The practice I am aware of is more logic- than evidence-based. Having said that, surgery, unlike medicine, being interventional relies on best surgical practice, which includes experience of self and peers, rather than just the best evidence-based literature that is available. Hence the usefulness of this site! A lap Nissen is a completely different procedure to a sleeve gastrectomy. Whereas in a lap Nissen, an iatrogenic injury is an unforeseen rarity, thus not requiring routine imaging; most bariatric procedures except the unpopular lap bands are different. Lap by-pass procedures and lap,gastrectomies involve anastomoses or at least resection-staple lines. The incidence of missed leaks is high enough for one to require early reassurance that the staple line is intact. In fact, in the practice I am aware of by a senior laparoscopic bariatric surgeon, he always performs a leak test on table, followed by a postoperative swallow test for confirmation of stability of staple lines, before discharging the patients within 24 hours, even after a lap bypass. This data has been presented at SAGES and is to be published in Surgical Endoscopy, under the main author's name of Harish Kumar.

Thus, if there is significant risk of an iatrogenic leak such that it prevents you from allowing your patient to drink immediately, it seems logical to rule this risk out by documentation of an intact suture line by good-quality imaging, in a radiology department, reported formally by a radiologist, rather than on-table fluoroscopy. Choose your imaging in each case, depending on the way the operation has gone. If in doubt; image sooner rather than later.

Thank You for the reply, but your answer is out of topic. First UGI at POD 1 after sleeve has a very low sensibility to rule out a leak (experience of 4 universitary hospital in France ). As i mentioned in the initial post the UGI after sleeve is not to rule out a leak, but is to have an image of your surgery, in case you need to compare later, after few years. 

Second if you have looked to the only reference I mark in the initial post the UGI after Nissen Is to rule out Early complications. Their results: Esophagogram detected two of three observed complications: acute paraesophageal hernia and intrathoracic migration, but not a fundic perforation. "

I looked for other similar reports, but I cannot find it, I was curious if others can have it.

OK- didn't understand your question clearly. Re post op sleeve gastrectomy, a lot of us are not sold on the theory of gastric dilatation only occurring longitudinally over the greater curvature being the important mechanism of weight loss in the long ter. If one believes this is the important mechanism of action and if one wants to demonstrate the postoperative size of the reminent pouch then one could perform a swallow. However, it might be more useful to look at other non-restrictive mechanisms of weight loss instead. Similarly, I wrote a paper many years ago on wrap migration in lap Nissen, as along with most we believed it was the repair of the hiatal defect that is important, which is a technical step. As most people take care while repairing the crura it is difficult to see how a swallow would be justifiable nowadays. ( C O'Boyle, K Heer...C Royston; Surgical Endoscopy Jan 2000)

After Nissen I dont see the interest but after sleeve gastrectomy, I think it's a mistake to stop performint X ray opacification. This swallow is of no interest for fistula diagnosis. If you are looking for fistula it's CT scan with injection and absorption which is the best. The interest ot swallow opacification after sleeve is to give you a picture of what did you do and so for sleeve beginers I think it's the best way to learn. For skilled sleeve surgeons this permit you to compare the result to what you thought hava done.

not necessary to do routine contrast studies...if severe post op vomiting is seen... Then we may go for it...

Thank you very much for the comments. Thank you Dr Deepraj for the interesting references and we should all agree and keep in mind this lesson: it is better to re operate immediate a wrap migration. Of course that when it is problem ( vomiting) we should do an UGI, but I still consider ( despite non sustainable literature) useful to do it routinely for 3 reasons. First, we can identify few migration less symptomatic, or sometimes patients have difficult wake up after anesthesia with a lot of physical stress on the repair. Second I think for the follow up of the patient could be very helpful. And third I was trained like this by a remarkable Professor, and I need at least 20 years of experience

Regarding the sleeve I completely agree with Prof. Verhaeghe that UGI can be like a photo of the sleeve you have performed for both experienced and unexperienced bariatric surgeon, but we should stop speaking about the interest of UGI as a leak test

I agree with Marius. For me it's aspecially the postoperative picture which I use to compare it with later X-Rays to see if there is migration. It' s not a leak test. It is a confirmation of that floppyness of the Nissen.

Wraps hardly migrate if sutured to the esophagus - we use 3 sutures for a standard Nissen fundoplication where the two most anal also fixate the plicate to the esophagus, but retaining full floppyness. We do not use the Rosetti suture. The plication can theoretically herniate through the hiatus, but that will become evident from symptoms. We see no value of routine postoperative contrast studies in Nissen/Toupét fundoplication or paraesophageal hernia repair (or in bariatric surgery).

Excellent discussion with references.The role of routine contrast study after Nissen is not necessary and is not being done.I donot think that it is safer to do an upper Gi in the immidiate post op period following Sleeve.The explanation looking in to the sleeve for future comparison is not a scientific or practicle explanation.

I do agreeewith Dr Nedelcu to perform an early study to understand the new anatomy either after Nissen, gastric bypass or sleeve gastrectomy. The only difference is that I prefer CT scan without oral contrast, which allows us to have a 3-D reconstruction. This technique is better to identify rotation or twisted sleeve and Nissen. Regards

Thank you for the comments. For Dr.Lambrecht: there are asymptomatic migrations of the valve. It can happen to have a patient with migration in the early postop. period and to have symptoms only late in the follow up. For Dr. Reddy: there is no risk to perform UGI in the postop period for sleeve. There is no complicated related in the literature and there are a lot of teams that they are using per operative endoscopy to control the staple line. My question was not related to safety, but more to efficiency. I agree with you Dr. Madalosso that 3D reconstruction CT it is an interesting study that offers some interesting informations, but I prefer gastrografin swallow for 2 reasons. First it represent an exam that is more cost efficient and less radiation for the patient ( as the radiologist explained me) and second it offers a more dynamic image very useful to analyze the esophageal emptying. I completely agree with

Here is some literature on the subject post-fundoplication...............

World J Surg. 2010 Jan;34(1):79-84. doi: 10.1007/s00268-009-0217-x.

Early reoperation after laparoscopic fundoplication: the importance of routine postoperative contrast studies.

Tsunoda S1, Jamieson GG, Devitt PG, Watson DI, Thompson SK.

Author information

Abstract

BACKGROUND:

The necessity for routine postoperative contrast studies following laparoscopic fundoplication for either gastroesophageal reflux disease or paraesophageal hernia is unclear.

METHODS:

To determine whether a routine contrast X-ray film influenced surgical decision making following laparoscopic fundoplication, we reviewed records from a prospective database of 1,894 patients who underwent a primary laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia between October 1991 and June 2008, and identified those who underwent early reoperation. The value of early routine postoperative barium swallow examinations in the management of these patients was then determined.

RESULTS:

The review showed that 53 patients (2.8%) underwent reoperative procedures within seven days of their original operation: 21 had originally undergone surgery for a paraesophageal hernia, and 32 for reflux. Of the 53 patients who underwent reoperation, 25 (47.2%) were treated for dysphagia, 17 (32.1%) for acute paraesophageal hernia, 6 (11.3%) for a gastrointestinal leak, and 5 (9.4%) for bleeding or peritonitis. Fifteen of the 17 patients who underwent repair of an acute hiatus hernia (0.8% of all patients) had no symptoms and underwent reoperative surgery because of radiological findings alone. Primary surgery for a large hiatus hernia was associated with a higher incidence of early reoperation (5.2 vs. 2.2%; P = 0.001).

CONCLUSIONS:

Approximately 1 in 125 patients who underwent laparoscopic surgery for reflux or a large hiatus hernia had an important finding on an early postoperative contrast swallow, and benefited from this investigation by undergoing early reoperative intervention.

Br J Radiol. 2012 Jun;85(1014):792-9. doi: 10.1259/bjr/57095992. Epub 2011 Jul 26.

Post-fundoplication contrast studies: is there room for improvement?

Raeside MC1, Madigan D, Myers JC, Devitt PG, Jamieson GG, Thompson SK.

Author information

Abstract

OBJECTIVE:

Since the mid-1990s, laparoscopic fundoplication for gastro-oesophageal reflux disease has become the surgical procedure of choice. Several surgical groups perform routine post-operative contrast studies to exclude any (asymptomatic) anatomical abnormality and to expedite discharge from hospital. The purpose of this study was to determine the accuracy and interobserver reliability for surgeons and radiologists in contraststudy interpretation.

METHODS:

11 surgeons and 13 radiologists (all blinded to outcome) retrospectively reviewed the contrast studies of 20 patients who had undergone a laparoscopic fundoplication. Each observer reported on fundal wrap position, leak or extravasation of contrast and contrast hold-up at the gastro-oesophageal junction (on a scale of 0-4). A κ coefficient was used to evaluate interobserver reliability.

RESULTS:

Surgeons were more accurate than radiologists in identifying normal studies (specificity = 91.6% vs 78.9%), whereas both groups had similar accuracy in identifying abnormal studies (sensitivity = 82.3% vs 85.2%). There was higher agreement amongst surgeons than amongst radiologists when determining wrap position (κ = 0.65 vs 0.54). Both groups had low agreement when classifying a wrap migration as partial or total (κ = 0.33 vs 0.06). Radiologists were more likely to interpret the position of the wrap as abnormal (relative risk = 1.25) while surgeons reported a greater degree of hold-up of contrast at the gastro-oesophageal junction (mean score = 1.17 vs 0.86).

CONCLUSION:

Radiologists would benefit from more information about the technical details of laparoscopic anti-reflux surgery. Standardised protocols for performing post-fundoplication contrast studies are needed.

Int J Surg. 2015 Aug;20:123-7. doi: 10.1016/j.ijsu.2015.06.052. Epub 2015 Jun 26.

Routine versus selective contrast imaging to identify the need for early re-intervention following laparoscopicfundoplication: A retrospective cohort study.

Shahzad K1, Menon A1, Turner P2, Ward J2, Pursnani K2, Alkhaffaf B3.

Author information

Abstract

BACKGROUND:

The prompt recognition of complications is essential in reducing morbidity following anti-reflux surgery. Consequently, many centres employ a policy of routine post-operative contrast studies. The study aimed to examine whether routine contrast studies more effectively recognised early post-operative complications following anti-reflux surgery compared with selective use.

METHODS:

This was a retrospective analysis of 240 adults who had undergone primary anti-reflux surgery. Selective use of water-soluble contrastswallows was employed for 115 patients (Group 1) while 125 patients (Group 2) had routine studies.

RESULTS:

10 (0.9%) patients from Group 1 underwent contrast studies, four (40%) of which were abnormal. Routine studies in Group 2 identified thirty-two abnormalities (27%) however the inter-group difference was not significant (p = 0.32). Only one case from group 2 required immediate re-intervention. This was not statistically significant (p = 0.78). Multivariate analysis found no significant association between selective or routine imaging and re-intervention rates. One patient from group 2 presented three days following discharge with wrap migration requiring reoperation despite a normal post-operative study.

CONCLUSION:

Routine use of contrast imaging following anti-reflux and hiatus hernia surgery is not necessary. It does not identify a significantly greater number of post-operative complications in comparison to selective use. Additionally, routine use of contrast studies does not ensure the diagnosis of all complications in the post-operative period.

Dear Dr. Ewen,

 thank you for the references, but all three have already been posted before by Dr.Deepraj. It will be interesting to know your opinion about the topic and related articles. I have some personal remarks about the cited article. The first one is an interesting paper and we have to look to the results and to see that 15 out 17 patients underwent reinterventions being asymptomatic at POD 1, but with positive radiological findings. Second paper illustrates very well the importance of training in analyzing radiological studies. For the third one, I invite authors to comment because I do not agree with their conclusion for several reasons: 1 in group 2 they have identified 32 radiological abnormalities and they have reoperated only one patient . They do not offer ( I read 2 times the complete manuscript) data regarding more long term follow up wit the other 31 patients. 2. In group 1 they had 10 patients with wrap migration , maybe few of them were identified by radiology? 3. Ingroup 1 they were performed radiological studies only 10 patients finding 4 abnormalities. 4. I don't like their discussion about cost efficiency. It will be very difficult to do an analyze of cost as reoperative has an additional cost and morbidity when is performed later, patient is out of work, etc

In the majority of patients a swallow test is unnecessary as they will progress well with oral diet after surgery. In some patients who have pre op dysphagia, ineffctive or absent oesophageal motility, any questions about gastric emptying, challenging surgery or large intra thoracic stomach i find it can help give you the confidence to progress them quickly with diet