Radiographic Measurement of Gastric Remnant Volume After Laparoscopic Sleeve Gastrectomy: Assessment of Reproducibility and Correlation with Weight Loss

Background As a restrictive procedure, laparoscopic sleeve gastrectomy (LSG) relies primarily on the reduction of gastric volume. It has been suggested that an immediate postoperative gastric remnant volume (GRV) may influence long-term results of LSG; however, there are no consensus in this matter. The aim of this study was to assess the reproducibility of different radiographic methods of GRV calculation and evaluate their correlation with the weight loss (WL) after surgery. Methods This retrospective study evaluated 174 patients who underwent LSG in the period from 2014 to 2017. Using UGI, GRV was measured with 3 different mathematical methods by 2 radiologists. Intraobserver and interobserver calculations were made. Correlation between GRV and WL were estimated with calculations percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL) after 1, 3, 6, 12, 18, and 24 months postoperatively. Results During analysis of intraobserver similarities, the results of ICC calculation showed that reproducibility was good to excellent for all GRV calculation methods. The intraobserver reproducibility for Reader I was highest for cylinder and truncated cone formula and for Reader II for ellipsoid formula. The interobserver reproducibility was highest for ellipsoid formula. Regarding correlation between GRV and WL, significant negative correlation has been shown on the 12th month after LSG in %TWL and %EWL for every method of GRV calculation, most important for ellipsoid formula (%TWL – r(X,Y) = -0.335, p < 0.001 and %EWL – r(X,Y) = -0.373, p < 0.001). Conclusion Radiographic methods of GRV calculation are characterized by good reproducibility and correlate with the postoperative WL. Graphical Abstract

A Case and Brief Review of Bilious Ascites and Abdominal Compartment Syndrome from Pancreatitis-Induced Post-Roux-En-Y Gastric Remnant Leak

This is a case of a 55-year-old man with Roux-en-Y gastric bypass surgery 15 years prior who presented with acute pancreatitis and developed distributive shock, bacteremia, acute respiratory distress syndrome, anuric acute renal failure, and a distended abdomen with increasing ascitic fluid on imaging. An elevated bladder pressure, lactic acidosis, and anuria raised concern for abdominal compartment syndrome. Paracentesis was done and four liters of bilious ascitic fluid were drained. Intra-abdominal pressure was measured and improved from 27 cmH2O to 13 cmH2O with paracentesis. Mean arterial pressure and urine output also improved. The patient developed recurrent loculated intra-abdominal fluid collections, though ultrasound, CT scans with and without contrast, MRCP, ERCP, upper GI fluoroscopy, and small bowel enteroscopy failed to reveal a source of the bilious output. Ultimately, a gastrostomy tube was placed and delivery of contrast material through the tube revealed active extravasation from the remnant stomach. This case underscores the importance of considering post-surgical leak regardless of how remotely a Roux-en-Y surgery took place, confirms the importance of pursuing early gastrostomy tube placement and contrast administration when post-Roux-en-Y gastric remnant leaks are suspected, and demonstrates the role of paracentesis in critically ill patients with abdominal compartment syndrome.

Double Flap Technique is an Effective Reconstruction Procedure After Proximal Gastrectomy for Gastric Cancer

Background In accordance with an increase of proximal gastric cancer, proximal gastrectomy came to be widely performed. Several types of reconstructive procedures after proximal gastrectomy have been developed and it is still controversial which procedure has the advantages in preservation of postoperative gastric stump function and nutritional status after proximal gastrectomy. In this study, we retrospectively analyzed reconstructive procedures in our consecutive case series for proximal gastrectomy, with particular focus on postoperative body weight maintenance, nutritional status, and gastric remnant functional preservation. Methods We enrolled 69 patients who received proximal gastrectomy for gastric cancer in our institute from 2005 to 2020. Short-term complications, preservation of gastric remnant functions, nutritional status, and post-operative weight changes were compared. Results After proximal gastrectomy, the numbers of cases receiving Direct Esophago-Gastrostomy, Jejunal Interposition, Double Tract Reconstruction, and Double Flap Technique were 9, 10, 14, and 36, respectively. Double Flap Technique cases suffered no reflux esophagitis after surgery. Prevalence of gastric residual at 12-month after surgery of Double Flap Technique was the lowest. Double Flap Technique group has better tendency in post-operative changes of serum albumin ratios. Furthermore, post-operative body weight changes ratio of Double Flap Technique was the smallest and significantly better than Double Tract at all the time points. Conclusions Double Flap Technique after proximal gastrectomy was considered as the most effective reconstruction which can maintain body weight, cause less reflux esophagitis and gastric residual.

Early gastrogastric fistula after Roux-en-Y gastric bypass: successful fistula treatment with self-expandable endoscopic stent

A 25-year-old patient underwent laparoscopic Roux-en-Y gastric bypass surgery with an initially uneventful postoperative course. Two weeks postoperatively, the patient presented with acute abdominal pain. CT scan revealed a gastrogastric fistula from the gastric pouch to the gastric remnant. Laparoscopic drainage was performed, and intraoperative endoscopy confirmed a large gastrogastric fistula. Due to intense adhesions between pouch and remnant, a closure by suture of the fistula was not possible. The fistula was initially treated with a fully covered metal stent. After multiple stent migrations despite clip attachment to the mucosa, the stent was changed to a partially covered metal stent. Fistula healing progress was documented every 2 weeks. After 10 weeks of stent treatment, fistula closure was accomplished.In conclusion, early fistula from the gastric pouch to the gastric remnant is a rare complication and can be managed with endoscopic stent placement.