Common, Less Common, and Unexpected Complications after Bariatric Surgery: A Pictorial Essay

Abstract

Bariatric surgery has demonstrated a higher rate of success than other nonsurgical treatments in selected patients with obesity; however, like all medical procedures, postoperative complications may occur, ranging between 2 and 10% and, although rare, they can be life threatening. Complications may be unspecific (any surgery-related complications) or specific (linked to the specific surgical procedure) and can be distinguished as common, less common, and unexpected. According to the onset, they may be acute, when occurring in the first 30 days after surgery, or chronic, with a presentation after 30 days from the procedure. The aim of this pictorial essay is to review the radiological aspects of surgical techniques usually performed and the possible complications, in order to make radiologists more confident with the postsurgical anatomy and with the normal and abnormal imaging findings.

Keywords: bariatric surgery; bariatric surgery complications; computed tomography; emergency; gastric banding; gastric bypass; imaging; leak; obesity; sleeve gastrectomy.

Figure 1

A well-placed gastric balloon in the gastric corpus and antrum seen at CT in axial (a,b), sagittal (c), and coronal (d) views, with an estimated volume of 461 cc (b).

Figure 2

Correct positioning of the gastric banding seen in the CT axial (a) and coronal (b,c) views. (d) The CT localizer at the phi angle. This is the angle that needs to be reviewed to confirm that the gastric band is normally positioned. This is formed by the profile of the gastric band and the vertical axis of the spine on frontal view. The normal range is between 4° and 58°. In the shown case, it is at 40°.

Figure 3

Surgical suture of sleeve gastrectomy seen on CT coronal oblique CT view.

Figure 4

A correct positioning of BariClip^® seen at CT coronal MIP (a) and MPR (b) views.

Figure 5

Gastric bypass. Surgical sutures seen at CT. Gastric pouch with gastrojejunostomy (a,b axial oblique view) and excluded stomach (b, arrow). Roux limb (c, coronal oblique view) of length of 75 to 150 cm from the jejunal division point for an average of 120 cm, jejunojenuostomy (d, circle, coronal view) between the biliopancreatic limb and the distal segment of jejunum (roux limb). The scheme was adapted from https://www.uptodate.com/contents/image/print?imageKey=GAST%2F79256 (accessed on 23 October 2022).

Figure 6

Mini-gastric bypass. Surgical sutures seen at CT. Gastric pouch (a,b, coronal view (a) and MIP (b) straight arrows). Bypassed stomach (a,b, curved arrows). Gastrojejunostomy (c, coronal oblique view). The scheme was adapted from https://www.theossi.com/mini-gastric-bypass-obesity-surgery.html (accessed on 23 October 2022).

Figure 7

Deflated gastric balloon. A 17-year-old female patient with gastric balloon placed two months before, came to the emergency department complaining of a change in urine color due to spreading of methylene blue from the balloon lumen. A CT was requested to evaluate balloon position. The deflated balloon is still in the gastric cavity (a, coronal oblique view, b axial view, arrows).

Figure 8

Gastric outlet obstruction. A 28-year-old female patient with a gastric balloon came to the emergency department complaining of sudden abdominal pain followed by persistent vomiting. Note the stomach overdistension proximal to the balloon, displaced in the antro-pyloric region (a–c, axial views, d, coronal view; balloon, arrows).

Figure 9

Migration of ruptured balloon with SBO. A 30-year-old female patient with a gastric balloon came to the emergency department complaining of abdominal pain and constipation. The balloon is displaced as the gastric cavity is empty (a, axial view). There are signs of mechanic ileus with air-fluid mixed stasis in the small bowel (b, axial view) proximal to the ruptured balloon (c, axial view, arrow) causing SBO, best seen in the coronal view (d, arrow).

Figure 10

Gastric band slippage with gastric obstruction. A 40-year-old female with known gastric banding was complaining of abdominal pain and vomiting. There is dilatation of the esophagus (a, axial view, arrow) and of the gastric lumen proximal to the gastric banding (b, axial view, arrow). These findings are best seen in the coronal views (c,d, esophagus and stomach, straight arrows; gastric banding curved arrows). In (e) is shown the phi angle, excessively wide (134,699°), and in (f) the volume rendering reconstruction in which the excessive angulation of the device is clearly seen.

Figure 11

Gastric banding, detachment of the catheter from the port. A female patient in whom it was no longer possible to adjust the gastric banding. In the CT scout, the detachment of the catheter extremity (a, curved arrow) from the port (a, straight arrow) is clearly evident. In (b), the same findings are shown in the volume three-dimensional reconstruction.

Figure 12

Type I leak after sleeve gastrectomy. See the air collection adjacent to the surgical suture (a, axial view, arrow; b, coronal view, arrow).

Figure 13

Type III leak after sleeve gastrectomy (a, axial, b, coronal oblique view, arrows) requiring surgical re-suturing. Eight days later, the CT again showed an air–fluid collection adjacent to the proximal gastric suture (c, axial, d, coronal oblique view, arrows) with extraluminal spreading of oral contrast medium (e, axial, f coronal oblique view, arrows). After any attempt at conservative treatment, the patient underwent total gastrectomy.

Figure 14

Stenting of proximal stricture of the gastric suture. Coronal oblique view.

Figure 15

Spleno-portal thrombosis and liver abscesses after sleeve gastrectomy with suture leak. A 46-year-old female with a type I leak after sleeve gastrectomy complained of abdominal pain, fever and kidney failure. Note the gastric surgical suture (a, coronal oblique view), the presence of a type I leak (b, axial view, straight arrow), and of multiple liver abscesses (b–d, axial view, curved arrows) related to extensive spleno-portal thrombosis (d–f, straight arrows). The leak is responsible for spread of gastric content and bacteria, causing septic spleno-portal thrombosis and, consequently, liver abscesses. The leak was conservatively treated and the thrombosis was successfully treated with multiple sessions of transhepatic catheter-directed thrombolysis.

Figure 16

Internal hernia with bowel necrosis after cesarean delivery. A 37-year-old-female patient complaining of abdominal pain, fever, and constipation early after cesarean delivery. Note the presence of intraperitoneal free air (a, axial view, curved arrow), overdistension of a small bowel loop with thin wall, some of them with barely noticeable enhancement (a,b, straight arrows), and the convergence of bowel, mesentery, and vessels of the closed loop at the hernia orifice (c, coronal view, straight arrow). The prompt volume reduction of the lower abdomen is probably due to the delivery, which solicited the bowel herniation. The patient underwent prompt surgery confirming the CT diagnosis and leading to bowel resection due to necrosis (d, straight arrows, bowel loops in different stages of ischemia/infarction). Image courtesy of Dr. Michele Lanza, Dr. Antonio Brillantino and Dr. Maurizio Castriconi Department of Emergency Surgery, “A. Cardarelli” Hospital, Naples, Italy.

Figure 17

Small bowel volvulus in patient with gastric bypass. A 55-year-old male patient was complaining of acute abdominal pain and constipation. See the gastric bypass (a,b axial oblique view; a, straight arrow, gastric suture; a, curved arrow, gastrojejunostomy; b, straight arrow jejunojejunostomy) and the closed loop obstruction due to volvulus (c, axial view, circle; d, coronal view, circle).

Figure 18

Relapse of anastomotic stricture in patients with mini-gastric bypass. A 58-year-old patient underwent previous gastric bypass followed by surgery for anastomotic stenosis, and came back still complaining of abdominal pain and dyspepsia. See the dilated stomach (a,b axial views, straight arrows), proximal to the anastomosis (a,b, curved arrows) with endoluminal stasis of the iodinated contrast agent that was orally administered (b, straight arrow).

Figure 19

Patient 1. Porto-spleno-mesenteric venous thrombosis and colonic ischemia after sleeve gastrectomy. A 37-year-old female patient underwent sleeve gastrectomy. The patient came to the emergency department complaining of abdominal pain and fever. See the surgical gastric suture (a, coronal oblique view), the enlarged and thrombosed spleno-portal lumen (b, axial view; c, coronal oblique view, straight arrows), the consequential mesenteric congestion (d, axial view; e, coronal view, curved arrows), and the colonic ischemia (d, axial view; e, coronal view, circles). In the coronal view (e), the thrombosis that extends to the superior mesenteric vein lumen can be seen best. The patient was treated with multiple session of transhepatic catheter-directed thrombolysis.

Figure 20

Patient 2. Suture leak with spleen abscess after sleeve gastrectomy. A 48-year-old patient underwent sleeve gastrectomy and complained in the following days of abdominal pain, fever, and dyspnea. At the first CT examination is seen the leak (a, axial view, straight arrow), free peritoneal fluid (a, curved arrow) and inhomogeneous enhancement of the spleen (a, circle). In more cranial scans, a splenic abscess is seen (b, circle) associated with the reactive pleural effusion (b, curved arrow), and the coronal view (c) further clarifies the finding (c, circle, splenic abscess). It was decided that the patient should be managed with percutaneous drainage of the splenic abscess. The patient came back after the drainage positioning, with chest pain and dyspnea (d–f) and at CT the left anterior pneumothorax (d, axial view, curved arrow) was detected due to the drainage positioning, which is actually in the splenic abscess (e, axial view, circle). However, in its course it crosses the left diaphragm (f, coronal view, circle).

Figure 21

Patient 3. Huge hematoma with active bleeding. A 48-year-old patient developed abdominal pain and tachicardia suddenly after surgery for mini-gastric bypass. See the surgical suture (a, axial view). There is also a large hyperdense collection (b, coronal view, arrow) with active arterial bleeding (c, axial view, arrow), increasing conspicuously in the following portal-venous phase (d, MIP coronal view, straight arrow), arising from the gastroduodenal artery (branch of hepatic artery). It was promptly treated by gastroduodenal artery embolization (e,f).

Figure 22

Patient 4. Leak from excluded stomach after gastric bypass. A 47-year-old male patient with previous gastric bypass was complaining of abdominal pain and fever. Note the surgical sutures of the gastric bypass (a,b, axial view) and in (c) the fluid collection (circle) that seems to arise from the excluded stomach (d, circle) and not supplied after the oral contrast administration (e,f axial views). According to the interventional radiologist and the surgeon, it was decided to conservatively treat the patients and at the CT follow-up 13 days later the fluid collection was reduced (g, axial view; h, coronal view, arrows).

Figure 23

Patient 5. Gastro-bronchial fistula after sleeve gastrectomy. A 52-year-old female was complaining for persistent cough and fever more than one month after sleeve gastrectomy followed by a leak conservatively treated. See the surgical suture of the sleeve gastrectomy (a, axial view, straight arrow), close to which there is a small hyperdensity (a, curved arrow). Furthermore, there is a pulmonary consolidation (b, axial view, circle) in the context of which there is an inhomogeneously hypodense round collection with some air bubbles suspected for pulmonary abscess (b, arrow). This area appears continuously to the gastric suture, and it is best seen in the coronal view (c, arrow). After the hydrosoluble oral contrast administration, this migrates into the abscess (d, axial view; e,f, coronal view; arrows) that was demonstrated to be related to the presence of a gauze.