Complicated gallstones after laparoscopic sleeve gastrectomy.

BACKGROUND: The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. METHODS: A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. RESULTS: Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3-8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. CONCLUSION: A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.

Role of preoperative imaging with multidetector computed tomography in the management of patients with gastroesophageal reflux disease symptoms after laparoscopic sleeve gastrectomy.

BACKGROUND: The aims of the study were to evaluate if multidetector computed tomography (MDCT) can be helpful and useful in the decision-making process in sleeve patients with gastroesophageal reflux disease (GERD) symptoms and to demonstrate the reproducibility and accuracy of the technique. METHODS: Twenty-three patients submitted to laparoscopic sleeve gastrectomy (LSG), complaining upper gastrointestinal (GI) symptoms and/or weight regain and candidated to laparoscopic surgical revision were investigated. All patients underwent upper GI barium study, endoscopy, and MDCT for the identification of esophageal dilatation, neofundus development, thoracic sleeve migration, sleeve dilatation, and/or antrum dilatation. Selected patients underwent laparoscopic sleeve revision, cruroplasty, and/or fundectomy according to MDCT findings. Surgical findings were considered as "gold standard." Symptom persistence or resolution was investigated after 6 months with a standard clinical questionnaire. A total of 21 patients with sleeve migration or dilatation and neofundus underwent laparoscopic revision. RESULTS: A strong correlation between MDCT preoperative findings and intraoperative findings was observed. The presence of sleeve migration was significantly underestimated by both conventional radiology and upper GI endoscopy (sensitivity of 57.1 and 50 %, respectively). Symptom remission was observed in 19 out of 21 patients at 6 months. In two cases, surgical revision was not indicated on the basis of MDCT findings. CONCLUSIONS: MDCT is more accurate than the conventional radiology and endoscopy for the detection of morphological alteration causing GERD symptoms after LSG and can be considered a valid noninvasive method to guide surgery and monitoring patients following revision.

Laparoscopic sleeve gastrectomy: imaging of normal anatomic features and postoperative gastrointestinal complications.

Morbid obesity is a public health problem in the United States and Europe and its prevalence is on the increase. Despite certain progress the efficacy of medical treatment remains limited. Bariatric surgery has consequently become an effective alternative for patients with morbid obesity. The bariatric operations most frequently performed are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (LGB), but laparoscopic sleeve gastrectomy (LSG) is increasingly popular with both bariatric surgeons and patients due to its simplicity, rapidity and decreased morbidity. The purpose of this pictorial essay is to familiarize radiologists with the normal postoperative anatomic features and the imaging findings of postoperative gastrointestinal complications of laparoscopic sleeve gastrectomy because little literature exists on this subject.

[Acute pancreatitis and afferent loop syndrome. Case report]. / Pancreatitis aguda y síndrome de asa aferente. Reporte de caso.

BACKGROUND: The afferent syndrome loop is a mechanic obstruction of the afferent limb before a Billroth II or Roux-Y reconstruction, secondary in most of case to distal or subtotal gastrectomy. Clinical case: Male 76 years old, with antecedent of cholecystectomy, gastric adenocarcinoma six years ago, with subtotal gastrectomy and Roux-Y reconstruction. Beginning a several abdominal pain, nausea and vomiting, abdominal distension, without peritoneal irritation sings. Amylase 1246 U/L, lipase 3381 U/L. Computed Tomography with thickness wall and dilatation of afferent loop, pancreas with diffuse enlargement diagnostic of acute pancreatitis secondary an afferent loop syndrome. CONCLUSION: The afferent loop syndrome is presented in 0.3%-1% in all cases with Billroth II reconstruction, with a mortality of up to 57%, the obstruction lead accumulation of bile, pancreatic and intestinal secretions, increasing the pressure and resulting in afferent limb, bile conduct and Wirsung conduct dilatation, triggering an inflammatory response that culminates in pancreatic inflammation. The severity of the presentation is related to the degree and duration of the blockage.

Antecedentes: el síndrome de asa aferente se caracteriza por la obstrucción mecánica del asa aferente luego de la reconstrucción tipo Billroth II o en Y de Roux, en la mayoría de los casos secundaria a gastrectomía distal o subtotal. Caso clínico: paciente masculino de 76 años de edad, con antecedentes de: colecistectomía, adenocarcinoma gástrico seis años previos, gastrectomía subtotal y reconstrucción en Y de Roux. Inició con dolor abdominal, náusea y vómito; abdomen distendido, sin datos de irritación peritoneal. Amilasa 1246 U/L, lipasa 3381 U/L. La tomografía computada abdominal mostró dilatación y engrosamiento de la pared del asa aferente y el páncreas con incremento de tamaño. Se le diagnosticó pancreatitis aguda, originada por síndrome de asa aferente. Conclusiones: el síndrome de asa aferente aparece en 0.3 a 1% de los casos de pacientes con reconstrucción Billroth II, a consecuencia de la obstrucción mecánica del asa aferente, con mortalidad incluso de 57%. La obstrucción del intestino aferente por acumulación de secreción biliar, pancreática e intestinal incrementa la presión, que resulta en dilatación del asa aferente de la vía biliar y del conducto de Wirsung, lo que desencadena una respuesta inflamatoria que finaliza en un cuadro de pancreatitis. Su manifestación severa se relaciona con el grado y duración de la obstrucción.

The postoperative radiological features of laparoscopic sleeve gastrectomy.

Obesity is rapidly becoming one of the major challenges for health care systems. Surgery has proved to be one of the most effective methods of helping patients to achieve sustainable weight loss. Laparoscopic sleeve gastrectomy is a relatively new bariatric surgical technique. A staple line is placed in a line parallel to the lesser curve of the stomach, excluding up to 85% of the volume of the stomach. The excluded stomach is then resected leaving a 'tube' of residual stomach. Radiologists may be asked to perform and interpret imaging studies in the postoperative period and should be familiar with the normal appearances and common complications. Postoperative radiological investigations will typically be for suspected leak or obstruction. A water soluble contrast upper gastrointestinal (UGI) series should be performed in both suspected leak and obstruction if the patient is conscious and able to swallow. A normal postoperative UGI series will show free flow of contrast into the gastric remnant, which will be tubular with no spillage of contrast beyond the staple line, which is located on the caudal aspect of the gastric remnant. Stenosis or obstruction of the stomach may occur if the stomach remnant is too tight or torsion of the stomach. Stenosis is usually treated endoscopically with dilation and torsion is treated surgically. Leaks are often treated with covered stents which may be placed with endoscopic or radiological guidance. Collections may be drained under fluoroscopic, ultrasound or computed tomography guidance.

Complications of laparoscopic adjustable gastric banding: our local experience.

Obesity is a major medical problem both within Australia as well as throughout the developed world. Achievement of weight loss for any individual patient brings an additional desirable benefit of improvement or resolution of a wide range of comorbid conditions. Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and allied diseases. The term bariatrics was created around 1965, from the Greek root baro ('weight' as in barometer), suffix-iatr (relating to medical treatment) and suffix -ic ('pertaining to'). Besides the pharmacotherapy of obesity, it is concerned with obesity surgery. Bariatric surgery refers to surgical procedures of the gastrointestinal tract that are designed to induce weight loss. The treatment of obesity traditionally relied on non-surgical techniques to modify behaviour in regard to diet and exercise. This has variable and limited success. More recently, bariatric surgery has become the most rapidly growing form of treatment for obesity in recent years. In fact, it is the only current therapy that has been shown to achieve major and durable weight loss. It is important for the radiologist to be familiar with the normal anatomical appearance of the more common bariatric operations and to be able to recognise their potential complications on imaging. The aim of this pictorial essay is to give an insight into some of the more common complications of laparoscopic adjustable gastric banding surgery encountered in our centre during the period of 2001-2007.

Analysis of esophageal reflux after proximal gastrectomy measured by wireless ambulatory 24-hr esophageal pH monitoring and TC-99m diisopropyliminodiacetic acid (DISIDA) scan.

BACKGROUND AND OBJECTIVES: Reflux is one of the most common sequela after proximal gastrectomy (PG). The aim of this study was to find a predicting factor related to the character of esophageal reflux after PG. METHODS: Wireless ambulatory 24-hr pH monitoring (for acid reflux, AR) and diisopropyliminodiacetic acid hepatobiliary scan (for bile reflux, BR) were performed on 24 patients who had reflux symptoms after PG with esophagogastrostomy from July 2008 to March 2009. Endoscopic examination was done and the length of remnant stomach (LoRS) was measure by postoperative UGI series. RESULTS: Eleven patients (45.8%) had only BR, 7 (29.2%) had AR only, Two patients (8.3%) had both acid and BR, and 3 (12.5%) had neither. The LoRS along greater curvature was significantly shorter in patients with only BR (16.11 +/- 2.87 cm) than in patients with only AR (23.69 +/- 6.15 cm, P = 0.003). Severity of symptoms or esophagitis was not significantly correlated with the content of acid or BR. CONCLUSION: Reflux symptom after PG is caused by either bile or acid rather than both. Character of reflux was related to the LoRS.

Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy.

BACKGROUND: Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery. METHOD: Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation. RESULTS: 670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005]. CONCLUSIONS: Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

[Dynamic hepatobiliary scintigraphy in the evaluation of the efficiency of reconstructive surgery in patients after gastrectomy].

The study was aimed at defining the informative value of dynamic hepatobiliary scintigraphy (HBSG) in the evaluation of duodenal reflux in patients with postgastrectomic disorders after reconstructive surgery. HBSG was performed in 23 patients. After intravenous injection of 99mTc bromeside in a dose of 74-80 MBq, the areas concerned were identified in the projection of the liver, gallbladder, hepaticocholedochus, duodenum, and stomach for 120 minutes with 60-min cholagogic breakfast. Histrograms were plotted in the activity-time coordinates; hepatic function, gallbladder contractility, and hepaticocholedochal patency were evaluated; the duodenal motor function index and the gastroduodenal reflux were estimated. HBSG is physiological, which makes it possible to reveal duodenal motor-and-evacuation disorders, to specify the reason for poor outcomes of gastrectomy, to objectively evaluate the severity of postgastrectomic disorders, and to determine further treatment policy for this difficult group of patients.

[X-ray characteristics of the functional performance of the gastrointestinal tract after radical surgery for gastric cancer]. / Rentgenologicheskaia kharakteristika funktsional'noi deiatel'nosti organov zheludochno-kishechnogo trakta posle radikal'nykh operatsii, vypolnennykh po povodu raka zheludka.

The paper gives the X-ray characteristics of the functional performance of the gastrointestinal tract in 127 patients after radical operations performed by classical and plastic techniques for gastric cancer.

A composite score of enterogastric reflux quantitation on 99mTc-HIDA scintigraphy.

BACKGROUND/AIM: Enterogastric reflux of bile, and duodenal and pancreatic secretions may occur either spontaneously or, more commonly, after gastric surgery. The most reliable method in discriminating symptomatic from asymptomatic postgastric surgery refluxers, and in predicting a good clinical result after surgical diversion in the former group, is the quantitation of reflux by 99mTc-HIDA scintigraphy. MATERIALS AND METHODS: In 28 normal subjects and 143 postgastric surgery patients, the enterogastric reflux (EGR) was demonstrated by 99mTc-HIDA scintigraphy on 230 occasions. The EGR index was quantitated according to two different formulae: the former one based on the amount of refluxate (percentage of maximal radioactivity of the gastric area over the total abdominal activity--EGR-Im) and the latter one based on the amount and the duration of the time of reflux (CompEGR-Im) and representing the area of the surface below the curve, which was yield by plotting EGR-Im values (obtained every 5 min for one hour) against time. RESULTS: Although there was a highly significant correlation of values between the two methods (p<0.0000001), the latter one was more reliable in classifying postgastric surgery patients according to the presence of reflux symptoms and the reflux index. CONCLUSIONS: In patients with a CompEGRpIm>770 and postgastric surgery symptoms, at least some of the symptoms can be safely be attributed to enterogastric reflux.

[The radionuclide diagnosis of post-gastric resection disorders]. / Radionuklidnaia diagnostika postgastrorezektsionnykh rasstroistv.

The article studies the possibilities of radionuclide method in disclosing the basic postgastroresectional syndromes: dumping syndrome, duodenogastric reflux and afferent loop syndrome. After resection of stomach 92 patients were examined throughout a period from 1 to 10 years. During dynamic scintigraphy of liver characteristic changes were disclosed in biliary secretory system which could have diagnostic significance. This method gives the possibility to determine the frequency, duration and volume of duodenogastric reflux. It was found out that Roux's [correction of Rue's] method of resection have resulted in minimal number of duodenogastric refluxes. Dynamic scintigraphy of stomach is useful for studying evacuative function of the resected stomach and for afferent loop syndrome diagnosis, which sometimes is more informative than a wide-spread barium sulfate roentgenological method.

Gastroesophageal scintigraphy following gastrectomy: comparison to endoscopy and esophageal biopsy.

We evaluated the relationship between gastroesophageal scintigraphy, endoscopy, and biopsy in 48 gastrectomy patients (33 with reflux and 15 without reflux symptoms). Endoscopic esophagitis was demonstrated in 78.8% of the patients with reflux symptoms, histological esophagitis was found in 72.2% of them, and scintigraphic reflux was found in 81.8%. Either endoscopic or histological esophagitis was recognized in 93.7% of the patients with reflux symptoms, while either scintigraphic reflux or endoscopic esophagitis was demonstrated in 97.0%. Scintigraphic reflux was significantly more common in patients with histological esophagitis than in those without it (92.9% vs. 40%, p < 0.01). In addition, it was found in 74.2% of patients with and 64.7% of patients without endoscopic esophagitis. The reflux index tended to increase as the grades of esophagitis increased; there was an approximate relationship between the two parameters. Our study suggested that scintigraphy reflects histological esophagitis rather than endoscopic esophagitis, and that there was an approximate relationship between the reflux index and the endoscopic grade of esophagitis. In addition, performance of scintigraphy and endoscopy combined with esophageal biopsy increased the diagnostic yield in gastrectomy patients with reflux symptoms.

[The effectiveness of Braun's anastomosis in Billroth II surgery. The role of hepatobiliary sequence scintigraphy (HBSS) in the diagnosis of bile flow following stomach resection]. / Zur Effektivität der Braunschen Fusspunktanastomose bei der Operation nach Billroth II. Stellenwert der hepatobiliären Sequenzszintigraphie (HBSS) bei der Diagnostik des Galleflusses nach Magenresektion.

After resection of the stomach the alkaline reflux of the duodenal contents into the residual stomach is a major factor to be taken into consideration when assessing the causes leading to irregularities of the mucosal barrier. Illnesses that may arise subsequent to gastric surgery are gastritis of the resected stomach, inflammation of the anastomosis, anastomotic ulcers and--with reservations--anastomotic carcinoma. In view of these clinical pictures, a protective function for the biliary system is ascribed to Braun's entero-anastomosis. With the aid of hepatobiliary sequence scintigraphy (HBSS) a functional analysis was obtained from 30 patients, subsequent to gastric surgery--after Billroth II with entero-anastomosis--which showed a surprisingly high rate of reflux into the residual stomach, in 16 out of these 30 patients. The high-grade HBSS data with regard to the biliary reflux proportions after gastric surgery and the low-grade effectiveness of Braun's entero-anastomosis are clearly evidenced.

Scintigraphic evaluation of gastroesophageal reflux following gastrectomy.

We used scintigraphy to detect and quantify gastro-esophageal reflux, and determined the sensitivity of this method for identifying patients with clinical symptoms and/or endoscopic evidence of reflux. Thirty gastrectomy patients with heartburn and regurgitation, and 8 healthy controls were studied. The gastro-esophageal reflux index, calculated from imaging data, correlated significantly with the symptom score of the subjects, and the index was significantly larger in the symptomatic patients group (7.07 +/- 1.21) than in the healthy control group (1.54 +/- 0.22) (p < 0.001). Our study suggests that scintiscanning is capable of detecting gastro-esophageal reflux accurately, rapidly, noninvasively, and with a high degree of sensitivity. In addition, scintiscanning can be employed to quantify reflux in gastrectomy patients.

[Study of postgastrectomy fatty liver].

Fatty liver was often found concomitantly by the ultrasound during the follow up study of the gastric cancer operation. By ultrasound, development of postgastrectomy fatty liver was seen in 29 out of 176 patients (16.5%) with several gastrectomies. The number of the patients with postgastrectomy fatty liver was 12 out of 104 patients (11.5%) with distal partial gastrectomy with B-I reconstruction, while that was 17 of 72 patients (23.6%) with total gastrectomy with several reconstructions. The incidence of postoperative fatty liver change was significantly higher in the patients under 59 years old compared to the elders. Seventy-five g oral glucose test induced oxyhyperglycemia and hyperinsulinemia in patients with gastrectomy, especially with total gastrectomy. Integrated plasma insulin and triglyceride responses during first one hour in postgastrectomy patients were significantly higher than preoperative values. Moreover, plasma insulin and blood sugar in response to oral glucose test were significantly higher in patients with postgastrectomy fatty liver, compared to those in patients without fatty liver. These results suggested that the postgastrectomy fatty liver was resulted from the abnormality of the glucose metabolism.

[Results of stomach resection with Roux gastrojejunostomy for gastroduodenal ulcers]. / Ergebnisse der Magenresektion mit Gastrojejunostomie nach Roux wegen gastroduodenaler Ulcera.

In a follow-up study operative risk, postoperative functional disorders and incidence of anastomotic (recurrent) ulcer after partial gastrectomy with Roux-en-Y gastrojejunostomy for gastroduodenal ulcer were evaluated in 52 patients. Lethality for elective treatment was 0 and for emergency surgery (ulcer bleeding) 16.7%. 29.5% of the patients reported postoperative functional disorders. Because Roux-en-Y reconstruction prevented duodenogastric reflux, intragastric pH was low (median 2.2) and in the absence of ulcer protective, neutralizing reflux anastomotic ulcer occurred in 15.9% of the patients. With regard to the high rate of recurrent ulcer Roux-en-Y reconstruction after partial gastrectomy for primary ulcer surgery should be avoided and reconstruction procedures preferred, which guarantee duodenogastric reflux.

[The value of barium double-contrast study in the aftercare of gastrectomy patients (Roux-Y)]. / Stellenwert der Barium-Doppelkontrast-Untersuchung in der Nachsorge von Gastrektomierten (Roux-Y).

We evaluated 32 patients who had undergone jejuno-oesophagostomy for gastric carcinoma. Double contrast radiography was performed 3 to 36 months after gastrectomy, 3 to 14 days prior to routine endoscopy. Endoscopy is superior to double contrast radiography in detecting tumour recurrence, particularly in small tumours, due to the possibility of biopsy. Double contrast radiography is excellent in demonstrating the afferent loop. We found a high number of jejuno-oesophageal reflux and very different small intestine transit times without correlation to clinical signs and symptoms.