[size=20px]You are seeing a 17-year old young woman with a body mass index of 54 who underwent laparoscopic sleeve gastrectomy 12 days previously. Her initial postoperative course was uneventful and she was discharged home on postoperative day two. She subsequently presents with gradually worsening left upper quadrant pain, nausea and fever. Her heart rate is 130 bpm, blood pressure is 104/72, respiratory rate is 26 breaths/minute with room air oxygen saturation of 99%. Her abdominal exam reveals mild left sided tenderness and her incisions are unremarkable.

 

Which of the following is the best initial diagnostic study in the patient with pain after sleeve gastrectomy?

 

A upper gastrointestinal series

 

B abdominal ultrasound

 

C computerized tomography scan of the abdomen

 

D upper endoscopy

 

E liver-spleen scan[/size]

(Untitled)

 

c

c

correct

 

A staple line leak is perhaps the complication most feared by the bariatric surgeon, particularly because initial clinical signs (such as unexplained tachycardia) may be subtle in the absence of other findings. Failure to recognize and treat this condition promptly can be life-threatening. Fever and left upper quadrant pain in this patient, along with tachycardia in the setting of normal oxygen saturations, should prompt evaluation for a staple line leak. Recent series have reported a leak rate of one to three percent in adult patients after laparoscopic sleeve gastrectomy and up to 10% following revisional procedures with lower leak rates described in adolescent patients. While leaks often present early in the postoperative period, those following laparoscopic sleeve gastrectomy have been reported to present up to twelve weeks postoperatively.

 

Priorities of management include initial resuscitation of the patient and prompt adequate drainage if needed. Of the available choices, a computerized tomography (CT) scan of the abdomen would be most likely to detect a staple line leak and can typically be done expeditiously. If a leak is small and difficult to detect directly, CT would demonstrate secondary signs such as small amounts of extraluminal air, a fluid collection or perigastric inflammation. Abdominal ultrasound may show an intra-abdominal fluid collection but is not specific for the diagnosis of a leak. A small leak may be missed on upper gastrointestinal series or upper endoscopy and a liver-spleen scan would not be helpful in this scenario.