Value of Routine Gastrografin Upper Gastrointestinal Study After Sleeve Gastrectomy | Bariatric Surgery | JAMA Surgery | JAMA Network
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1.
English  WJ, DeMaria  EJ, Brethauer  SA, Mattar  SG, Rosenthal  RJ, Morton  JM.  American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016.  Surg Obes Relat Dis. 2018;14(3):259-263. doi:10.1016/j.soard.2017.12.013PubMedGoogle ScholarCrossref
2.
Gagner  M, Buchwald  JN.  Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review.  Surg Obes Relat Dis. 2014;10(4):713-723.doi:10.1016/j.soard.2014.01.016PubMedGoogle ScholarCrossref
3.
Aurora  AR, Khaitan  L, Saber  AA.  Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.  Surg Endosc. 2012;26(6):1509-1515. doi:10.1007/s00464-011-2085-3PubMedGoogle ScholarCrossref
4.
Sethi  M, Magrath  M, Somoza  E,  et al.  The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.  Surg Endosc. 2016;30(6):2266-2275. doi:10.1007/s00464-015-4516-zPubMedGoogle ScholarCrossref
5.
Mizrahi  I, Tabak  A, Grinbaum  R,  et al.  The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy.  Obes Surg. 2014;24(9):1415-1419. doi:10.1007/s11695-014-1243-9PubMedGoogle ScholarCrossref
6.
Smith  M, Saunders  R, Stuckhardt  L, McGinnis  JM, eds . Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013.
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    Research Letter
    Association of VA Surgeons
    October 31, 2018

    Value of Routine Gastrografin Upper Gastrointestinal Study After Sleeve Gastrectomy

    Author Affiliations
    • 1Case Western Reserve University School of Medicine, Cleveland, Ohio
    • 2Department of General and Bariatric Surgery, Jesse Brown VA Medical Center, Chicago, Illinois
    JAMA Surg. 2019;154(2):181-182. doi:10.1001/jamasurg.2018.3197

    Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric procedure worldwide.1 Leak rates between 0% and 5.5% have been reported.2 The long staple line and high intraluminal pressure synergize to create the risk for leaks.3 Leaks are difficult to manage, and 80% of leaks occur after hospital discharge.4 Many surgeons believe that routine gastrografin upper gastrointestinal (GUGI) series on postoperative day 1 or 2 can aid in earlier identification and intervention and can minimize morbidity and mortality in patients who develop a leak.3 This practice is controversial4 and adds to health care cost and radiation exposure, and it should be abandoned.

    Methods

    This study was approved by the Jesse Brown VA Institutional Review Board. The Institutional Review Board waived patient informed consent because this was a retrospective medical record review.

    We reviewed a prospectively maintained database of LSG performed at a single center (Jesse Brown Veterans Administration Medical Center) by a single surgeon (J.M.V.). The records of consecutive patients (N = 197) who underwent LSG between January 1, 2012, and December 31, 2017, were reviewed. A standardized operative technique was used for all patients with a 34-Fr bougie for sleeve calibration. The gastric resection was performed using a 60-mm linear stapler starting 5 cm proximal to the pylorus. Staple-line reinforcements and intraoperative endoscopy to assess for leaks were used in every case. All patients received GUGI study on postoperative day 1 or 2. Patient demographics, number of GUGI studies, and standard postoperative outcomes were collected. Subsequently, we examined the sensitivity, specificity, and positive and negative predictive value of the GUGI studies. A cost analysis was also performed.

    Results

    Of the 197 patients, 140 (71.1%) were men and 57 (28.9%) were women with a mean (range) age of 51.5 (28-68) years and a mean (range) body mass index of 44.5 (34-66.5) (calculated as weight in kilograms divided by height in meters squared). No deaths occurred. In total, 200 GUGI studies were performed on 197 patients. Twelve patients (6.1%) had more than 1 study because of the delayed transit of contrast seen on initial examination. The leak rate was 1%. Two leaks (1.0%) occurred after hospital discharge on postoperative days 3 and 5, respectively, and both were detected by computed tomography.

    Three false-positive studies (1.5%) occurred, and reoperation was performed on 1 of these patients because of a concerning leukocytosis. The laparoscopic findings determined there was no leak. The other 2 false positives were reviewed by the surgeon and a radiologist and were deemed to be over-reads. Both patients had benign postoperative courses. The positive predictive value and sensitivity of the 200 GUGI studies were both 0, owing to the lack of true positive studies. The specificity was 98.5%. The negative predictive value was 100%, as all negative studies were determined to not have a leak as measured against clinical assessment standards.

    The Veterans Administration does not generate a charge for these radiography studies; however, according to Medicare cost attribution, the cost of a GUGI study is $249 without the professional fee. The total cost to implement these 200 studies would be $47 800. Calculated charges from a nearby private hospital were $840 for 1 study and $160 000 for 200 studies.

    Discussion

    This study demonstrates that GUGI series on postoperative day 1 or 2 is an ineffective tool for the detection of a leak after LSG in asymptomatic patients. Both leaks in this analysis occurred in symptomatic patients after hospital discharge. The false-positive rate of a GUGI study may lead to unnecessary workup, radiation exposure, or reoperation.5 Because of the low incidence of leaks during the index hospitalization, no true-positive x-rays were detected, making the sensitivity and positive predictive value of GUGI essentially 0. These routine radiography studies contribute to the budget of wasteful health care spending, which has been estimated to exceed $200 billion annually.6 In the absence of clinical suspicion, a routinely performed GUGI study after sleeve gastrectomy has low sensitivity and positive predictive value. Its use should be eliminated, and we no longer routinely obtain such studies. Postoperative studies to determine a leak after LSG should be based on symptoms of tachycardia, shoulder or abdominal pain, or other worrisome clinical criteria.

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    Article Information

    Corresponding Author: Joseph M. Vitello, MD, Department of General and Bariatric Surgery, Jesse Brown VA Medical Center, 820 S Damen Ave, Chicago, IL 60612 (joseph.vitello@va.gov).

    Published Online: October 31, 2018. doi:10.1001/jamasurg.2018.3197

    Accepted for Publication: July 8, 2018.

    Author Contributions: Dr J. M. Vitello had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: J. M. Vitello, Beach-Bachmann.

    Acquisition, analysis, or interpretation of data: D. J. Vitello, J. M. Vitello, Bentrem.

    Drafting of the manuscript: D. J. Vitello, J. M. Vitello, Beach-Bachmann.

    Critical revision of the manuscript for important intellectual content: D. J. Vitello, J. M. Vitello, Bentrem.

    Statistical analysis: D. J. Vitello, J. M. Vitello.

    Administrative, technical, or material support: J. M. Vitello, Beach-Bachmann.

    Supervision: J. M. Vitello, Bentrem.

    Conflict of Interest Disclosures: None reported.

    Meeting Presentation: The results of this study were presented at the 2018 Association of VA Surgeons Annual Meeting; May 5, 2018; Miami, Florida.

    References
    1.
    English  WJ, DeMaria  EJ, Brethauer  SA, Mattar  SG, Rosenthal  RJ, Morton  JM.  American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016.  Surg Obes Relat Dis. 2018;14(3):259-263. doi:10.1016/j.soard.2017.12.013PubMedGoogle ScholarCrossref
    2.
    Gagner  M, Buchwald  JN.  Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review.  Surg Obes Relat Dis. 2014;10(4):713-723.doi:10.1016/j.soard.2014.01.016PubMedGoogle ScholarCrossref
    3.
    Aurora  AR, Khaitan  L, Saber  AA.  Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.  Surg Endosc. 2012;26(6):1509-1515. doi:10.1007/s00464-011-2085-3PubMedGoogle ScholarCrossref
    4.
    Sethi  M, Magrath  M, Somoza  E,  et al.  The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.  Surg Endosc. 2016;30(6):2266-2275. doi:10.1007/s00464-015-4516-zPubMedGoogle ScholarCrossref
    5.
    Mizrahi  I, Tabak  A, Grinbaum  R,  et al.  The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy.  Obes Surg. 2014;24(9):1415-1419. doi:10.1007/s11695-014-1243-9PubMedGoogle ScholarCrossref
    6.
    Smith  M, Saunders  R, Stuckhardt  L, McGinnis  JM, eds . Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013.
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