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Radiologic evaluation before gastric bypass for morbid obesity
Radiologic EvaluationBefore Gastric Bypass for Morbid Obesity James 0. Bova, 00, San Antonio, Texas John Ft. Robinson,MO, kan Antonio, Texas Arthur S. McFee, MO, San Antonio, Texas
Over the last two decades, the surgical management of morbid obesity has gained in popularity and acceptance. Initially, jejunoileal bypass procedures were performed. The purpose of this technique was to limit the caloric absorption by reducing the length of the small intestine. However, because of the number of complications, especially metabolic, inherent in this type of operation, the approach has become less .popular. More recently, gastric parti+ tioning procedures have gained favor for the surgical treatment of morbid obesity. In 1967, Mason and Ito [Z] introduced the gastric bypass operation. This type of procedure produces weight loss by restricting caloric intake without interfering with the absorptive capacity of the bowel, thus avoiding many of the complications of the jejunoileal bypass operation. The gastric bypass originally described by Mason and Ito involved transection of the stomach so that the upper segment had a small pouch of approximately 60 cm3, with the cut end almost completely oversewn, leaving a small stoma for anastomosis to a loop of jejunum brought out through an opening in the transverse mesocolon. An end-to-side gastrojejunostomy was then performed. Over the years there have been modifications of this original technique. The procedure currently used in our institution is the Griffen modification of the Alden technique. This procedure avoids transection of the stomach and involves a staple line across the upper stomach, leaving a small pouch of approximately 60 cm3 followed by a side-to-side gastrojejunostomy along the greater curvature of the pouch to a Roux-Y loop of jejunum [Z]. Most of the reported series of gastric bypass surgery for morbid obesity have indicated that, as part of preoperative evaluation, radiographic contrast From the Departments of Radiology and Surgery, The University of Texas Health Science Certter at San Antonio, San Antonio, Texas. Requests for reprints should be addressed to James G. Swa, DO, The University of Texas Health Scwnce Center at San Antonlo. 7703 Floyd Curl Drive, San Antonio, Texas 78284.
372
examinations have been performed on the gastrointestinal tract, including the gallbladder. However, to our knowledge, the results of the preoperative studies have not been noted. There have been a number of articles describing the postoperative radiographic findings, both normal and abnormal [3-51. It is our purpose to report the results of the preoperative radiographic studies of the gastrointestinal tract in a series of patients who had gastric bypass for morbid obesity. Material and Methods All referral candidates for this procedure were evaluated by a team consisting of a surgeon, a gastroenterologist, a psychiatrist, a psychologist, a respirologist, and a nutritionist. Several criteria served as guidelines for selection of possible patients. They included severe obesity defined as a weight that was 45.5 kg (100 pounds) over the ideal weight for at least 5 years, documented evidence of previous failures of vigorous efforts at dietary management, absence of any correctable endocrinopathy, absence of disease that significantly increases the risk of surgery, the presence of specific complications of obesity, and reasonable assurance of the patient’s cooperation in the preoperative and postoperative assessment and prolonged follow-up evaluation. The preoperative evaluation included a standard battery of laboratory tests. Echocardiography, pulmonary function studies, measurements of arterial blood gases, and sigmoidoscopy were performed. Radiographic evaluation included chest films, upper gastrointestinal series, barium enema, and oral cholecystogram. The small bowel follow-through examination was undertaken in patients who had previous jejunoileal bypass surgery. The oral cholecystograms that were performed were carried out in the standard double-dose fashion with commercially available contrast agents. The upper gastrointestinal examinations performed were of the biphasic type and included double-contrast and single-contrast views of the esophagus, stomach, and duodenum. Double-contrast barium enemas were performed in the standard fashion. The data recorded for this report were obtained from initial reports from the radiology department. The patients who did not have visualization of the gallbladder on oral
The American Journal of Surgery
Radiologic Evaluation Before Gastrk Etypass
cholecystogram had sonography of the gallbladder, and those data were also recorded. Results A total of 69 patients were accepted for operation. One of the patients did not have the complete preoperative gastrointestinal evaluation and thus was excluded from the analysis. One other patient had undergone gastroplasty previously for obesity and was also excluded from analysis. The age range was 21 to 73 years (mean 36 years). Women outnumbered men 3:l. Twelve of the 67 patients who underwent oral cholecystogram had previous cholecystectomies for cholelithiasis, for an incidence of previously treated gallbladder disease of 17.9 percent. Four patients had gallstones. In eight patients, there was nonvisualization of the gallbladder, one of which was due to vomiting of the contrast tablets. This patient had a normal sonogram and the gallbladder was normal at operation. One other patient had a normal sonogram and was also normal at operation. The remaining six patients with nonvisualixation had gallstones found by sonography and at operation. The preoperative diagnosis of gallstones was 14.6 percent (10 of 67 patients). Forty-three examinations revealed no abnormalities. In this group of patients, there was a total of 22 of 67 with previously treated or newly diagnosed gallstone disease (an incidence of 32.8 percent). There were 61 patients with normal findings on examination of the upper gastrointestinal tract. One patient had a small hiatal hernia without reflux, and three patients had hiatal hernias with reflux. One of the latter patients had evidence of reflux esophagitis. Two patients had incidental duodenal diver&&. No other abnormalities were found. Small bowel follow-through examination was not carried out in 59 patients. There were four patients who underwent this examination who had a previously performed jejunoileal bypass. Other than the altered anatomy, no radiographic abnormality was seen. Six other patients without previous small bowel procedures also had this examination and all had normal findings. Forty-nine double-contrast barium enema examinations revealed no abnormalities. There was one failed examination. This patient had an antegrade peroral examination which revealed no abnormalities. Sixteen patients had diverticulosis of a mild to moderate degree, predominately of the left colon. One patient had a mass in the cecal region at the iliocecal valve. At colonoscopy, this was confirmed to be a prominent fatty iliocecal valve, and no tumor was found. Comments The routine preoperative radiographic evaluation of the gastrointestinal tract has been a consistent part of the protocol in patients requesting gastric bypass
vohnlm
147, March 1984
procedures for obesity. This “standard workup” appears to be performed without much consideration as to the expected results or relation to the actual results obtained. The main purpose of these preoperative studies is to rule out disease that can be surgically managed at the same time a gastric bypass operation is performed [5]. Patients with hiatal hernia and reflux esophagitis or other preexisting gastrointestinal disease, such as peptic ulcer, have been denied gastric bypass procedures because of the high incidence of postoperative esophagitis and gastritis occurring with the procedure described by Mason and Ito [2,6]. However, with the technique used in our series of patients, which included a Roux-Y anastomosis, biliary reflex gastritis and esophagitis have not been a problem postoperatively. There was one patient with the preoperative diagnosis of reflux esophagitis in whom no antirefhrx procedure was performed nor did the patient have difficulty postoperatively. Our incidence of cholecystectomy for cholelithiasis at the time of gastric bypass surgery was consistent with previous reports (14.6 percent) [3,7j. The overall incidence of gallstone disease, including those with previous cholecystectomies, was quite high (32.8 percent). Therefore, there is no question that all patients having gastric bypass surgery should have preoperative evaluation of their gallbladder for gallstone disease. The lack of significant radiographic fmdii in the evaluation of the upper and lower portions of the gastrointestinal tract in our series of patients does not support the use of these studies in the routine preoperative evaluation. Of course, patients who have signs (for example, guaiac positive stool), symptoms of gastrointestinal disease, or significant previous known disease should be examined preoperatively. It is important to note that technically, examinations on these patients are very difficult because of their massive size. There are weight limits (396 pounds in our radiology department) for the fluoroscopic-radiographic table above which there is increasing risk of mechanical breakage. Other technical problems in completing satisfactory examinations include the difficulty in positioning patients for optimal radiographs, inability to place the image intensifier over the patient, the extreme difficqlty during fluoroscopy of seeing the intraobdominal structures to be examined, and the suboptimal radiographs due to marked scatter radiation. There are also time and cost considerations involved with these studies. The analysis of the results of preoperative radiographic evaluation of the gastrointestinal tract in this series of patients indicates such an insignificant yield that unless the patient has a history of gastrointestinal disease, a previous gastric operation, or current gastrointestinal tract symptoms, routine upper gas-
373
trointestinal series, and double-contrast enemas are unnecessary.
barium
Summary During a 4 year period, 69 patients received gastric bypass with stapling and Roux-Y gastrojejunostomy for morbid obesity. The results of 67 preoperative radiologic evaluations of the gastrointestional tract were analyxed. Of these patients, 17.9 percent (12 of 67) had previous cholecystectomy for cholelithiasis; 14.6 percent (10 of 67) had cholelithiasis found on preoperative evaluation. This gave an overall incidence of gallbladder disease of 32.3 percent. The upper gastrointestinal examination revealed four patients with hiatal hernia, three with reflux, and one with evidence of reflux esophagitis. Two patients had one duodenal diverticulum each. Ten small bowel follow-through examinations were performed, six of which revealed no abnormalities and four of which were consistent with previous jejunoileal bypass. Results of air-contrast barium enema showed 1 patient with a cecal mass which was subsequently found to be a fatty iliocecal valve and 16 patients had diverticulosis without evidence of diverticulitis. The remainder of the findings of all studies were unre-
See
374
markable. When all is considered, including radiation dose, difficulty in performing examinations, and cost, we conclude that because of the low incidence of significant abnormalities, routine preoperative evaluation of these patients should only include radiographic or sonographic evaluation of the gallbladder. Other examinations should be obtained if the patients have current symptoms or previous gastrointestinal disease or gastric surgery. References 1. Mason EE, fto C. Gastric bypass in obesity. Surg Clin North Am 1967;47:1347-51. 2. Qiffen WO Jr. Gastrff bypass for morbkl obestiy. Svg Clin Nrxth Am 1979;59:1103-12. 3. Agha FP, Harris HH, Boustany MM. Gastroplasty for morbid obesity-roentgen evaluation and spectrum of complications. Gastrointest Radio1 1982;7:217-23. 4. Koehler RE. Halverson JD. Radiographic abnormalities after gastric bypass. AJR 1982;138:267-70. 5. Pot&e A, Peat K, Lorman JB. Hatffefd DR. Gfffen WO Jr. Gastric operation for the morbiily obese. AJR 1981;136:867-70. 6. Hsrmreck AS. Jewel1 WR, Hardin CA. Gastric bypass for morbkl obesity: results and complications. Surgery 1978;80:498505. 7. Hafverson JD, Zuckerman GR, Koehler RE, Gentry K, Michael HEB, DeSchryver-Kecskemeti K. Gastric bypass for morbid obesity. Ann Surg 1981;194:152-60.
page 427 for a related editorial comment.
The American Journal of Surgery
Over the last two decades, the surgical management of morbid obesity has gained in popularity and acceptance. Initially, jejunoileal bypass procedures were performed. The purpose of this technique was to limit the caloric absorption by reducing the length of the small intestine. However, because of the number of complications, especially metabolic, inherent in this type of operation, the approach has become less .popular. More recently, gastric parti+ tioning procedures have gained favor for the surgical treatment of morbid obesity. In 1967, Mason and Ito [Z] introduced the gastric bypass operation. This type of procedure produces weight loss by restricting caloric intake without interfering with the absorptive capacity of the bowel, thus avoiding many of the complications of the jejunoileal bypass operation. The gastric bypass originally described by Mason and Ito involved transection of the stomach so that the upper segment had a small pouch of approximately 60 cm3, with the cut end almost completely oversewn, leaving a small stoma for anastomosis to a loop of jejunum brought out through an opening in the transverse mesocolon. An end-to-side gastrojejunostomy was then performed. Over the years there have been modifications of this original technique. The procedure currently used in our institution is the Griffen modification of the Alden technique. This procedure avoids transection of the stomach and involves a staple line across the upper stomach, leaving a small pouch of approximately 60 cm3 followed by a side-to-side gastrojejunostomy along the greater curvature of the pouch to a Roux-Y loop of jejunum [Z]. Most of the reported series of gastric bypass surgery for morbid obesity have indicated that, as part of preoperative evaluation, radiographic contrast From the Departments of Radiology and Surgery, The University of Texas Health Science Certter at San Antonio, San Antonio, Texas. Requests for reprints should be addressed to James G. Swa, DO, The University of Texas Health Scwnce Center at San Antonlo. 7703 Floyd Curl Drive, San Antonio, Texas 78284.
372
examinations have been performed on the gastrointestinal tract, including the gallbladder. However, to our knowledge, the results of the preoperative studies have not been noted. There have been a number of articles describing the postoperative radiographic findings, both normal and abnormal [3-51. It is our purpose to report the results of the preoperative radiographic studies of the gastrointestinal tract in a series of patients who had gastric bypass for morbid obesity. Material and Methods All referral candidates for this procedure were evaluated by a team consisting of a surgeon, a gastroenterologist, a psychiatrist, a psychologist, a respirologist, and a nutritionist. Several criteria served as guidelines for selection of possible patients. They included severe obesity defined as a weight that was 45.5 kg (100 pounds) over the ideal weight for at least 5 years, documented evidence of previous failures of vigorous efforts at dietary management, absence of any correctable endocrinopathy, absence of disease that significantly increases the risk of surgery, the presence of specific complications of obesity, and reasonable assurance of the patient’s cooperation in the preoperative and postoperative assessment and prolonged follow-up evaluation. The preoperative evaluation included a standard battery of laboratory tests. Echocardiography, pulmonary function studies, measurements of arterial blood gases, and sigmoidoscopy were performed. Radiographic evaluation included chest films, upper gastrointestinal series, barium enema, and oral cholecystogram. The small bowel follow-through examination was undertaken in patients who had previous jejunoileal bypass surgery. The oral cholecystograms that were performed were carried out in the standard double-dose fashion with commercially available contrast agents. The upper gastrointestinal examinations performed were of the biphasic type and included double-contrast and single-contrast views of the esophagus, stomach, and duodenum. Double-contrast barium enemas were performed in the standard fashion. The data recorded for this report were obtained from initial reports from the radiology department. The patients who did not have visualization of the gallbladder on oral
The American Journal of Surgery
Radiologic Evaluation Before Gastrk Etypass
cholecystogram had sonography of the gallbladder, and those data were also recorded. Results A total of 69 patients were accepted for operation. One of the patients did not have the complete preoperative gastrointestinal evaluation and thus was excluded from the analysis. One other patient had undergone gastroplasty previously for obesity and was also excluded from analysis. The age range was 21 to 73 years (mean 36 years). Women outnumbered men 3:l. Twelve of the 67 patients who underwent oral cholecystogram had previous cholecystectomies for cholelithiasis, for an incidence of previously treated gallbladder disease of 17.9 percent. Four patients had gallstones. In eight patients, there was nonvisualization of the gallbladder, one of which was due to vomiting of the contrast tablets. This patient had a normal sonogram and the gallbladder was normal at operation. One other patient had a normal sonogram and was also normal at operation. The remaining six patients with nonvisualixation had gallstones found by sonography and at operation. The preoperative diagnosis of gallstones was 14.6 percent (10 of 67 patients). Forty-three examinations revealed no abnormalities. In this group of patients, there was a total of 22 of 67 with previously treated or newly diagnosed gallstone disease (an incidence of 32.8 percent). There were 61 patients with normal findings on examination of the upper gastrointestinal tract. One patient had a small hiatal hernia without reflux, and three patients had hiatal hernias with reflux. One of the latter patients had evidence of reflux esophagitis. Two patients had incidental duodenal diver&&. No other abnormalities were found. Small bowel follow-through examination was not carried out in 59 patients. There were four patients who underwent this examination who had a previously performed jejunoileal bypass. Other than the altered anatomy, no radiographic abnormality was seen. Six other patients without previous small bowel procedures also had this examination and all had normal findings. Forty-nine double-contrast barium enema examinations revealed no abnormalities. There was one failed examination. This patient had an antegrade peroral examination which revealed no abnormalities. Sixteen patients had diverticulosis of a mild to moderate degree, predominately of the left colon. One patient had a mass in the cecal region at the iliocecal valve. At colonoscopy, this was confirmed to be a prominent fatty iliocecal valve, and no tumor was found. Comments The routine preoperative radiographic evaluation of the gastrointestinal tract has been a consistent part of the protocol in patients requesting gastric bypass
vohnlm
147, March 1984
procedures for obesity. This “standard workup” appears to be performed without much consideration as to the expected results or relation to the actual results obtained. The main purpose of these preoperative studies is to rule out disease that can be surgically managed at the same time a gastric bypass operation is performed [5]. Patients with hiatal hernia and reflux esophagitis or other preexisting gastrointestinal disease, such as peptic ulcer, have been denied gastric bypass procedures because of the high incidence of postoperative esophagitis and gastritis occurring with the procedure described by Mason and Ito [2,6]. However, with the technique used in our series of patients, which included a Roux-Y anastomosis, biliary reflex gastritis and esophagitis have not been a problem postoperatively. There was one patient with the preoperative diagnosis of reflux esophagitis in whom no antirefhrx procedure was performed nor did the patient have difficulty postoperatively. Our incidence of cholecystectomy for cholelithiasis at the time of gastric bypass surgery was consistent with previous reports (14.6 percent) [3,7j. The overall incidence of gallstone disease, including those with previous cholecystectomies, was quite high (32.8 percent). Therefore, there is no question that all patients having gastric bypass surgery should have preoperative evaluation of their gallbladder for gallstone disease. The lack of significant radiographic fmdii in the evaluation of the upper and lower portions of the gastrointestinal tract in our series of patients does not support the use of these studies in the routine preoperative evaluation. Of course, patients who have signs (for example, guaiac positive stool), symptoms of gastrointestinal disease, or significant previous known disease should be examined preoperatively. It is important to note that technically, examinations on these patients are very difficult because of their massive size. There are weight limits (396 pounds in our radiology department) for the fluoroscopic-radiographic table above which there is increasing risk of mechanical breakage. Other technical problems in completing satisfactory examinations include the difficulty in positioning patients for optimal radiographs, inability to place the image intensifier over the patient, the extreme difficqlty during fluoroscopy of seeing the intraobdominal structures to be examined, and the suboptimal radiographs due to marked scatter radiation. There are also time and cost considerations involved with these studies. The analysis of the results of preoperative radiographic evaluation of the gastrointestinal tract in this series of patients indicates such an insignificant yield that unless the patient has a history of gastrointestinal disease, a previous gastric operation, or current gastrointestinal tract symptoms, routine upper gas-
373
trointestinal series, and double-contrast enemas are unnecessary.
barium
Summary During a 4 year period, 69 patients received gastric bypass with stapling and Roux-Y gastrojejunostomy for morbid obesity. The results of 67 preoperative radiologic evaluations of the gastrointestional tract were analyxed. Of these patients, 17.9 percent (12 of 67) had previous cholecystectomy for cholelithiasis; 14.6 percent (10 of 67) had cholelithiasis found on preoperative evaluation. This gave an overall incidence of gallbladder disease of 32.3 percent. The upper gastrointestinal examination revealed four patients with hiatal hernia, three with reflux, and one with evidence of reflux esophagitis. Two patients had one duodenal diverticulum each. Ten small bowel follow-through examinations were performed, six of which revealed no abnormalities and four of which were consistent with previous jejunoileal bypass. Results of air-contrast barium enema showed 1 patient with a cecal mass which was subsequently found to be a fatty iliocecal valve and 16 patients had diverticulosis without evidence of diverticulitis. The remainder of the findings of all studies were unre-
See
374
markable. When all is considered, including radiation dose, difficulty in performing examinations, and cost, we conclude that because of the low incidence of significant abnormalities, routine preoperative evaluation of these patients should only include radiographic or sonographic evaluation of the gallbladder. Other examinations should be obtained if the patients have current symptoms or previous gastrointestinal disease or gastric surgery. References 1. Mason EE, fto C. Gastric bypass in obesity. Surg Clin North Am 1967;47:1347-51. 2. Qiffen WO Jr. Gastrff bypass for morbkl obestiy. Svg Clin Nrxth Am 1979;59:1103-12. 3. Agha FP, Harris HH, Boustany MM. Gastroplasty for morbid obesity-roentgen evaluation and spectrum of complications. Gastrointest Radio1 1982;7:217-23. 4. Koehler RE. Halverson JD. Radiographic abnormalities after gastric bypass. AJR 1982;138:267-70. 5. Pot&e A, Peat K, Lorman JB. Hatffefd DR. Gfffen WO Jr. Gastric operation for the morbiily obese. AJR 1981;136:867-70. 6. Hsrmreck AS. Jewel1 WR, Hardin CA. Gastric bypass for morbkl obesity: results and complications. Surgery 1978;80:498505. 7. Hafverson JD, Zuckerman GR, Koehler RE, Gentry K, Michael HEB, DeSchryver-Kecskemeti K. Gastric bypass for morbid obesity. Ann Surg 1981;194:152-60.
page 427 for a related editorial comment.
The American Journal of Surgery