1

Emergency Radiology in Bariatric Surgery

Magnus Sundbom, Ass Prof Head of Esophageal and Gastric Surgery Uppsala, 15th of May 2013

Case from Uppsala

•  39-year man, 50-kg weight loss after gastric bypass •  Episodes with colicky pain

•  Emergency laprotomy –  Necrotic small bowel –  Resection > 3m

•  Short bowel syndrome •  Long hospital stay, death

2

Internal Hernia

•  Entrapment of the small bowel •  Warning signs

–  Colicky pain –  Laparoscopic operation –  Maximum weight loss

•  1-2 years postop

High level of suspicion in all bariatric patients

Radiology

•  Dilated prox small bowel •  Normal distal loops

•  Swirl sign

•  Dilated excluded stomach

3

4

5

End

Focus on two main areas

1.  Why operate?

2.  Changes in anatomy?

6

Morbidly obese patients have

•  High risk of comorbidities –  Diabetes, sleep apnea, CHD

•  Shortened life expectancy –  7 years at BMI>40

•  Reduced quality of life –  Spinal cord injury, cancer with metastasis

Indications for bariatric surgery

•  Failed conservative treatment – Diet, medication, and others

•  BMI>35 kg/m2 (100 kg) –  Mean weight 130-160 kg

•  18-60 years

•  Understand the life-long consequences

7

Operative technique Gastric bypass (GBP) •  Exclude the stomach

–  Small gastric pouch –  Quick passage into

the small bowel

•  Laparoscopy –  94% av all GBPs –  2-day hospital stay

Weight loss during the first year

Johansson L, Roos M, Kullberg J, Weis J, Ahlström H, Sundbom M, Edén Engström B, Karlsson FA. Lipid Mobilization Following Gastric Bypass Examined by Magnetic Resonance Imaging. Obes Surg. 2008

8

Results

•  Weight loss of 14 BMI-units –  45-60 kg or 70% of previous overweight

•  Reduced sleep apnea, CHD, mortality •  Diabetes

–  Remission in 65% of diabetics –  6 operations prevent 1 case of diabetes

•  Improved quality of life –  92% of Uppsala patients satisfied at 10 years

Changes in anatomy

•  Internal hernia – Behind Roux limb – Small bowel

•  Enteroanastomosis

9

Entero-enteroanastomosis

Defect often closed with suture or clips at present

Carucci L R et al. Radiology 2009;251:762-770

Herniation behind entero-enteroanastomosis

Most common! Distal bowel loops caught in hernia

10

•  Bariatric surgery helps morbidly obese – Comorbidity, life expectancy, QoL

•  10-fold increase in number of operations

Please help us find internal hernias!

Conclusion