Figure 1
First post-operative contrast study (2 days after surgery)
Complicating leak after sleeve gastrectomy
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsTurturici L, Ginanni B, Vallini V, Giusti P, Caramella D, Bartolozzi C.
Connected authors
61 years, female
Clinical History
A 61-year-old female obese patient underwent a sleeve gastrectomy.
Imaging Findings
A 61-year-old female patient with 124 kg body weight (BMI=45), DM type II and hypertension underwent a sleeve gastrectomy. During the first postoperative night she removed the naso-gastric probe but remained asymptomatic with a mild leukocytosis at laboratory tests. Two days after surgery an upper gastrointestinal X-ray study was performed to exclude early complications. An iodine contrast examination demonstrated a leakage in proximity of the gastric suture, indicating a fistula. The naso-gastric probe was repositioned and the patient was kept at rest in bed (Fig.1).
Another two days later, the patient developed fever and abdominal pain. A subsequent radiological examination confirmed a progressive leakage and showed a contrast material opacification along the drainage previously positioned (Fig.2). Surgeons repaired the leakage with clips positioned endoscopically.
Three days after clipping a contrast study confirmed a repaired leakage and no extragastric contrast material accumulation was visible (Fig.3).
Another two days later, the patient developed fever and abdominal pain. A subsequent radiological examination confirmed a progressive leakage and showed a contrast material opacification along the drainage previously positioned (Fig.2). Surgeons repaired the leakage with clips positioned endoscopically.
Three days after clipping a contrast study confirmed a repaired leakage and no extragastric contrast material accumulation was visible (Fig.3).
Discussion
Laparoscopic sleeve gastrectomy (LSG) is an innovative new surgical procedure used in patients with severe obesity (BMI≥35-40 with severe comorbid diseases). Its purpose is to ensure a clinically effective weight loss and to reduce the risk of complications. LSG is a restrictive operation that reduces the size of the gastric reservoir to 60–100 mL, permitting the intake of only small amounts of food and imparting a feeling of satiety earlier during a meal. It involves a longitudinal resection of the stomach on the greater curvature from the antrum to the angle of His, leaving a narrow stomach tube.
More recently, however, it has been suggested that the drop of endogenous ghrelin levels may also contribute to the success of LSG. Ghrelin is a hunger-regulating peptide hormone, mainly produced in the fundus of the stomach. By resecting the fundus in LSG, the majority of ghrelin-producing cells are removed, thus reducing plasma ghrelin levels and subsequently hunger.
In LSG no digestive anastomosis is involved, the risk of internal hernia is eliminated because mesenteric defects are not created, and no foreign material is used as in the case of gastric banding. Further, the entire digestive tract remains accessible to endoscopy, LSG is not associated with Dumping syndrome, the risk of peptic ulcer is low and the absorption of nutrients, vitamins, minerals and drugs is not altered.
LSG can be as effective as gastric bypass in terms of weight loss in obese patients and is associated with fewer perioperative risks. Postoperative complications include staple line leak, bleeding, and intra-abdominal abscess.
More recently, however, it has been suggested that the drop of endogenous ghrelin levels may also contribute to the success of LSG. Ghrelin is a hunger-regulating peptide hormone, mainly produced in the fundus of the stomach. By resecting the fundus in LSG, the majority of ghrelin-producing cells are removed, thus reducing plasma ghrelin levels and subsequently hunger.
In LSG no digestive anastomosis is involved, the risk of internal hernia is eliminated because mesenteric defects are not created, and no foreign material is used as in the case of gastric banding. Further, the entire digestive tract remains accessible to endoscopy, LSG is not associated with Dumping syndrome, the risk of peptic ulcer is low and the absorption of nutrients, vitamins, minerals and drugs is not altered.
LSG can be as effective as gastric bypass in terms of weight loss in obese patients and is associated with fewer perioperative risks. Postoperative complications include staple line leak, bleeding, and intra-abdominal abscess.
Differential Diagnosis List
Gastric leak after sleeve gastrectomy surgery.
Oesophageal perforation
Gastric perforation
Final Diagnosis
Gastric leak after sleeve gastrectomy surgery.
References
[1] Karmali S, Schauer P, Birch D, Sharma AM, Sherman V (2010) Laparoscopic sleeve gastrectomy: an innovative new tool in the battle agaist the obesity epidemic in Canada. Can J Surg 53:126-32 (PMID: 20334745)
[2] Iannelli A, Dainese R, Piche T, Facchiano E, Gugenheim J (2008) Laparoscopic sleeve gastrectomy for morbid obesity. World J Gastroenterol 14: 821-827 (PMID: 18240338)
[3] Catheline JM, Cohen R, Khochtali I, Bihan H, Reach G, Benamouziog R et al. (2006) Treatment of super super morbid obesity by sleeve gastrectomy. Presse Méd 35: 383-7 (PMID: 16550126)
[4] Wong SK, Kong AP, Mui WL, So WY, Tsung BY, Yau PY, Chow FC, Ng EK (2009) Laparoscopic bariatric surgery: a five-year review. Hong Kong Med J 15:100-9 (PMID: 19342735)
Case information
| URL: | https://www.eurorad.org/case/9054 |
| DOI: | 10.1594/EURORAD/CASE.9054 |
| ISSN: | 1563-4086 |
Figure 2
Second postoperative contrast study (4 days after surgery)
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
Second postoperative contrast study (4 days after surgery)
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
Persistence of the leakage and fistula opacification (arrows) along the drainage tube previously positioned.
