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Imaging studies after bariatric surgery

Marina Kurian, MD
Section Editor
Daniel Jones, MD
Deputy Editor
Wenliang Chen, MD, PhD


Postoperative radiographic imaging studies following bariatric surgical procedures are typically obtained to identify the integrity and patency of anastomoses and to identify postoperative complications (eg, anastomotic leaks) precisely and early [1]. In addition, for patients who have had a gastric banding procedure, radiographic images allow for evaluation of band position and the size of the gastric pouch.

This topic review will present the normal and abnormal findings seen on radiologic evaluation after gastric banding, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion. An overview of the various bariatric procedures and their complications and the role of endoscopic management of gastrointestinal complications of the most common bariatric surgical procedures are presented separately. (See "Bariatric operations for management of obesity: Indications and preoperative preparation" and "Late complications of bariatric surgical operations" and "Endoscopy in patients who have undergone bariatric surgery".)


There is no consensus as to whether imaging should be performed routinely, or selectively following bariatric surgery [2-4]. Before initiating a diet, most bariatric surgeons who obtain imaging following bariatric procedures that involve an anastomosis or stapling get an upper gastrointestinal series (UGI) series on postoperative day one. The advantage of this approach is that any leak, if present, can be addressed quickly. However, some surgeons only perform postoperative imaging selectively, based upon the patient's clinical progress [4-6].

A systematic review evaluated the sensitivity and specificity of UGI from data obtained from 19 studies involving 10,139 patients [7]. UGI had an overall sensitivity of 54 percent and a specificity of 100 percent for detecting anastomotic leak within two days of bariatric surgery. The threshold used to distinguish between positive and negative test results varied between institutions. Given the moderate sensitivity, the authors of this study suggested that treating marginal radiological evidence of leakage as presumptively positive maximizes the clinical utility of UGI. Although a majority of articles show that UGI series are better for identifying leak following bariatric surgery, a later study found better sensitivity and specificity with abdominal computed tomography (CT) compared with UGI (100 versus 95 percent) [8]. Irrespective of imaging modality chosen, any clinical suspicion of leak warrants investigation.

When bariatric surgery patients present with complaints of heartburn, nausea or vomiting, abdominal pain, or weight loss failure, imaging studies should be obtained to ensure prompt diagnosis of infection, obstruction, ischemia, or mechanical or technical failures of an operation [9,10]. Radiologic examination of severely obese patients can be technically difficult because of patient size, resulting in suboptimal imaging [11].


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Literature review current through: Sep 2016. | This topic last updated: Apr 12, 2016.
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  1. Labrunie, E, Marchiori, E, Pitombo, C. Chapter 41. Radiographic Evaluation and Treatment. In: Pitombo C, Jones K, Higa K, Pareja JC, eds. Obesity Surgery: Principles and Practice. New York: McGraw-Hill; 2008. www.accesssurgery.com/content.aspx?aID=145518. (Accessed on March 13, 2013).
  2. Sims TL, Mullican MA, Hamilton EC, et al. Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003; 13:66.
  3. Doraiswamy A, Rasmussen JJ, Pierce J, et al. The utility of routine postoperative upper GI series following laparoscopic gastric bypass. Surg Endosc 2007; 21:2159.
  4. White S, Han SH, Lewis C, et al. Selective approach to use of upper gastroesophageal imaging study after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:122.
  5. Kolakowski S Jr, Kirkland ML, Schuricht AL. Routine postoperative upper gastrointestinal series after Roux-en-Y gastric bypass: determination of whether it is necessary. Arch Surg 2007; 142:930.
  6. Chousleb E, Szomstein S, Podkameni D, et al. Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients. Obes Surg 2004; 14:1203.
  7. Mbadiwe T, Prevatt E, Duerinckx A, et al. Assessing the value of routine upper gastrointestinal contrast studies following bariatric surgery: a systematic review and meta-analysis. Am J Surg 2015; 209:616.
  8. Bingham J, Shawhan R, Parker R, et al. Computed tomography scan versus upper gastrointestinal fluoroscopy for diagnosis of staple line leak following bariatric surgery. Am J Surg 2015; 209:810.
  9. Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg 2011; 98:1345.
  10. Hampson F, Sinclair M, Smith S. The surgical management of obesity with emphasis on the role of post operative imaging. Biomed Imaging Interv J 2011; 7:e8.
  11. Merkle EM, Hallowell PT, Crouse C, et al. Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging. Radiology 2005; 234:674.
  12. Brethauer SA, Nfonsam V, Sherman V, et al. Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg Obes Relat Dis 2006; 2:643.
  13. Eid I, Birch DW, Sharma AM, et al. Complications associated with adjustable gastric banding for morbid obesity: a surgeon's guides. Can J Surg 2011; 54:61.
  14. Roy-Choudhury SH, Nelson WM, El Cast J, et al. Technical aspects and complications of laparoscopic banding for morbid obesity--a radiological perspective. Clin Radiol 2004; 59:227.
  15. Koppman JS, Poggi L, Szomstein S, et al. Esophageal motility disorders in the morbidly obese population. Surg Endosc 2007; 21:761.
  16. Gulkarov I, Wetterau M, Ren CJ, Fielding GA. Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc 2008; 22:1035.
  17. Kurian M, Sultan S, Garg K, et al. Evaluating gastric erosion in band management: an algorithm for stratification of risk. Surg Obes Relat Dis 2010; 6:386.
  18. Chousleb E, Szomstein S, Lomenzo E, et al. Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2005; 15:24.
  19. Kirshtein B, Avinoach E, Mizrahi S, Lantsberg L. Presentation and management of port disconnection after laparoscopic adjustable gastric banding. Surg Endosc 2009; 23:272.
  20. Edwards MA, Grinbaum R, Schneider BE, et al. Benchmarking hospital outcomes for laparoscopic adjustable gastric banding. Surg Endosc 2007; 21:1950.
  21. Bauman RW, Pirrello JR. Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure--a single surgeon series of 1047 cases. Surg Obes Relat Dis 2009; 5:565.
  22. Rodríguez A, Mosti M, Sierra M, et al. Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced? Obes Surg 2010; 20:1380.
  23. Hope WW, Sing RF, Chen AY, et al. Failure of mesenteric defect closure after Roux-en-Y gastric bypass. JSLS 2010; 14:213.
  24. Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc 2011; 25:1594.
  25. Carucci LR, Turner MA, Shaylor SD. Internal hernia following Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of radiographic findings at small-bowel examination. Radiology 2009; 251:762.
  26. Iannuccilli JD, Grand D, Murphy BL, et al. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Clin Radiol 2009; 64:373.
  27. Ahmed AR, Rickards G, Johnson J, et al. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg 2009; 19:1530.
  28. Rosenkrantz AB, Kurian M, Kim D. MRI appearance of internal hernia following Roux-en-Y gastric bypass surgery in the pregnant patient. Clin Radiol 2010; 65:246.
  29. Decker GA, DiBaise JK, Leighton JA, et al. Nausea, bloating and abdominal pain in the Roux-en-Y gastric bypass patient: more questions than answers. Obes Surg 2007; 17:1529.
  30. Abu Dayyeh BK, Lautz DB, Thompson CC. Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. Clin Gastroenterol Hepatol 2011; 9:228.
  31. Soricelli E, Casella G, Rizzello M, et al. Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy. Obes Surg 2010; 20:1149.
  32. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis 2009; 5:476.
  33. Bellanger DE, Greenway FL. Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 2011; 21:146.
  34. Carter PR, LeBlanc KA, Hausmann MG, et al. Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2011; 7:569.
  35. Braghetto I, Lanzarini E, Korn O, et al. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010; 20:357.
  36. Zundel N, Hernandez JD, Galvao Neto M, Campos J. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech 2010; 20:154.
  37. Iannelli A, Schneck AS, Noel P, et al. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg 2011; 21:832.
  38. Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003; 13:649.
  39. Keidar A, Appelbaum L, Schweiger C, et al. Dilated upper sleeve can be associated with severe postoperative gastroesophageal dysmotility and reflux. Obes Surg 2010; 20:140.
  40. Bellanger DE, Hargroder AG, Greenway FL. Mesenteric venous thrombosis after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2010; 6:109.
  41. Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. Obes Surg 2010; 20:386.
  42. Mitchell MT, Carabetta JM, Shah RN, et al. Duodenal switch gastric bypass surgery for morbid obesity: imaging of postsurgical anatomy and postoperative gastrointestinal complications. AJR Am J Roentgenol 2009; 193:1576.
  43. Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S. Duodenal switch operative mortality and morbidity are not impacted by body mass index. Ann Surg 2008; 248:541.
  44. Roesel DM, Remer EM, Brethauer SA, Schauer PR. Imaging evaluation of laparoscopic greater curvature plication: preliminary observations. AJR Am J Roentgenol 2013; 201:W262.
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