AJR 2000; 175:135-139
© American Roentgen Ray Society
Silicon Ring Vertical Gastroplasty for Morbid Obesity
Spectrum of Radiologic Findings
Niloufar Sadeghi1,
Jean Closset2,
Jean-Jacques Houben2,
Julien Struyven1 and
Marc Zalcman1
1
Department of Diagnostic Radiology, Hôpital
Erasme, Université Libre de Bruxelles, 808
Rte. de Lennik, 1070, Brussels, Belgium.
2
Department of Gastrointestinal Surgery, Hôpital
Erasme, Université Libre de Bruxelles, 1070,
Brussels, Belgium.
Received September 22, 1999;
accepted after revision December 10, 1999.
Address correspondence to N. Sadeghi.
Introduction
Morbidly obese patients whose body mass index exceeds 40 kg/m2
and less severely obese patients with high-risk conditions may be considered
for bariatric surgery [1]. One
of the most commonly performed bariatric procedures is the silicon ring
vertical gastroplasty. This stapling procedure creates a small gastric pouch
with a restricted outlet, leading to early satiety and reduction of food
intake. During the follow-up period of patients who undergo this procedure,
upper gastrointestinal series are performed to define the altered anatomy of
the stomach and to detect early and late postoperative complications.
Occasionally, abdominal CT is performed. For a radiologist, thorough
understanding of the surgical anatomy and familiarity with the corresponding
complex images are essential for the accurate detection of postoperative
complications. In this pictorial essay, the surgical procedure and the
radiologic techniques are first described. Normal radiographic findings and
various early and late postoperative complications are then illustrated.
Surgical Technique
The vertical gastroplasty, first described by Mason
[2], has undergone several
modifications and is now a widely used procedure
[3,
4]. In silicon ring vertical
gastroplasty, four vertical rows of staples extend parallel to the lesser
curvature from the angle of His to create a small pouch along the superomedial
aspect of the stomach. A silicon ring with a 5-cm circumference is placed
around the outlet of the pouch, called the stoma, creating a permanent support
(Fig. 1). With this procedure,
the capacity of the resulting pouch is about 90 ml and the diameter of the
stoma is approximately 15 mm. This technique permits endoscopic recalibration
if stomal narrowing occurs
[5].
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Fig. 1. —Diagram illustrating configuration of stomach after silicon ring
vertical gastroplasty. Gastric pouch (short solid arrows) is
separated from distal stomach (open arrows) by four rows of staples
(arrowheads). Note stoma with silicon ring (long solid
arrow) around it.
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Radiologic Technique
An upper gastrointestinal study is performed during the early postoperative
period (third to fifth day) with water-soluble contrast material. The stomach
must be examined before a detailed study of the esophagus is performed because
abnormalities may be obscured by excessive contrast material. Pouch emptying
is examined with the patient in the upright position on right posterior
oblique images [6].
Complications, such as staple-line leaks and gastric perforation, are then
evaluated with the patient in the supine position with additional contrast
material. The stoma is best examined on frontal images or, occasionally, on
oblique images while the patient is in the supine position. The right
posterior oblique position is optimal for the evaluation of the vertically
oriented staple lines and of the pouch configuration and volume
[6]. Further follow-up studies
are performed during the late postoperative period when warranted by symptoms
such as food intolerance or weight gain. In the late postoperative period,
leaks are rare and barium can be used in either single- or double-contrast
studies [7]. High-density
barium can be used with a single dose of effervescent powder on
double-contrast studies. When gastric perforation is suspected, CT may be
useful in evaluating the extent of fluid collection.
Normal Postoperative Findings
The normal pouch is oblong and empties without delay through the stoma into
the distal stomach (Fig.
2A,2B).
The rows of staples and the mucosal details are best examined on
double-contrast studies (Figs.
3 and
4).
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Fig. 2A. —Normal early postoperative appearance of silicon ring vertical
gastroplasty in 27-year-old woman with morbid obesity who underwent silicon
ring vertical gastroplasty 3 days earlier. Single-contrast radiograph of
stomach obtained with patient in upright position shows gastric pouch that is
opacified and empties into distal stomach through stoma (arrow)
without significant delay.
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Fig. 2B. —Normal early postoperative appearance of silicon ring vertical
gastroplasty in 27-year-old woman with morbid obesity who underwent silicon
ring vertical gastroplasty 3 days earlier. Single-contrast radiograph obtained
with patient in supine position shows line of staples outlined by contrast
material (arrowheads) with no disruption.
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Fig. 3. —Normal late postoperative appearance of silicon ring vertical
gastroplasty in 30-year-old woman who underwent vertical gastroplasty 2 years
earlier for morbid obesity. Double-contrast radiograph shows gastric pouch,
which is oblong in shape. Stoma is 1 cm in diameter (arrowheads).
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Fig. 4. —Normal late postoperative appearance of silicon ring vertical
gastroplasty in 28-year-old woman with morbid obesity who underwent vertical
gastroplasty 3 years earlier. Double-contrast radiograph shows row of vertical
staple lines separating excluded fundus from pouch (arrowheads).
Mucosal relief is also evident.
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Early Postoperative Complications
Stomal Narrowing
Early stomal narrowing, which may require endoscopic dilatation in severe
cases, is usually caused by spontaneously resolving edema. A nasogastric tube
is sometimes placed through the stoma with its tip in the distal stomach
(Fig. 5).
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Fig. 5. —Early stomal narrowing in 40-year-old woman with morbid obesity who
underwent vertical gastroplasty 3 days earlier. Single-contrast radiograph
reveals stomal edema and early narrowing (arrow). Gastric pouch
emptying into distal stomach is significantly delayed. Nasogastric tube is
also seen in stomal lumen (arrowheads).
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Gastric Perforation
Gastric perforation, although quite rare, is a severe complication and must
be detected early. The perforation is usually caused by ischemia of the
gastric wall and is located along the staple line
(Fig. 6). Abdominal CT is
helpful in showing the extent of extraluminal fluid and gas collections
(Fig. 7).
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Fig. 6. —Gastric perforation after vertical gastroplasty in 51-year-old woman
with morbid obesity who underwent surgery 3 days earlier. Single-contrast
radiograph shows contrast leak from superior part of staple lines
(arrow).
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Fig. 7. —Gastric perforation after vertical gastroplasty in 42-year-old woman
who presented with pain and fever on 12th day after surgery for morbid
obesity. Contrast-enhanced CT scan of upper abdomen shows large air and fluid
collection (arrows). Row of staples can also be identified
(arrowhead).
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Staple-Line Disruption
Staple-line dehiscence is an exceptional complication in the early
postoperative period. It may be found incidentally on the first postoperative
examination (Fig. 8).
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Fig. 8. —Early staple-line disruption in 31-year-old woman who underwent
vertical gastroplasty for morbid obesity 3 days earlier. Single-contrast
radiograph identifies two sites of disruption on superior part of staple lines
(arrowheads).
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Late Postoperative Complications
Stomal Narrowing
One of the most frequent late postoperative complications is narrowing of
the gastric pouch outlet, which results in vomiting and marked weight loss
(Fig. 9). The stomal narrowing
may be caused by inflammatory changes around the stoma or, more rarely,
erosion of the ring through the stoma and leads to pouch dilatation of
variable significance. This complication is usually treated by endoscopic
dilatation. Laparoscopic or endoscopic removal of the ring may be necessary if
the ring protrudes into the gastric lumen. Stomal narrowing may also lead to a
horizontal orientation of the pouch and stoma and a vertical orientation of
the ring (Fig. 10). This
distorted configuration of the stomach contributes to delayed pouch emptying.
In such cases, endoscopic dilatation is usually not effective, and the gastric
pouch must be surgically revised. Weight gain may occur, despite stomal
narrowing, if the dilated pouch reaches the capacity of a normal stomach.
Because of the lack of precision of pouch capacity measurements
[7,
8], the diagnosis of pouch
dilation is subjective and must be assessed on the basis of the signs and
symptoms of each patient.
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Fig. 9. —Late stomal narrowing in 52-year-old woman who presented with food
intolerance and vomiting 2 years after vertical gastroplasty. Double-contrast
radiograph shows stomal narrowing (arrow) with moderately dilated
pouch. Staple lines are also well visualized and there is no disruption.
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Fig. 10. —Late stomal narrowing and horizontalization with pouch dilatation in
39-year-old woman who presented with food intolerance and vomiting 3 years
after vertical gastroplasty for morbid obesity. Single-contrast radiograph
shows stomal horizontalization (arrow) and pouch dilatation
(arrowheads) caused by stomal narrowing with patent cardia and
gastroesophageal reflux.
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Stomal Widening
In patients with weight gain, an abnormally wide stoma may be caused by
ring migration (Figs. 11 and
12). In such patients, a
laparoscopic recalibration of the silicon ring may be performed. However,
another operation is required when associated staple-line disruption
occurs.
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Fig. 11. —Stomal widening in 53-year-old woman who presented with weight gain
2 years after vertical gastroplasty for morbid obesity. Double-contrast
radiograph shows enlarged stoma (arrowheads) with rapid emptying of
pouch.
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Fig. 12. —Stomal widening in 52-year-old woman who presented with weight gain
2 years after vertical gastroplasty for morbid obesity. Double-contrast
radiograph shows small pouch (arrows). Pouch emptying was also
accelerated by stomal widening in this patient.
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Staple-Line Disruption
Dehiscence of the staples usually appears during the late postoperative
period. It is caused by continued distention of the gastric pouch by food.
When the zone of dehiscence is large enough, it is usually associated with
weight gain (Fig. 13) and must
be surgically corrected.
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Fig. 13. —Late staple-line disruption in 30-year-old woman who presented with
weight gain 2 years after vertical gastroplasty for morbid obesity.
Double-contrast radiograph of stomach shows large zone of disruption in
inferior portion of staple lines (arrowheads). Stoma cannot be
visualized on this image.
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Food Impaction
Acute food intolerance and vomiting may be caused by food impaction and
bezoar formation in the gastric pouch, resulting in outlet obstruction without
stomal narrowing (Fig. 14).
The bezoar can be endoscopically removed.
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Fig. 14. —Bezoar in 53-year-old woman who presented with acute episodes of
vomiting 5 years after vertical gastroplasty for morbid obesity.
Single-contrast radiograph shows large barium-coated bezoar in dependent
portion of gastric pouch (arrows), causing outlet obstruction
(arrowhead).
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Gastric Perforation
Gastric perforation may occur during endoscopic stomal dilatation and may
be depicted on the water-soluble study that is usually performed after each
endoscopic dilatatation (Fig.
15).
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Fig. 15. —Gastric perforation after stomal dilatation in 32-year-old woman who
underwent endoscopic stomal dilatation for stomal narrowing 3 years after
surgery for morbid obesity. Single-contrast radiograph obtained immediately
after endoscopic dilatation shows extravasation of contrast material at site
of dilatation (arrow).
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Conclusion
The most frequent complications in patients with silicon ring vertical
gastroplasty are detected by upper gastrointestinal series. CT is helpful in
assessing the extragastric extent of complications. The radiologic
contribution to diagnosis and therapeutic strategies requires the permanent
cooperation of surgeons and endoscopists.
Acknowledgments
We thank Pierre-Alain Gevenois for his assistance in the preparation of
this manuscript.
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