0:02

Hello, and welcome to Noon Conferences hosted by MRI Online.

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In response to the changes happening around

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the world and the shutting down of in-person

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events, we have decided to provide free daily

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Noon Conferences to all radiologists worldwide.

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Today, we are joined by

0:13

Dr. David Coy for a lecture on complications

0:15

following bariatric surgery.

0:17

He completed his diagnostic radiology

0:19

residency and abdominal imaging fellowship

0:21

at the University of Washington.

0:22

He currently serves as chief imaging

0:24

at Virginia Mason Medical Center.

0:25

His area of special interest specialty are

0:27

hepatobiliary and pancreatic imaging and GU imaging.

0:31

A reminder that there will be time at the

0:33

end of this lecture for a Q&A session.

0:35

So please use that Q&A feature

0:36

to ask all of your questions.

0:38

We'll get to as many as we can before our time is up.

0:40

Uh, that being said, thanks so

0:42

much for joining us today.

0:43

Dr.Coy, I will let you take it from here.

0:45

So good, uh, good afternoon or good

0:47

morning, uh, depending on where you're at.

0:49

My name is, uh, David Coy.

0:50

I'm a body imager, uh, here in Seattle.

0:53

Uh, for those of you who are on the video, you can see

0:55

that the sun's just now starting to come up in Seattle.

0:57

We're pretty far up north, so, um,

1:00

we're getting into the short days now.

1:02

Long days in the summer, but short

1:03

days when we get to the winter.

1:04

So it's good to see the sun out, and it's actually

1:06

not even raining right now, so it's great.

1:08

Um, well, I'm going to be talking about

1:10

complications following bariatric surgery.

1:12

These surgeries are very, very common.

1:15

They are still a growth area in, uh, surgery.

1:18

And so you're going to see these things, even

1:21

if you're at a small and medium-sized hospital,

1:23

many of those places have bariatric, um, centers

1:26

of excellence where they do those surgeries.

1:28

Or even if you're not, um, it's so common that when patients

1:32

are coming into the ED, um, or, um, you know, an urgent

1:36

care, you're gonna definitely be seeing them as well.

1:39

So, um, these are my disclosures.

1:41

They're not really relevant to the talk today.

1:45

So just to kind of give a roadmap of where we're headed.

1:48

So we're going to basically focus on three, uh,

1:51

bariatric surgeries, the Roux-en-Y gastric

1:54

bypass, which is a pretty long-standing bariatric

1:58

surgery that's considered the gold standard.

2:01

The laparoscopic adjustable band or the lap band, which

2:05

10 years ago was probably the most

2:07

commonly performed bariatric surgery.

2:09

Now it's really fallen off and is, you know,

2:11

very rarely performed, but you still see

2:14

patients coming in with potential complications.

2:16

So we'll talk about that.

2:17

And then, uh, we'll talk about sleeve gastrectomy,

2:20

which in the last, as laparoscopic band, uh, has become,

2:24

uh, out of favor, the sleeve gastrectomy has

2:26

become in favor and it's gone from about maybe

2:30

15 to 20 percent of the bariatric surgeries done

2:32

on an annual basis to now well over half.

2:34

There are a number of other surgeries that have been

2:37

done in the past, um, switches, um, all kinds of things.

2:42

Um, you really don't see those patients anymore.

2:44

The reason we don't see them is because

2:45

they have a lot of complications.

2:47

And so it's very, very rare that you will ever come

2:50

across a patient who has one of these, um,

2:53

uh, bariatric surgeries, if you haven't

2:55

heard of it, were performed in the 80s.

2:56

I see maybe about one a year in my practice.

2:59

So, um, at this point, they've all

3:01

had complications and been revised

3:03

so it's very uncommon to see other types.

3:05

I think the aim here is just to look at the

3:08

normal appearance on CT and fluoroscopy.

3:11

Um, so you understand what you should be seeing, because

3:14

that's the first step in understanding when you are seeing

3:17

something that you should not be seeing, and sort of come

3:21

to the conclusion that you may be looking at a complication.

3:24

I think that, um, this is one of the

3:26

areas where everything old is new.

3:28

Again, fluoroscopy is not going to ever go away.

3:31

Even though we have great CT scanners

3:32

and MR scanners, because there's, uh,

3:34

they're really complementary, uh, for this.

3:36

There's some things you can see much easier

3:38

under fluoroscopy, um, than you can with CT.

3:41

And sometimes having that dynamic information as you're

3:44

seeing the contrast go by is really, really helpful.

3:46

So they're really complementary, really,

3:48

uh, many of, in many cases rely on both.

3:52

And then we're going to go over and talk about

3:54

some of the more common complications you can see.

3:57

Just as a, um, review.

4:00

Uh, the obesity, uh, is defined based on your BMI.

4:06

In the United States right now, approximately 20%,

4:09

20% of our population is considered overweight,

4:13

roughly around 10% would meet criteria for

4:15

obesity and about 5% for morbid obesity.

4:18

Um, having this bariatric procedure performed,

4:22

at least to be paid for by commercial insurance,

4:24

is usually reserved for people who are morbidly obese.

4:28

Or if you're, um, obese and have other medical complications

4:32

related to your weight, so diabetes type 2 and other

4:35

things, um, then that may be an indication to do the

4:38

surgery, or at least an indication for them to pay to

4:40

do the surgery, um, before you become morbidly obese.

4:43

Uh, right now, we're doing about a quarter of

4:45

a million procedures a year as of 2018,

4:49

and that's been on the, uh, gradual increase.

4:52

So about 10 years ago, it's about

4:54

200,000 a year, now about 252,000.

4:57

So it continues to go up again, still a growth area.

5:01

And regardless of where you practice and

5:03

what kind of practice you're doing, if you're

5:07

looking at CTs of the abdomen or pelvis,

5:09

you're definitely going to be seeing these patients.

5:12

Right now, the average cost runs

5:14

somewhere around 14 to 33,000 dollars.

5:17

Um, it's because of the cost and people

5:20

whose insurance may not pay for it.

5:21

There is a, um, uh, motivation for medical tourism.

5:26

So there are people who leave the

5:28

United States that have the procedure performed if

5:30

they, uh, if their insurance won't cover it.

5:33

Um, in our part of the country in the West,

5:35

it's typically down to Mexico, uh, and then come back up.

5:38

The problem with that, of course, is that I'm sure their

5:42

physicians and surgeons are quite good in Mexico, but the

5:45

problem is if they run into complications, they're a long

5:47

way from where they, from their surgeons and physicians.

5:50

Um, and so, um, I think that can be

5:52

challenging for the patients as well.

5:56

Um, again, understanding the surgical anatomy is

6:00

really, um, vital, uh, because you're going to have a

6:03

hard time figuring out if there's even a complication

6:06

if you don't understand what it's going to look like.

6:08

Again, CT and fluoroscopy are complementary.

6:11

You know, generally speaking, we start when we're

6:13

doing fluoroscopy in these kinds of cases,

6:15

you start out with a water-soluble contrast agent.

6:18

If everything's looking good and, and so

6:20

forth, then you can move on to barium.

6:23

This is old-time radiology literature from the

6:25

eighties, showing that if you're looking for

6:27

subtle leaks, people would start with water soluble.

6:30

If they didn't, they remove to barium

6:32

and occasionally would find a small leak with the

6:34

barium that they didn't see with the water soluble.

6:36

Although, quite honestly, the literature is flawed

6:40

because you don't know whether they saw the leak

6:43

with the barium just because it was really the barium or

6:45

just because it did more swallows, and with more swallows

6:47

eventually you see the leak come up, but that is the

6:50

current teaching based on that old-time literature.

6:54

When I think of complications,

6:55

I like to organize, have them in

6:57

some kind of an organized, uh, form.

6:59

So I think about the type of surgery, and then

7:02

I think about the timing from the surgery.

7:04

Um, so it's a Roux-en-Y or it's a

7:06

gastric band, or it's a sleeve gastrectomy.

7:08

And then are we talking days or weeks after surgery

7:11

or are we talking months or years after surgery?

7:13

So just based on, um, you know, knowing the type of

7:17

surgery and knowing how far out from surgery the patient

7:20

is, you can already sort of narrow down to what you

7:23

really need to be looking for because these are the most

7:25

common things you're going to see in this time frame.

7:27

And so that's the way I'm going

7:28

to present them this afternoon.

7:33

When you look at the complications,

7:35

uh, they come in different flavors.

7:37

Um, so the big headings here are leaks.

7:40

Um, so typically anastomotic leaks, leaks,

7:43

or suture disruptions are things that

7:45

happen pretty early right after surgery.

7:47

Occasionally you can get a leak

7:49

from an ulcer that's, uh, very late.

7:51

So it's usually in the late period following surgery.

7:54

One of the more common issues is obstruction.

7:57

So, uh, you can see some of those sometimes that are seen in

8:00

the early postoperative period, just due to the swelling.

8:03

Other times it can be seen in

8:05

the later postoperative period.

8:06

Postoperative period.

8:07

It can be due to anastomotic strictures,

8:10

internal hernias, adhesions, and also scarring

8:13

from the gastric band, and we'll see examples

8:15

of those coming up in the next few slides.

8:19

With the gastric band, one of the most common

8:21

complications was the band being malpositioned,

8:25

meaning it was placed in the correct location, but

8:28

over time, it slips down the stomach, or some people

8:31

will say there's a gastric protrusion through the

8:33

band, so the band is no longer positioned correctly.

8:35

Or the band can actually partially

8:37

or completely erode into the stomach.

8:39

And these are complications that are usually seen well

8:42

after surgery and kind of the late postoperative period.

8:45

And they occurred with some frequency.

8:47

Um, and so I think this is probably one of the main

8:50

driving forces for why commercial insurance does not

8:53

want to pay for the gastric bands, which are one of the easier

8:56

ones to do that can be done laparoscopically, and it

8:59

doesn't really require much in the way of surgery.

9:02

But because of the high number of complications that

9:04

were encountered after the procedure, um, the commercial

9:08

insurances just decided they did not want to pay for these.

9:11

They wanted them to do either a

9:13

gastric sleeve or a Roux-en-Y.

9:16

And then one of the other things that sometimes you get,

9:18

you may get asked to look at, especially if you're doing

9:21

a fluoroscopy service, are patients who are beginning

9:24

to gain weight after, so they, uh, after their surgery.

9:27

So they lose weight after the surgery,

9:29

and at some point they level out.

9:30

And then beyond that, sometimes

9:32

they start to creep up in weight.

9:33

So the question is, um, has something

9:35

happened, uh, with the surgical anatomy to

9:39

make it easier for the person to gain weight?

9:41

And so we'll also take a look at

9:43

some of those, uh, examples as well.

9:45

And these are just some key references.

9:47

They're, um, they're a little bit old, but still very good.

9:50

Um, you can find them in the Gray Journal,

9:53

the Yellow Journal, and in Radiographics,

9:55

and they're very easily accessed.

9:56

So if you want to find out more detail, these

9:58

are really great references to start out with.

10:03

So we'll start out with the surgical anatomy.

10:07

Um, on the right side of the screen

10:09

is the Roux-en-Y gastric bypass.

10:12

So this is good.

10:13

Kind of a gold standard; it's the one that's best studied.

10:16

Um, and it's sort of a tried and true,

10:20

um, way of doing bariatric surgery.

10:22

As you can see, it's very complex

10:25

in what the surgeon needs to do.

10:27

Um, so I think, um, even though it's the tried

10:30

and true form of best studied, um, it's because

10:33

of the amount of difficulty in doing it.

10:35

It's much more detailed.

10:37

It's probably not done as much.

10:39

Um, on the far left side is the gastric band, which

10:42

I'm sure many of you, if not all of you, have already seen.

10:46

And we'll talk more about that.

10:47

But essentially, put a, um, a ring down just below the

10:52

GE junction, and the ring has an inflatable sleeve within the

10:55

ring that, um, you can inflate or deflate through that port

10:59

by putting saline in or pulling saline out of the port.

11:02

And so you can have, um, and you can

11:05

adjust how tight it is, you know.

11:08

Coming at it, you know, from the mentality when it was

11:12

first developed, it seemed like a great way of doing it.

11:14

It's potentially reversible.

11:16

You can remove the band.

11:17

Um, you know, so you're not really committing to a surgery.

11:21

If it's not working right, you can take it out.

11:23

As I said, the problem that was encountered in real life

11:25

is that there were a lot of complications for patients

11:28

following this, so that's why it's not done anymore.

11:30

But you still will see patients coming in with

11:33

a gastric band and complications from that.

11:35

And then in the middle is the sleeve gastrectomy.

11:37

This is the one that's done most commonly these days.

11:40

Um, essentially what it's done, uh, is that they,

11:44

um, essentially do a suture line and essentially

11:47

they cut out the greater curvature of the stomach.

11:49

So that

11:50

part that says stomach resection there.

11:52

That's completely removed.

11:53

So what you're left with, I don't know if you can

11:55

see my pointer here, but what you're left with

11:57

is this long thin channel from the GE junction.

12:00

And then as you get to the distal stomach and the

12:02

antrum and the pylorus, it kind of opens up and has

12:05

normal size and then drains down into the duodenum

12:08

normally, but you have this sort of long channel.

12:10

So this is, uh, more of a restrictive mechanism.

12:13

The band is really more of a restrictive mechanism.

12:16

The Roux-en-Y is both restrictive, uh, and has from a

12:20

small gastric pouch, and also it has a bypass limb.

12:23

So you actually have both mechanisms

12:25

to sort of get weight down.

12:28

And we'll talk a little bit more about that as it comes up.

12:32

So let's talk about the Roux-en-Y.

12:34

And so if you haven't seen the surgical

12:37

anatomy, it can look a little bit complex.

12:40

We'll look at it sort of on a cartoon, and

12:42

then we'll move on to CT and fluoroscopy so you

12:45

can see what the normal Roux-en-Y looks like.

12:48

So essentially what happens is, uh, and these surgeries

12:52

these days are all done laparoscopically. You know, 10,

12:56

15 years ago, you would still see patients who were having

12:58

open surgery, but I haven't seen a patient in recent times

13:01

who's had an open surgery for these unless there's been

13:04

some kind of complication to try to achieve the surgery.

13:08

These are almost always done laparoscopically these days.

13:11

So what they do is they partition off the stomach.

13:13

So they do a little line, a stapled line just below the

13:17

GE junction to create what's termed the gastric pouch.

13:21

Uh, and so that's excluded from the rest of the stomach.

13:23

The rest of the stomach still remains.

13:26

So these two things are located very close to one

13:28

another, but there's no longer a communication between them.

13:31

So, um, the outlet for the gastric

13:34

pouch is a gastrojejunostomy.

13:37

This is a side-to-side anastomosis.

13:39

And this small bowel limb that's

13:41

brought up is called the Roux limb.

13:43

Um, there's usually a little short overhang here.

13:46

So you'll see a little stump that's usually pretty short.

13:49

Uh, and then it comes down.

13:50

And so this is essentially, this loop that's brought

13:52

up as part of the Roux limb was, uh, what was incised

13:55

down kind of, uh, mid small bowel and then brought up.

13:59

And then the, um, the limb that includes the proximal

14:03

duodenum is anastomosed in sort of this Y configuration.

14:08

This is called the Y.

14:09

Um, the limb that goes up to

14:11

the gastric pouch is called the Roux limb.

14:13

You'll also see it, um, discussed

14:16

as the efferent limb.

14:18

Um, I don't like using this terminology because

14:21

it sounds very similar to afferent limb.

14:23

I think people get confused.

14:24

So I usually call it the Roux limb.

14:26

Um, the limb that includes the duodenum and sort of

14:29

the, uh, pancreatic and biliary, uh, secretions, uh,

14:34

exocrine functions are called the biliopancreatic

14:36

limb or some people call it the afferent limb.

14:40

Um, so this is what it looks like.

14:42

This is so you have both a restrictive

14:44

mechanism and this bypass mechanism.

14:47

How far you do your incision and bring this up

14:50

determines how much of a bypass there is, so there's

14:52

some variability in that, but you don't want to bypass

14:56

too much or otherwise, they will have a malabsorption

14:59

syndrome. They won't be able to absorb and they'll

15:00

have diarrhea, and they'll have really horrible

15:02

weight loss that they won't be able to, uh, do well

15:06

with. So this is what it looks like on a CT scan.

15:10

This is a patient who had some oral contrast, and on

15:14

the axial images, what you're going to see is you're

15:17

going to see what looks like stomach here, but what

15:19

you're going to see are these suture lines here, and

15:22

essentially that's the partitioning of the gastric

15:24

pouch from the rest of the stomach, which you'll see the

15:27

gastric pouch has oral contrast, but the excluded portion

15:30

of the stomach, which we see here, whoops, here, here,

15:34

and here doesn't have, um, any oral contrast because

15:38

it's no longer in communication with the gastric pouch.

15:41

What you will see is you will see that there'll be a

15:43

small bowel limb coming from the ventral portion of

15:45

the abdomen, coming right up to that gastric pouch.

15:48

And that's the Roux limb.

15:49

And when you see this configuration of this

15:52

the sutures and partition here and then

15:54

a small bowel limb coming to this pouch,

15:56

that's how you know you're dealing with a Roux-en-Y.

15:58

Um,

15:59

if you look at it on a coronal image,

16:03

you're gonna see this is the Y anastomosis.

16:05

You can kind of see it's kind of an oblique

16:07

anastomosis down in the jejunum, usually

16:09

somewhere about the left mid abdomen.

16:11

Looking at a sagittal image, here we have the

16:13

gastric pouch, and you'll see, again, here's

16:16

this Roux limb that comes from the ventral portion.

16:18

It's brought up and anastomosed to the gastric pouch.

16:22

There are two different ways this can be anastomosed, so

16:24

it can, um, they can bring it up sort of ventral to the

16:28

transverse colon, which is called an anticolic Roux limb.

16:31

Or they can actually make a hole in the transverse mesocolon

16:35

and bring the limb up through that defect to get it up here.

16:38

And so that's called a retrocolic Roux limb.

16:43

And there's some sort of implications

16:45

with that that we'll talk about.

16:47

Again, here you see the excluded portion of the

16:49

stomach, so the rest of the stomach is lying right

16:51

adjacent, but should not have any oral contrast in it.

16:56

So that's what it looks like normally on a CT.

16:59

I think this is the same, uh, patient.

17:02

This is a, uh, upper GI.

17:04

So same sort of thing.

17:05

So here we see the gastric pouch.

17:08

The gastric pouch roughly should

17:10

be about the size of the patient's fist.

17:12

So there about, so that's what would

17:14

be considered a normal gastric pouch.

17:16

Here's the gastrojejunostomy

17:17

that we're seeing here.

17:19

You can see it's quite widely open.

17:22

Here's the Roux limb, and as I mentioned, there's this

17:24

short overhang, this blind-ending overhang that you

17:27

see here, and then the rest of the Roux limb going down.

17:29

Here we're seeing a frontal view that's

17:31

kind of going further down, and here you see

17:33

more small bowel filling out with contrast.

17:35

It's oftentimes with all the contrast filling

17:38

the small bowel down here, it gets to be very

17:40

difficult to actually identify the

17:43

exact location of the, um, Y anastomosis.

17:47

Usually you'll see a loop that looks kind

17:48

of wider than normal for a short segment.

17:51

And that's usually the anastomosis, but

17:52

it can sometimes be difficult there.

17:55

This is a lateral view that we're looking at here.

17:57

And in this patient, this is a retrocolic Roux limb,

18:00

meaning that the transverse colon is ventral to this Roux limb.

18:04

Um, and actually, you can see there's a little indent, uh,

18:08

as it goes through the transverse mesocolon, and that's

18:11

normal, though I have seen in rare circumstances where

18:14

perhaps the defect wasn't large enough, and it's actually

18:16

caused a little bit of an obstruction here as well.

18:19

So that's what that would look like under fluoroscopy.

18:23

So let's move on to what

18:24

problems look like; you can encounter

18:26

what they might look like on CT.

18:28

So, um, this is a really good example of this first

18:32

case of, uh, why I think you need to understand what

18:34

the anatomy looks like, because if you don't understand

18:37

the surgical anatomy, I think it might be hard to figure

18:40

out that you're actually looking at a complication.

18:42

And so on the CT images here, uh, this patient has had

18:47

a gastric bypass, um, we're seeing, uh, a gastric pouch,

18:51

but we're also seeing contrast filling out a space that's

18:54

ventral to the gastric pouch and not in the Roux limb.

18:57

And so that's what we're seeing here.

18:59

And again, on this coronal, same sort of thing, here,

19:02

um, the excluded portion of the stomach looks okay,

19:04

the gastric pouch has contrast in it, but there's all

19:06

this contrast around the outside of the gastric pouch.

19:09

And so this is a leak.

19:10

This is the same patient under fluoroscopy.

19:13

So again, you see the patient's taking enteric contrast

19:16

into the gastric pouch, and then you immediately see a leak of

19:18

contrast coming out, uh, and going out, uh, extraluminal.

19:22

Almost, these occur about five percent of the

19:25

time, almost always at the gastrojejunostomy.

19:29

So this is going to be something that you're typically

19:31

going to see, you know, just shortly after surgery.

19:34

Uh, you know, it typically in our practice we have,

19:39

um, you know, very active, uh, procedural endoscopists.

19:43

So all these complications in our practice are

19:45

really managed, you know, with endoscopic techniques.

19:48

It's very, very rare that a patient actually gets taken

19:51

back to surgery to repair this, at least in our practice.

19:56

Here's another example of a leak

19:58

that we're seeing that's late.

20:00

And this is from an ulcer.

20:02

And so one of the complications from their own lives is

20:07

that patients can get what is called a marginal ulcer.

20:10

And essentially it's an ulcer that occurs

20:12

in the gastric pouch right adjacent to or

20:15

including the gastrojejunostomy.

20:18

Typically the ulcers can be there and they're

20:21

not really horrible enough or deep enough

20:24

to actually cause a gross perforation.

20:26

And so they can actually quite

20:28

honestly be very hard to detect.

20:29

Certainly usually not detectable on CT and usually

20:33

actually not really well detectable on fluoroscopy either.

20:37

Uh, in this case, it was quite a

20:38

large ulcer, uh, that was leaking.

20:41

And so we can actually see here, this is the gastric pouch.

20:44

You can see the gastric pouch is really thickened.

20:46

And you can see that there's

20:47

contrast coming out through here.

20:49

This is actually the ulcer crater

20:51

that we're seeing right here.

20:52

And then again, it's not a surprise that

20:54

there's a leak, given that you see all this

20:56

fluid and air located in the peritoneal space.

21:01

So this is a leak.

21:02

It's a late leak due to a marginal ulcer.

21:05

Again, this in the last 15 years, I think

21:08

this might be the only ulcer I've seen that

21:10

was bad enough to actually grossly perforate.

21:13

So most typically you will not see this,

21:14

but this is what it would look like.

21:19

So narrowing.

21:21

Um, so this is a fluoroscopic image.

21:24

You see the patient standing upright and you can

21:26

see that we have a column of contrast filling

21:29

out the esophagus and the gastric pouch.

21:32

And then where the G.

21:33

J.

21:34

anastomosis should be,

21:35

it is quite, uh, narrowed and there's

21:37

hardly any filling of the limb.

21:39

So this is too narrow.

21:41

So if you're in the immediate postoperative period,

21:43

this is just usually due to postoperative swelling.

21:45

It usually gets better in a couple of days

21:47

and people can start tolerating feeds.

21:49

If this is, uh, in months or years after surgery,

21:52

then this is probably due to anastomotic stricture

21:55

or a stricture that's a sequela of a marginal ulcer.

21:58

Um, these can be difficult to deal with.

22:00

They will try oftentimes with endoscopy

22:02

to go and balloon them up, but they can be

22:04

difficult and recalcitrant to treatment.

22:08

And I will say just as it says here, it's very

22:10

rare to have a stricture at the, uh, Y anastomosis.

22:13

So very, very uncommon.

22:15

Um, this is, uh, an obstruction due to adhesions.

22:19

So same patient.

22:19

We're looking at a CT image.

22:21

We see that the Roux limb looks pretty distended.

22:24

It's almost got that high-bounded appearance and

22:26

you come through and then as you're getting close

22:28

to the Y anastomosis it just comes to an abrupt

22:30

termination, very abrupt caliber transition.

22:33

This is the CT.

22:34

This is actually the limb coming over here that you

22:36

can see it gets really small and beak-like here.

22:39

And so this is before the anastomosis

22:41

and this is due to adhesions.

22:43

These can be seen in any of the patients.

22:45

They are more common in patients who have open surgeries.

22:47

And as I said, typically, that's not done

22:49

anymore, but we still do see them from time to time.

22:52

And so that's something you would want to be looking for.

22:56

Um, this is a tough one.

22:58

This is, um, this is an internal hernia.

23:02

And so, uh, you've seen about 3

23:04

percent of patients with Roux-en-Y.

23:06

It's usually in the late postoperative period.

23:08

And like all internal hernias, it's due to small

23:11

bowel, usually herniating through some kind of a

23:13

mesentery and getting itself sort of twisted around.

23:16

Um, it can be very common.

23:18

It's very important to recognize because it can be life

23:21

threatening, and it's a really critical diagnosis to make.

23:25

So, in this image, what we're seeing

23:26

is, um, this patient's had a Roux-en-Y.

23:28

You see these dilated fluid-filled loops and

23:31

sort of stymied in the left upper quadrant.

23:33

As you see, they have this sort of encapsulated look to them

23:38

and you can, um, and they're very, uh, as I said, dilated.

23:41

The wall is a little bit hard to see here.

23:43

Um, these are all the kinds of

23:45

things you see with internal hernias.

23:47

And as you probably know, the imaging findings

23:49

are dilated clustered small bowel loops,

23:52

mesenteric swirling, or converging, or bulging.

23:54

Wasting of the small bowel loops and vessels to an aperture.

23:58

I think these can be somewhat difficult.

24:01

I think internal hernias are sort of like

24:03

the Holy Grail for abdominal imaging.

24:04

And I, even after all these years, I

24:06

still think they're very challenging.

24:08

Oftentimes junior residents will see the

24:11

mesentery kind of twisting around and think

24:13

there's a volvulus or an internal hernia.

24:15

And actually that can be very normal

24:17

in people who haven't had surgery.

24:18

And it's very normal in people who have had surgery.

24:21

So you really want to see

24:22

a lot of these things together.

24:24

You want to see the dilated small bowel loops.

24:25

You want to see these loops that are all kind of clustered

24:27

together and looking like they're encapsulated and

24:30

then some kind of an idea that everything is kind of

24:32

going through some kind of an aperture that's luminal

24:34

and that is what you'll see with an internal hernia.

24:38

These are the kinds of hernias

24:39

that you can see with Roux-en-Y.

24:41

Um, the most common one is going, uh, through the

24:44

transverse, uh, mesocolon for a retrocolic Roux limb.

24:47

There's also a potential space, uh, that has to do with the

24:51

Y anastomosis and a potential space between the transverse mesocolon.

24:54

So that will usually be off in

24:57

the left lateral, uh, abdomen.

24:58

You can see that.

25:01

Um, there's also a Peterson, uh, type hernia,

25:04

which is, uh, pretty rare and not frequently seen.

25:09

Uh, this is a complication, a late complication

25:13

of a patient who is gaining weight.

25:14

Um, and so what we see here, um,

25:17

the patient's had a Roux-en-Y.

25:18

Here's the Roux limb.

25:19

Here's the gastric pouch.

25:20

But I'm seeing some contrast in the

25:22

excluded portion of the stomach.

25:24

And so that's a leak.

25:26

You've developed a fistula between the gastric

25:28

pouch and the excluded portion of the stomach.

25:30

Here on a fluoroscopic image in real

25:33

time, we're seeing this come through.

25:34

And you're seeing the contrast come right

25:36

into the excluded portion of the stomach.

25:37

So clearly, um, there's been a development of a

25:40

communication. Um, the one pitfall here that you

25:44

need to be careful of is if you're looking at cross

25:46

sectional imaging, sometimes the contrast will go

25:50

the normal way through the Roux limb, but it can get to

25:52

the Y and that's most of the time sort of reflux

25:55

back up the pancreatic biliary limb and sometimes

25:57

get a little bit in the excluded portion of the stomach.

25:59

So if you see a little bit of contrast there, it's not

26:02

100% certainty that it's actually a fistula.

26:06

Sometimes, so it's really helpful to actually do the fluoroscopic

26:08

image where you can watch it in real time and see whether

26:10

it's leaking in real time or whether there was some kind of

26:13

reflux that occurred through the pancreatic biliary limb.

26:17

This is just a reminder of when I first put this

26:19

talk together, I had a patient that came in just

26:22

as I was finishing up my slides with the Roux limb.

26:25

He was saying he couldn't get his food down.

26:27

So I was thinking to myself, okay,

26:29

what should I be thinking here?

26:30

And I did the first image in fluoroscopy.

26:33

And what it just reminded me, and I'm hopefully

26:36

reminding you, is that you have to think about the

26:37

other things that we encounter in GI radiology.

26:40

So we see the distal esophagus here.

26:42

There's a really, really bad looking stricture here.

26:46

Um, it's relatively long.

26:47

It's got a lot of mucosal irregularity,

26:50

circumferential, uh, going through here.

26:52

This is well, this is above the GE junction.

26:55

So this is actually an esophageal neoplasm.

26:58

So as soon as I saw this, I knew that we, he had problems.

27:02

So right after the study, we

27:03

got him right on the CT scanner.

27:05

And so what we see here is, um, the mass

27:07

is not only in the distal stomach, but it's

27:09

actually going down to the gastric pouch.

27:11

So it's really, this is all narrowed and irregular

27:13

through here, um, due to the presence of cancer.

27:16

And unfortunately, at this point, he already

27:18

has liver metastases, as you can see here.

27:23

Okay, gastric band.

27:24

So we'll move on to that.

27:26

Um, again, you will see patients, uh, not being placed

27:30

with this, but patients are coming up with complications.

27:32

It accounts for less than 1 percent of surgeries these days.

27:35

You should see the band just right below the GE

27:37

junction, so the pouch is really quite small.

27:41

Um, you should be able, because of the hardware, you should

27:44

know where the hardware lives, and so you can look at

27:46

a plain film and have a good idea if there's a problem.

27:49

So what you should see is this band

27:51

is right below the GE junction.

27:53

They talk about a phi angle, which is the orientation

27:56

relative to the spine, so it's roughly around 45 degrees.

27:59

Then you can see the tubing, and then here you

28:01

can see the port that they inject through here.

28:04

This is what it looks like on a lateral view.

28:05

And you can see there's some constriction.

28:07

There's hardly any stomach above this.

28:09

And this is what it looks like.

28:10

It's very, very close to the GE junction.

28:13

And you can see there's narrowing as it goes through.

28:15

Um, the question is, well, how, how tight should this be?

28:19

And there's really no correct answer.

28:21

As far as a quantitative number, you tighten it up until

28:24

the patient's losing weight and not becoming obstructed.

28:26

And that's how you know you're in the,

28:27

you've tightened it up sufficiently.

28:30

So this is what it should look like on TT, very

28:32

similar. See the tubing, you see it wrapped

28:35

around at a 45-degree angle, just really up

28:38

high in the stomach, just below the GE junction.

28:42

This is an example of an overtightened band, so in this

28:44

patient, um, we can see there's narrowing as it

28:48

goes through the band, but what you can see here is that

28:50

the distal esophagus is getting quite dilated, so that's

28:53

usually an indication that the band may be overtightened.

28:56

Overtightened.

28:57

Oftentimes, people are coming and saying that

29:00

they feel like their food is not getting through.

29:02

Uh, in our practice, the adjustments of these bands

29:05

for the inner sleeve are done by the bariatric service.

29:08

So they keep very close track of how many cc's of saline

29:12

they've got in there so they know how open or tight it is.

29:15

And they do all those procedures on their own.

29:20

Um, this is an example of a slippage.

29:23

So just on this image alone, we

29:25

know that there's a problem, right?

29:26

This band is too low.

29:28

It's flattened out more about, uh, 90 degrees to the spine.

29:32

And also, you can see it's starting to tilt.

29:34

So instead of seeing just the two edges overlapping,

29:36

it's becoming more of an oval shape or O shape.

29:39

And so just from the get-go, this

29:40

is, you know, this is a problem.

29:42

It's not positioned correctly.

29:44

And when we get the patient contrast, sure enough, what

29:46

you see is that the band has slipped down the stomach.

29:48

So there's a lot more stomach above

29:50

the band than there should be.

29:51

The problem is, is that with more stomach going through

29:55

this band, you're also getting other things, vessels.

29:57

Veins, arteries going to it, and as you kind of shove more

30:00

things through the band, you're putting yourself at risk

30:03

for more complications. And so this is sort of a big deal.

30:07

It needs to be dealt with typically. The patients are

30:10

presenting with inability to tolerate drinking and eating

30:13

with nausea and emesis. Um, the way it's treated typically

30:17

and it will work is they deflate the inner sleeve and

30:21

typically at that point, the stomach will kind of work its

30:24

way back down and it'll be positioned normally so that and

30:27

this is one of the reasons this happened very frequently.

30:29

This is one of the reasons why I think

30:30

the band is sort of dropped out of favor.

30:35

So here's another example of a case we saw.

30:37

So this is, you know, the band's not positioned normally.

30:40

It's well below the GE junction.

30:41

It's tilted and twisted.

30:43

So we actually gave the patient contrast.

30:45

And what you can see here is the contrast is

30:47

actually touching the band, all sides of the band.

30:49

So this band is completely in the gastric lumen.

30:52

It's not outside the gastric wall at all.

30:54

And this is an erosion.

30:55

This is a complete erosion, which is not as commonly seen

30:59

where the entire thing has eroded in the gastric lumen.

31:02

It's interesting because it's sort of like a mole.

31:03

There's not a hole left behind.

31:05

So as it erodes into the gastric lumen, it's kind

31:07

of, the scar outside is kind of, you know, patching

31:10

itself up almost like a mole going through the ground.

31:12

So there is no perforation here.

31:15

Um, this patient, they actually went in with an

31:17

endoscope and just pulled it out with an endoscope.

31:22

This is a patient who had her band done in Mexico and came

31:26

up because she was developing an abscess over the port.

31:30

And so we did a CT and you can see that sure

31:33

enough, there's an abscess over the port here.

31:35

And as I was looking through, I could see the abscess had

31:38

actually tracked back along the tubing into the abdomen.

31:42

But then as I looked at the band, I thought at first,

31:44

well, the band looks like it's positioned pretty well.

31:45

It's at 45 degrees.

31:47

That's good.

31:47

It's near just below the junction.

31:49

But on these images, you can see that there's

31:51

gastric contents actually touching the band here,

31:54

not on this medial side, but on the lateral side.

31:57

And if you look, same thing here.

31:59

And so this is a partial or incomplete erosion.

32:02

And this band, uh, situation part of the band

32:05

has eroded the gastric lumen while other parts

32:07

of the band are still in the normal location.

32:10

So this is a partial, and this is probably more

32:12

commonly seen than a full complete erosion.

32:17

Um, this is another complication

32:19

that you will definitely be seeing.

32:20

So after the bands have been there for a long time,

32:23

oftentimes that part of the stomach will really scar

32:25

down, and even if you, um, deflate the inner sleeve or

32:30

actually even remove the band, the stomach does not open

32:32

up again. And so here's a patient, you know, you look here.

32:36

It looks really tight. You can, this isn't

32:37

the greatest image, we can see the band's

32:39

here. So they went ahead and deflated it.

32:42

It didn't look any different. They actually went ahead

32:44

and removed the band, and in this patient, since this

32:46

is the same patient, the band's removed, but it looks

32:49

like you would think the band is still there because it

32:50

looks exactly identical to what it looked like before.

32:53

And so in this case, because of the scarring, this

32:56

is not, this has become a permanent structure.

32:58

You know, they have gone in and tried to deal with

33:00

these endoscopically, they really don't work very well.

33:03

They, uh, it doesn't work as an effective treatment.

33:06

So frequently these patients get converted to a Roux-

33:08

en-Y, and finally we'll get to the gastric sleeve.

33:12

So this is the one that, um, you're going to

33:15

be seeing most frequently done these days.

33:18

Um, again, uh, the band has fallen out of favor, the

33:22

Roux-en-Y is a more technically complex surgery to perform.

33:26

So I think this is why his sleeve, uh, sometimes called

33:29

the vertical sleeve gastrectomy, has become more popular.

33:31

It's quicker and easier to perform than a Roux-en-Y.

33:35

Essentially, what happens here is they come in and they

33:37

basically suture off the greater curvature, and the greater

33:40

curvature portion of the stomach is removed, and you get this

33:43

long common channel, and that should open up to a complete full

33:46

stomach lumen and aperture as you get to this full stomach.

33:51

This is what it looks like on, uh, fluoroscopy and CT.

33:54

So on CT, you're going to see a suture line, uh, here.

33:58

It, superficially, it may look very similar to

34:00

the Roux-en-Y, but the difference is you don't

34:02

see, uh, an excluded portion of the stomach

34:05

and also there's no Roux limb coming up here.

34:07

If you follow this out, it's just

34:08

going to empty through the duodenum.

34:10

And so that's a way really quickly you can tell whether

34:12

am I looking at a gastric pouch or am I looking at a sleeve.

34:15

No Roux limb coming up here, so you're looking at a sleeve.

34:18

This is what it looks like under fluoroscopy.

34:19

Again, you'll see this long common channel.

34:21

Typically, there'll be suture and clips along

34:24

where the greater curvature should have been.

34:25

And then as you get to the distal

34:26

stomach, it kind of opens up normally.

34:28

Uh, so that's what it will look like normally.

34:31

These are complications of leaks.

34:34

Um, there's a long suture line involved with this.

34:37

These are things you're going to see, um, immediately

34:39

following surgery. You know, you do the CP and it's not

34:42

a surprise that you see fluid. You see extracellular gas

34:45

that you've got a leak. One of the things to be aware

34:48

of, and that your surgical colleagues will know, is that

34:50

post-op tachycardia is a reason to do a swallow study,

34:53

because that's the earliest sign of there being a leak.

34:56

And so if the patient gets tachycardic, they

34:58

definitely get a swallow very quickly after that.

35:01

Um, you know, the leaks can be, are usually quite small,

35:05

and you will not see them on CT, even with enteric contrast.

35:09

And sometimes, even on fluoroscopy, they can be very

35:12

hard to see, and you have to do multiple swallows,

35:14

because the leaks are just like little pinholes.

35:16

So, in this case, this is an example

35:18

of when we knew there was a leak.

35:19

There's a drainage catheter, abscess drainage

35:23

catheter, coming up in the left abdomen.

35:25

We do multiple swallows.

35:27

I can't really see the leak, but over time what I

35:29

do see is I can see that there's contrast filling

35:32

out into that, uh, abscess drainage catheter.

35:34

So I know that there still is a leak, although

35:36

the leak is very, very small and hard to see.

35:38

So again, this is an example of why

35:40

fluoroscopy is still really important.

35:42

It's really hard to evaluate this

35:44

and see how big the leak is on CP.

35:48

This is another fairly common complication that

35:50

you encounter, and this is a delayed complication.

35:53

It's a stricture, and so you can see this

35:55

patient has had a sleeve and it looks

35:57

pretty good, and you get down this sleeve.

35:59

The stenosis I've seen are usually been along

35:01

the distal portion of the sleeve where you get a

35:03

really tight stenosis and it just doesn't open up.

36:07

Um, this is usually occurs, you know, years

36:10

after surgery and it's progressive again.

36:13

Oftentimes they'll try to treat it with

36:15

ballooning to do endoscopic techniques.

36:18

I've never seen it really be successful.

36:20

So almost always these, uh, end up, these patients,

36:23

because they're not being able to tolerate eating or

36:25

drinking, end up being converted to a ruined wine.

36:30

So just to kind of sum up here in the last minute or two.

36:35

So we've talked about the different

36:37

complications you're going to see.

36:38

Um, we talked about the different kinds of

36:40

flavors and also when you're going to see

36:42

them, uh, in the post operative course.

36:44

So for a Roux en Y, we're thinking about

36:46

leaks, post op swelling, causing some

36:49

narrowing of the anastomosis for a sleeve.

36:51

We talked about leaks usually

36:52

occurring just shortly after surgery.

36:55

And the tip off there is post operative tachycardia.

36:58

The late complications that you see in the months or years

37:01

Following are going to be strictures, uh, at the anastomosis

37:05

or from marginal ulcers, and obstruction that can be

37:08

due to adhesions, or we talked about internal hernias.

37:11

Um, we also talked about the gastro-gastric fistula,

37:14

which is relatively rare, but frequently you'll be

37:17

asked to evaluate for that, and there is a potential

37:19

pitfall on cross-sectional imaging to be aware of,

37:22

and it's a reason why you might want to actually look

37:24

under fluoroscopy in real-time. For the sleeve, we also

37:27

talked about the distal strictures, which you will

37:30

see, uh, are definitely a complication that you will

37:33

encounter and typically result in Roux-en-Y revision.

37:37

And then for the gastric bands, even though they're not

37:39

doing them, there's still patients out there and you're

37:41

going to see them, and the reason you don't see them much

37:44

anywhere is because of the complications we see here.

37:46

Overtightened band slippage, band erosion,

37:49

or permanent scarring or, uh, stenosis,

37:52

even after removal or deflation of the band.

37:54

So those are the complications you're going to see in

37:57

the kind of time period you're going to be seeing them in.

38:00

So just to kind of sum up the basic points, um,

38:05

regardless of where you practice, if you're doing

38:08

imaging of the abdomen, you have to have some

38:10

familiarity with what bariatric surgical anatomy

38:13

looks like so you can understand what it should

38:15

not look like and whether there's a complication.

38:17

These patients are all over our country.

38:19

It doesn't matter what kind of practice you're

38:21

in or what kind of, whether you're rural or

38:22

urban, you're going to see these patients.

38:24

Okay.

38:25

These days it's really the sleeve gastrectomy, uh, that's

38:28

performed most frequently followed by the Roux-en-Y.

38:31

Um, again, understanding the time course after

38:34

surgery can be very helpful in sort of framing your

38:37

thinking about what do I really need to be looking for

38:40

if the patient is, you know, years after surgery that I

38:42

need to make sure I can tick off as I look through the

38:45

scans and say, yes, there's no anastomotic stricture.

38:48

You know, no, there's no slippage.

38:50

So those are the, it's very helpful to sort of frame

38:52

your thinking before you start looking at the scan to

38:55

know at a minimum, you have to be looking for these

38:57

complications as well as anything else you can find.

39:00

And I think the other big point I would have

39:02

tried to make is that, um, fluoroscopy is not dead.

39:05

Fluoroscopy is not going away.

39:07

I love CT.

39:08

I was raised on reading CTs and cross-sectional

39:11

imaging, but fluoroscopy has some very important

39:13

uses, especially in these types of patients.

39:15

There are things you can see with fluoroscopy

39:18

that are really, really hard or impossible to see.

39:21

Uh, with CT.

39:22

So they really should be thought of as complementary,

39:25

um, techniques and oftentimes they may both be needed.

39:28

You may need to do cross-sectional imaging, but you

39:30

may need to do fluoroscopy where you can watch things in

39:32

real time and see, um, how they actually, uh, occur.

39:36

So I'm gonna stop there.

39:40

Um, and my email is there, so if anybody has

39:43

anything they want to contact me with later,

39:45

they're very welcome to do so, and I think I see

39:49

some Q&A questions, so I'm going to click on that.

39:52

Um, okay, so I'll start with some questions.

39:56

Um, one of the first questions comes with how do

39:59

you manage oral contrast with a patient vomiting?

40:02

You know, um, if the patient is really that, that

40:07

ill, you're not going to get any oral contrast down.

40:10

Um, so, you know, I think that at that point I would

40:14

just do cross-sectional imaging and see what you can do.

40:16

But I agree if the patient's really, you know,

40:18

severely obstructed and really just throwing up,

40:22

there's no way you can get the contrast down.

40:24

So I'd start with.

40:25

You're so you're probably talking about some kind of

40:27

an obstruction of some sort and you have a pretty good

40:29

chance of making a diagnosis based on the cross-sectional

40:32

imaging, so I would not certainly try to give the patient

40:35

any oral contrast because it will, number one, they're not

40:39

going to tolerate it anyway, you will just have a very

40:42

irate, even more irate and more upset patient on your hands.

40:47

Second question.

40:49

I guess I can show him answer live here. Okay, so...

40:54

Do you do complimentary fluoroscopy for all leak cases?

40:58

Um, generally the answer to that is yes, because

41:01

frequently the leaks are small. So, um, if you don't

41:05

see... If you don't see the, you oftentimes can tell

41:09

by cross-sectional imaging there's a leak because

41:10

there's extraluminal fluid or extraluminal gas.

41:13

So you know there's a leak, but oftentimes these

41:15

leaks are not like big giant, you know, holes.

41:17

They're actually little, little tiny holes.

41:20

Sometimes they're like a pinhole.

41:21

So you're, you're not going to see that.

41:23

So you can get the patient in tarot contrast before the CT.

41:26

Um, you may or may not see the leak.

41:28

And if you do see that there's actually a little

41:30

contrast, you will not, you'll still have a lot of

41:32

difficulty actually identifying the hole and seeing,

41:35

you know, typically the surgeons are going to want

41:36

to know, well, where's the hole and how big is it?

41:38

Um, so typically you will have to, um,

41:41

Um, you will have to, uh, do fluoroscopy.

41:44

So yes, I would say the answer to that is yes.

41:46

Um, with respect to another follow-up question, do you

41:50

do a delayed scan if you don't see a leak at first?

41:53

Um, not cross-sectional.

41:56

Um, if we do cross-sectional CT and we

41:58

think there's a leak, we go to fluoroscopy.

42:01

Um, and at that point do try to do as many

42:03

swallows and as many different obliquities

42:05

as we can to see if we can identify it.

42:07

Um, some, it's so on occasion you will not be able to find

42:11

it because it may be intermittent or very, very small.

42:13

Um, I would not necessarily do a delayed CT at that point.

42:16

The only time in my practice where I do delayed

42:19

CTs is if I see something on fluoroscopy and I'm

42:22

not sure where it is or why I'm seeing it, then I

42:25

will go back to CT to see where the contrast is.

42:27

And that's not common, but every once in a

42:29

while you'll see, um, uh, you will see, like,

42:34

wait a minute, I don't know where this is.

42:36

I can't understand what's going on here.

42:38

And so in that case, I will take the patient to the

42:40

scanner and scan and see where the contrast has ended up.

42:44

Uh, the next question you said,

42:46

internal hernias are the Holy Grail.

42:48

Have you seen any, uh, what to

42:50

get a sense of how rare they are?

42:52

Um, so in our practice, we are, we see a

42:55

lot of patients, um, oncologic patients.

42:58

We also see a lot of patients.

42:00

Uh, with complex surgical anatomy, and I have to say

42:03

internal hernias, and that, so we see a lot of patients

42:06

who are at risk for internal hernias, um, I would say I

42:09

see a handful a year, and it's a really hard diagnosis,

42:13

and sometimes I'm wrong, and so actually, interesting

42:15

enough, about two weeks ago, I saw a patient that came

42:18

to the ED whose bowel was positioned a way I could not

42:21

understand how he'd get there without going through a

42:24

mesentery, and so I said, Yeah, she's not obstructed,

42:27

but I think she may have an internal hernia and

42:29

actually put a scope in and looked and she just had very

42:31

tortuous bowel, but she did not have an internal hernia.

42:34

So sometimes you will be wrong.

42:35

They're very, very hard to diagnose.

42:38

I think the main point I would make to you is that.

42:42

Just seeing twisting the mesentery is not really sufficient.

42:45

You will see that very, very frequently in even normal

42:48

patients and certainly in post-operative patients.

42:50

I tell our residents that the way you know there's

42:53

a problem with twisting mesentery, if it's so tight

42:56

that you don't see any vessels, um, uh, any of the

42:59

arteries that are filling out beyond it, or you see

42:01

the veins on the other side engorged, but nothing

42:04

coming up beyond it, then, you know, that's a problem.

44:06

Maybe evolve.

44:07

If you see that it's twisting, it looks like

44:08

it's going through a little hole of some

44:10

sort, you know, you know, you won't see it.

44:12

You'll get the idea.

44:13

That's kind of wasting down.

44:15

That's another, uh, uh, way to kind of sort

44:19

of start thinking about whether it be there,

44:20

but I think it's very, very difficult.

44:23

Um, so the next question is, is the course

44:26

of the tubing intra-abdominal important?

44:28

Any complications related to its course?

44:30

No, I haven't seen for the lap band.

44:33

I haven't seen the tubing be an issue.

44:35

The only two issues I've really seen are the abscess

44:38

at the port site that I showed you and the other issue.

44:42

And actually, that abscess, you can see the infection.

44:44

It was actually tracking back there.

44:46

On the port along the tube and actually into

44:48

the abdomen. The other thing I've seen is

44:50

occasionally I've seen once where it's fractured.

44:54

And so those are the only two complications

44:56

I've actually seen with that. Which contrast

44:59

is actually used and when to use both?

45:01

Barium.

45:02

So, you know, we typically use OmniPaque 350.

45:07

Um, I don't, I think that's an off-label

45:08

use for OmniPaque, for at least for 350.

45:12

I think one of the other OmniPaque concentrations are

45:14

actually, is actually FDA approved, but we use that.

45:16

It's, uh, water soluble, you know, iodine-based

45:19

contrast, it's iso-osmolar, uh, so it's well tolerated.

45:23

Even if the patient aspirates it, it's not

45:26

going to cause a pneumonitis or stay there forever.

45:29

So we usually start with that and then again if it

45:32

looks okay with that, but we're still suspecting that

45:34

we think that there's a, um, uh, leak, then we will go

45:39

on to thin barium and occasionally with barium you'll

45:42

see a little pinhole that you couldn't see with the

45:45

water-soluble and again, it's not clear whether it's

45:47

really truly the barium, which is a little denser, or

45:50

whether just the fact you just kept doing many, many

45:52

swallows and eventually you saw it. Um, next question.

45:58

Have you seen mediastinitis with leaks?

45:02

Um, no, not that I recall.

46:04

Usually, everything is below the diaphragm.

46:06

So, I can't recall there being a leak where

46:09

we actually had stuff coming through the

46:11

hiatus and ending in the mediastinum.

46:13

So, I don't believe I've seen that, at least in the

46:16

setting of bariatric surgeries and their complications.

46:20

Um, reflux and delayed gastric emptying

46:23

in different times after surgery.

46:25

Um, you know, I think you can certainly, um,

46:29

you're going to, in the immediate post-operative

46:32

period, usually the anastomosis is swollen.

46:34

So, patients are going to have to go slow.

46:36

They're going to not be able to get much down.

46:38

So, that's not uncommon.

46:40

You do get patients that continue

46:42

to have reflux, uh, afterward.

46:44

It's sort of a fine line between how quickly

46:47

slow do you want to go to the gastric pouch?

46:49

Um, or how fast do you want to go to it?

46:52

Right?

46:52

If you go liquidly split to it, you won't get

46:54

reflux, but then you can get dumping syndrome.

46:56

If the anastomosis is too narrow, then you'll

46:59

fill up the gastric pouch, but then you'll, at

46:01

some point, you'll have problems actually eating

46:03

and you'll also be at more risk for reflux.

46:05

So, it's a little bit of the Goldilocks phenomenon,

46:08

not too tight, not too loose, just right.

47:12

Um, reflux and, oh, we just answered that one.

47:15

What concentration of barium do you

47:16

use to look for leakage and sleep?

47:18

Um, so we use just thin barium.

47:21

I, you know, I don't, can't remember.

47:22

So, we usually, we have thick and thin barium.

47:24

We use the thin barium, um, usually

47:26

don't go to the thick barium.

47:27

And again, that's only in, when I use barium, we're only

47:31

in instances where, um, we are pretty sure that there

47:35

must be a leak based on the cross-sectional imaging.

47:36

And we've done the water-soluble

47:38

multiple times and haven't seen it.

47:40

And so we're, we know it must be there, but it may be small.

47:44

Post-op imaging comment on internal hernias.

47:47

Yeah, you know, I think that, um, as far as

47:51

internal hernias and Ruin Y, um, bypass patients,

47:55

I probably see about two or three of those a year.

47:57

We scan a lot of those patients

47:58

You know, I think that, um, you know,

48:00

in other post-operative patients, again,

48:04

I still, you know, I spend a lot of time reading abdominal

48:06

and pelvic CTs, and I still find it challenging when I read,

48:07

I read all the literature on it, and it's always interesting

48:11

either after surgery or, um, at post-mortem.

48:14

I don't know how much of these are

48:17

I think they're very difficult to do.

48:19

anatomy is the best way to start.

48:24

twirling mesentery, small bowel loops that look like

48:25

they're positioned in an unusual place and they're

48:27

kind of clustered together in an unusual place.

48:29

And I try to look for the mesentery group

48:31

on those loops and seeing if, if the bowel,

48:32

and you should see an inlet and outlet.

48:34

limb of the small bowel and also the mesenteric vessels

48:37

going through some kind of an aperture, and that's

48:38

the hint that you actually have an internal hernia.

48:41

Um, next question is, uh, gastric banding,

48:42

how long, uh, in situ without complications?

48:45

I think it's variable.

48:47

So, some patients I think did relatively well with the

48:50

gastric band, and then other patients did not do well.

48:52

So, there's, there's, in those examples where I showed

48:55

where the band was slipping down and, you

48:57

know, there was prolapse of the stomach above, I would

48:59

see the same group of patients over and over and over.

49:01

So I'd see 'em, they loosened, they un, they, uh,

49:04

loosened the, um, the sleeve, they deflate it,

49:06

and then the stomach would work its way back up.

49:08

They looked great, they put the sleeve back up, and

49:10

then a couple months later he'd be back with a prolapse.

49:12

So, at least for some patients it was very,

49:14

very common, even though it had been placed

49:16

properly, properly positioned, you know.

49:18

I would think that given the fact that the insurance

49:20

companies have stopped paying for it, it was probably

49:22

more common to have complications than not.

49:28

Uh, there's a question about gastroesophageal motility

49:30

two years post sleeve gastrectomy.

49:34

aware that there's a correlation in those things.

49:38

So certainly, you do see discoordinated esophageal motility.

49:43

I don't know if that's directly

49:44

related to the sleeve or not.

50:09

Uh, so I'm not aware that it may be that

50:11

may be the case, but I'm not aware of that.

50:15

And okay.

50:16

Have you seen hyaluronidase post-op?

50:18

The answer is yes.

50:19

I've seen, um, in Roux-en-Y, you can see that the

50:22

gastric pouch is coming up through the hiatus.

50:25

Usually, they're kind of partway up to the hiatus.

50:27

You'll see the hiatus.

50:28

You'll see that the gastric

50:30

pouch is kind of partway peeking up into

50:32

the lower mediastinum.

50:36

It's not, um, the lower mediastinum.

50:38

I haven't seen any complications at this point related to

50:40

it as far as being obstructed or getting a volvulus or

50:43

anything of that nature, but I have seen that on rare occasions.

50:47

Nobody's done anything about them.

50:48

So I don't know that they cause any issues.

50:51

So let me see.

50:52

I think, uh, oh, you mentioned swirling of the vessels

50:56

can be seen as a normal finding, not just ileus.

50:58

Do you know what the cause of the swirling is?

51:00

You know, um, you do see swirling of the vessels normally

51:03

the reason is 'cause your bowels are moving all the time.

51:05

Right.

51:06

You know, when you're, if you're watching

51:07

someone peristalsing, so if you do like a fluoroscopy

51:11

exam or you do a very quick scan on

51:14

the bowels moving all the time.

51:16

And so you do see twisting.

51:18

It's very, very common.

51:19

If you start looking, you'll find it very

51:21

frequently, especially in people who have

51:22

tortuous bowel, especially the colon.

51:24

And so you will definitely see it.

51:26

The issue is, and sometimes it'll be 180.

51:29

I've seen it even like 270 degrees and almost 360 degrees,

51:33

and you can go back and look at their scans over the years,

51:36

and sometimes they have it, and sometimes they don't.

51:37

Sometimes they have it, sometimes they don't,

51:39

and they're totally asymptomatic from it.

51:41

So just seeing twirling of the mesentery

51:43

or the whirlpool sign is not enough.

51:45

To call that, really you want to see that

51:47

there's some complication related to it.

51:49

So again, I tell the residents to look for there being

51:52

an obstruction of the bowel that's twisted around

51:54

or you look for the vessels that are going into

51:57

the twist to see if you're causing an outflow or

51:59

an inflow obstruction in the arteries and veins.

52:05

What type of contrast are you using for… I think I answered that one.

52:07

So we use on the pig 350 as the water-soluble.

52:11

And then we use 10 barium if we need it.

52:14

That's an off-label use.

52:15

I'll say, by the way, it's not FDA approved

52:17

for oral intake, but it's very well tolerated.

52:22

So I think one more.

52:25

So the band can't stay inside forever.

52:27

There are no complications.

52:28

At a certain time, you know, that's a good question.

52:33

I don't know, you know, ultimately,

52:36

typically patients who have the band.

52:38

I never, the only time I saw the band ever come out

52:41

was because, um, they had a complication from the

52:44

band or they just decided they didn't want to do it.

52:47

So I, to me, there was never, I never saw an

52:49

instance where they went to remove the band because

52:51

you'd reached your ideal weight and you were done.

52:53

So I'm not aware of that ever being the case and that,

52:56

or at least it never came into fruition because patients

52:59

were having complications and never got out that far.

53:04

So I think, oh, a little bit more.

53:09

Position of patient during fluoroscopy.

53:10

Uh, yeah, usually it's, I usually try to have them upright.

53:14

Um, if they can't stand very well, then kind of

53:16

semi-upright because you want the contrast to flow.

53:19

If you have them supine or prone, you know, to

53:22

get the contrast going into the pouch and where

53:24

you think the leak is, it's going to take forever.

53:26

So you usually want to use gravity to help you.

53:28

You want to make sure that the contrast is

53:29

going by where you think the problem is.

53:31

Okay.

53:32

Uh, and again, you want to do repeated swallows because

53:34

if it's going by really fast and the leak is really

53:36

small, it may take a couple of actually see it go by.

53:39

Um, I think, uh, is there one more here?

53:44

I guess.

53:47

I think I've answered them all.

53:48

I don't see any, um, I don't see any more left.

53:53

So I will just say thank you.

53:55

Oh, uh, yeah.

53:56

Thank you very much.

53:57

Um, I hope that this, uh, gave you some information

54:01

about what to look for on CT and fluoro.

54:03

Uh, you will definitely see these

54:05

patients coming regardless of where you're

54:07

practicing if you're looking at the abdomen.

54:09

So, um, you should be ready for it

54:11

if you're not seeing it already.

54:12

So I'll go ahead and leave it at that.

54:14

So thank you very much.

54:16

Perfect.

54:17

To bring this to a close, I want to thank you, Dr.

54:18

Coy, for your time today, and thanks to all of

54:20

you for participating in this noon conference.

54:22

A reminder that it will be made

54:23

available on demand at MRIonline.

54:25

com, in addition to all previous noon conferences, and

54:27

be sure to join us tomorrow for a lecture from Dr.

54:30

Diego Lemos on easily missed knee injuries on radiographs.

54:34

Um, thank you and have a wonderful day.