4 APPLICATIONS IN CONTRAST IMAGING Applied Radiology (AR): Welcome, Drs. Canon and Grams. In general, what is the role of fluoroscopy in the evaluation of the bariatric patient? Dr. Canon: Relative to other im- aging methods used to evaluate the gas- trointestinal (GI) tract, fluoroscopy is noninvasive, safe, inexpensive and, most importantly, provides dynamic images in real time. 8 The fluoroscopic imaging exam performed by the radiologist is patient-specific, and depends primarily on the pre- vs postoperative status of the patient, as well as any specific signs or symptoms the patient is experiencing. Pre- operative evaluation for bariatric surgery is critical to investigate gastric anatomy and delineate any existing abnormalities such as hiatal hernia, scarring from prior ulcer disease, or anything else that alters normal anatomy. Evaluation of esophageal structure and motility is equally import- ant. In addition, findings from the preoper- ative examination may influence decision making regarding which bariatric opera- tion is most appropriate for the patient. Postsurgically, fluoroscopic imaging of the GI tract is useful to address complications, including leaks, which typically occur shortly after surgery, as well as complica- tions that develop at a later time, such as gastrojejunostomy stricture or marginal ulcer. 9,10 (Table 1) AR: More specifically, how is fluo- roscopy with barium contrast used to evaluate the bariatric patient prior to surgery? Dr. Canon: The typical preoperative patient may undergo either barium esoph- agography (also referred to as a “barium swallow”) or an upper GI study, or both. An esophagram is the fluoroscopy-guided examination of the esophagus that eval- uates motility and esophageal morphol- ogy, including the gastroesophageal (GE) junction, and assesses for gastroesopha- geal reflux (GER). An upper GI study in- cludes esophageal morphology (but not typically motility) and extends the fluo- roscopic evaluation to include the stom- ach and duodenum. 11 In the preoperative patient, whether one or both exams are ordered depends on the patient and clin- ical scenario. Considerations may include: whether the patient is currently experi- encing symptoms of a motility disorder or reflux disease; whether the surgeon has questions about the gastric anatomy of the patient, such as history of ulcer disease or prior bariatric surgery; and any limitations related to patient weight, girth, or mobility. 12 Dr. Grams: As Dr. Canon mentioned, preoperative assessment of the bariatric patient may help guide decisions regard- ing which bariatric procedure is most appropriate for the patient. Currently, the most common bariatric procedures performed at UAB are sleeve gastrectomy and Roux-en-Y gastric bypass.At UAB, all patients being considered for sleeve gas- trectomy undergo an esophagram. If bar- ium esophagography reveals significant esophageal dysmotility or GER, further testing may be indicated and Roux-en-Y gastric bypass may be a better option, since sleeve gastrectomy can worsen both of these conditions. Fluoroscopic Evaluation of the Bariatric Surgery Patient A question-and-answer session with Cheri Canon, MD, Professor and Chair of the Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, and Jayleen Grams, MD, PhD, Associate Professor, The University of Alabama at Birmingham, Birmingham, AL, and Associate Chief of Surgery at the Birmingham MA Medical Center. Cheri Canon, MD Professor and Chair of the Department of Radiology The University of Alabama at Birmingham Birmingham, AL Jayleen Grams, MD, PhD Associate Professor The University of Alabama at Birmingham Birmingham, AL Associate Chief of Surgery, Birmingham MA Medical Center