title: The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.
abstract: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG.
  
  
  
  A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls.
  
  
  
  Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028].
  
  
  
  Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA. monica.sethi@nyumc.org.
authors.forename: Monica
authors.identifier: 0000-0001-7784-0954
authors.initials: M
authors.lastname: Sethi
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Magrath
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Somoza
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Manish
authors.initials: M
authors.lastname: Parikh
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: John
authors.initials: J
authors.lastname: Saunders
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Aku
authors.initials: A
authors.lastname: Ude-Welcome
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Schwack
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Marina
authors.initials: M
authors.lastname: Kurian
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: George
authors.initials: G
authors.lastname: Fielding
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Ren-Fielding
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D005767:Gastrointestinal Diseases / Q000000981:diagnostic imaging*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging*; D012189:Retrospective Studies; D012307:Risk Factors; D013529:Surgical Wound Dehiscence / Q000000981:diagnostic imaging*; D018746:Systemic Inflammatory Response Syndrome; D041742:Upper Gastrointestinal Tract / Q000000981:diagnostic imaging*; D055815:Young Adult
keywords: Bariatric surgery; Clinical signs; Esophagram; Gastric leak; Laparoscopic sleeve gastrectomy; Upper gastrointestinal series