Canadian Association of Radiologists Journal xx (2018) 1e13

www.carjonline.org

Abdominal Imaging / Imagerie abdominale

Laparoscopic Sleeve Gastrectomy: A Radiological Guide

to Common Postsurgical Failure
Fabio Garofalo, MDa,*, Radu Pescarus, MDa, Ronald Denis, MDa, Henri Atlas, MDa,
Pierre Garneau, MDa, Michel Philie, MDb, Karl Sayegh, MDc
a
D
epartement de Chirurgie, Division de Chirurgie Bariatrique, H^opital du Sacr
e-Coeur de Montr
eal, Universit
e de Montr
eal, Montreal, Quebec, Canada
b
D
epartement de Radiologie, H^opital du Sacr
e-Coeur de Montr
eal, Universit
e de Montr
eal, Montreal, Quebec, Canada
c
Department of Radiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada

Abstract
Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because
of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical
technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy.
Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate
interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

R
esum
e
La gastrectomie longitudinale par laparoscopie figure parmi les interventions bariatriques les plus courantes a l’
echelle mondiale. Depuis
peu, elle gagne en popularit
e, car elle entra^ıne un faible taux de complications, une r
esolution satisfaisante des comorbidit
es et une perte de
poids importante. Le pr
esent article traite de la technique chirurgicale, des aspects d’imagerie postchirurgicaux attendus et des r
esultats
d’imagerie associ
es aux complications courantes suivant la gastrectomie longitudinale par laparoscopie. La compr
ehension de cette technique
chirurgicale et des caract
eristiques anatomiques normales suivant l’intervention permet une interpr
etation juste des r
esultats d’imagerie dans
les cas de perte de poids insuffisante, de reprise de poids et de complications postchirurgicales.
Crown Copyright Ó 2017 Published by Elsevier Inc. on behalf of Canadian Association of Radiologists. All rights reserved.

Key Words: Gastric leak; Gastric stenosis; Radiology; Sleeve gastrectomy

Obesity continues to be a major public health problem in
the United States, with more than one-third of adults
considered obese in 2009-2010, as defined by a body mass
index (BMI) >30 kg/m2 [1e3]. Bariatric surgery procedures
are indicated for patients with a BMI >40 kg/m2 without
coexisting medical problems and for whom bariatric surgery
would not be associated with excessive risk should they be
eligible for a bariatric procedure [4]. Patients with a BMI
>35 kg/m2 and 1 or more severe obesity-related comorbid-
ities may also be offered a bariatric procedure [4,5].
Among different surgical options, laparoscopic sleeve
gastrectomy (LSG) has demonstrated benefits comparable to
* Address for correspondence: Fabio Garofalo, MD, Division de Chirurgie
Bariatrique, H^
opital du Sacr
e-Coeur de Montr
eal, Universit
e de Montr
eal,
5400 boul. Gouin ouest, Montr
eal, Qu
ebec H4J 1C5, Canada.
E-mail address: garofalofabio@inwind.it (F. Garofalo).
other bariatric procedures and is currently becoming one of
the most common bariatric procedures worldwide. In com-
parison with other bariatric surgeries such as the laparoscopic
Roux-en-Y gastric bypass (LRYGB), LSG is a shorter and
more technically straightforward procedure that leads to fewer
changes to the body’s normal anatomy and physiology. It has
recently increased in popularity because of proven efficacy in
achieving considerable weight loss and comorbidities resolu-
tion without increasing the risk of complications [6,7].
Sleeve gastrectomy was originally performed by Hess [8]
and Marceau [9] in 1998 as the first part of the duodenal
switch operation. In high-risk and super-obese patients (BMI
>50 kg/m2), the gastric sleeve part of the duodenal switch
operation was often performed alone in an attempt to reduce
morbidity and mortality, and to facilitate the laparoscopic
approach [10]. In the past 15 years, LSG has increasingly been
used as a stand-alone primary bariatric procedure and has

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2 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13

gained popularity among patients and bariatric surgeons [11].

In a meta-analysis published in 2013 by Buchwald and Oien
[12] LSG appears to be the second leading bariatric operation
in the world, only surpassed by LRYGB. Moreover, LSG has
surpassed LRYGB as the most frequently performed bariatric
procedure in American academic centres since 2013 [13].
The ultimate goal of the procedure is to remove between
60%-70% of the stomach, including the fundus, leaving only
a thin ‘‘banana-shaped’’ gastric tube from the esophagus to
the duodenum. The narrowing of the stomach results in a
significant restriction of the gastric capacity as well as in
other metabolic modifications. Interestingly, ghrelin, one of
the main hormones that stimulates and increases the patient’s
appetite, is primarily produced by cells located in the fundus
[14,15]. Resection of the fundus dramatically decreased the
basal level of ghrelin, reducing appetite in patients who
underwent LSG [16e18].
We discuss the surgical technique of LSG and imaging
appearance of failure including insufficient weight loss,
weight regain, and the most frequently encountered surgical
complications.
Figure 1. Diagram showing the normal surgical anatomy following laparo-
scopic sleeve gastrectomy. The resected stomach is removed out of the
Surgical Technique of LSG abdomen through a small incision. The thick interrupted line outlines the
gastric transection plane along the greater curvature from the proximal
After the creation of a pneumoperitoneum, 5 laparoscopic antrum to the gastroesophageal junction. The thin interrupted line outlines
ports are placed across the upper abdomen. The first step of the the incisura angularis. Illustration courtesy of Ildiko A. Horvath, Medical
Illustrator, McGill University Health Center, Montreal General Hospital,
procedure is to divide the vascular attachments of the gastro-
Montreal, Quebec, Canada.
epiploic arcade and the short gastric vessels. The stomach and
fundus must be fully mobilized during the dissection. The
presence of a hiatal hernia is verified and repaired if necessary. excess weight loss <50%) [22,23] or weight regain and
Subsequently, gastric transection begins 4-6 cm proximal surgical complications.
to the pylorus by successive application of a laparoscopic
linear stapler, using a gastric calibration bougie (36-40 F). Radiological Evaluation of Complications of LSG
This bougie is essential, as it helps to prevent excessive
narrowing of the gastric tube (Figure 1). The imaging evaluation of patients following LSG relies
The position of the final staple firing is critical to avoid a primarily on fluoroscopy or upper gastrointestinal (UGI)
leak. Leaving a significant portion of fundus will not be series and computed tomography (CT) scan and to a limited
optimal in terms of weight loss or gastroesophageal reflux extent on plain radiographs (Figure 2). Radiologists should
disease (GERD) in the long term. Approximately 1 cm of therefore be familiar with the weight and size limitations of
cardia should be left after the last stapler is fired [19]. their equipment since a subset of a bariatric population is
Intraoperative endoscopy can be useful in ruling out leaks, likely to exceed these limitations [24].
abnormal angulation of the sleeve, or gastric stenosis [20]. Imaging plays an essential role in the evaluation of
postoperative failure and in the detection of postsurgical
Failure After LSG complications, although its routine use in the postoperative
period is debated [24]. According to the American Society
LSG has demonstrated its effectiveness in achieving weight for Metabolic and Bariatric Surgery, the decision to perform
loss and resolution of obesity-related comorbidities [21]; the routine vs selective fluoroscopy studies should be left to the
concept of sleeve gastrectomy is simple, but some compo- discretion of the surgeon, depending on factors related to the
nents of the operation, if performed incorrectly, can result in system of care in place including available expertise and on
serious complications. A recent expert panel consensus patient characteristics such as size, the ability to swallow, the
statement has been published with a resulting drive toward ability to stand, and the ability to be cooperative [24]. The
standardization, providing guidance for essential aspects of routine use of CT scan following LSG has been sparsely
the procedure, indications and contraindications, surgical investigated [25] and to the best of our knowledge almost
technique, management, and prevention of complications [7]. never performed in clinical practice.
Nevertheless, even in the hands of expert surgical teams At our institution, conventional fluoroscopy of the UGI
and high-volume bariatric centres, failure exists. LSG failure tract is used for the evaluation of gastric leaks and stenosis and
can be classified as insufficient weight lost (defined as an less commonly in cases of weight loss failure or weight
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 3

Figure 2. A 45-year old woman who underwent laparoscopic sleeve gastrectomy. (A, B) Sequential computed tomography images show the sleeve gastrectomy
staple line (arrows) with orally administrated iodinated contrast inside the stomach. (C, D) Anteroposterior fluoroscopic images of the same patient post laparoscopic
sleeve gastrectomy. No angulation is demonstrated at the level of the incisura angularis (arrows). The patient presented no postoperative complications.

regain. Water-soluble contrast is usually preferred to barium
when there is concern for perforation. In patients with risk of
aspiration, iso-osmolar, low-osmolar, or barium contrast may
be used. If a leak is highly suspected clinically but undetected
with water-soluble contrast, barium administration may be
attempted. Fluoroscopic spot images are initially obtained
before contrast ingestion followed by fluoroscopic monitoring
in the upright or semiupright position while the patient takes
sips of contrast. Cine video clips are usually acquired during
sequential swallows to evaluate for leaks [26]. Frontal,
shallow oblique and lateral projections are obtained. This is
complemented by the reverse Trendelenburg position, which
can reveal a leak at the upper part of the stomach not visible
on the other projections due to rapid passage of contrast in this
region [27]. Final images are usually obtained after the study
to evaluate for delayed extravasation of contrast and leak [26].
Abdominal CT scan can also demonstrate leaks and stenosis
in addition to providing greater detail about extragastric
findings and complications, including the presence of intra-
abdominal hematoma, abscess, and incisional hernia. The
CT parameters used are identical to the parameters used in the
nonbariatric population, although higher kVp or mA may be
required to achieve diagnostic image quality. At our centre
thin-section images are initially acquired in an axial plane
(1.25-mm thickness) and reconstructed in axial, coronal, and
sagittal planes with a 2.5-mm thickness. An initial abdominal
CT without oral or intravenous iodinated contrast immediately
followed by an abdominal CT with oral and intravenous
contrast is the routine protocol at our institution whenever a
leak is suspected. Administration of intravenous iodinated
contrast and image acquisition in portovenous phase (70-
second delay after the start of intravenous [IV] contrast ma-
terial injection) may aid in the detection of complications such
as abscesses (2 cm3/kg, maximum 120 mL). The use of oral
iodinated contrast ingested immediately before the contrast
enhanced scan can also be very helpful in demonstrating a site
of leak or fistula formation (diluted mixture of 20-25 cm3 of
water-soluble contrast in 180-225 cm3 of water). The initial
noncontrast enhanced scan is useful in ensuring the absence of
pre-existing hyperdense material in the surgical bed, such as
hyperdense clot or blood or iodinated contrast from a prior CT
examination. When reviewing CT images performed with oral
or IV contrast, the brightness and the contrast of the image
should be properly set by respectively adjusting the window
width (W) and the window level (L). Failing to do so may lead
to false negatives and false positives. For instance, a high
concentration of iodinated material in the postoperative
stomach may result in streak artifact in the surgical bed,
obscuring a small extraluminal air locule (false negative) or
simulating contrast extravasation (false positive). There are no
widely accepted display window settings; however, in our
experience, review of images for leaks are best performed
4 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13

Figure 3. A 46-year old woman presented with weight regain 18 months after sleeve gastrectomy. (A, B) Sequential anteroposterior fluoroscopy images show
dilatation due to incompletely resected fundus (arrows). The patient subsequently underwent conversion to laparoscopic Roux-en-Y gastric bypass.

using a wide window width (400-2000 HU range) and a
window level set between 40-400 HU. Finally, radiographs are
of limited value but can be useful to detect free peritoneal air
[28] or to confirm position of various drains or stents.
A normal UGI examination shows a regular sleeve and the
staple line may or may not be visible [27]. Passage of oral
contrast should be prompt, although in the very early post-
operative phase, delayed passage of contrast material can be
observed, presumably due to secondary oedema of the pylorus
and residual stomach. The sleeve can have a filiform pattern,
presumably due to spasm, or a more relaxed appearance [27].
As gastric transection begins 4-6 cm proximal to the pylorus,
the pylorus can sometimes appear wider than the sleeve [27].
Normal postoperative CT shows a sleeve with a staple line
along the transection site with no contrast material leak or
collection in the vicinity of the staple line [27].
Insufficient Weight Loss or Weight Regain
Patients appear to be subject to weight regain starting
3 years after their LSG. A systematic review published
recently by Parikh et al [6], showed 29.9% of weight regain or
insufficient weight loss of the LSG patients after 3 years.
Several factors may be responsible for insufficient weight loss
or weight regain. These factors include preoperative super
obesity, preoperative metabolic syndrome, and changing di-
etary habits to high-caloric meals. Furthermore, loss of patient
follow-up and inadequate counseling may also play an
important role in failure.
Anatomic changes of the sleeve can be also a cause of
failure. Radiological interpretation of these modifications

Figure 5. A 44-year-old man presenting with dysphagia following resleeve

Figure 4. A 24-year-old woman presented insufficient weight loss 1 year
after sleeve gastrectomy. Anteroposterior fluoroscopy image shows a dilated
antrum and a large fundus. In this case, dilatation is a result of incomplete
resection of the antrum during laparoscopic sleeve gastrectomy. Patient
underwent regastrectomy with good long-term outcome.
gastrectomy. Anteroposterior fluoroscopic image demonstrates a long gastric
stenosis (arrows) leading to dilatation and formation of a proximal neo-
fundus (arrowhead). The patient was successfully treated by conversion to
laparoscopic Roux-en-Y gastric bypass with a gastrojejunal anastomosis
proximal to the strictured segment.
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 5

during the surgeon’s learning curve or in difficult cases

Figure 6. A 52-year-old patient referred to our bariatric clinic for insufficient
weight loss after sleeve gastrectomy performed in another centre. The
anteroposterior fluoroscopic image shows a homogenously dilated stomach.
This is an example of dilatation as a result of poor surgical technique. This
patient underwent resleeve gastrectomy.
(super obesity) with poor posterior exposure, and incomplete
visualization of the left crus of the diaphragm [29]. Dilation
can also be defined as a homogeneous dilated gastric tube of
more than 250 mL in volume on CT scan volumetry [29] as
seen later during follow-up. Different mechanisms contrib-
uting to dilatation of the sleeve gastrectomy exist: excessive
narrowing of the gastric incisura during the primary opera-
tion, patients’ eating habits, natural history of LSG, use of a
large calibration bougie during surgery, a planned second
procedure, or a combination [29] (Figures 3, 4, 5, 6, and 7).
Different surgical options are available once the diagnosis
of a dilated gastric sleeve is established. One such option is
to resleeve the residual stomach over a bougie (36-40 F) [30].
Other options of revision of the sleeve gastrectomy such as
LRYGB, omega loop mini gastric bypass [31], and bil-
iopancreatic diversion with duodenal switch [32,33] have
been proposed in the literature and they seem to be associ-
ated with a significant weight loss improvement.

can play a vital role in the shared decision-making process.
Indeed, failure may be due to dilatation of the sleeve gas-
trectomy. Dilation can occur when the upper posterior gastric
pouch is incompletely dissected during the initial procedure
(Figure 3). This may occur as a result of inexperience early
Surgical Complications
The increasing popularity of LSG is also partly due to major
advantages that we do not find in other bariatric procedures,
such as LRYGB and laparoscopic adjustable gastric banding.

Figure 7. A 42-year-old woman who presented with severe dysphagia to solids and liquids 1 year after sleeve gastrectomy. (A) Axial oblique computed
tomography image shows sharp angulation and severe narrowing at the level of the incisura angularis (arrow). (B) There is homogenous dilatation of the
proximal gastric sleeve with presence of heterogenous intragastric material and iodinated contrast. (C) Notice also the sliding hiatal hernia (arrow) potentially
caused (or increased) by the distal obstruction. Endoscopically, there was a severe angulation and twist at the incisura with difficult passage of the endoscope
and presence of solid food proximally. Conversion to laparoscopic Roux-en-Y gastric bypass resolved the symptoms in this patient.
6 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13

Table 1 at the incisura, resulting in a functional obstruction with

Complications of laparoscopic sleeve gastrectomy resultant proximal overpressure [24]. The incidence of gastric
Complication Incidence Time period leaks can increase from 2.2% for primary LSG to 5.7% for
Staple line leak 2.2%-5.7% [6,36,37] Early, and late revisional LSG [6,36,37].
Stenosis 0.1%-3.9% [38e41] Late more than early A high index of suspicion and early identification of leaks
Hemorrhage <2% [19] Early more than late after LSG are critical to achieve an acceptable outcome after
GERD 0.5%-31% [18,42e44] Late more than early
Splenic injury 0.1% [27] Early
this complication. Unexplained tachycardia, fever, abdom-
Incisional hernia <1% [45,46] Late more than early inal pain, or persistent hiccups after the procedure are some
Wound infection Rare Early of the clinical clues that should alert surgeons to investigate
GERD ¼ gastroesophageal reflux disease. for a leak.
Early is defined as 7 days; late is defined as >7 days. A gastric leak may be confirmed on imaging with fluo-
roscopy or CT, although they are frequently not visible at
These advantages include technical efficiency, lack of an in- imaging during the early postoperative period for up to
testinal anastomosis, normal and intact intestinal absorption, approximately 3 days [47]. Fluoroscopy typically shows
absence of risk of internal hernias, no implantation of a foreign extravasation of iodinated contrast material into the left upper
body, pylorus preservation preventing dumping syndrome, and quadrant (Figure 8). Interestingly, the only indication of a leak
appropriate first step in extremely obese patients [34]. by fluoroscopy or CT scan can be contrast opacification of a
Moreover, following surgery the entire UGI tract remains surgical drain in the surgical bed, a subtle finding that can be
accessible for endoscopic assessment. Concerns remain, how- easily overlooked (Figure 9) [48]. The role of routine UGI
ever, regarding potential complications associated with LSG contrast study in all operated patients in the early post-
including staple line leak, stenosis, and postoperative hemor- operative period remains unclear, and a risk of false negative
rhage. A recent review of the literature, with a total of 940 exists [27]. Gnecchi et al [49], in a retrospective study of 101
patients included, showed a mortality rate of 0%-3.3% and consecutive LSGs, showed no advantage to systematic early
major complications ranged from 0%-29% (average 12.1%) UGI studies for detecting surgical gastric leak and suggested
after LSG [35]. Radiologists should be familiar with these that this examination should be performed on symptomatic
potential complications (Table 1) and their imaging appearance patients and on those at high risk for leaks. In cases of sus-
(Table 2). pected leaks, a CT scan with oral contrast material (with or
without IV contrast) could provide more information,
Staple Line Leak including the site of gastric leak and localization of fluid
collections in the left upper quadrant (Figures 10 and 11) in
Leak is the most concerning complication after LSG. The addition to other potential postoperative complications such as
most common location of a leak is at the gastroesophageal hematomas, pulmonary embolisms, and pleural effusions [24].
junction (GEJ). This complication may result from placement Typically, the site of contrast or air extravasation is identified
of the final staple line across the GEJ or distal esophagus. at the GEJ, near the angle of His, with associated inflamma-
Another important factor that can contribute to proximal leak tion and fat stranding at the staple line [47].
is distal gastric stenosis. This can be from a truly stenotic According to best practices guidelines from the Interna-
lumen, or, more commonly, twisting or kinking, of the sleeve tional Sleeve Gastrectomy Expert Panel Consensus, leaks

Table 2
CT finding of sleeve gastrectomy complications
Oral iodinated Intravenous
Complication Most common location Most common findings on CT contrast iodinated contrast
Staple line leak Upper stomach Contrast material extravasation. Useful Optional
Free air and/or air fluid levels adjacent to site of leakage.
Phlegmon or abscess formation.
Gap in the staple line.
Stenosis Incisura angularis Dilatation of proximal stomach and esophagus. Useful Optional
Narrowing of the lumen of the stomach.
Persistent column of contrast proximal to the stenosis.
Sharp angulation at the level of the incisura angularis.
Hematoma Left upper abdomen Perigastric collection with high-density internal contents indicating blood Optional Useful
contents and/or internal hematocrit level.
Possible blush of intravenous contrast material, if active bleeding.
Spleen infarction Upper pole Wedge shaped hypodensity in the spleen. Optional Useful
GERD Gastroesophageal Esophageal reflux of oral contrast material. Useful Not needed
junction Presence of a hiatal hernia.
Distended/patulous esophagus.
Neofundus.
CT ¼ computed tomography; GERD ¼ gastroesophageal reflux disease.
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13
Figure 8. A 36-year-old woman presenting with a leak at the gastroesoph-
ageal junction 8 weeks after the index surgical procedure. Anteroposterior
fluoroscopy image shows extravasated contrast material (arrow). The patient
was successfully treated by laparoscopic abscess drainage and endoluminal
stenting across the leakage site (not shown).
should be categorized according to their occurrence time from
the operative procedure (acute is within 7 days, early is within
1-6 weeks, late is 6-12 weeks, and chronic is >12 weeks) [7].
The current treatment algorithm includes drainage, antibiotics,
nutritional support, and endoluminal control. Stent placement
is also an appropriate treatment choice for acute, early, and
late leaks but not chronic leaks (>12 weeks) [7].
The management of perigastric abscesses depends on the
patient’s clinical condition and available resources [24,50,51].
If the leak presents as a well-defined abscess and the patient is
clinically stable, percutaneous image-guided drainage is
appropriate. In case of an unstable patient, surgical drainage
(laparoscopically by experienced bariatric team) is the
preferred choice [24]. Together with drainage, endoluminal
control must be established to facilitate closure of the leak.
Figure 9. A 62-year-old woman with leak at the gastroesophageal junction.
Fluoroscopic image shows small amount of extravasated contrast at the
gastroesophageal junction (arrowhead) and iodinated contrast material
opacifying the surgical drain (arrows). The patient was initially treated by
primary laparoscopic suture. The patient presented with recurrence of the
leak and final treatment was achieved by endoscopic stenting (not shown).
7
Figure 10. A 68-year old patient presented to the emergency department with
fever and abdominal pain 23 days after laparoscopic sleeve gastrectomy.
Axial maximum intensity projection image (15 mm thickness) of a computed
tomography scan following administration of intravenous and oral iodinated
contrast material shows a large left upper quadrant abscess (asterisks) con-
taining extravasated contrast material (arrow) and air. Notice the gap in the
staple line (arrowhead) indicating the site of leakage. The patient was treated
by percutaneous drainage and endoluminal stenting.
In our institution, endoscopic treatment includes placement
of a partially covered metallic stent (Wallstent, Boston Sci-
entific, Galway, Ireland), fully covered stent (Megastent,
Taewoong Medical Industries, Gimpo, South Korea) and Over-
the-Scope Clip (Ovesco Endoscopy, T€ubingen, Germany)
[52e54]. Partially covered esophageal metallic stents have
Figure 11. A 44-year-old woman presented with nausea, vomiting, and inter-
mittent abdominal pain without fever 35 days after revisional sleeve gastrectomy.
This patient had laparoscopic sleeve gastrectomy after insufficient weight lost
postegastric plication. Axial image of a computed tomography scan following
administration of oral iodinated contrast material shows a small amount of
contrast extravasation and free air (arrows) indicating a microleak at the
gastroesophageal junction. Treatment was achieved by endoluminal stenting.
8 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13

been until recently the best option in the treatment of sleeve
leaks. They are, however, prone to migration given their
shorter length (up to 155 mm) and are harder to remove due to
the ingrowth occurring at both ends of the stent. More recently,
fully covered Megastents (Taewoong Medical Industries) up to
230 mm in length and with a large diameter (up to 28 mm)
appear to be more resistant to migration. They are also easy to
remove given the full silicone covering. Finally, longer Meg-
astents allow for a complete stenting of the gastric sleeve past
the incisura angularis, therefore reducing proximal over-
pressure and allowing for a better healing of the tract or fistula
(Figure 12).
Recently, treatment with endoscopically inserted double
pigtail catheters has been proposed in the European literature
[55]. The pigtail is placed across the fistula between the
lumen of the esophagus and the cavity of the abscess
(Figure 13). This is conceptually similar to the endoscopic
transgastric drainage of pancreatic pseudocysts. The pigtail
allows for internal drainage of the abscess. It is usually
endoscopically removed after 3-6 weeks of drainage.
A chronic fistula after LSG is a challenging problem. If a
fistula persists for more than 3 months despite adequate
drainage, endoluminal therapy, and nutritional support, reop-
eration may be the only solution. Several surgical options have
been reported including the creation of a fistulojejunostomy
connecting a jejunal Roux limb to the fistula (Figure 14) and
total gastrectomy with esophagojejunostomy [24,51]. A
chronic leak can also progress into gastrocolic fistula, espe-
cially when initial control of the leak is not achieved. In the
medical literature, few case reports have been published
documenting the treatment of a gastrocolic fistula post-LGS
[56,57]. Laparoscopic resection of the fistula tract can be a
valid option in these rare cases (Figure 15).
Abnormal Angulation or Stenosis
Stenosis or obstruction of stomach due to abnormal
angulation following sleeve gastrectomy has been
increasingly recognized with a reported incidence ranging
between 0.1%-3.9% [38e41]. The most common site of

Figure 12. A 62-year-old woman with a leak at the gastroesophageal junction, 7 days after laparoscopic sleeve gastrectomy. Healing of the leak was initially
attempted via placement of a Wallstent (Boston Scientific, Galway, Ireland) for 4 weeks. (A, B) Axial images and (C) coronal image of a computed tomography
scan following administration of oral (and intravenous) contrast showing the Wallstent (155 mm length, 23 mm diameter) in position across the gastro-
esophageal junction. There is persistent tract and leakage (A, arrow) of contrast material into the collection (B, arrow) in the left upper quadrant. While the
proximal part of the stent covers the site of leak (A, arrowhead), the distal end of the stent (C, arrowhead) is not able to overcome the incisura angularis (C,
arrows). Despite the presence of a Wallstent for 4 weeks, leakage persisted. Complete healing of the leak was achieved by placement of a Megastent (230 mm
length, 28 mm diameter; Taewoong Medical Industries, Gimpo, South Korea) for another 3 weeks. (D) Coronal oblique image of a computed tomography scan
showing the full extent of the Megastent. Not only does the Megastent cover the leak site at the gastroesophageal junction but it also overcomes the incisura
angularis (D, arrow), reducing proximal overpressure, hence promoting healing of the leak.
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 9

Figure 13. A 65-year-old patient presented with a leak at the level of the gastroesophageal junction, 2 days after laparoscopic sleeve gastrectomy. Initial control
of the leak despite Megastent (Taewoong Medical Industries, Gimpo, South Korea) placement was incomplete. Final treatment was achieved by endoscopic
insertion of a double pigtail through the stent allowing internal drainage of the abscess cavity into the esophageal lumen. (A) Scout image showing the
Megastent (A, arrow) and the double pigtail (A, arrowhead). (B) Axial image of a computed tomography scan with intravenous and oral contrast in bone
window (width 2500, length 480) showing the position of the distal loop of the double pigtail in the residual air-containing cavity (B, arrow). (C) Coronal
oblique maximum intensity projection image (10 mm) and (D) axial oblique maximum intensity projection image (20 mm) in the bone window (width 2500,
length 480) showing contrast within the Megastent (C and D, asterisks) and the double pigtail with its distal loop positioned within the residual abdominal
cavity/collection (C, arrowhead) and its proximal loop kept inside the esophageal lumen (D, arrow).

abnormal angulation is at the incisura angularis. Although

Figure 14. A 43-year-old patient with a chronic fistula 9 months following
LSG, successfully treated by Roux-en-Y fistulojejunostomy. Anteroposterior
view from an upper gastrointestinal study following oral iodinated contrast
administration outlines the normal anatomy of the Roux-en-Y fistulojeju-
nostomy. There is normal concomitant passage of contrast material through
the sleeve gastrectomy (arrowheads) and the jejunal limb (arrows).
true strictures can occasionally occur (Figure 16), these are
not common. Obstructive symptoms after LSG are typi-
cally not due to a true luminal stricture but rather a result of
sharp angulation of more than 30 or indentation at the
incisura angularis of the gastric tube (Figure 17). This
functional obstruction presents as persistent dysphagia to
solids progressing to liquids accompanied by nausea and
vomiting.
Gastric sleeve stenosis or abnormal angulation can be
diagnosed using an UGI series, CT scan or endoscopy.
Fluoroscopy studies may show an area of stenosis or kinking
with a persistent contrast column within a dilated proximal
gastric remnant and sometimes a distended distal esophagus
and gastroesophageal reflux [47]. Although CT is rarely used
for assessment of a gastric stenosis, it may demonstrate
similar findings to fluoroscopy [47]. In our experience,
routine review of multiplanar reformations (coronal and
sagittal) can sometimes aid in detecting sharp angulations
overlooked when only axial images of a CT scan are
reviewed. The timing of clinical presentation following
10 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
Figure 15. A 47-year-old woman with a gastrocolic fistula 4 years following
laparoscopic sleeve gastrectomy. Anteroposterior view from an upper gastro-
intestinal study following oral iodinated contrast administration shows direct
passage of contrast material from the antrum to the transverse colon (asterisks)
through the fistulous tract (arrow). Following nutritional optimization the
patient was successfully treated by a combination of laparoscopic resection of
the tract with omental interposition and intraoperative endoscopy.
sleeve gastrectomy varies among patients but may occur
within days or in some cases months after the surgery.
Management includes symptomatic treatment with anti-
emetics, IV fluids, and endoscopic treatment with balloon
dilatation or stenting [40,41]. Large achalasia-type balloons
often succeed in treating true stenoses but often fail in
adequately treating complex angulations. For these patients
with twisted sleeves, revisional laparoscopic surgery is often
necessary. Nevertheless, revisional bariatric surgery is tech-
nically demanding and associated with higher complications
Figure 16. A 57-year-old woman presented with dysphagia, nausea, and
vomiting on postoperative day 27 following laparoscopic sleeve gastrectomy.
Anteroposterior fluoroscopy image demonstrates a segment of fixed distal ste-
nosis at the level of the incisura (arrows). Endoscopic treatment with a 30-mm
achalasia balloon dilatation was performed (result postdilatation not shown).
Figure 17. A 37-year-old woman with functional obstruction leading to
dysphagia to solids, 2 years following laparoscopic sleeve gastrectomy.
Axial image of a computed tomography scan following administration of
oral and intravenous iodinated contrast shows a very sharp angulation at the
level of the incisura angularis (arrow). Despite the kink, there is passage of
contrast distally. Treatment was achieved by conversion to LRYGB.
and mortality compared with primary bariatric procedures
[58]. A review of revisional bariatric surgeries conducted by
Jones [59] (n ¼ 883) reported 14% major complication rate
and 0.8% mortality rate. LRYGB is currently considered the
best surgical option in case of refractory stenosis, with good
short- and long-term outcomes [33,38,60,61]. Laparoscopic
seromyotomy, in which a partial thickness cut on the gastric
wall is performed on the stenotic gastric segment, has been
described in a few case series [62]. Moreover, a gastric wedge
resection, in which the stenotic segment is resected and a
gastrogastric anastomosis is performed, is another option [63].
Both options have been associated with poor results in the
bariatric literature [62,63].
Postoperative Hemorrhage
Significant bleeding requiring transfusion or reoperation
occurs in <2% of LSG [19]. Minor bleeding is often
managed conservatively with no sequelae for the patients.
Common sites of bleeding include the gastric staple line, the
short gastric vessels, the splenic and the omental vessels that
have been divided during dissection of the greater curvature.
There is some evidence suggesting that the use of but-
tressing, with bioabsorbable material, or running suturing of
the staple line can decrease intraoperative and postoperative
bleeding [64,65]. Nevertheless, no evidence of reduced rate
of gastric leaks has been demonstrated after staple line
reinforcement [6].
When bleeding is suspected in the postoperative period
based on significant hemoglobin drop or changes in the vital
signs, a CT scan is helpful in establishing the diagnosis
(Figure 18). Hematomas on CT have variable density
depending on the age of the bleed. On unenhanced CT, acute
bleeding has an attenuation of 30-45 HU then becomes
hyperdense (>60 HU) in the first few hours after bleeding as
the concentration of hemoglobin increases [66]. The blood
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 11

Figure 19. A 46-year-old patient who presented with gastroesophageal reflux

disease symptoms associated to dysphagia, 1 year after laparoscopic sleeve
Figure 18. A 59-year-old man presented with hemoglobin drop on
gastrectomy. Anteroposterior fluoroscopic image of an upper gastrointestinal
postoperative day 1 after laparoscopic sleeve gastrectomy. Axial image of
study shows a sharp angulation at the level of the incisura angularis (arrow),
a computed tomography scan with intravenous contrast shows a
causing functional obstruction. Herniation of the cardia (arrowhead) through
10.4 cm  14.4 cm perigastric high-density collection (60 HU) compatible
the esophageal hiatus is also visualized. Functional distal obstruction creates
with hematoma (asterisk) along the gastric staple line (arrow). Conservative
proximal overpressure and together with the presence of a sliding hiatal
treatment was successful.
hernia contributes to the gastroesophageal reflux disease symptoms.
Incidentally, distribution of small bowel loops in the right upper quadrant
indicates intestinal malrotation (asterisk). The patient was successfully
density then decreases in the subacute and chronic setting, treated by laparoscopic hiatal hernia repair and conversion to laparoscopic
and the hematoma involutes with time. A chronic hematoma Roux-en-Y gastric bypass.
may be indistinguishable from postoperative collections or
abscess [27]. A hematocrit level may be seen when bleeding
occurs at different time points within the same collection. Other Complications
Intravenous and oral contrast are usually not required to
establish the diagnosis of hematoma but depending on the Other complications have been described after sleeve
clinical context, administration of IV or oral iodinated gastrectomy. Splenic injury is rare, occurring in 0.1% of
contrast may be useful in the assessment of other potential cases and likely related to surgical dissection in the left upper
complications such as leaks. The detection of active bleeding quadrant [27]. Infarction of the spleen is the most frequently
also requires administration of IV contrast. Active bleeding
on contrast-enhanced CT will appear as a blush of contrast
more or less isodense to adjacent vasculature, in the vicinity
of a forming hematoma [66].

Gastroesophageal Reflux Disease

GERD remains a problem after LSG, and the onset of

severe refractory GERD after LSG may be an indication to
revise the procedure to LRYGB or other antireflux procedures.
New-onset GERD after LSG has been reported to be
0.5%-31% [18,42e44]. In the report by Himpens et al [42],
GERD symptoms are attributed to a neofundus, corre-
sponding to a dilated pouch of the proximal sleeve that can
be found in association with weight regain. Concomitant
sliding hiatal hernia or a patulous gastroesophageal valve can
also contribute to symptoms of reflux. It is therefore
important that the radiologist highlights the presence of even Figure 20. A 35-year-old patient on postoperative day 1 after laparoscopic
a small hiatal hernia in a bariatric patient, both preopera- sleeve gastrectomy. Axial image of a computed tomography scan following
tively or post-LSG (Figure 19). Concomitant hiatal hernia administration of intravenous and oral iodinated contrast material shows a
repair and LSG have been proposed to reduce postoperative typical wedge shaped hypodensity at the upper pole of the spleen compatible
with infarction (arrow) following short gastric vessel ligation during lapa-
GERD. In a recent study from Samkar et al [67], the authors roscopic sleeve gastrectomy. Incidentally, there is also subsegmental atel-
reported that 15.6% of asymptomatic patients developed de ectasis at the lung bases (arrowheads). The patient was asymptomatic and
novo GERD symptoms despite a hiatal hernia repair. was discharged home shortly after the computed tomography scan.
12 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
seen splenic injury after LSG and usually occurs at the su-
perior pole of the spleen. It can result from intraoperative
ligation of the short gastric vessels to mobilize the gastric
fundus during LSG. A contrast-enhanced CT shows a well-
demarcated wedge shaped peripheral nonperfused hypoden-
sity [27] (Figure 20). Subcapsular hematoma and laceration
are less common splenic injuries and typically appear as a
crescentic subcapsular fluid collection and a serpentine linear
hypodensity in the spleen, respectively [27].
Incisional hernias have also been described. Their inci-
dence rate is comparable to other bariatric procedures per-
formed laparoscopically (<1%) [45,46]. When they are
present they usually occur at the gastric extraction site,
which is the bigger 15-mm incision that sometimes has to be
dilated to allow the passage of the gastric specimen.
Conclusions
Laparoscopic sleeve gastrectomy has rapidly become one
of the most popular bariatric procedures worldwide. Given
the expected tremendous increase in surgical volume, radi-
ologists will be faced with increasing numbers of post LSG
exams. Radiological evaluation plays an essential role in
recognizing the most frequent and feared complications of
LSG such as gastric leaks and sleeve stenosis.
References
[1] Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic
review and network meta-analysis of randomized trials. Obes Rev
2011;12:602e21.
[2] Yatsuya H, Li Y, Hilawe EH, et al. Global trend in overweight and
obesity and its association with cardiovascular disease incidence. Circ J
2014;78:2807e18.
[3] Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in
the United States, 2009-2010. NCHS Data Brief 2012;82:1e8.
[4] Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines
for the perioperative nutritional, metabolic, and nonsurgical support of
the bariatric surgery patiente2013 update: cosponsored by American
Association of Clinical Endocrinologists, the Obesity Society, and
American Society for Metabolic & Bariatric Surgery. Surg Obesity
Relat Dis 2013;9:159e91.
[5] Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus
intensive medical therapy for diabetese3-year outcomes. N Engl J Med
2014;370:2002e13.
[6] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A,
Gagner M. Surgical strategies that may decrease leak after laparoscopic
sleeve gastrectomy: a systematic review and meta-analysis of 9991
cases. Ann Surg 2013;257:231e7.
[7] Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve
Gastrectomy Expert Panel Consensus Statement: best practice guide-
lines based on experience of >12,000 cases. Surg Obes Relat Dis 2012;
8:8e19.
[8] Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch.
Obes Surg 1998;8:267e82.
[9] Marceau P, Biron S, St Georges R, Duclos M, Potvin M, Bourque RA.
Biliopancreatic diversion with gastrectomy as surgical treatment of
morbid obesity. Obes Surg 1991;1:381e7.
[10] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-
stage laparoscopic Roux-en-Y gastric bypass as an alternative in the
super-super obese patient. Obes Surg 2003;13:861e4.
[11] Franco JV, Ruiz PA, Palermo M, Gagner M. A review of studies
comparing three laparoscopic procedures in bariatric surgery: sleeve
gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding.
Obes Surg 2011;21:1458e68.
[12] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011.
Obes Surg 2013;23:427e36.
[13] Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads
the U.S. utilization of bariatric surgery at academic medical centers.
Surg Obes Relat Dis 2015;11:987e90.
[14] English PJ, Ghatei MA, Malik IA, Bloom SR, Wilding JP. Food fails to
suppress ghrelin levels in obese humans. J Clin Endocrinol Metab
2002;87:2984.
[15] Tritos NA, Mun E, Bertkau A, Grayson R, Maratos-Flier E, Goldfine A.
Serum ghrelin levels in response to glucose load in obese subjects post-
gastric bypass surgery. Obes Res 2003;11:919e24.
[16] Benaiges D, Mas-Lorenzo A, Goday A, et al. Laparoscopic sleeve
gastrectomy: More than a restrictive bariatric surgery procedure?
World J Gastroenterol 2015;21:11804e14.
[17] Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy
and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;
15:1024e9.
[18] Bohdjalian A, Langer FB, Shakeri-Leidenmuhler S, et al. Sleeve gas-
trectomy as sole and definitive bariatric procedure: 5-year results for
weight loss and ghrelin. Obes Surg 2010;20:535e40.
[19] Brethauer SA. Sleeve gastrectomy. Surg Clin North Am 2011;91:
1265e79, ix.
[20] Nimeri A, Maasher A, Salim E, Ibrahim M, Al Hadad M. The use of
intraoperative endoscopy may decrease postoperative stenosis in
laparoscopic sleeve gastrectomy. Obes Surg 2016;26:1398e401.
[21] Yang X, Yang G, Wang W, Chen G, Yang H. A meta-analysis: to
compare the clinical results between gastric bypass and sleeve gas-
trectomy for the obese patients. Obes Surg 2013;23:1001e10.
[22] Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines
for the perioperative nutritional, metabolic, and nonsurgical support of
the bariatric surgery patiente2013 update: cosponsored by American
Association of Clinical Endocrinologists, The Obesity Society, and
American Society for Metabolic & Bariatric Surgery. Obesity (Silver
Spring) 2013;21(suppl 1):S1e27.
[23] Brethauer SA, Kim J, el Chaar M, et al. Standardized outcomes
reporting in metabolic and bariatric surgery. Surg Obes Relat Dis 2015;
11:489e506.
[24] Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM. ASMBS
position statement on prevention, detection, and treatment of gastro-
intestinal leak after gastric bypass and sleeve gastrectomy, including
the roles of imaging, surgical exploration, and nonoperative manage-
ment. Surg Obes Relat Dis 2015;11:739e48.
[25] Lainas P, Tranchart H, Gaillard M, Ferretti S, Donatelli G, Dagher I.
Prospective evaluation of routine early computed tomography scanner
in laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2016;12:
1483e90.
[26] Gaetke-Udager K, Wasnik AP, Kaza RK, Al-Hawary MM,
Maturen KE, Cohan RH. A guide to imaging in bariatric surgery.
Emerg Radiol 2014;21:309e19.
[27] Chivot C, Robert B, Lafaye N, et al. Laparoscopic sleeve gastrectomy:
imaging of normal anatomic features and postoperative gastrointestinal
complications. Diagn Interv Imaging 2013;94:823e34.
[28] Riaz RM, Myers DT, Williams TR. Multidetector CT imaging of
bariatric surgical complications: a pictorial review. Abdom Radiol
(NY) 2016;41:174e88.
[29] Noel P, Nedelcu M, Nocca D, et al. Revised sleeve gastrectomy:
another option for weight loss failure after sleeve gastrectomy. Surg
Endosc 2014;28:1096e102.
[30] Nedelcu M, Noel P, Iannelli A, Gagner M. Revised sleeve gastrectomy
(re-sleeve). Surg Obes Relat Dis 2015;11:1282e8.
[31] Cheung D, Switzer NJ, Gill RS, Shi X, Karmali S. Revisional bariatric
surgery following failed primary laparoscopic sleeve gastrectomy: a
systematic review. Obes Surg 2014;24:1757e63.
 Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13
[32] Dapri G, Cadiere GB, Himpens J. Laparoscopic repeat sleeve gas-
trectomy versus duodenal switch after isolated sleeve gastrectomy for
obesity. Surg Obes Relat Dis 2011;7:38e43.
[33] Homan J, Betzel B, Aarts EO, van Laarhoven KJ, Janssen IM,
Berends FJ. Secondary surgery after sleeve gastrectomy: Roux-en-Y
gastric bypass or biliopancreatic diversion with duodenal switch. Surg
Obes Relat Dis 2015;11:771e7.
[34] Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gas-
trectomy as an initial weight-loss procedure for high-risk patients with
morbid obesity. Surg Endosc 2006;20:859e63.
[35] Shi X, Karmali S, Sharma AM, Birch DW. A review of laparoscopic
sleeve gastrectomy for morbid obesity. Obes Surg 2010;20:1171e7.
[36] Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Laparoscopic sleeve
gastrectomy (LSG)-a good bariatric option for failed laparoscopic
adjustable gastric banding (LAGB): a review of 90 patients. Obes Surg
2013;23:300e5.
[37] Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as
revisional procedure for failed gastric banding or gastroplasty. Surg
Obes Relat Dis 2010;6:146e51.
[38] Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic
sleeve gastrectomy in morbidly obese patients. Obes Surg 2013;23:
1481e6.
[39] Lacy A, Ibarzabal A, Pando E, et al. Revisional surgery after sleeve
gastrectomy. Surg Laparosc Endosc Percutan Techn 2010;20:351e6.
[40] Jones M, Healey AJ, Efthimiou E. Early use of self-expanding metallic
stents to relieve sleeve gastrectomy stenosis after intragastric balloon
removal. Surg Obes Relat Dis 2011;7:e16e7.
[41] Ogra R, Kini GP. Evolving endoscopic management options for
symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid
obesity: experience at a large bariatric surgery unit in New Zealand.
Obes Surg 2015;25:242e8.
[42] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic
sleeve gastrectomy for obesity. Ann Surg 2010;252:319e24.
[43] Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve
gastrectomy on gastroesophageal reflux disease: a systematic review.
Surg Obes Relat Dis 2011;7:510e5.
[44] Laffin M, Chau J, Gill RS, Birch DW, Karmali S. Sleeve gastrectomy
and gastroesophageal reflux disease. J Obes 2013;2013:741097.
[45] Coblijn UK, de Raaff CA, van Wagensveld BA, van Tets WF, de
Castro SM. Trocar port hernias after bariatric surgery. Obes Surg 2016;
26:546e51.
[46] Lee DY, Rehmani SS, Guend H, et al. The incidence of trocar-site
hernia in minimally invasive bariatric surgery: a comparison of multi
versus single-port laparoscopy. Surg Endosc 2013;27:1287e91.
[47] Lehnert B, Moshiri M, Osman S, et al. Imaging of complications of
common bariatric surgical procedures. Radiol Clin North Am 2014;52:
1071e86.
[48] Carucci LR, Turner MA. Radiologic evaluation following Roux-en-Y
gastric bypass surgery for morbid obesity. Eur J Radiol 2005;53:353e65.
[49] Gnecchi M, Bella G, Pino AR, et al. Usefulness of x-ray in the
detection of complications and side effects after laparoscopic sleeve
gastrectomy. Obes Surg 2013;23:456e9.
13
[50] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after
laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4:33e8.
[51] Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS. Diagnosis and
management of gastric leaks after laparoscopic sleeve gastrectomy for
morbid obesity. Obes Surg 2010;20:403e9.
[52] Galloro G, Ruggiero S, Russo T, et al. Staple-line leak after sleve
gastrectomy in obese patients: a hot topic in bariatric surgery. World J
Gastroenterol Endosc 2015;7:843e6.
[53] Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents
to treat anastomotic complications after bariatric surgery. J Am Coll
Surg 2008;206:935e8, discussion 938e9.
[54] Keren D, Eyal O, Sroka G, et al. Over-the-scope clip (OTSC) system
for sleeve gastrectomy leaks. Obes Surg 2015;25:1358e63.
[55] Soufron J. Leak or fistula after sleeve gastrectomy: treatment
with pigtail drain by the rendezvous technique. Obes Surg 2015;25:
1979e80.
[56] Bhasker AG, Khalifa H, Sood A, Lakdawala M. Management of gastro-
colic fistula after laparoscopic sleeve gastrectomy. Asian J Endoscop
Surg 2014;7:314e6.
[57] Trelles N, Gagner M, Palermo M, Pomp A, Dakin G, Parikh M. Gas-
trocolic fistula after re-sleeve gastrectomy: outcomes after esophageal
stent implantation. Surg Obes Relat Dis 2010;6:308e12.
[58] Lim CS, Liew V, Talbot ML, Jorgensen JO, Loi KW. Revisional bar-
iatric surgery. Obes Surg 2009;19:827e32.
[59] Jones KW Jr. Revisional bariatric surgeryepotentially safe and effec-
tive. Surg Obes Relat Dis 2005;1:599e603.
[60] Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie R, Regimbeau JM.
Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and
management. Obes Surg 2016;26:995e1001.
[61] Parikh A, Alley JB, Peterson RM, et al. Management options for
symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in
the morbidly obese. Surg Endosc 2012;26:738e46.
[62] Dapri G, Cadiere GB, Himpens J. Laparoscopic seromyotomy for long
stenosis after sleeve gastrectomy with or without duodenal switch.
Obes Surg 2009;19:495e9.
[63] Vilallonga R, Himpens J, van de Vrande S. Laparoscopic management
of persistent strictures after laparoscopic sleeve gastrectomy. Obes Surg
2013;23:1655e61.
[64] Dapri G, Cadiere GB, Himpens J. Reinforcing the staple line during
laparoscopic sleeve gastrectomy: prospective randomized clinical study
comparing three different techniques. Obes Surg 2010;20:462e7.
[65] Albanopoulos K, Alevizos L, Flessas J, et al. Reinforcing the staple line
during laparoscopic sleeve gastrectomy: prospective randomized clin-
ical study comparing two different techniques. Preliminary results.
Obes Surg 2012;22:42e6.
[66] Furlan A, Fakhran S, Federle MP. Spontaneous abdominal hemorrhage:
causes, CT findings, and clinical implications. AJR Am J Roentgenol
2009;193:1077e87.
[67] Samakar K, McKenzie TJ, Tavakkoli A, Vernon AH, Robinson MK,
Shikora SA. The effect of laparoscopic sleeve gastrectomy with
concomitant hiatal hernia repair on gastroesophageal reflux disease in
the morbidly obese. Obes Surg 2016;26:61e6.