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Frezza EE, Mammarappallil JG, Witt C, Wei C, Wachtel MS. Value of Routine Postoperative Gastrographin Contrast Swallow Studies After Laparoscopic Gastric Banding. Arch Surg. 2009;144(8):766–769. doi:10.1001/archsurg.2009.138
Laparoscopic adjustable gastric banding (LAGB) effectively treats morbid obesity and yields improved quality of life with low morbidity and mortality rates. The current standard of care is to perform a postoperative gastrographin study. This study evaluated a series of patients to determine the usefulness of this routine procedure.
Texas Tech University Health Sciences Center, Lubbock.
A series of 100 patients who had undergone LAGB between August 1, 2006, and February 28, 2007, were evaluated by medical record review and a blinded examination of the upper gastrointestinal tract.
Main Outcome Measures
Laboratory test results and patient vital signs.
The mean age of the patients was 42 years. The mean initial body mass index (calculated as weight in kilograms divided by height in meters squared) was 50.0. Median excess weight loss was 49.0% after 12 months. Three patients did not undergo gastrographin studies because of a history of allergic reactions to the dye. No differences between the opinion of the surgeon and that of the original radiologist were uncovered. The 97 patients who underwent gastrographin studies lacked leaks; the only radiologic abnormalities were slow passage and reflux in 23 patients. No alteration in patient care resulted. The total cost for the 97 patients was $49 470. The 95% confidence interval for 0 useful results for 97 studies is 0.00 to 0.03; at best, 3.2% of patients undergoing this expensive study would have garnered some benefit.
Routine postoperative upper gastrointestinal tract studies are expensive and of limited value. Instead of relying on them to detect leaks, which are extremely rare after LAGB, reliance should be given to the presence or absence of tachypnea and tachycardia, as is currently done for Roux-en-Y gastric bypass. In this way there will be a cost savings and the potential to make LAGB a same-day procedure.
Laparoscopic adjustable gastric banding (LAGB) effectively treats morbid obesity and yields improved quality of life with low morbidity and mortality rates.1-7 A feared complication is a leak from the esophagus or stomach created by the dissection needed for placement of the band.8-12 The current protocol is to perform a postoperative gastrographin study to ensure proper band placement, appropriate passage of food through the stomach, and the absence of a leak,4,12-14 but performance of this procedure remains controversial. We evaluated 100 patients who underwent consecutive LAGB procedures to test the hypothesis that this radiographic study adds no benefit to patient care.
The medical records of 100 consecutive patients who had undergone LAGB between August 1, 2006, and February 28, 2007, at Texas Tech University Health Sciences Center, Lubbock, were retrospectively evaluated after institutional review board approval. Patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) greater than 40, with or without comorbidities, and those with a body mass index of 35 to 40 were candidates for LAGB (Table 1). All patients underwent routine preoperative medical and surgical evaluations, preoperative upper gastrointestinal (GI) tract endoscopic examinations, preoperative esophageal manometric studies, and mechanical evaluation. Follow-up of the patients was performed for 24 hours to evaluate signs of tachycardia and tachypnea. Postoperatively, we evaluated a series of blood tests and vital signs to match with potential upper GI tract abnormalities (Table 2). A liquid diet was instituted on postoperative day 1. The morning after surgery, each patient who did not have a contraindication for a radiologic examination experienced an upper GI tract radiologic examination with gastrographin (Omnipaque; GE Healthcare Services, Chalfont St Giles, England) at a concentration of 300 mg/mL; 30 to 50 mL was swallowed by the patient while standing, after which radiographic images were taken every 2 to 4 seconds. Follow-up images were obtained in both the anteroposterior and left oblique projections at the level of the port and band site. On the morning of the upper GI examination, the surgeon independently read the upper GI tract report at the end of the study and compared it with the radiologic report written by the attending radiologist. Therefore, the surgeon knew about the clinical situation but did not know about the report of the radiologist and the findings of the upper GI tract report because the report had been written by the radiologist after the surgeon had read the study. In this type of reading, the radiologist overestimated some of the reflux and stasis conditions. There was only an 83.0% concordance between the 2 readings.
The data were collected independently by 2 medical students (C.W. and J.G.M.), and the radiographs were interpreted independently by the surgical and radiologic attending physicians. Costs were obtained from the medical records of the patient. The 95% confidence interval for the proportion of patients who might have had an alteration in patient care from the study was calculated by the use of an online calculator.15
Of 100 patients who underwent LAGB, 88 were women. The mean age of the patients was 42 years. The mean initial body mass index was 50.1. The demographics are reported in Table 1. We evaluated laboratory test results and vital signs for each patient, and the results are reported in Table 2. Median excess weight loss was 49.0% after 12 months. Three patients did not undergo gastrographin studies because of a history of allergic reactions to the dye. No differences between the opinion of the surgeon and that of the original radiologist were uncovered. The 97 patients who underwent gastrographin studies lacked leaks; the only radiologic abnormalities were slow passage and reflux in 23 patients. No alteration in patient care resulted. Each study yielded a technical fee charge of $400 and a radiologist bill of $110 for a total of $510 per patient and $49 470 for all 97 patients. The 95% confidence interval for 0 useful results for 97 studies is 0.00 to 0.03; at best, 3% of patients undergoing this expensive study would have garnered some benefit.
This study found that 97 consecutive upper GI tract examinations at a total cost of $49 470 yielded no results that altered patient care. Devised in 1983 and put into practice in 1993, LAGB was the first bariatric procedure that added an element of adjustability to the armamentarium of the bariatric surgeon.15-19 The procedure produces low morbidity and mortality rates,8,9,20,21 with only approximately one-third of patients experiencing problems.22 Approximately 1 in 10 patients require additional surgery in the immediate postoperative period.8-11,22-25 Early complications include band malpositioning, perforation, stomal obstruction, regurgitation, and pouch esophageal reflux; late complications include band herniation, band migration, slippage, port dilatation, port infection, and erosion.8-12,21-33 In 1% of the patients there is improper positioning of the band at surgery30 and early slippage.8,9,11,23 Stomal obstruction may occur in 1.4% of patients, but most of the time this does not require surgery and the medical therapy is sufficient.25 Dysphagia can occur in 14% of patients,21 and regurgitation and pouch esophageal reflux are common and usually resolve with dietary change.12 In the long term, complications include pouch dilatation and slippage of the gastric band.11,12,21,22,30 These complications require a diagnostic tool, such as fluoroscopy.12,21 Other complications, such as intragastric erosion with secondary obstruction, potential leak, and system infection, require surgery.25,26,31 Gastric necrosis occurs in 0.3% of the patients.8-10
Gastroesophageal perforation occurs in less than 0.5% of patients8-12; leaks are usually related to the operative technique and are the most severe immediate postoperative complication. The severity of this complication has rendered postoperative upper GI tract radiologic examinations with gastrographin the standard of care. The rarity of this complication renders somewhat dubious the benefits of performance of a study that costs more than $500 per patient and sometimes fails to detect leaks.34 Moreover, the radiologic study places the patient at risk for aspiration pneumonia, although the exact incidence of these complications has not been determined. Apart from detection of leaks, there is little reason to order such a radiologic study. Radiologic demonstration of free passage of food through the stomach is not mandatory in the postoperative follow-up.35,36 Apart from leaks, all other abnormalities that might be detected by this study are managed without surgery and then only if symptoms that would lead to their detection are bothersome; their radiologic postoperative identification does not serve to advance patient care. Only a potential leak has to be repaired surgically; all others can be treated medically.
In our study, we also evaluated whether there was any correlation between upper GI tract abnormalities and blood test results, such as complete blood cell counts and electrolyte levels, and vital signs, such as blood pressure, heart rate, and oxygenation. As reported in Table 2, no notable differences were found in patients with reflux or stasis. We cannot comment on leaks because we did not have any. Seven patients were seen in the office or in the emergency department for nausea and dehydration, but no correlation was found with previous upper GI tract procedures. For other bariatric procedures, such as Roux-en-Y gastric bypass (RYGBP) and duodenal switch, the best monitor is nonradiologic: tachycardia and tachypnea are sufficiently sensitive to allow surgeons to rely on them to determine when and if a leak should occur and are sufficiently specific to warrant a subsequent operation without any other study.37-42 In our study, we did not have tachycardia or tachypnea, and we did not find any leaks of contrast. We therefore recommend following up the patient for 24 hours for tachycardia and tachypnea. Only a few have recommended routine use of a radiologic study on postoperative day 1 after RYGBP.43-46 Given that the chances of leak after LAGB are much lower than after RYGBP, the rationale for the utility of this expensive study is almost nonexistent in LAGB. An upper GI tract examination can be “selective” by the use of patients who continue to have symptoms, such as tachycardia and tachypnea, or who have a hard time swallowing clear fluid the day after the operation because the examination reveals band tightness and any potential inflammation that probably need to be treated. Patients who have these problems might require longer hospitalization and intravenous fluids before we discharge them postoperatively. Unexplained tachycardia, fever, abdominal pain, elevated white blood cell count, and low urine output are also potential indications of upper GI tract issues.
In conclusion, routine postoperative upper GI tract radiologic studies are expensive and of limited value. Instead of relying on them to detect leaks, which are extremely rare after LAGB, reliance should be given to the presence or absence of tachypnea and tachycardia, as is currently done for RYGBP.
Correspondence: Eldo E. Frezza, MD, MBA, Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, MS 8312, Lubbock, TX 79430 (firstname.lastname@example.org).
Accepted for Publication: July 18, 2008.
Author Contributions:Study concept and design: Frezza and Mammarappallil. Acquisition of data: Mammarappallil, Witt, and Wei. Analysis and interpretation of data: Frezza, Mammarappallil, Witt, and Wachtel. Drafting of the manuscript: Frezza, Wei, and Wachtel. Critical revision of the manuscript for important intellectual content: Frezza, Mammarappallil, and Wachtel. Statistical analysis: Wachtel. Administrative, technical, and material support: Frezza, Mammarappallil, and Witt. Study supervision: Frezza.
Financial Disclosure: None reported.
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