Laparoscopic Sleeve Gastrectomy

Canadian Association of Radiologists Journal xx (2018) 1e13 www.carjonline.org

Abdominal Imaging / Imagerie abdominale

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure Fabio Garofalo, MDa,*, Radu Pescarus, MDa, Ronald Denis, MDa, Henri Atlas, MDa, Pierre Garneau, MDa, Michel Philie, MDb, Karl Sayegh, MDc a

Departement de Chirurgie, Division de Chirurgie Bariatrique, H^opital du Sacre-Coeur de Montreal, Universite de Montreal, Montreal, Quebec, Canada b Departement de Radiologie, H^opital du Sacre-Coeur de Montreal, Universite de Montreal, Montreal, Quebec, Canada c Department of Radiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada

Abstract Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications. Resume La gastrectomie longitudinale par laparoscopie figure parmi les interventions bariatriques les plus courantes a l’echelle mondiale. Depuis peu, elle gagne en popularite, car elle entra^ıne un faible taux de complications, une resolution satisfaisante des comorbidites et une perte de poids importante. Le present article traite de la technique chirurgicale, des aspects d’imagerie postchirurgicaux attendus et des resultats d’imagerie associes aux complications courantes suivant la gastrectomie longitudinale par laparoscopie. La comprehension de cette technique chirurgicale et des caracteristiques anatomiques normales suivant l’intervention permet une interpretation juste des resultats d’imagerie dans les cas de perte de poids insuffisante, de reprise de poids et de complications postchirurgicales. Crown Copyright Ó 2017 Published by Elsevier Inc. on behalf of Canadian Association of Radiologists. All rights reserved. Key Words: Gastric leak; Gastric stenosis; Radiology; Sleeve gastrectomy

Obesity continues to be a major public health problem in the United States, with more than one-third of adults considered obese in 2009-2010, as defined by a body mass index (BMI) >30 kg/m2 [1e3]. Bariatric surgery procedures are indicated for patients with a BMI >40 kg/m2 without coexisting medical problems and for whom bariatric surgery would not be associated with excessive risk should they be eligible for a bariatric procedure [4]. Patients with a BMI >35 kg/m2 and 1 or more severe obesity-related comorbidities may also be offered a bariatric procedure [4,5]. Among different surgical options, laparoscopic sleeve gastrectomy (LSG) has demonstrated benefits comparable to * Address for correspondence: Fabio Garofalo, MD, Division de Chirurgie Bariatrique, H^ opital du Sacre-Coeur de Montreal, Universite de Montreal, 5400 boul. Gouin ouest, Montreal, Quebec H4J 1C5, Canada. E-mail address: [email protected] (F. Garofalo).

other bariatric procedures and is currently becoming one of the most common bariatric procedures worldwide. In comparison with other bariatric surgeries such as the laparoscopic Roux-en-Y gastric bypass (LRYGB), LSG is a shorter and more technically straightforward procedure that leads to fewer changes to the body’s normal anatomy and physiology. It has recently increased in popularity because of proven efficacy in achieving considerable weight loss and comorbidities resolution without increasing the risk of complications [6,7]. Sleeve gastrectomy was originally performed by Hess [8] and Marceau [9] in 1998 as the first part of the duodenal switch operation. In high-risk and super-obese patients (BMI >50 kg/m2), the gastric sleeve part of the duodenal switch operation was often performed alone in an attempt to reduce morbidity and mortality, and to facilitate the laparoscopic approach [10]. In the past 15 years, LSG has increasingly been used as a stand-alone primary bariatric procedure and has

0846-5371/$ - see front matter Crown Copyright Ó 2017 Published by Elsevier Inc. on behalf of Canadian Association of Radiologists. All rights reserved. https://doi.org/10.1016/j.carj.2017.10.004

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F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13

gained popularity among patients and bariatric surgeons [11]. In a meta-analysis published in 2013 by Buchwald and Oien [12] LSG appears to be the second leading bariatric operation in the world, only surpassed by LRYGB. Moreover, LSG has surpassed LRYGB as the most frequently performed bariatric procedure in American academic centres since 2013 [13]. The ultimate goal of the procedure is to remove between 60%-70% of the stomach, including the fundus, leaving only a thin ‘‘banana-shaped’’ gastric tube from the esophagus to the duodenum. The narrowing of the stomach results in a significant restriction of the gastric capacity as well as in other metabolic modifications. Interestingly, ghrelin, one of the main hormones that stimulates and increases the patient’s appetite, is primarily produced by cells located in the fundus [14,15]. Resection of the fundus dramatically decreased the basal level of ghrelin, reducing appetite in patients who underwent LSG [16e18]. We discuss the surgical technique of LSG and imaging appearance of failure including insufficient weight loss, weight regain, and the most frequently encountered surgical complications. Surgical Technique of LSG After the creation of a pneumoperitoneum, 5 laparoscopic ports are placed across the upper abdomen. The first step of the procedure is to divide the vascular attachments of the gastroepiploic arcade and the short gastric vessels. The stomach and fundus must be fully mobilized during the dissection. The presence of a hiatal hernia is verified and repaired if necessary. Subsequently, gastric transection begins 4-6 cm proximal to the pylorus by successive application of a laparoscopic linear stapler, using a gastric calibration bougie (36-40 F). This bougie is essential, as it helps to prevent excessive narrowing of the gastric tube (Figure 1). The position of the final staple firing is critical to avoid a leak. Leaving a significant portion of fundus will not be optimal in terms of weight loss or gastroesophageal reflux disease (GERD) in the long term. Approximately 1 cm of cardia should be left after the last stapler is fired [19]. Intraoperative endoscopy can be useful in ruling out leaks, abnormal angulation of the sleeve, or gastric stenosis [20]. Failure After LSG LSG has demonstrated its effectiveness in achieving weight loss and resolution of obesity-related comorbidities [21]; the concept of sleeve gastrectomy is simple, but some components of the operation, if performed incorrectly, can result in serious complications. A recent expert panel consensus statement has been published with a resulting drive toward standardization, providing guidance for essential aspects of the procedure, indications and contraindications, surgical technique, management, and prevention of complications [7]. Nevertheless, even in the hands of expert surgical teams and high-volume bariatric centres, failure exists. LSG failure can be classified as insufficient weight lost (defined as an

Figure 1. Diagram showing the normal surgical anatomy following laparoscopic sleeve gastrectomy. The resected stomach is removed out of the abdomen through a small incision. The thick interrupted line outlines the gastric transection plane along the greater curvature from the proximal antrum to the gastroesophageal junction. The thin interrupted line outlines the incisura angularis. Illustration courtesy of Ildiko A. Horvath, Medical Illustrator, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada.

excess weight loss 12 weeks) [7]. The management of perigastric abscesses depends on the patient’s clinical condition and available resources [24,50,51]. If the leak presents as a well-defined abscess and the patient is clinically stable, percutaneous image-guided drainage is appropriate. In case of an unstable patient, surgical drainage (laparoscopically by experienced bariatric team) is the preferred choice [24]. Together with drainage, endoluminal control must be established to facilitate closure of the leak.

Figure 9. A 62-year-old woman with leak at the gastroesophageal junction. Fluoroscopic image shows small amount of extravasated contrast at the gastroesophageal junction (arrowhead) and iodinated contrast material opacifying the surgical drain (arrows). The patient was initially treated by primary laparoscopic suture. The patient presented with recurrence of the leak and final treatment was achieved by endoscopic stenting (not shown).

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Figure 10. A 68-year old patient presented to the emergency department with fever and abdominal pain 23 days after laparoscopic sleeve gastrectomy. Axial maximum intensity projection image (15 mm thickness) of a computed tomography scan following administration of intravenous and oral iodinated contrast material shows a large left upper quadrant abscess (asterisks) containing extravasated contrast material (arrow) and air. Notice the gap in the staple line (arrowhead) indicating the site of leakage. The patient was treated by percutaneous drainage and endoluminal stenting.

In our institution, endoscopic treatment includes placement of a partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Megastent, Taewoong Medical Industries, Gimpo, South Korea) and Overthe-Scope Clip (Ovesco Endoscopy, T€ubingen, Germany) [52e54]. Partially covered esophageal metallic stents have

Figure 11. A 44-year-old woman presented with nausea, vomiting, and intermittent abdominal pain without fever 35 days after revisional sleeve gastrectomy. This patient had laparoscopic sleeve gastrectomy after insufficient weight lost postegastric plication. Axial image of a computed tomography scan following administration of oral iodinated contrast material shows a small amount of contrast extravasation and free air (arrows) indicating a microleak at the gastroesophageal junction. Treatment was achieved by endoluminal stenting.

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been until recently the best option in the treatment of sleeve leaks. They are, however, prone to migration given their shorter length (up to 155 mm) and are harder to remove due to the ingrowth occurring at both ends of the stent. More recently, fully covered Megastents (Taewoong Medical Industries) up to 230 mm in length and with a large diameter (up to 28 mm) appear to be more resistant to migration. They are also easy to remove given the full silicone covering. Finally, longer Megastents allow for a complete stenting of the gastric sleeve past the incisura angularis, therefore reducing proximal overpressure and allowing for a better healing of the tract or fistula (Figure 12). Recently, treatment with endoscopically inserted double pigtail catheters has been proposed in the European literature [55]. The pigtail is placed across the fistula between the lumen of the esophagus and the cavity of the abscess (Figure 13). This is conceptually similar to the endoscopic transgastric drainage of pancreatic pseudocysts. The pigtail allows for internal drainage of the abscess. It is usually endoscopically removed after 3-6 weeks of drainage.

A chronic fistula after LSG is a challenging problem. If a fistula persists for more than 3 months despite adequate drainage, endoluminal therapy, and nutritional support, reoperation may be the only solution. Several surgical options have been reported including the creation of a fistulojejunostomy connecting a jejunal Roux limb to the fistula (Figure 14) and total gastrectomy with esophagojejunostomy [24,51]. A chronic leak can also progress into gastrocolic fistula, especially when initial control of the leak is not achieved. In the medical literature, few case reports have been published documenting the treatment of a gastrocolic fistula post-LGS [56,57]. Laparoscopic resection of the fistula tract can be a valid option in these rare cases (Figure 15). Abnormal Angulation or Stenosis Stenosis or obstruction of stomach due to abnormal angulation following sleeve gastrectomy has been increasingly recognized with a reported incidence ranging between 0.1%-3.9% [38e41]. The most common site of

Figure 12. A 62-year-old woman with a leak at the gastroesophageal junction, 7 days after laparoscopic sleeve gastrectomy. Healing of the leak was initially attempted via placement of a Wallstent (Boston Scientific, Galway, Ireland) for 4 weeks. (A, B) Axial images and (C) coronal image of a computed tomography scan following administration of oral (and intravenous) contrast showing the Wallstent (155 mm length, 23 mm diameter) in position across the gastroesophageal junction. There is persistent tract and leakage (A, arrow) of contrast material into the collection (B, arrow) in the left upper quadrant. While the proximal part of the stent covers the site of leak (A, arrowhead), the distal end of the stent (C, arrowhead) is not able to overcome the incisura angularis (C, arrows). Despite the presence of a Wallstent for 4 weeks, leakage persisted. Complete healing of the leak was achieved by placement of a Megastent (230 mm length, 28 mm diameter; Taewoong Medical Industries, Gimpo, South Korea) for another 3 weeks. (D) Coronal oblique image of a computed tomography scan showing the full extent of the Megastent. Not only does the Megastent cover the leak site at the gastroesophageal junction but it also overcomes the incisura angularis (D, arrow), reducing proximal overpressure, hence promoting healing of the leak.

Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13

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Figure 13. A 65-year-old patient presented with a leak at the level of the gastroesophageal junction, 2 days after laparoscopic sleeve gastrectomy. Initial control of the leak despite Megastent (Taewoong Medical Industries, Gimpo, South Korea) placement was incomplete. Final treatment was achieved by endoscopic insertion of a double pigtail through the stent allowing internal drainage of the abscess cavity into the esophageal lumen. (A) Scout image showing the Megastent (A, arrow) and the double pigtail (A, arrowhead). (B) Axial image of a computed tomography scan with intravenous and oral contrast in bone window (width 2500, length 480) showing the position of the distal loop of the double pigtail in the residual air-containing cavity (B, arrow). (C) Coronal oblique maximum intensity projection image (10 mm) and (D) axial oblique maximum intensity projection image (20 mm) in the bone window (width 2500, length 480) showing contrast within the Megastent (C and D, asterisks) and the double pigtail with its distal loop positioned within the residual abdominal cavity/collection (C, arrowhead) and its proximal loop kept inside the esophageal lumen (D, arrow).

Figure 14. A 43-year-old patient with a chronic fistula 9 months following LSG, successfully treated by Roux-en-Y fistulojejunostomy. Anteroposterior view from an upper gastrointestinal study following oral iodinated contrast administration outlines the normal anatomy of the Roux-en-Y fistulojejunostomy. There is normal concomitant passage of contrast material through the sleeve gastrectomy (arrowheads) and the jejunal limb (arrows).

abnormal angulation is at the incisura angularis. Although true strictures can occasionally occur (Figure 16), these are not common. Obstructive symptoms after LSG are typically not due to a true luminal stricture but rather a result of sharp angulation of more than 30 or indentation at the incisura angularis of the gastric tube (Figure 17). This functional obstruction presents as persistent dysphagia to solids progressing to liquids accompanied by nausea and vomiting. Gastric sleeve stenosis or abnormal angulation can be diagnosed using an UGI series, CT scan or endoscopy. Fluoroscopy studies may show an area of stenosis or kinking with a persistent contrast column within a dilated proximal gastric remnant and sometimes a distended distal esophagus and gastroesophageal reflux [47]. Although CT is rarely used for assessment of a gastric stenosis, it may demonstrate similar findings to fluoroscopy [47]. In our experience, routine review of multiplanar reformations (coronal and sagittal) can sometimes aid in detecting sharp angulations overlooked when only axial images of a CT scan are reviewed. The timing of clinical presentation following

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Figure 15. A 47-year-old woman with a gastrocolic fistula 4 years following laparoscopic sleeve gastrectomy. Anteroposterior view from an upper gastrointestinal study following oral iodinated contrast administration shows direct passage of contrast material from the antrum to the transverse colon (asterisks) through the fistulous tract (arrow). Following nutritional optimization the patient was successfully treated by a combination of laparoscopic resection of the tract with omental interposition and intraoperative endoscopy.

sleeve gastrectomy varies among patients but may occur within days or in some cases months after the surgery. Management includes symptomatic treatment with antiemetics, IV fluids, and endoscopic treatment with balloon dilatation or stenting [40,41]. Large achalasia-type balloons often succeed in treating true stenoses but often fail in adequately treating complex angulations. For these patients with twisted sleeves, revisional laparoscopic surgery is often necessary. Nevertheless, revisional bariatric surgery is technically demanding and associated with higher complications

Figure 17. A 37-year-old woman with functional obstruction leading to dysphagia to solids, 2 years following laparoscopic sleeve gastrectomy. Axial image of a computed tomography scan following administration of oral and intravenous iodinated contrast shows a very sharp angulation at the level of the incisura angularis (arrow). Despite the kink, there is passage of contrast distally. Treatment was achieved by conversion to LRYGB.

and mortality compared with primary bariatric procedures [58]. A review of revisional bariatric surgeries conducted by Jones [59] (n ¼ 883) reported 14% major complication rate and 0.8% mortality rate. LRYGB is currently considered the best surgical option in case of refractory stenosis, with good short- and long-term outcomes [33,38,60,61]. Laparoscopic seromyotomy, in which a partial thickness cut on the gastric wall is performed on the stenotic gastric segment, has been described in a few case series [62]. Moreover, a gastric wedge resection, in which the stenotic segment is resected and a gastrogastric anastomosis is performed, is another option [63]. Both options have been associated with poor results in the bariatric literature [62,63]. Postoperative Hemorrhage

Figure 16. A 57-year-old woman presented with dysphagia, nausea, and vomiting on postoperative day 27 following laparoscopic sleeve gastrectomy. Anteroposterior fluoroscopy image demonstrates a segment of fixed distal stenosis at the level of the incisura (arrows). Endoscopic treatment with a 30-mm achalasia balloon dilatation was performed (result postdilatation not shown).

Significant bleeding requiring transfusion or reoperation occurs in 60 HU) in the first few hours after bleeding as the concentration of hemoglobin increases [66]. The blood

Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13

Figure 18. A 59-year-old man presented with hemoglobin drop on postoperative day 1 after laparoscopic sleeve gastrectomy. Axial image of a computed tomography scan with intravenous contrast shows a 10.4 cm 14.4 cm perigastric high-density collection (60 HU) compatible with hematoma (asterisk) along the gastric staple line (arrow). Conservative treatment was successful.

density then decreases in the subacute and chronic setting, and the hematoma involutes with time. A chronic hematoma may be indistinguishable from postoperative collections or abscess [27]. A hematocrit level may be seen when bleeding occurs at different time points within the same collection. Intravenous and oral contrast are usually not required to establish the diagnosis of hematoma but depending on the clinical context, administration of IV or oral iodinated contrast may be useful in the assessment of other potential complications such as leaks. The detection of active bleeding also requires administration of IV contrast. Active bleeding on contrast-enhanced CT will appear as a blush of contrast more or less isodense to adjacent vasculature, in the vicinity of a forming hematoma [66].

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Figure 19. A 46-year-old patient who presented with gastroesophageal reflux disease symptoms associated to dysphagia, 1 year after laparoscopic sleeve gastrectomy. Anteroposterior fluoroscopic image of an upper gastrointestinal study shows a sharp angulation at the level of the incisura angularis (arrow), causing functional obstruction. Herniation of the cardia (arrowhead) through the esophageal hiatus is also visualized. Functional distal obstruction creates proximal overpressure and together with the presence of a sliding hiatal hernia contributes to the gastroesophageal reflux disease symptoms. Incidentally, distribution of small bowel loops in the right upper quadrant indicates intestinal malrotation (asterisk). The patient was successfully treated by laparoscopic hiatal hernia repair and conversion to laparoscopic Roux-en-Y gastric bypass.

Other Complications Other complications have been described after sleeve gastrectomy. Splenic injury is rare, occurring in 0.1% of cases and likely related to surgical dissection in the left upper quadrant [27]. Infarction of the spleen is the most frequently

Gastroesophageal Reflux Disease GERD remains a problem after LSG, and the onset of severe refractory GERD after LSG may be an indication to revise the procedure to LRYGB or other antireflux procedures. New-onset GERD after LSG has been reported to be 0.5%-31% [18,42e44]. In the report by Himpens et al [42], GERD symptoms are attributed to a neofundus, corresponding to a dilated pouch of the proximal sleeve that can be found in association with weight regain. Concomitant sliding hiatal hernia or a patulous gastroesophageal valve can also contribute to symptoms of reflux. It is therefore important that the radiologist highlights the presence of even a small hiatal hernia in a bariatric patient, both preoperatively or post-LSG (Figure 19). Concomitant hiatal hernia repair and LSG have been proposed to reduce postoperative GERD. In a recent study from Samkar et al [67], the authors reported that 15.6% of asymptomatic patients developed de novo GERD symptoms despite a hiatal hernia repair.

Figure 20. A 35-year-old patient on postoperative day 1 after laparoscopic sleeve gastrectomy. Axial image of a computed tomography scan following administration of intravenous and oral iodinated contrast material shows a typical wedge shaped hypodensity at the upper pole of the spleen compatible with infarction (arrow) following short gastric vessel ligation during laparoscopic sleeve gastrectomy. Incidentally, there is also subsegmental atelectasis at the lung bases (arrowheads). The patient was asymptomatic and was discharged home shortly after the computed tomography scan.

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seen splenic injury after LSG and usually occurs at the superior pole of the spleen. It can result from intraoperative ligation of the short gastric vessels to mobilize the gastric fundus during LSG. A contrast-enhanced CT shows a welldemarcated wedge shaped peripheral nonperfused hypodensity [27] (Figure 20). Subcapsular hematoma and laceration are less common splenic injuries and typically appear as a crescentic subcapsular fluid collection and a serpentine linear hypodensity in the spleen, respectively [27]. Incisional hernias have also been described. Their incidence rate is comparable to other bariatric procedures performed laparoscopically (12,000 cases. Surg Obes Relat Dis 2012; 8:8e19. [8] Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998;8:267e82. [9] Marceau P, Biron S, St Georges R, Duclos M, Potvin M, Bourque RA. Biliopancreatic diversion with gastrectomy as surgical treatment of morbid obesity. Obes Surg 1991;1:381e7. [10] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861e4.

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