Indian Journal of Surgery

, Volume 81, Issue 4, pp 326–331 | Cite as

Routine Early Fluoroscopy and Clinical Observations Following Laparoscopic Roux-En-Y Gastric Bypass for Obesity Fail to Predict Subsequent Anastomotic Leakage

  • James TankelEmail author
  • Reut Rotem
  • Joseph Wiess
  • Alexander Mintz
  • Ram M. Spira
Original Article


One of the most feared complications of Roux-en-Y gastric bypass is anastomotic leak; early identification of which is associated with reduced morbidity and mortality. Efforts to identify patients who may suffer from such leaks have focused around routine early fluoroscopy, post-operative blood tests and clinical signs. We aimed to assess the role of these factors in our patient cohort. A retrospective cohort analysis was performed in order to assess the sensitivity, specificity and negative/positive predictive values of routine early fluoroscopy, post-operative blood tests and clinical signs in predicting anastomotic failure. 108 patients were identified for whom 107 files were available. Leaks occurred in 4 patients (3.7%), none of whom were identified on fluoroscopy. Of the clinical signs and blood tests examined, only average heart rate was significantly different in the leak ground (94.5 versus 108.5 beats per minute, p = 0.02). Nevertheless, as with other measurements, a low positive predictive value was noted. Fluoroscopy in our cohort of patients was not useful in identifying subsequent anastomotic leaks. The low positive and high negative predictive value of clinical signs and routine blood tests means that stratifying patients who may benefit from fluoroscopy is also challenging. Therefore, identifying patients who will subsequently leak remains a challenge with a high index of suspicion remaining in the main technique used to identify leaks.


Roux-en-Y Gastric bypass Obesity Leak Fluoroscopy 


Author Contribution

JT: study design, data collection, analysis and interpretation, drafting of manuscript and approval of final version.

RR: data collection, analysis and interpretation, drafting of manuscript, approval of final version.

JW: data collection, analysis and interpretation, drafting of manuscript, critical review of manuscript and approval of final version.

AM: data collection, analysis and interpretation, drafting of manuscript, critical review of manuscript and approval of final version.

RS: study design, data collection, analysis and interpretation, drafting of manuscript, critical review of manuscript and approval of final version.

All authors agree to be accountable for all aspects of the manuscript and the data/analysis included.

Compliance with Ethical Standards

Ethics Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Requirement for informed consent was waived by the hospital ethics committee.

Conflict of Interest

The authors declare that they have no conflict of interest and no grant support or assistance was available for this study.


  1. 1.
    Craig BM, Tseng DS (2002) Cost-effectiveness of gastric bypass for severe obesity. Am J Med 113(6):491–498CrossRefGoogle Scholar
  2. 2.
    Sjostrom L (2013) Review of the key results from the Swedish obese subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med 273(3):219–234CrossRefGoogle Scholar
  3. 3.
    Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Ågren G, Carlsson LMS (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med [Internet] 357(8):741–752 Available from: CrossRefGoogle Scholar
  4. 4.
    Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N (2015) Bariatric surgery worldwide 2013. Obes Surg 25(10):1822–1832CrossRefGoogle Scholar
  5. 5.
    Bertucci W, White S, Yadegar J, Patel K, Soo HH, Blocker O et al (2006) Routine postoperative upper gastroesophageal imaging is unnecessary after laparoscopic Roux-en-Y gastric bypass. Am Surg 72(10):862–864Google Scholar
  6. 6.
    Schiesser M, Guber J, Wildi S, Guber I, Weber M, Muller MK (2011) Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass. Obes Surg 21(8):1238–1242CrossRefGoogle Scholar
  7. 7.
    Gonzalez R, Sarr MG, Smith CD, Baghai M, Kendrick M, Szomstein S, Rosenthal R, Murr MM (2007) Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 204(1):47–55CrossRefGoogle Scholar
  8. 8.
    Schauer P, Ikramuddin S, Hamad G, Gourash W (2003) The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 17(2):212–215 Available from: CrossRefGoogle Scholar
  9. 9.
    Leslie DB, Dorman RB, Anderson J, Serrot FJ, Kellogg TA, Buchwald H, Sampson BK, Slusarek BM, Ikramuddin S (2012) Routine upper gastrointestinal imaging is superior to clinical signs for detecting gastrojejunal leak after laparoscopic roux-en-y gastric bypass. J Am Coll Surg 214(2):208–213CrossRefGoogle Scholar
  10. 10.
    Quartararo G, Facchiano E, Scaringi S, Liscia G, Lucchese M (2014) Upper gastrointestinal series after Roux-en-Y gastric bypass for morbid obesity: effectiveness in leakage detection. A systematic review of the literature. Obes Surg 24:1096–1101CrossRefGoogle 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(5):679–684CrossRefGoogle Scholar
  12. 12.
    Katasani VG, Leeth RR, Tishler DS, Leath TD, Roy BP, Canon CL et al (2005) Water-soluble upper GI based on clinical findings is reliable to detect anastomotic leaks after laparoscopic gastric bypass. Am Surg 71(11):916–918Google Scholar
  13. 13.
    Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT (2003) Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 138:957–961CrossRefGoogle Scholar
  14. 14.
    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(1):66–72CrossRefGoogle Scholar
  15. 15.
    Doraiswamy A, Rasmussen JJ, Pierce J, Fuller W, Ali MR (2007) The utility of routine postoperative upper GI series following laparoscopic gastric bypass. Surg Endosc 21(12):2159–2162CrossRefGoogle Scholar
  16. 16.
    Carter JT, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM (2007) Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation. Surg Endosc 21(12):2172–2177CrossRefGoogle Scholar
  17. 17.
    Frezza EE, Mammarappallil JG, Witt C, Wei C, Wachtel MS (2009) Value of routine postoperative gastrographin contrast swallow studies after laparoscopic gastric banding. Arch Surg 144(8):766–769 Available from: CrossRefGoogle Scholar
  18. 18.
    Xu T, Rosculet N, Steele K, Auster M (2017) Comparison of upper gastrointestinal fluoroscopy versus computer tomography for evaluation of post-operative leak in bariatric surgery. BJR Case Rep 2:20160076Google Scholar
  19. 19.
    Bingham J, Shawhan R, Parker R, Wigboldy J, Sohn V (2015) Computed tomography scan versus upper gastrointestinal fluoroscopy for diagnosis of staple line leak following bariatric surgery. Am J Surg 209(5):810–814CrossRefGoogle Scholar
  20. 20.
    Barreca M, Renzi C, Tankel J, Shalhoub J, Sengupta N (2016) Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis 12:119–126 Available from: CrossRefGoogle Scholar
  21. 21.
    Alvared A, Goudra BG, Singh PM (2016) Enhanced recovery after bariatric surgery. Curr Opin Anaesthesiol 30(1):133–139Google Scholar
  22. 22.
    Awad S, Carter S, Purkayastha S, Hakky S, Moorthy K, Cousins J, Ahmed AR (2014) Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg 24(5):753–758CrossRefGoogle Scholar

Copyright information

© Association of Surgeons of India 2018

Authors and Affiliations

  1. 1.Department of General SurgeryShaare Zedek Medical CenterJerusalemIsrael

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