Bariatric surgery: Spectrum of complications at imaging.

Transcription

1 Bariatric surgery: Spectrum of complications at imaging. Poster No.: C-070 Congress: ECR 20 Type: Scientific Exhibit Authors: M. D. C. GARCÍA VÁZQUEZ, E. GARCÍA CASADO, J. A. ALVARADO ROSAS, A. VICENTE BÁRTULOS, I. VILLAR 2 BLANCO, O. Sanz-deLeón, L. CUBILLO DE OLAZABAL, M. C. GONZALEZ GORDALIZA, R. PEROMINGO FRESNEDA ; 2 MADRID/ES, madrid/es Keywords: Complications, CT, Stomach, Gastrointestinal tract, Abdomen DOI: 0.594/ecr20/C-070 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page of 6

2 Purpose To evaluate the frequency and type of postoperative complications of the bariatric surgery on Multidetector Computer Tomography (MDCT). Methods and Materials From January 2006 to September 200, 200 patients (22 women, 78 men; age range years) with morbid obesity underwent bariatric surgery. Radiology files of these patients were searched for gastrointestinal complications. In order to verify the results of the CT image analysis, CT findings were correlated with surgical findings when possible. Results The surgical procedures for weight reduction were: sleeve gastrectomy (n=), gastric bypass (n=23) and gastric band (n=76). Complications occurred in 50 patients and included small bowel obstruction, internal hernias, dilatation in the excluded stomach, hematoma, abscess, leaks... The laparoscopic sleeve gastrectomy is a relatively new operation. The reduction of the size of the stomach, to about 60-80cc in volume results in a powerful restrictive weight loss. In our series there was only one patient with this surgery and it was complicated with intrabdominal collection. (Figure ) on page 5 The Roux-en-Y gastric bypass may be considered the standard of reference for bariatric surgery. This technique combines restrictive and malabsortive properties by creating a food receiving pouch of small volume (30-50 ml) which empties through A Roux-en-Y gastrojejunostomy. The Roux-en-Y limb ranges from cms in length and it is anastomosed side-to-side to the jejunum. In the literature the most ominous complication in the gastric bypass is a leak on page 6 from the gastrojejunal anastomosis or the enteroenteric anastomosis, both of which may be life Page 2 of 6

3 threatening. Contrast material outside the confines of the gastric pouch and anastomosis indicates a leak and may be seen on UGI images or CT scans. Although leaks from the enteroenteric anastomosis are rapidly clinically evident and severe, they are usually nor diagnosed radiographically and surgical exploration is indicated if there is high clinical suspicion of a leak. (Figure 2) on page 6 In our serie there were complications in 6 patients. The main complications were: small bowel obstruction, gastrojejunal anastomotic strictures, intraabominal collections and fistulas. - The small bowel obstruction was the most frequent complication (62,6%). Small bowel obstruction may occur anywhere and the diagnostic criteria were the presence of dilatation of proximal small bowel loops with collapse or nondistention of distal small bowel and colon. Most obstruction were secondary to adhesions (8,75%) (Figure 3 on page 7,4 on page 8)or internal hernias (2,5%). Internal hernias occur through defects in the small bowel mesentery or transverse mesocolon or through a potential space posterior to the Roux limb termed the Peterson Space. Signs of internal hernia into a small bowel mesenteric defect include a cluster of small Page 3 of 6

4 bowel loops pressed against the anterior abdominal wall with crowding and engorgement of mesenteric vessels at CT. There is often an abrupt mesenteric twist, on page 8 producing dramatic edema both radiographically and intraoperatively, as lymphatic obstruction is superimposed on venous obstruction. Delay in diagnosis of any type of internal hernia may be devastating and cause ischemia or death. (Figure 5 on page 8,6 on page 9,7 on page 9) - Gastrojejunal anastomotic strictures (2,5%). They are suspected when patient presents postprandial pain and vomiting. They are usually diagnosed by persisting pouch distention, with spherical appearance and air fluid-contrast material levels in the pouch and esophagus. These are treated endoscopically, with ballon dilatation.(figure 8 on page 0, 9 on page 0) - Intraabdominal collection (8,75%) due to a leak, hemorrhage, hematoma or abscess. On CT scans hematomas are demonstrated as highattenuation material (60-80UH). These often occur adjacent to the gastrojejunostomy, with hematoma in the lesser sac, adjacent to or within the excluded stomach. (Figure 0) on page The anastomotic leaks are demonstrated as a collection with a combination of extravasated contrast material adjacent to the anastomosis.(figure 2) on page 6 Page 4 of 6

5 Abscess formation is usually the result of intestinal perforation (2,5%). CT is the primary means for abscess evaluation, depicting fluid collections, generally in the left upper quadrant. These demonstrate rim enhancement and often contain both gas and fluid. Orally administered contrast material within the collection is diagnostic of an abscess from a leak. - Fistula gastrogastric (6,25%) is a potential cause of weight gain. It is uncommon. A fistulous tract arising from the pouch may opacify the excluded stomach on UGI images or CT scans. The gastric band is a prosthetic device that wraps around the upper part of stomach to make a barrier for the passage of food. Radiographics studies are crucial in the postoperative management because stomal adjustment to 3-4 mms is essential to achieve an optimal weight loss. In our series there were complications in 33 patients. The principal complication of the gastric band surgery described in the literature and also the main complication in our serie is the band slippage (58%). This complication is when the stomach slides up through the band, making the pouch bigger. There are two types of gastric band slippage: anterior and posterior which basically refers to whether the back or front side of the stomach slips. This complication is better evaluated with UGI than with MDCT. Other complications, founded on MDCT, were pancreatitis (8,3%) (Figure ) on page 2, on page 2intrabdominal collection (25%)(Figure 2) on page 2 and stomach perforations (8,3%)(Figure 3) on page 3 Images for this section: Page 5 of 6

6 Fig. : Intraabdominal collection with hydroaereal level near the anastomosis and pneumoperitoneum Page 6 of 6

7 Fig. 2: Perforation of the excluded stomach. CT scans show contrast material outside the confines of the gastric pouch. Page 7 of 6

8 Fig. 3: Small bowel obstruction due to an adhesion. CT scans show dilated jejunal loops and change in diameter of the loops in the left iliac fossa. Fig. 4: Small bowel obstruction. CT scans show dilatedand fluid-filled duodenal and jejunal loops. Page 8 of 6

9 Fig. 5: Internal Hernia: CT scans show a abrupt mesenteric twist, with crowding and engorgement of mesenteric vessels at CT. Fig. 6: Internal Hernia: CT scans show a cluster of jejunal loops pressed againts the anterior abdominal wall with crowding and engorgement of messenteric vessels at CT. Page 9 of 6

10 Fig. 7: CT scans show a cluster of jejunal loops pressed againts the anterior abdominal wall with crowding and engorgement of messenteric vessels at CT and pneumoperitoneum Fig. 8: Obstruction of the excluded stomach and biliopancreatic limb. CT scans show a distended, fluid filled excluded stomach Page 0 of 6

11 Fig. 9: Roux limb obstructions secundary to stricture. CT scans show fluid-filled dilated Roux limb. Page of 6

12 Fig. 0: Hematoma. CT scans shows high-attenuation collection adjacent to the gastrojejunostomy. Fig. : Severe pancreatitis with peripancreatic collections and intraglandular necrosis. Balthazar grade E Page 2 of 6

13 Fig. 2: Intraabdominal collection: CT scans shows a large abscess adjacent to the excluded stomach Page 3 of 6

14 Fig. 3: Perforation of stomach. CT scans shows contrast material outside the confines of the gastric pouch. Page 4 of 6

15 Conclusion Morbid obesity is an epidemic today and the bariatric surgery is increasing in popularity. This surgery has a high rate of complications. Radiology plays a crucial role in postoperative evaluation. MDCT of the abdomen and pelvis has high sensibility to diagnose postoperative complications that guide surgical exploration. References Christopher D. Sheirey, MD, Francis F. Scholz MD, Paresh C. Shah, MD, David M. Brams, MD, Brian B. Wong, MD, Michael Pedrosa, MD. Radiology of the laparoscopic Roux-en-Y Gastric By Pass procedure: Conceptualization and Precise Interpretation of Results. Radiograhics 2006; 26: Jinxing Yu, MD, mary Ann Turner, MD, Shao-Ro, Cho, MD, Ann S. Fulcher, MD, Eric J. DeMaria, MD, Jonh M. Kellum, MD, Harvey J. Sugerman, MD: Normal Anatomy and Complications after gastric Bypass surgery: helical CT findings. Radiology 2004; 23: Elmar M.Merckel, MD, Peter T. Hallowell, MD, Cathleen Crouse, RN, Dean A. Nakamoto, MD, Thomas A. Stellato, MD. Roux -en-y Gastric Bypass for clinically severe obesity: normal appearance and Spectrum of complications at imaging. Radiology 2005;234: Burton BT, Foster WR. Health implications of obesity: an NIH Consensus Development Conference J Am Diet Assoc 985;85:7-2. Schauer PR. Open and laparoscopic surgical modalitiesfor the management of obesity. J GastrointestSurg 2003;7: Miller K, Hell E. Laparoscopic surgical concepts ofmorbid obesity. Langenbecks Arch Surg 2003;388: Blachar A, Federle MP. Gastrointestinal complications of laparoscopic Rouxen-Y gastric bypass surgery in patients who are morbidly obese: findings on radiography and CT. AJR Am J Roentgenol 2002; 79: Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;38: Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology 2002;223: Byrne TK. Complications of surgery for obesity. Surg Clin North Am 200;8:8-93. Page 5 of 6

16 Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR. Gastrointestinal complications of laparoscopic Roux en- Y gastric bypass surgery: clinical and imaging 625 findings. Radiology 2002; 223:-632 Silverman PM, Cooper CJ, Weltman DI,Zeman RK. Helical CT: practical considerations and potential pitfalls. RadioGraphics 995; 5:25-36 Personal Information Page 6 of 6