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wall perfusion and clinical implications

Alan A. Saber, M.D., F.A.C.S.a,*, Nami Azar, M.D.b,

Mahmoud Dekal, M.D.c, Tamer N. Abdelbaki, M.D., M.S., M.R.C.S.a

a

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.

attributed to ischemia. Recently, there has been increasing

interest in gastric surgery because of the surge in the

number of bariatric surgery. Sleeve gastrectomy has been

The authors declare no conflicts of interest.

* Corresponding author. Tel.: 11-440-991-6765; fax: 11-216-9837230.

E-mail address: saber6231@gmail.com

Manuscript received May 2, 2013; revised manuscript April 26, 2014

0002-9610/$ - see front matter 2014 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.amjsurg.2014.05.023

procedure with an excellent long-term effectiveness in

terms of weight loss and comorbidity resolution.13

However, the dreaded risk of gastric leak through the staple

line is still considered a setback for the sleeve gastrectomy.

Ischemia has been incremented for leak in several gastrointestinal surgeries. There are very few studies analyzing the

gastric blood flow.4 It was found that most leaks after sleeve

gastrectomy occur at the angle of His (AOH).5 The rational

of this study is to evaluate the gastric wall perfusion to

computed tomography (CT) scan perfusion index (PI).

enhanced computed tomography

study

The CT perfusion techniques are based on a direct

correlation between enhancement of the soft tissue after

intravenous contrast agent administration and the blood

volumetric flow to this tissue.6

Compartmental and deconvolution analyses are the 2

commonly used analytical methods to quantify vascular

physiology from the data acquired in the dynamic CT. A

general perfusion CT (PCT) technique typically requires a

baseline unenhanced image acquisition, followed by a

series of images acquired over a time period after an

intravenous bolus injection of iodinated contrast media.7

The study and analysis by PCT involve temporal

alterations of tissue attenuation measured in Hounsfield

units following intravenous contrast injection. The tissue

enhancement depends on the iodine concentration, and

indirectly reflects the tissue vascularization and the vascular

physiology.8

After iodinated contrast medium injection, the tissue

enhancement may be divided into 2 phases according to

the contrast agent distribution in the intra- and extravascular compartments.8 At the early phase, the enhancement is purely attributed to the contrast agent

distribution within the intravascular space, and such a

phase usually last 40 to 60 seconds after uptake into

this compartment.

A commercially available contrast agent (Iodixanol,

Visipaque 320; GE Healthcare, West Milwaukee, WI) was

infused intravenous injection (IV) using an automated

power injector (Stellant Dual Head Injector; Medrad

Healthcare, Warrendale, PA). Eighty milliliter of Visipaque 320 was administrated through a 20-guage IV

catheter placed in a peripheral vein. The infusion rate

was 5 mL/second. Thirty milliliter of normal saline was

infused at 5 mL/second after the infusion of contrast

material.

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.

perfusion in different parts of the stomach had not been

undertaken before. In our retrospect study, we compared

the gastric perfusion at the AOH with other gastric points:

fundus, greater curvature, lesser curvature, incisura angularis, and mid gastric. In all patients, these gastric points

were determined and an region of interest of chosen size

was placed to obtain the CT Hounsfield units (CT density

measurement), which reflects the amount of the IV contrast

enhancement in these points and therefore the perfusion of

these points separately. By comparing the enhancement of

the AOH with the other gastric points at the same time of

the enhancing study, we evaluate the pattern of gastric

perfusion with these points.

A retrospective study of patients who had CT scan of the

abdomen with intravenous contrast during the month of

July 2012 at the Case Western Medical Center was

screened. A total of 205 patients were included. Our

exclusion criteria were any patient with decompress gastric

tube (nasogastric tube, percutaneous endoscopic gastrostomy tube), hiatal hernia, patients younger than 18 years

old, previous upper abdominal surgery, hemodynamically

unstable patients, and any space occupying the mass

compressing the stomach.

PI of the gastric mucosa was measured at 5 points: the

AOH (junction between the esophagus and stomach),

highest point of the gastric fundus, greater and lesser

curvature at the level of incisura angularis, and mid gastric

antrum, respectively. The technique used to measure the

gastric PI is similar to that described by Choi et al.9 All the

images were reviewed by the same radiologist (N.A.).

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.

Table 1

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

AOH

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.

bariatric surgery. Leakage after sleeve gastrectomy was

reported to vary between .7% and 7%.1215 Sleeve gastrectomy is a high-pressure system; this may explain the

possible persistence of leak after sleeve gastrectomy for a

couple of months to heal.

The nonspecific clinical presentations and limitations of

most of the radiological studies contribute to the challenges

of early diagnosis of leak in such patient populations with a

low tolerance for complications. The possible progression of

leak to peritonitis, septic shock, multiple organ failure, and

even death further complicates the situation. In those who

survived the event, recovery can be protracted and

Table 4

hospitalization, transfer to the intensive care unit, total

parental nutrition, intravenous antibiotics, frequent images,

image-guided drainage, or even reoperation. Endoluminal

stents have been used in acute leak; however, stent migration

and erosion can be problematic. As a result, a stormy

postoperative course with increase morbidity, mortality,

financial burden, and potential medicolegal action may

follow.

Leak following sleeve gastrectomy (LSG) is a unpredictable complication; however, 75% to 100% of leaks

occur at AOH.13,16 Several underlying mechanisms have

been incriminated in the pathogenesis of leak, including

Age (year)

r at angle of His

MinimumMaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at LC

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

P value for Student t test.

LC 5 leaser curvature.

,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

Table 5

Sex

r at angle of His

Minimummaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at leaser curvature

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

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

and gastric inflammation. However, extensive devascularization of the AOH has been postulated as the incriminating

factor for leak in susceptible patients.15

Table 6

exact cause of leaks in such a procedure and consequently

no definitive preventive measures have been clearly

identified.15

Height (m)

r at angle of His

Minimummaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at leaser curvature

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

P value for Student t test.

*Statistically significant at P % .05.

,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

Comorbidity

r at angle of His

Minimummaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at leaser curvature

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

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

HTN 5 Hypertension.

*Statistically significant at P % .05.

on cadavers.4,8 The rational of our study is to evaluate any

possible vascular pattern of the stomach of living human

Table 8

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

r at AOH

Minimummaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at leaser curvature

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

P value for Student t test.

AOH 5 angle of His; BMI 5 body mass index.

*Statistically significant at P % .05.

,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

Table 9

BMI

r at angle of His

Minimummaximum

Mean 6 standard deviation

Median

r at fundus

Minimummaximum

Mean 6 standard deviation

Median

r at greater curvature

Minimummaximum

Mean 6 standard deviation

Median

r at leaser curvature

Minimummaximum

Mean 6 standard deviation

Median

r at pylorus

Minimummaximum

Mean 6 standard deviation

Median

.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

ANOVA 5 analysis of variance; BMI 5 body mass index.

*Statistically significant at P % .05.

of gastrointestinal tract. CT perfusion imaging has been

described for evaluation of gastric perfusion,16,17 as well as

small bowel perfusion.7 CT perfusion measurements have

been reported to differentiate between colon cancer and

diverticulitis with a sensitivity of 80% and specificity of

70%.18 In a prospective study, 52 patients with treatment of

HCV infection underwent PCTand percutaneous liver biopsy

on the same day. Liver samples were scored for fibrosis. CT

perfusion detected that perfusion changes occur early in the

liver during fibrosis in chronic hepatitis C virus infection

with a sensitivity of 71% and a specificity of 65%.19

Gastric PI was measured, in this study, at 5 gastric points

and demonstrated a statistically significant decrease in the

mean PI at the AOH (53.51 6 14.38; P , .001) compared

with PI measured at the other gastric point (4 gastric

points). It is to be noted that perfusion at the gastric fundus

was also low although not statistically significant. These

findings when considered with the increased incidence of

post sleeve gastrectomy leak at the upper third of the stomach may point to an underlying impaired vascular perfusion

as a possible cause of leakage.

In addition, gastric leakage occurs commonly in the first

2 postoperative weeks. In a multicenter study13 on 2,834

patients, 73.2% of leakage cases occurred between days 3

and 14 postoperatively, 20% occurred between days 0 and

2 postoperatively, and 7% after day 14. The fact that

leakage occurs during the active healing phase support

the assumption that leak could be attributed to alteration

in the normal acute healing process because of local risk

of staple line.

In this large multicenter study,13 sleeve gastrectomy leak

occurred in 1.5% of the cases and intraoperative leak tests

and postoperative swallow test failed to detect leakage in

97.3% of the cases that developed leakage. This could

minimize the possibility of technical errors with stapling

as a cause of post LSG leak.

Prevention is the best treatment for such a complication,

so every effort must be made to create a reliable staple line

at the initial operation. An appropriate height intact staple

line with well-perfused tissue, good local hemostasis, and

intraoperative evaluation of staple line integrity must be

achieved to minimize the risk for leak. The above information emphasizes the importance of developing a new

strategy to avoid leak during sleeve gastrectomy particularly at the high-risk area, that is, AOH.

In our study, age and sex of the patient did not impact

the gastric perfusion; however, BMI did. Gastric perfusion

was significantly lower at all the gastric points (particularly

at the AOH) among obese patients (33 cases) compared

with nonobese patients (18 cases), and this was statistically

significant only at the fundus. Gastric perfusion at all the

points studied showed a decrease as the BMI increases.

These findings partially agree with a recent review of 4,888

laparoscopic sleeve gastrectomies; significantly high leak

rates were found in heavier patients (BMI .50 vs ,50).16

Our finding of decrease in gastric PI at the AOH and

fundus correlate with the literature that most gastric leakage

following sleeve gastrectomy occurs at AOH. This

major factor for leak at the AOH.

A short height staple may over compress the gastric wall

and augment ischemia in an inherited vascular compromised area of the stomach; AOH, gastric fundus. The

resulting ischemia can explain relatively high incidence of

leak at those susceptible gastric locations, for example,

AOH in sleeve gastrectomy and gastric fundus in esophagogastric anastomosis following esophageal resection.

Also, extensive dissection and devascularization at the

AOH may augment the inherited local ischemia at the

AOH.

The vascular anatomy of the stomach is also particularly

relevant to other surgical procedures, such as esophageal

resections.20 Esophagogastric anastomotic leak has been

associated with leak-related mortality up to 5% in cervical

anastomoses and as high as 60% for thoracic anastomoses.21,22 The most important predisposing factors are attributed to ischemia of the gastric conduit.23 Our findings of

decrease in the gastric mucosal perfusion at the dome of

the gastric fundus may explain the relatively high risk for

esophagogastric anastomotic leak following esophageal

resection.

During laparoscopic sleeve gastrectomy procedures, we

have used several technical maneuver at the AOH to avoid

such catastrophic but potentially preventable complications. These include the following: upgrading the height

of staple line from 3.5 mm to 4.2 mm, avoiding excessive

gastric devascularization at the AOH, and avoiding lateral

thermal gastric injury at the AOH during mobilization with

energy source. If we suspect over-compression of the

stomach at the staple line, we extraluminally support the

staple line with omentum and glue. In addition, in high-risk

patients placing drains, postoperative swallow study may

help in early detection of leak. Because we used these

preventive maneuvers, we did not have any case of leak.

However, prospective randomized studies with large number of procedures comparing these maneuvers are required

to evaluate the utility of such maneuvers.

In conclusion, our study of CT scan mapping of gastric wall

perfusion on 51 cases showed a statistically significant

decrease in vascular perfusion 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 BMI. Gastric leakage in obese patients following

LSG could be attributed to a decrease in the blood supply at the

high-risk gastric area, rather than because of technical error.

Our study has several limitations including the retrospective

design of our study, small sample number, and no comparison

of gastric perfusion before and after such procedures.

A prospective study of CT gastric perfusion scan mapping

of a large number of patients undergoing sleeve gastrectomy

comparing preoperative and postoperative gastric perfusion

in the patients developing this complication compared with

those who did not get postoperative leakage will be helpful to

clarify our findings.

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