Patel [7] stated that radiology is an important element that must be accessible to individuals undergoing a bariatric operation, and radiology plays a great part in the management of these patients in both late and early post-operative periods. The radiologist should have satisfactory information on the surgical procedure performed and expected anatomical presentations and post-operative complications. Computed tomography and upper GI studies are considered the keystone imaging modalities.
The aim of this study was to evaluate the outcome of bariatric surgery and the detection of complications in 49 obese patients who failed to reach the ideal weight by non-surgical trials. They had comparable age, sex, duration of obesity, and different procedures of bariatric surgery.
There are two primary categories of surgical strategy: [1] restrictive strategy induces weight loss by considerably decreasing gastric capacity and developing early satiety, examples include laparoscopic adjustable gastric banding and sleeve gastrectomy and [2] combined restrictive and mal-absorptive strategy incorporate the Roux-en-Y gastric bypass [4].
Shah et al. [4] proved that Roux-en-Y gastric bypass is the commonest bariatric operation that was performed in North America. Lo Menzo et al. [8] stated that the gastric band won adorability in the period between 2007 and 2010, and it became the commonest bariatric operation done in the world. Nearby, a dramatic drop in popularity of the gastric band and increment interest in sleeve gastrectomy have occurred.
In the present study, the results show that sleeve gastrectomy is the commonest procedure of 57% (28 patients) and then Roux-en-Y gastric bypass 24% (12 patients), stomach band 12% (6 patients), and mini-gastric bypass 6% (3 patients).
According to Bairdain and Samnaliev [9], the prevalence of bariatric surgery among the obese students and adolescents was more common in females near 90% and in males are only 10%.
In this study, 14 students underwent bariatric surgery; 10 of them were female students (71.5%), while male students were 4 (28.5%). Lee and Almulaifi [10] reached that mortality for bariatric surgery was 2% in the first month post-operative, and 1-year mortality was up to 5% in the USA. The operative risk was found to be closely related to surgeon’s encounter and hospital capacity. Development in technology has significantly moved forward the safety of this strategy.
In the current study, a 30-day operation death after bariatric surgery (RYGB) was 2% coping with Lee & Almulaifi [10], but in contrary, the incidence of 1-year mortality (after sleeve gastrectomy) was 2%.
Concors et al. [11] stated that stenosis/stricture regularly presents as dysphagia, vomiting, nausea, and/or abdominal cramps. Stenosis can happen following 4 to 7.5% of RYGB and 3.5% of SG. Usually, endoscopic dilatation treated stenosis successfully. Stenosis can happen either intensely after surgery or as a late way. Acute stenosis regularly happens in the first weeks after surgery auxiliary to tissue edema and is self-limited. Long-term stenosis presents as nausea, spewing, and late dysphagia and usually was diagnosed by UGI studies with oral contrast material.
In the present study, the incidence of stricture/stenosis following RYGB is 8.5% and 7% in SG. The percentage of stenosis is 16% in the gastric band, which is due to a dramatic disappearance of the procedure (one patient out of 6).
Kehagias et al. [12] reported that gastric leak (spill) is a dangerous complication with a frequency rate of 3.7%. Distal staple line leaks are less common than proximal ones. The essential concept is that a leak occurs when the intraluminal pressure surpasses the tissue strength of the staple line. When local factors such as poor blood supply, stapling issues, or infection are found, leaks usually happen. So, to avoid leakage (spill), tissues should be handled carefully and devices like staples, electro-cautery, or other surgical devices should be utilized wisely.
In the current study, the incidence of leaks was 6% in early 30 days after the operation and 6% as a delayed complication, with a percentage of 14% following SG and 8% following RYGB.
In the present study, no cases of leaks were diagnosed by ultrasound examination. By using the upper GI series: two cases were free, and after CT examination, there was an obvious leak (one for patients who underwent SG and the other who underwent RYGB). The sensitivity of upper GI series is 70% and specificity 94%, while CT study sensitivity is 95% and specificity 95%. These results are consistent with many studies such as Kehagias et al., Xu et al., and Lager et al. [12,13,14], and they concluded that CT is more sensitive in diagnosis of leaking and CT scans should only be performed when the clinical suspicion is high and not for screening.
Many surgical schools routinely perform upper gastro-intestinal swallow studies post-operatively in order to evaluate the presence of an early leak, between the 1st and 3rd post-operative day. But the sensitivity of these studies is low and a negative test does not exclude the presence of a leak [14].
Boerlage et al. [15] said that staple line leakage is a severe adverse event of both RYGB and SG. Revisional surgery (surgical repair of the staple line) has been often necessary, although conservative management consisting of abscess drainage, antibiotics, and nil per os in combination with a naso-jejunal feeding tube is sometimes sufficient. Endoscopically placed self-expandable stents can be an alternative to surgery in selected cases when there is relatively limited leakage or when leakage persists despite revisional surgery. Stent placement is effective in more than 50% of these selected cases.
Al Hajj & Chemaly [16] stated that diagnosis of leak/fistula was radiologically confirmed in 100% of cases after water-soluble UGI series and double-contrast abdominal-pelvic CT scan. The three anticipated types of fistula were readily defined as either a type I fistula, a tiny leak; type II fistula, extensive leak or abscess; or type III fistula, a complex leak with internal sub-diaphragmatic fistula or external gastro-cutaneous fistula.
In the present study, 6 patients suffered from leaks; 4 patients showed good improvement after stenting with a percentage near 66% (two were considered as type I fistula, the other two were type II fistula), while two cases with type II fistula still leak and surgical closure of staple line became necessary (one underwent SG and the other underwent RYGB).
According to Susmallian et al. [17], ultrasound may be useful to assess for superficial wound collections, but it is less useful to exclude deep post-operative collections. A common ultrasound indication is to assess for gallstones. Obese patients are at higher risk of cholelithiasis, and there is also an increased frequency of stone formation following bariatric surgery, particularly Roux-en-Y gastric bypass. Ultrasound remains the best first test for the assessment of gallstone disease.
In the present study, no cases of gallstone formation were reported after bariatric surgery. This is probably due to short post-operative follow-up period. In the current study, incisional hernia occurred in 1 patient (8.5%) after RYGP (2% of all cases). This is not matched with Vilallonga et al. [18], who found that the percentage of incisional hernia was 11% (this may be related to a small sample number of patients in the current study). Morbidly obese patients are predisposed to developing abdominal wall hernias, and these are a common cause of morbidity and mortality. Overweight is an important issue for incisional hernias. Incarceration of such hernias can lead to small bowel obstruction (SBO).
As regards band slippage, Mazzariol and Wolf [19] stated that gastric band slippage was observed in 4 to 13% of patients and resulted in an eccentrically dilated pouch. In a rare type of slippage, the pouch was eccentrically dilated medial to the band, resulting in a Φ angle < 4°. More commonly, tearing of the anterior fundoplication sutures can lead to anterior slippage of the band with upward herniation of the stomach, resulting in a Φ angle > 58°. Plain-film findings of slippage include inferior displacement of the upper margin of the band by greater than 2.4 cm from the diaphragm. The “O sign” is specific for band slippage and refers to a circular, or O-shaped, configuration of the band seen in the supine AP radiograph of the abdomen, due to a tilt of the horizontal axis of the band caused by the weight of superiorly herniated stomach.
In the present study, the percentage of band slippage was 16%, which is the commonest type (anterior slippage) with Φ angle > 58°, and O sign was noted.
Yazgan et al. [20] reported that stricture or stenosis at the gastro-jejunostomy site is a relatively common complication of mini-gastric bypass. Post-operative edema obstructs the passage which is transient, and recovery is expected within 2 weeks. Anastomotic leaks are uncommon but very essential complications and occur in only 0.5–1.9% of patients. Ulcers at the gastro-jejunal anastomosis are important complications which occur 0.6–8%. Detecting marginal ulcers on a UGI study or CT scan is less reliable than endoscopy. However, findings of scar or fibrosis might be identified on CT images. This study included only 3 cases that underwent mini-gastric bypass (not yet widespread). One case showed leak (33%) 2 days post-operative.
In brief, both imaging modalities (post-contrast CT study and upper GI series) should be used in diagnosing complications following bariatric surgery as complementary to the clinical manifestations of the patient.
