Routine Postoperative Upper Gastrointestinal Series After Roux-en-Y Gastric Bypass

Abstract

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 Rouxen-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.

Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide

“…17 Gastric leaks can be diagnosed either incidentally on a routine upper gastrointestinal series performed postoperatively without any clinical signs or during exploratory laparoscopy/laparotomy performed owing to unexplained tachycardia. In a study by Kolakowski and colleagues, 18 a combination of clinical signs of fever, tachycardia and tachypnea was found to be 58.33% sensitive and 99.75% specific for detection of anastomotic leaks. Diabetes mellitus and sleep apnea were associated with a greater incidence of anastomotic leak.…”

ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management

“…Routine postoperative upper GI contrast studies (UGIs) are performed by many surgeons to detect leaks [34], but there is evidence to support selective, rather than routine contrast studies after gastric bypass [35][36][37][38][39]. There can be information provided by routine UGIs regarding anastomotic narrowing, edema or stricture of both the gastrojejunal anastomosis and jejunojejunostomy, abnormal dilation of the gastric remnant as well as other causes of early post operative bowel obstruction such as internal hernia or trocar site hernia which can be useful and may influence subsequent care [40].…”

Clinical utility of routine barium esophagram after laparoscopic anterior esophageal myotomy for achalasia

“…Several authors have determined that routine UGI studies in the early postoperative period after laparoscopic Roux-en-Y gastric bypass and esophagectomy are unnecessary. In this context, UGI has demonstrated poor sensitivity and a high false-negative error rate and has failed to detected leaks already suspected by the patient's clinical appearance [15][16][17][18][19][20].…”