Use of upper gastrointestinal studies after laparoscopic gastric bypass.

We appreciate the interest of Rodriguez-Cuellar et al. in our previous publication [1]. Their insightful comments underscore the controversy about routine radiological tests after laparoscopic Roux-en-Y gastric bypass (LRYGB). We agree that computed tomography (CT) scan has better sensitivity and specificity than upper gastrointestinal (UGI) studies, partly due to the modality and partly due to radiologist experience. Unfortunately, many of our patients cannot fit into our current CT scan machine, and we are fortunate to have an experienced radiologist to help with our UGI studies. Another excellent point brought up by the authors is that leak rates after LRYGB in experienced hands is low (under 1%). We have seen the learning curve effect ourselves when our first 300 LRYGB cases were examined [2]. In our personal experience, UGI studies may not have ‘‘helped’’ in the last year due to the lack of any leaks after LRYGB. However, even with a low incidence, a leak carries a 50% mortality. The cost in terms of human life and dollars due to a leak cannot be ignored. Early diagnosis can and will decrease mortality and morbidity. From our data, routine UGI series can help in this early diagnosis. Clinical signs and symptoms may not be enough to diagnose all leaks early, but neither are UGI studies; they are just another piece of data to help guide clinical care. Some ‘‘late’’ leaks probably start ‘‘slowly’’ when clinical signs and symptoms do not suggest any issues. In these patients, UGI may be helpful. How many of these patients exist? Fortunately, I do not have enough leaks to give you an exact incidence. We have had patients with no or few clinical signs that had a positive UGI which led to early operative treatment (\24 hours after surgery) with no resulting major morbidity after their reoperation. I do not know what would happen if there was a delay in the diagnosis. To be honest, as Rodriguez-Cuellar et al. suggested, leak rates are under 1%. Due to low rates, sensitivity rates may not be precise, thus the large variation reported in the literature. One should not feel that UGI study can take the place of good clinical judgment. Again, UGI study should be examined as an important but not the only piece of data. The reason we still perform routine UGI studies after LRYGB is that in some cases an UGI study may diagnose a leak before clinical signs and symptoms become obvious. The reason not to perform routine UGI studies is cost and patient discomfort. The cost of a delayed diagnosis of a leak needs to be considered when performing only selective UGI studies. Due to the current controversy, standard of care still involves either routine or selective UGI studies after LRYGB. Our personal recommendation is to utilize UGI studies routinely at least for surgeons in their learning curve. To suggest that UGI studies are not needed for this group of surgeons seems a bit nonchalant since a leak is a major cause of mortality after LRYGB. Even in experienced hands, an UGI study may help avoid the disastrous consequences of a delay in diagnosis of a leak after LRYGB. A. K. Madan (&) H. H. Stoecklein D. S. Tichansky Department of Surgery, University of Tennessee Health Science Center, 956 Court Ave., Room G210, Memphis, TN 38163, USA e-mail: amadan@utmem.edu