roux-En-Y Gastric Bypass

Background: Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP. Methods: Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin?, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P<0.05) using the Mann-Whitney U test statistic. Results: Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n=17), partial obstruction (n=12), anastomotic leak (n=3), complete bowel obstruction (n=3), diverticulum (n=1), hiatal hernia (n=1), and proximal Roux limb narrowing (n=1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7±1.5 days vs 40.2±12.3 days, P<0.03). Conclusions: Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.     

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study

Background

Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG.

Methods

A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls.

Results

Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028].

Conclusions

Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2–3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

     

Water-soluble upper GI based on clinical findings is reliable to detect anastomotic leaks after laparoscopic gastric bypass

Anastomotic leak after laparoscopic Roux-en-Y gastric bypass (LGB) is a major complication that must be recognized and treated early for best results. There is controversy in the literature regarding the reliability of upper GI series (UGI) in diagnosing leaks. LGB was performed in patients meeting NIH criteria for the surgical treatment of morbid obesity. All leaks identified at the time of surgery were repaired with suture and retested. Drains were placed at the surgeon's discretion. Postoperatively, UGI was performed by an experienced radiologist if there was a clinical suspicion of leak. From September 2001 until October 2004, a total of 553 patients (age 40.4 +/- 9.2 years, BMI 48.6 +/- 7.2) underwent LGB at UAB. Seventy-eight per cent (431 of 553) of patients had no clinical evidence suggesting anastomotic leak and were managed expectantly. Twenty-two per cent (122 of 553) of patients met at least one inclusion criteria for leak and underwent UGI. Four of 122 patients (3.2%) had a leak, two from anastomosis and two from the perforation of the stapled end of the Roux limb. No patient returned to the operating room without a positive UGI. High clinical suspicion and selectively performed UGI based on clinical evidence is reliable in detecting leaks.