1. Imaging of Bariatric Surgery: Normal Anatomy and Postoperative Complications Journal Club March 2014 Daniel Oppenheimer, M.D. Marc S. Levine, MD and Laura R. Carucci, MD Radiology: Volume 270: Number 2—February 2014

2. Goals Describe the surgical anatomy and normal imaging findings for three major forms of bariatric surgery Identify the major complications of these forms of bariatric surgery and their relevant clinical features. Discuss the imaging findings of bariatric surgery complications on UGI and CT exams

3. Introduction BMI (kg/m2) –25-29 kg/m2 = overweight –30-35 kg/m2 = obesity –35+ = morbid obesity Obesity Epidemic –USA Adults 2004: 66% overweight, 32% Obese 300,000+ deaths annually –2 nd only to tobacco in preventable deaths Bariatric Surgery increasing dramatically –5x # procedures in 2003 vs. 1998

4. Bariatric Surgery Concepts Restrictive procedure –Decrease gastric volume  early satiety –Laparoscopic adjustable gastric banding and laparascopic sleeve gastrectomy Bypass procedure –Intentional malabsorption

5. Laparoscopic Roux-en-Y Most popular procedure in the USA –Highest long-term success and greater weight loss –Malabsorptive and Restrictive Stomach divided –Small gastric pouch – restrictive effect –Larger excluded stomach Jejunum divided –Roux (efferent) limb anastomosed to gastric pouch proximally and jejunojejunostomy distally –Biliopancreatic (afferent) limb anastomosed to jejunojejunostomy http://www.utswmedicine.org

6. Roux-en-Y Normal Anatomy

7. Assessment of Roux-en-Y Bypass UGI: –Scout image! –Gastric pouch, gastrojejunal anastomosis, Roux limb and jejunojejunal anastomosis Leak, stricture, obstruction, ulcers Excluded stomach and biliopancreatic limb not well evaluated CT: –Oral contrast right before exam –Contrast in gastric pouch, Roux limb to jejunojejunal anastomosis –Excluded stomach collapsed and non-opacified –Leak, stricture, obstruction, ischemia, collections

8. Roux-en-Y Complications Leaks Stricures Marginal Ulcers Jejunal ischemia Small bowel obstruction Recurrent weight gain

9. Leak Up to 5% of patients ~3/4 at gastrojejunal anastomosis Usually <10 days post-op Abscess, peritonitis, sepsis H20 soluble UGI POD #1-2 Percutaneous drainage and Abx vs. surgery

10. Anastomotic Stricture Transient edema and spasm post op 4+ weeks post-op 3-9% of patients Usually at gastrojejunal anastomosis Scarring vs. chronic ischemia Endoscopic dilatation Chandler et. al, AJR 2008;190(1):122–135.

11. Marginal Ulcers At gastrojejunal anastomosis 3-13% of patients Chronic exposure of gastric acid to Roux limb Epigastric pain, UGIB PPIs, surgical revision

12. Jejunal Ischemia Acute –Pain, bleeding, N/V early post-op –UGI: Thickened spiculated mucosal folds – submucosal edema and hemorrhage –CT: Bowel wall thickening with mesenteric edema and engorged mesenteric vessecls Chronic –Intractable N/V secondary to jejunal stricture –UGI: Smooth tubular narrowing, loss of mucosal folds, non-healing giant ulcer(s) > 2.5 cm –CT: Jejunal narrowing with bowel wall thickening

13. Jejunal Ischemia

14. Small Bowel Obstruction Up to 5% of patients Adhesions, internal hernias, abd wall hernias, strictures, intussuception Type A –Dilated Roux limb, decompressed B-P limb and excluded stomach Type B –Dilated B-P limb and excluded stomach –Closed loop – risk ischemia, perforation Type C –SBO distal to jejunojejunostomy –Dilated Roux and B-P limbs

15. Type A SBO

16. Type B SBO

17. Recurrent Weight Gain Dehiscence of gastric staple line “Gastrogastric fistula” Food enters excluded stomach Restrictive effect gone Patients no longer have early satiety Contrast in excluded stomach –Must exclude reflux from B-P limb Dilation of gastrojejunal anastomasosis another cause recurrent weight gain

18. Laparoscopic Adjustable Gastric Banding Silicone band with inflatable balloon sutured around proximal stomach ~2 cm below GE jxn Creates small gastric pouch Inflatable inner sleeve – sub q port in abd wall –adjust band intermittently to alter degree of restrictive effect Early satiety  decreased caloric intake Less invasive vs. Roux-en-Y Comparable (short-term) weight loss Fewer complications

19. Laparoscopic Adjustable Gastric Banding Chandler et. al, AJR 2008;190(1):122–135. Normal Phi angle 4-58 deg

20. Lap Band Complications Stomal stenosis Pouch dilation Band slippage Malpositioned Band

21. Stomal Stenosis Most common complication, 8- 11% Band overinflation, edema Excessive luminal narrowing, obstruction N/V, regurgitation, dysphagia, pain Findings –Excessive luminal narrowing at band, dilated of proximal stomach/esoph, GE reflux, slow emptying/lack of contrast through stoma Deflate band +/- repeat fluoro Chandler et. al, AJR 2008;190(1):122–135.

22. Band Slippage 4-13% Band overinflation, recurrent emesis, poor surgical technique Herniation of fundus above band Luminal narrowing, obstruction Increased Phi angle, “O” sign, air-fluid level in gastric pouch Deflate band +/- surgical correction

23. Malpositioned Band Inexperienced surgeon Band placed in perigastric fat – no restrictive effect Band placed in lower stomach - gastric outlet obstruction

24. Perforation <1% Traumatic injury to gastric wall at surgery Pain, fever, leukocytosis UGI: Contained or free extravasation of contrast CT: Contrast extravasation, extraluminal gas, fluid collections

25. Gastric Volvulus Rare Band slippage with twisting of stomach around band Closed loop obstruction –Strangulation, ischemia, infarction UGI: converging gastric folds, stomach rotated upwards to left above fundus, luminal obstruction CT: Gastric wall thickening, pneumatosis Urgent surgical removal

26. Intraluminal Band Erosion Late complication, <2% Pressure necrosis from inflated band Usually incomplete erosion Rarely complete erosion –migrate distally in antrum, duodenum, or proximal jejunum or proximally to GE jxn –mechanical obstruction Contrast surrounding band Surgical removal

27. Port and Band-related complications Port infection and port eversion Port, tubing or band kink or disruption Tube erosion into stomach or bowel Chandler et. al, AJR 2008;190(1):122–135.

28. Port and Band-related complications Chandler et. al, AJR 2008;190(1):122–135.

29. Laparoscopic Sleeve Gastrectomy Newer technique - ~5% of bariatric surgeries in 2008 Stomach divided along long axis ~75% stomach removed – Banana shaped pouch created – restrictive effect ~100 cc total volume No need for periodic adjustments Irreversible http://www.massgeneral.org Kiriakopolus et. al, Hormones 2009, 8(2):138-143

30. Laparscopic Sleeve Gastrectomy Complications Gastric Leak Gastric Stricture/Gastric outlet obstruction Gastric Dilation Gastroesophageal Reflux

31. Gastric Leak <1% Long staple line along greater curvature Most commonly at proximal end of staple line laterally near GE jxn Pain, fever, leukocytosis Extravasation of contrast, extraluminal collections/abscesses

32. Gastric Leak

33. Gastric Stricture/Gastric Outlet Obstruction Scarring along greater curvature staple line –Narrowing of pouch Focal strictures or long segment narrowing Delayed emptying of contrast from residual stomach Dilated proximal stomach and esophagus Endoscopic dilatation +/- surgical revision

34. Gastric Dilation ~4.5% Inadequate weight loss, recurrent weight gain Widening of gastric sleeve, loss of tubular/banana shape

35. Gastroesophageal Reflux Increased incidence of GE reflux –up to 20% –Altered gastric anatomy, stasis Reflux on UGI studies Esophagitis, Barrett’s esophagus, carcinoma

36. Question #1 Which of the following anatomic regions usually is NOT opacified with oral contrast material on CT images after Roux-en-Y gastric bypass? a. Gastric pouch b. *Excluded stomach c. Jejunal Roux limb d. Common small bowel channel (distal to jejunojejunostomy)

37. Question #2 What is the most common site of leak after Roux-en-Y gastric bypass? a. Gastric pouch b. *Gastrojejunal anastomosis c. Blind-ending jejunal stump d. Jejunojejunal anastomosis

38. Question #3 Which set of findings is most likely to be associated with small bowel obstruction distal to the site of the jejunojejunostomy after Roux-en-Y gastric bypass? a. Collapsed Roux limb and collapsed biliopancreatic limb b. Dilated Roux limb and collapsed biliopancreatic limb c. Collapsed Roux limb and dilated biliopancreatic limb d. *Dilated Roux limb and dilated biliopancreatic limb

39. Question #4 7. Which of the following is LEAST likely to be a sign of distal band slippage on abdominal radiographs after laparoscopic adjustable gastric banding? a. Increased Phi angle b. Dilated gastric pouch above band c. *More vertical orientation of band than usual d. O-shaped configuration of band

40. Question #5 Leaks from the gastric sleeve after sleeve gastrectomy most commonly involve which of the following portions of the gastric staple line? a. *The proximal end of the staple line laterally b. The proximal end of the staple line medially c. The distal end of the staple line laterally d. The distal end of the staple line medially

41. References Chandler RC, Srinivas G, Chintapalli KN, Schwesinger WH, Prasad SR. Imaging in bariatric surgery: a guide to postsurgical anatomy and common complications. AJR Am J Roentgenol 2008;190(1):122–135. Kiriakopoulos A, Varounis C, Tsakayannis D, Linos D. Laparoscopic sleeve gastrectomy in morbidly obese patients. Technique and short term results. Hormones (Athens) 2009; 8: 138-43. http://www.massgeneral.org http://www.utswmedicine.org

42. Thank You Dr. Sidhu