Normal Anatomy and Complications of Bariatric Surgery:
An Interactive Teaching File with CT-Fluoroscopic Correlation

What is Laparoscopic Sleeve Gastrectomy?

• Minimally invasive partial resection of the stomach along the greater curvature to create a sleeve or tubular morphology.
• Weight loss results due to restrictive and endocrine mechanisms

Indications

• Morbid obesity BMI >40
  • Stand-alone treatment
  • High-risk patients
  • Kidney and liver transplant candidates
  • Metabolic syndrome
  • BMI 30-35 with comorbidities

Contraindications

• Barrett’s esophagus
  • Some consider it an absolute contraindication due to future need for gastric-pull surgery with cancer.
• GERD (relative)
• Prohibitive anesthesia risk
• Uncontrolled psychiatric illness
• Coagulopathy

Laparoscopic

• Identify pylorus
• Mobilize greater curvature and ligate gastroepiploic and short gastric vasculature
• Assess hiatus for hernia
• Insert Bougie
• Transect stomach beginning 3-6 cm proximal to the pylorus
• Extract specimen

Advantages

• No enteric anastomosis
• No risk of internal hernia, dumping syndrome, or marginal hernia
• Decreases ghrelin
• Maintains access to pancreaticobiliary system
• Similar effect on weight loss
• Technically simpler

What is Laparoscopic Sleeve Gastrectomy? CT Case Study 1 CT Case Study 2 Medical Illustration

• Minimally invasive partial resection of the stomach along the greater curvature to create a sleeve or tubular morphology.
• Weight loss results due to restrictive and endocrine mechanisms

Overall rate is less than gastric bypass

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Leak- most common CT Case Study

• More susceptible to a leak than RYGB (2.4 versus 0.7%)
• Most often occurs at the proximal end
• Majority occur more than 10 days postop
• Imaging
  • Contrast extravasation or opacification of a drain
  • Free air or air fluid level adjacent to site of leak
  • Staple line gap
  • Phlegmon or abscess

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Fistula CT Case Study

• Gastrocutaneous, gastrocolic, and gastrobronchial
• Imaging
  • Contrast connection
  • Fluid collection or abscess, effusion

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Bleeding CT Case Study Medical Illustration

• Staple line, splenic Injury
• Imaging
  • Fluid collection with high-density content or fluid-fluid level
  • Contrast extravasation

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Stricture CT Case Study Medical Illustration

• Acute or chronic
• Often occurs at incisura angularis
• Imaging- use MPRs
  • Dilated proximal stomach and esophagus
  • Luminal narrowing of stomach
  • Contrast stasis proximally
  • Angulation of stomach at stenosis

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Portal Vein Thrombosis

• Rare

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Splenic infarct- rare

• Related to ligation of short gastric vessels to mobilize fundus
• Imaging
  • Wedge shaped peripheral area of hypodensity

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Redundant gastric remnant

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GERD

• Imaging
  • Reflux of oral contrast
  • Hiatal hernia
  • Distended esophagus

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Wound complications and trocar site hernia