Michael T Rossi, MD, Rami Lutfi, MD. University of Illinois at Chicago Metropolitan Group Hospitals.
Introduction: The use of upper gastrointestinal series (UGI) has become a routine practice after bariatric surgery and specifically laparoscopic sleeve gastrectomy (LSG) to rule out obstruction or leak. As the healthcare environment continues to evolve, scrutiny over cost from insurance companies and hospitals will continue to rise. We hypothesize that the practice of obtaining UGI series is unnecessary for routine post-operative evaluation after LSG.
Methods and Procedures: We analyzed 277 consecutive LSGs performed over 33 months by a single surgeon at the same institution. Routine UGI series was obtained on post-operative day one in every patient in the study. Abnormal radiographic findings were categorized as questionable leak, delayed emptying (or no emptying), and non-categorized (other). All abnormal UGIS and positive findings were investigated to determine if in-patient workup was generated and whether clinical outcome was affected.
Results: Of the 277 routine post-operative UGI series, 244 were read as normal. Despite 33 UGI series (12%) with radiographically determined abnormalities, none had clinical relevance affecting the outcome. The false positive results did lead to further unnecessary radiographic studies adding cost and radiation exposure to each patient. Three UGI series (1.08%) were read as a possible leak resulting in further radiographic investigation, with CT scan disproving this impression in each circumstance. Twenty-seven (9.7%) UGIs displayed delayed emptying or obstruction the following morning. Each of these cases necessitated follow up radiographic imaging to document passage of contrast and sleeve patency despite normal intra-operative endoscopy. Three (1.08%) had non-categorized (other) findings which included subcutaneous emphysema, gastric sleeve out-pouching and esophageal traction diverticulum. Of the 277 LSGs, we had one leak (0.3%) diagnosed on readmission 5 days post-discharge on CT scan in a patient who had a normal post-operative UGI. We had 2 clinically significant strictures (0.7%) and both had normal postoperative UGIs. Our study determined that the sensitivity of routine post-operative UGI in detecting a stricture or leak was 0% (95% CI). The specificity of the study ruling out a stricture or leak was 88.76% (95% CI). The positive predictive value of post-operative UGI was found to be 0% (95% CI) while the negative predictive value was 98.75% (95% CI).
Conclusion: UGIs are not reliable in diagnosing a leak, obstruction, or stricture after LSG. Their routine use should be abandoned and limited to cases with clinical indication.