Beruflich Dokumente
Kultur Dokumente
Department of Surgery, bDepartment of Radiology, University Hospitals Case Medical Center, Case
Western Reserve School of Medicine, Cleveland, OH, USA; cDepartment of Radiology, The Brooklyn
Hospital Center, Weill Cornel Medical College, New York, NY, USA
KEYWORDS:
Gastric perfusion;
Leaks;
Sleeve leak
Abstract
BACKGROUND: Several postoperative gastrointestinal complications are attributed to ischemia. We
herein evaluate the gastric wall perfusion using computed tomography (CT) scan perfusion index on
trial to address the etiology of ischemic complication after sleeve gastrectomy.
METHODS: A retrospective study of 205 patients undergoing CT scan of the abdomen to evaluate the
pattern of gastric vascular perfusion was performed. The perfusion index of the gastric mucosa was
measured at 5 gastric points using CT perfusion scanning.
RESULTS: Gastric perfusion at the angle of His (AOH) (53.51 6 14.38) was statistically significantly lower (P , .001) than that at the other gastric points studied: fundus, greater curvature, lesser
curvature, incisura angularis, and mid gastric points (76.16 6 15.21, 73.27 6 16.55, 76.12 6 16.12,
and 75.24 6 14.9, respectively). Gastric perfusion was significantly lower at all the gastric points
(and especially so at the AOH) among obese patients (33 cases) compared with nonobese patients
(18 cases). Gastric perfusion at all the points studied showed a decrease as the body mass index increases. Hypertensive patients had a better gastric perfusion compared with nonhypertensive patients.
CONCLUSIONS: Gastric wall perfusion is statistically significantly decreased at the AOH and gastric
fundus compared with perfusion at other gastric points. Gastric perfusion at all the gastric points studied decreased with the increase in body mass index. Gastric leakage in obese patients following sleeve
gastrectomy could be attributed to a decrease in the blood supply at AOH.
2014 Elsevier Inc. All rights reserved.
Imaging acquisition
All studies were performed using CT Phillips ingenuity
software version 4.0 mas 180 kvp 120 idose and 2 Phillips ict
brilliance software version 3.2.1.1 mas 225 kvp 120 idose 3.
All scans were obtained in the craniocaudal direction at end
inspiration. Slice thickness was 5 mm and additional sagittal
and coronal reconstructions were obtained. All scans were
obtained after 70 seconds from the beginning of the IV
contrast injection.
Statistical analysis
Data were fed to the computer using the Predictive
Analytics Software (PASW Statistics version 18). Quantitative data were described using median, minimum, and
maximum, as well as mean and standard deviation. The
distributions of quantitative variables were tested for
normality using KolmogorovSmirnov test and Shapiro
Wilk test. DAgstino test was used if there was a conflict
between the 2 previous tests. If it reveals normal data
distribution, parametric tests were applied. If the data were
abnormally distributed, nonparametric tests were used.
For normally distributed data, comparison between 2
independent population were done using independent t test
while more than 2 population were analyzed with F test
(analysis of variance) and (Scheffe) test. Significance test
results are quoted as 2-tailed probabilities. Significance of
the obtained results was judged at the 5% level.
Demographic data
Demographic data
Sex
Male
Female
Age (year)
Minimummaximum
Mean 6 standard deviation
Median
Weight (kg)
Minimummaximum
Mean 6 standard deviation
Median
Height (m)
Minimummaximum
Mean 6 standard deviation
Median
BMI
Minimummaximum
Mean 6 standard deviation
Median
Table 2
Number (%)
18 (35.3)
33 (64.7)
18.082.0
46.69 6 17.42
49.0
46.0204.1
83.38 6 29.11
75.7
1.502.0
1.70 6 .10
1.70
16.065.10
29.21 6 8.96
26.80
Results
Among the 205 patients CT scans, 154 were excluded
according to the above exclusion criteria. A total of 51 (18
male/33 female) patients were included in the study.
Demographic data showed that the mean age was 46.69
6 17.42 years (range 1882), mean height 1.7 6 .1 m,
mean weight 83.4 6 29.11 kg (range 46.0204.1), and
mean body mass index (BMI) 29.21 6 8.96 (range 16
65.1) (Table 1).
Table 2 shows the associated comorbidities; hypertension, dyslipidemia, and gastroesophageal reflux disease
were the most common, and 19 patients (37.3%) were in
fact hypertensive.
The mean PI at each of the 5 gastric points studied was
53.51 6 14.38, 76.16 6 15.21, 73.27 6 16.55, 76.12 6 16.12,
and 75.24 6 14.90 at the AOH, fundic dome, greater and lesser
curvature at the incisura angularis, and mid gastric antrum,
respectively. The perfusion at the AOH was significantly lower
(P ,.001) as compared with the other points. The perfusion at
the greater curvature was found, however, to be lower than that
at the lesser curvature but this was not statistically significant
(P , .898) (Table 3).
When the age of the patient was considered and we divided
the patients into 2 groups according to age, younger , 60 (39
patients) and older R 60 (12 patients), the PI was compared for
all 5 points; it was found that there were no statistically
significant differences between the PI at each of the 5 gastric
points in older and younger patients (Table 4). There were no
significant differences in the PI at each of the gastric points
studied in both male and female patients (Table 5).
The mean height of the patients studied was 1.7 6
.1 m (Table 1). We divided the patients studied into 2
Associated comorbidities
Comorbidity
Number (%)
Hypertension
Dyslipidemia
Gastroesophageal reflux
Depression
Coronary heart disease
Asthma
Diabetes mellitus
Chronic renal failure
Hypothyroid
Lymphoma
Lung cancer
19
10
8
6
5
5
5
4
3
3
3
(37.3)
(19.6)
(15.7)
(11.8)
(.1)
(.1)
(.1)
(.08)
(.06)
(.06)
(.06)
groups: taller (n 5 12) and shorter (n 5 39) patients according to whether the height of the patient was equal/
more or less than the mean height for the whole group,
respectively. The perfusion at the AOH was found to be
significantly lower in the taller patients (P , .029)
(Table 6).
We looked at the effect of the associated comorbidities
on the gastric PI. However, because of the sample size, we
only looked at the PI among hypertensive patients (32) and
compared with nonhypertensive patients.19 The PI was
found to be significantly higher among the hypertensive patients (P , .019) at the AOH but not at all the other gastric
points (Table 7).
In this study, we had 33 obese patients (BMI R 30) and
18 nonobese patients (BMI , 30); the PI at each of the 5
locations studied was found to be lower among obese
patients, and this was, however, statistically significant only
at the fundus (P , .02) (Table 8).
The relation between PI and BMI of the patients studied
is illustrated in Table 9. When the patients were divided
into 4 groups, normal weight, overweight, obese, and
morbidly obese, the PI varied significantly at the fundus,
lesser curvature, and greater curvature. It was found that
as the BMI increases the gastric perfusion decreases. It
was also found that the PI at AOH was always lower than
any other measured point when compared across all of
the subdivided BMI groups.
Comments
The worldwide outburst in bariatric surgery was only
dampened by a number of complications and technical
difficulties that is innate to each procedure. These challenges have inspired the search for an ideal surgical
procedure, and explain the dynamic nature and evolution
of the field of bariatric surgery.10,11
Sleeve gastrectomy, a relatively new weight loss procedure, has been recently gaining popularity for its technical
simplicity and excellent weight loss. However, leak after
sleeve gastrectomy can be a catastrophic complication. In
4
Table 3
Fundus
GC
LC
Pylorus
22.0100.0
53.51 6 14.38
50.0
,.001*
41.0110.0
76.16 6 15.21
75.0
34.0111.0
73.27 6 16.55
73.0
40.0105.0
76.12 6 16.12
76.0
37.0110.0
75.24 6 14.90
75.0
,.001*
,.001*
.894
,.001*
1.000
.898
,.001*
.999
.966
.999
r
Minimummaximum
Mean 6 SD
Median
P
P1
P2
P3
P4
P 5 P value for F test (ANOVA); P1 5 P value of Schaffer test between AOH with each other location; P2 5 P value of Schaffer test between fundus with
each other location; P3 5 P value of Schaffer test between GC with LC and pylorus; P4 5 P value of Schaffer test between LC and pylorus.
ANOVA 5 analysis of variance; AOH 5 angle of His; GC 5 greater curvature; LC 5 leaser curvature; SD 5 standard deviation.
*Statistically significant at P % .05.
Table 4
,60 (n 5 39)
R60 (n 5 12)
22.0100.0
53.41 6 15.19
50.0
41.086.0
53.83 6 11.92
49.50
53.0110.0
76.26 6 13.59
75.0
41.0105.0
75.83 6 20.35
74.0
46.0111.0
74.38 6 15.16
75.0
34.0109.0
69.67 6 20.80
66.0
50.0105.0
78.08 6 14.05
78.0
40.0105.0
69.75 6 21.01
67.0
58.0110.0
76.41 6 13.34
75.0
37.0102.0
71.42 6 19.32
67.0
P value
.930
.934
.393
.119
.417
Male (n 5 18)
Female (n 5 33)
28.086.0
49.11 6 12.25
49.0
22.0100.0
55.91 6 15.05
56.0
53.0110.0
80.17 6 17.28
79.50
41.0105.0
73.97 6 13.75
74.0
48.0111.0
72.78 6 19.09
68.50
34.0100.0
73.55 6 15.30
73.0
40.0105.0
73.22 6 17.71
71.0
46.0105.0
77.70 6 15.24
80.0
60.0105.0
74.06 6 13.57
69.50
37.0110.0
75.88 6 15.74
78.0
P value
.107
.167
.876
.349
.681
Table 6
,1.75 (n 5 39)
R1.75 (n 5 12)
39.0100.0
55.92 6 13.69
52.0
22.074.0
45.67 6 14.28
44.50
41.0105.0
76.08 6 14.15
75.0
53.0110.0
76.42 6 18.98
71.0
34.0100.0
73.72 6 14.46
73.0
46.0111.0
71.83 6 22.79
68.50
46.0105.0
76.74 6 14.46
76.0
40.0105.0
74.08 6 21.29
74.50
37.0110.0
74.72 6 15.38
75.0
60.0105.0
76.92 6 13.69
77.0
P value
.029*
.947
.791
.622
.659
6
Table 7
No HTN (n 5 32)
HTN (n 5 19)
22.094.0
49.91 6 12.81
49.0
40.0100.0
59.58 6 15.14
57.0
53.0110.0
77.38 6 15.14
75.50
41.0105.0
74.11 6 15.53
73.0
34.0111.0
73.22 6 18.61
72.50
52.0100.0
73.37 6 12.81
73.0
40.0105.0
76.38 6 17.98
78.0
49.095.0
75.68 6 12.84
75.0
55.0110.0
74.38 6 15.26
70.0
37.097.0
76.68 6 14.57
80.0
P value
.019*
.464
.975
.884
.598
through the abdominal CT scan and to look for any correlation that may explain the susceptibility of some patients
and certain gastric area for leak compared with others.
Relationship between BMI (nonobese vs obese) and gastric wall perfusion (r)
BMI
,30 (n 5 33)
R30 (n 5 18)
22.0100.0
54.58 6 16.03
50.0
28.075.0
51.56 6 10.86
50.0
53.0110.0
79.73 6 15.09
76.0
41.095.0
69.61 6 13.49
71.0
34.0111.0
76.58 6 17.80
78.0
46.088.0
67.22 6 12.23
68.50
40.0105.0
79.06 6 17.31
83.0
49.094.0
70.72 6 12.35
69.50
55.0110.0
77.36 6 14.78
75.0
37.091.0
71.33 6 14.72
69.0
P value
.479
.022*
.053
.077
.170
.24.9 (n 5 37)
2529.9 (n 5 16)
3034.9 (n 5 8)
R35 (n 5 10)
39.094.0
54.12 6 13.32
56.0
22.0100.0
55.06 6 18.93
49.50
41.061.0
49.88 6 5.82
49.50
28.075.0
52.90 6 13.85
50.0
69.0110.0
83.88 6 14.11
79.0
53.0105.0
75.31 6 15.27
74.50
53.085.0
70.0 6 11.89
70.0
41.095.0
69.30 6 15.28
71.0
56.0111.0
83.88 6 14.75
82.0
34.0100.0
68.81 6 17.86
65.0
55.088.0
72.50 6 11.70
74.0
46.078.0
63.0 6 11.46
64.0
59.0105.0
85.94 6 15.71
89.0
40.095.0
71.75 6 16.30
73.0
60.094.0
70.38 6 11.27
69.0
49.089.0
71.0 6 13.75
75.0
61.0110.0
81.71 6 14.13
80.0
55.099.0
72.75 6 14.47
68.0
60.091.0
73.75 6 12.08
73.0
37.091.0
69.40 6 16.92
66.50
P value
.870
.046*
.005*
.018*
.152
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