Radiological evaluation of postoperative gastrointestinal alterations in patients submitted to Fobi-Capella surgery

Abstracts

OBJETIVO: Estudar os achados radiológicos encontrados na seriografia digestiva alta no pós-operatório tardio de cirurgia de Fobi-Capella. MATERIAIS E MÉTODOS: Estudo radiológico de 41 pacientes realizado seis a nove meses após a cirurgia de Fobi-Capella. RESULTADOS: As alterações encontradas foram hérnia hiatal (17%), refluxo gastroesofágico (19,5%) e deslizamento do anel (4,8%). Os achados menos freqüentes foram fístula enterocutânea (2,4%), estenose da anastomose gastrojejunal (2,4%), bezoar (2,4%) e não-visualização do anel em decorrência da sua retirada por intolerância (2,4%). As alterações anatômicas da cirurgia foram claramente demonstradas. CONCLUSÃO: O estudo foi capaz de demonstrar as alterações anatômicas e as complicações da cirurgia de Fobi-Capella.

Obesidade mórbida; Gastroplastia; Seriografia; Cirurgia bariátrica; Fobi-Capella

ORIGINAL ARTICLE

Radiological evaluation of postoperative gastrointestinal alterations in patients submitted to Fobi-Capella surgery^*

Marina Celli Francisco^I; Simone Maluf Barella^I; Thiago Giansante Abud^II; Vanessa Sales Vilar^III; Samuel Reibscheid^IV; Carlos Harou Arasaki^V; Jacob Szejnfeld^VI

^IMDs, Residents, Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^IIMD, Fellow of Body/Abdomen, Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^IIIMD, Fellow of Body/Breast, Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^IVAffiliate Professor, Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^VPhD in Sciences, Teaching of the Discipline of Surgical Gastroenterology at Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^VIPrivate Docent, Head for the Group of Abdomen, Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil

^{Mailing address}

ABSTRACT

OBJECTIVE: The present study was aimed at evaluating radiological findings of delayed postoperative upper gastrointestinal series in patients submitted to Fobi-Capella surgery.

MATERIALS AND METHODS: Radiological studies of 41 patients, six to nine months following the surgery.

RESULTS: The following pathological alterations have been found: hiatal hernia (17%), gastroesophageal reflux disease (19.5%) and sliding of the silastic ring (4.8%). Least frequent findings have been the following: enterocutaneous fistula (2.4%), stenosis of the gastric pouch outlet (2.4%), bezoar (2.4%), and non-visualization of the silastic ring caused by its removal due to patient intolerance (2.4%). Anatomical alterations resulting from the surgery have been clearly demonstrated.

CONCLUSION: The present study could demonstrate anatomical alterations and complications resulting from Fobi-Capella surgery.

Keywords: Morbid obesity; Gastroplasty; Upper gastrointestinal series; Bariatric surgery; Fobi-Capella.

INTRODUCTION

Obesity is a severe public health problem, and, according to a survey performed late in 2004 in a partnership between the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics) and the Brazilian Ministry of Health, 40.6% of the Brazilian population above 20 years of age is overweight, differently from 30 years ago when only 16% of the adult population was affected by obesity. It is estimated that one million Brazilians are morbid obese⁽¹⁾.

The surgery for obesity management is indicated as an alternative for treating morbid obesity resulting in a marked reduction of comorbidities in patients who have not showed response to appropriate clinical treatments. This surgery is regulated by the Brazilian health authorities since 2001, and is performed in institutions that deliver services within the Sistema Único de Saúde (SUS) (Brazilian Public Health System). According to the Ministry of Health statistics, during 2004 in Brazil, 2,014 bariatric surgeries were performed within the SUS⁽¹⁾.

Several surgical techniques are currently available for morbid obesity management^(2–4). Currently, Roux-en-Y gastric bypass (Fobi Capella bariatric surgery) is the most frequently utilized technique for treating morbid obesity, because of its high effectiveness and low morbimortality⁽⁵⁾. This procedure involves the creation of a gastric pouch of approximately 20 cc. The remaining stomach, as well as the duodenum and the first 50 cm of the jejunum remain permanently excluded from the digestive tract. The small gastric pouch is anastomosed to an isolated jejunal loop in a Y configuration and its emptying process is limited by a silicone ring that reduces the gastric lumen to 12 mm. Secretions originated from the excluded stomach and duodenum flow into the jejunum through an anastomosis measuring 100–159 cm, this distance being related to the patient's body mass index (BMI). The silicone ring is distally placed at about 5.5 cm from the esophagogastric transition and 1.5 cm proximal to the gastrojejunal anastomosis⁽⁶⁾.

The method of choice for evaluating alterations resulting from bariatric surgery is the upper gastrointestinal series. Innumerable studies report that some of these complications may be structural (fistulas, intestinal obstruction, stenoses, internal hernias, marginal ulcers) or functional (nausea, emesis, diarrhea, dumping syndrome, constipation and gastroesophageal reflux disease)^(3,7,8).

The present study is aimed at reporting postoperative alterations resulting from Fobi-Capella surgery, diagnosed by upper gastrointestinal series.

MATERIALS AND METHODS

Prospective radiological study of 41 patients submitted to bariatric surgery (Fobi Capella technique) with insertion of a contention ring, between May/2000 and June/2005. Thirty-three of these patients were women, and eight men, with ages ranging between 23 and 63 years (mean age 45.3 years). Postoperative weight loss ranged between 22 kg and 71 kg (mean = 45.6 kg.).

The radiological study was initiated with an upper abdominal plain radiograph. After that, under radioscopic control, the patient was orally given small amounts of 50% barium sulfate, for evaluating the morphology and emptying of esophagus, stomach and anastomosis. Then, the amount of barium ingested was adequately increased, usually up to no more than 150 cc, according to the radiologist control. Radiographs were routinely taken in the following positions: orthostatic, for anteroposterior and oblique views; lateral orthostatic; dorsal decubitus in the right anterior oblique view; ventral decubitus (Schatzky's position).

Other radiographic views were taken under radioscopic control. A proximal jejunal radiograph completed the study. Patients weighting more than 130 kg were evaluated only in the orthostatic position, because the radiological table could not support such a weight.

RESULTS

Postoperative alterations have been found in 51.2% of studies, the most frequent being gastroesophageal reflux disease, followed by seven cases of hiatal hernia, with three patients presenting with both alterations (Table 1).

DISCUSSION

Obesity is a chronic and universal disease whose prevalence continues to increase at concerning rates, especially in Western countries. In the last 30 years, the obese population increased more than 90%⁽⁹⁾.

Bariatric surgery was firstly reported in 1954 by Kremer et al., in a study describing a jejunoileal bypass. The term "bariatric" is originally derived from the Greek baros, meaning "weight", and iatrike, meaning "treatment"⁽¹⁰⁾. In 1986, Mathias Fobi described the gastric bypass technique reported by the present study⁽¹¹⁾.

In the last years, bariatric surgery has gained acceptance both from the medical community and the public in general. It is considered as a relatively safe surgery⁽¹²⁾ (Figure 1).

With the remarkable increase in the incidence of morbid obesity, gastroplasty surgeries, particularly Fobi-Capella surgeries, have become increasingly frequent, so the knowledge of the technique and possible alterations and complications become more and more significant, considering that the clinical examination of these patients is impaired by the obesity itself. Many times, the radiologist is the first to detect complications as a result from this surgery. By this reason, it is extremely important that the specialist knows the possible complications as well as their appearance in imaging studies.

An extensive literature review has shown that 72.6% of the patients submitted to bariatric surgery were women, a data that also has shown to be more prevalent in the present casuistic, corresponding to 80.5% of the patients submitted to this procedure. Mean age was 38.97 years, a little below the mean age of the population included in the present study (45.3 years). The mortality rate described in the literature is 0.5%. An analysis of 936 gastroplasty surgeries has demonstrated a mean weight loss of 39.45 kg, a little below the 45.6 kg found in the present study⁽¹³⁾.

Upper gastrointestinal series have shown alterations in 51.2% of patients, however, not all gastroesophageal reflux diseases and hiatal hernias should be considered as postoperative surgical complications, considering that a preoperative examination has not been performed. With the exclusion of these complications, the total of remaining complications would correspond to 14.3%, a little below the percentage reported in the literature (20–25%)⁽¹⁴⁾. In another study performed by Arasaki et al., who have also performed the surgeries in the present study, 23% of patients have presented postoperative gastroesophageal reflux disease when a standard-sized silicone ring was utilized, and only 8% with a little larger ring, therefore it may be concluded that the resulting lower esophageal sphincter function may be related to some cases of postoperative gastroesophageal reflux disease⁽⁶⁾ (Figures 2 and 3).

In the present casuistic, 4.8% of patients presented sliding of the silicone ring, and in 2.4% of cases, the ring could not be visualized because of its removal due the patient´s intolerance. Closset et al., who have followed-up 214 patients, have reported the ring removal in 4.2% of cases⁽¹⁵⁾. Plain radiography plays an extremely significant role in the definition of the silicone ring presence and topography (Figure 4).

Stenosis of gastrojejunal anastomosis was found in only one patient (2.4%), a little below the percentages reported by the literature (3–27%)^(14–18). DeMaria et al. have evaluated 281 patients and reported this event in 6.6% of cases⁽¹⁷⁾.

Ulcers may be caused by exposure to gastric acids from the gastrojejunal anastomosis or by ischemia. Studies in the literature report ulcers occurrence in 1% to 5% of cases, however, no case of ulcer was found in the present study^(14–17).

The present study has found one case of bezoar (2.4%), while the literature reports a 1.9% incidence⁽¹⁹⁾. Also, one case of enterocutaneous fistula was found, while Capella et al. report a low incidence of this complication⁽²⁰⁾.

CONCLUSION

In the present study, upper gastrointestinal series has clearly demonstrated postoperative alterations in patients submitted to Fobi-Capella surgery. Gastroesophageal reflux disease (19.5%) and hiatal hernia (17%) cannot be attributed to the surgery, considering that a preoperative examination was not performed.

The radiological technique has been considered as satisfactory. The plain radiograph is mandatory for demonstrating the silicone ring presence and topography.

REFERENCES

Received September 7, 2006. Accepted after revision November 27, 2006.

• ¹
  Obesidade: SUS realiza três novos tipos de cirurgia para redução do estômago. [Acessado em: 23/7/2005]. Disponível em: http:/portal.saude.gov.br/portal
• 2. Buchwald H; Consensus Conference Panel. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg 2005;200:593604.
• 3. Capella JF, Capella RF. An assessment of vertical banded gastroplasty Roux-en-Y gastric bypass for the treatment of morbid obesity. Am J Surg 2002;183:117123.
• 4. Capella RF, Capella JF, Mandec H, Nath P. Vertical banded gastroplasty gastric bypass: preliminary report. Obes Surg 1991;1:389395.
• 5. Garrido ABJ. Cirurgia em obesos mórbidos: experiência pessoal. Arq Bras Endocrinol Metab 2000;44:106113.
• 6. Arasaki CH, Del Grande JC, Yanagita ET, Alves AK, Oliveira DR. Incidence of regurgitation after the banded gastric bypass. Obes Surg 2005;15: 14081417.
• 7. Huang CS, Farraye FA. Complications following bariatric surgery. Tech Gastrointest Endosc 2006; 8:5465.
• 8. Smith C, Gardiner R, Kubicka RA, Dieschbourg JJ. Radiology of gastric restrictive surgery. RadioGraphics 1985;5:193216.
• 9. Faria OP, Pereira VA, Gangoni CMC, et al. Obesos mórbidos tratados com gastroplastia redutora com bypass gástrico em Y de Roux: análise de 160 pacientes. Brasília Med 2002;39:2634.
• 10. Salameh JR. Bariatric surgery: past and present. Am J Med Sci 2006;331:194200.
• 11. Fobi MAL, Fleming AW. Vertical banded gastroplasty vs gastric bypass in the treatment of obesity. J Natl Med Assoc 1986;78:10911098.
• 12. Nguyen NT, Silver M, Robinson M, et al. Result of a National Audit of Bariatric Surgery Performed at Academic Centers; a 2004 University HealthSystem Consortium Benchmarking Project. Arch Surg 2006;141:445450.
• 13. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:17241737.
• 14. Sandrasegaran K, Rajesh A, Lall C, Gómez GA, Lappas JC, Maglinte DD. Gastrointestinal complications of bariatric Roux-en-Y gastric bypass surgery. Eur Radiol 2005;15:254262.
• 15. Closset J, Mehdi A, Barea M, Buedts K, Gelin M, Houben JJ. Results of silastic ring vertical gastroplasty more than 6 years after surgery: analysis of a cohort of 214 patients. Obes Surg 2004;14: 12331236.
• 16. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515529.
• 17. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 2002;235:640647.
• 18. Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg 2000;135:10291033.
• 19. Ferraz AAB, Sá VCT, Arruda PCL, Leão CS, Campos JM, Ferraz EM. Obstrução gastrointestinal por fitobezoar na cirurgia bariátrica. Rev Col Bras Cir 2006;33:3538.
• 20. Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg 1996;171:7479.

*

Study developed in the Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, SP, Brazil.

Publication Dates

• Publication in this collection
  21 Sept 2007
• Date of issue
  Aug 2007

History

• Accepted
  27 Nov 2006
• Received
  07 Sept 2006