Surgical Endoscopy

, Volume 21, Issue 12, pp 2172–2177 | Cite as

Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation

  • J. T. Carter
  • S. Tafreshian
  • G. M. Campos
  • U. Tiwari
  • F. Herbella
  • J. P. Cello
  • M. G. Patti
  • S. J. Rogers
  • A. M. Posselt



Many surgeons who perform Roux-en-Y gastric bypass (RYGB) for morbid obesity routinely obtain an upper gastrointestinal (GI) series in the early postoperative period to search for anastomotic leaks and signs of stricture formation at the gastrojejunostomy. We hypothesized that this practice is unreliable.


We analyzed 654 consecutive RYGBs, of which 63% were completed laparoscopically. An upper GI series was obtained in 634 (97%) patients. The radiographic findings (leak or delayed emptying) were compared with clinical outcomes (leak or stricture formation) to calculate the sensitivity and specificity. Univariate analysis identified risk factors for leaks or stricture formation; events were too few for multivariate analysis.


Of 634 routine upper GI series, anastomotic leaks at the gastrojejunostomy were diagnosed in 5 (0.8%); 2 of these 5 were later reinterpreted as artifacts. Four leaks were not seen on the initial upper GI series, yielding an overall sensitivity of 43% and a positive predictive value (PPV) of 60%. Univariate analysis showed that cases done early (odds ratio [OR] 5.4 for the first 100 cases, p = 0.02) and prolonged operating time (OR 7.8 for cases ≥ 300 min, p = 0.01) were associated with leaks. Emptying into the Roux-en-Y limb was delayed in 127 (20%) of the upper GI series. Strictures requiring dilatation developed in 16 (2.4%) patients. The PPV of delayed emptying for stricture formation was 6%. Risk factors for stricture formation included stapled anastomosis (OR 7.8, p = 0.002), surgeon inexperience (OR 2.9 for first 50 cases, p = 0.04), and delayed emptying (OR 3.3; p = 0.02).


Because the incidence of anastomotic complications and the sensitivity of upper GI series were both low, routine upper GI series did not reliably identify leaks or predict stricture formation. A selective approach, whereby imaging is reserved for patients with clinical evidence of a leak or stricture, may be more appropriate.


Bariatric surgery Laparoscopic gastric bypass Complications Upper GI series Anastomotic leak Stricture Outcomes 



The authors acknowledge the following people for their contributions to this study: Alan Bostrom, Ryan Lee, Errol Lobo, Jim Ostroff, Lawrence Way, Robin Andersen, Danielle Kreiger, and Joan O’Mahony. Grant support was provided by the American College of Surgeon Resident Research Fellowship.


  1. 1.
    Ahmad J, Martin J, Ikramuddin S, Schauer P, Slivka A (2003) Endoscopic balloon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass. Endoscopy 35: 725–728CrossRefPubMedGoogle Scholar
  2. 2.
    Arteaga JR, Huerta S, Livingston EH (2002) Management of gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass. Am Surg 68: 1061–1065PubMedGoogle Scholar
  3. 3.
    Barba CA, Butensky MS, Lorenzo M, Newman R (2003) Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Surg Endosc 17: 416–420CrossRefPubMedGoogle Scholar
  4. 4.
    Carrasquilla C, English WJ, Esposito P, Gianos J (2004) Total stapled, total intra-abdominal (TSTI) laparoscopic Roux-en-Y gastric bypass: one leak in 1000 cases. Obes Surg 14: 613–617CrossRefPubMedGoogle Scholar
  5. 5.
    Chousleb E, Szomstein S, Podkameni D, Soto F, Lomenzo E, Higa G, Kennedy C, Villares A, Arias F, Antozzi P, Zundel N, Rosenthal R (2004) Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients. Obes Surg 14: 1203–1207CrossRefPubMedGoogle Scholar
  6. 6.
    Csendes A, Burdiles P, Burgos AM, Maluenda F, Diaz JC (2005) Conservative management of anastomotic leaks after 557 open gastric bypasses. Obes Surg 15: 1252–1256CrossRefPubMedGoogle Scholar
  7. 7.
    DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG (2002) Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 235: 640–645; discussion 645–647CrossRefPubMedGoogle Scholar
  8. 8.
    Esmailzadeh H, Powell W, Lourie D (2004) Use of computed tomography in diagnosis of major postoperative gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery. Am Surg 70: 964–966PubMedGoogle Scholar
  9. 9.
    Fernandez AZ Jr, DeMaria EJ, Tichansky DS, Kellum JM, Wolfe LG, Meador J, Sugerman HJ (2004) Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 18: 193–197CrossRefPubMedGoogle Scholar
  10. 10.
    Goitein D, Papasavas PK, Gagne D, Ahmad S, Caushaj PF (2005) Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 19: 628–632CrossRefPubMedGoogle Scholar
  11. 11.
    Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA (2003) Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 17: 679–684CrossRefPubMedGoogle Scholar
  12. 12.
    Higa KD, Boone KB, Ho T (2000) Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients—what have we learned? Obes Surg 10: 509–513CrossRefPubMedGoogle Scholar
  13. 13.
    Higa KD, Ho T, Boone KB (2001) Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A 11: 377–382CrossRefPubMedGoogle Scholar
  14. 14.
    Katasani VG, Leeth RR, Tishler DS, Leath TD, Roy BP, Canon CL, Vickers SM, Clements RH (2005) Water-soluble upper GI based on clinical findings is reliable to detect anastomotic leaks after laparoscopic gastric bypass. Am Surg 71: 916–918; discussion 918–919PubMedGoogle Scholar
  15. 15.
    Lyass S, Khalili TM, Cunneen S, Fujita F, Otsuka K, Chopra R, Lahmann B, Lublin M, Furman G, Phillips EH (2004) Radiological studies after laparoscopic Roux-en-Y gastric bypass: routine or selective? Am Surg 70: 918–921PubMedGoogle Scholar
  16. 16.
    Marshall JS, Srivastava A, Gupta SK, Rossi TR, DeBord JR (2003) Roux-en-Y gastric bypass leak complications. Arch Surg 138: 520–523; discussion 523–524CrossRefPubMedGoogle Scholar
  17. 17.
    Matthews BD, Sing RF, DeLegge MH, Ponsky JL, Heniford BT (2000) Initial results with a stapled gastrojejunostomy for the laparoscopic isolated Roux-en-Y gastric bypass. Am J Surg 179: 476–481CrossRefPubMedGoogle Scholar
  18. 18.
    McCarty TM, Arnold DT, Lamont JP, Fisher TL, Kuhn JA (2005) Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 242: 494–498; discussion 498–501PubMedGoogle Scholar
  19. 19.
    Nguyen NT, Stevens CM, Wolfe BM (2003) Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass. J Gastrointest Surg 7: 997–1003; discussion 1003CrossRefPubMedGoogle Scholar
  20. 20.
    Papasavas PK, Caushaj PF, McCormick JT, Quinlin RF, Hayetian FD, Maurer J, Kelly JJ Gagne DJ (2003) Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 17: 610–614CrossRefPubMedGoogle Scholar
  21. 21.
    Perugini RA, Mason R, Czerniach DR, Novitsky YW, Baker S,Litwin DE, Kelly JJ (2003), Predictors of complication and suboptimal weight loss after laparoscopic Roux-en-Y gastric bypass: a series of 188 patients. Arch Surg 138: 541–545; discussion 545–546CrossRefPubMedGoogle Scholar
  22. 22.
    Rossi TR, Dynda DI, Estes NC, Marshall JS (2005) Stricture dilation after laparoscopic Roux-en-Y gastric bypass. Am J Surg 189: 357–360CrossRefPubMedGoogle Scholar
  23. 23.
    Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich K (2005) Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 232: 515–529CrossRefGoogle Scholar
  24. 24.
    Serafini F, Anderson W, Ghassemi P, Poklepovic J, Murr MM (2002) The utility of contrast studies and drains in the management of patients after Roux-en-Y gastric bypass. Obes Surg 12: 34–38CrossRefPubMedGoogle Scholar
  25. 25.
    Sims TL, Mullican MA, Hamilton EC, Provost DA, Jones DB (2003) Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass. Obes Surg 13: 66–72CrossRefPubMedGoogle Scholar
  26. 26.
    Singh R, Fisher BL (2003) Sensitivity and specificity of postoperative upper GI series following gastric bypass. Obes Surg 13: 73–75CrossRefPubMedGoogle Scholar
  27. 27.
    Toppino M, Cesarani F, Comba A, Denegri F, Mistrangelo M, Gandini G, Morino F (2001) The role of early radiological studies after gastric bariatric surgery. Obes Surg 11: 447–454CrossRefPubMedGoogle Scholar
  28. 28.
    Wittgrove AC, Clark GW (2000) Laparoscopic gastric bypass, Roux-en-Y—500 patients: technique and results, with 3–60 month follow-up. Obes Surg 10: 233–239CrossRefPubMedGoogle Scholar
  29. 29.
    Yu J, Turner MA, Cho SR, Fulcher AS, DeMaria EJ, Kellum JM, Sugerman HJ (2004) Normal anatomy and complications after gastric bypass surgery: helical CT findings. Radiology 231: 753–760CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • J. T. Carter
    • 1
  • S. Tafreshian
    • 1
  • G. M. Campos
    • 1
  • U. Tiwari
    • 1
  • F. Herbella
    • 1
  • J. P. Cello
    • 1
  • M. G. Patti
    • 1
  • S. J. Rogers
    • 1
  • A. M. Posselt
    • 1
  1. 1.Department of SurgeryUniversity of CaliforniaSan FranciscoUSA

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