6 APPLICATIONS IN CONTRAST IMAGING to distend the esophagus and stomach and assess for contour abnormalities or extrinsic masses. 11 The double-contrast upper GI exam combines the same two phases as the double-contrast esopha- gram exam, but the fluoroscopic assess- ment extends from the esophagus to include the stomach and duodenum. 11 During all of these exams, spot images should be obtained to document normal and abnormal findings. AR: What are some of the challenges to performing fluoroscopy in bariat- ric patients? Dr. Canon: The main challenge in fluoroscopic evaluation of the bariat- ric surgery patient is patient position- ing. The exam begins with the patient standing, but is followed by the patient lying on the table, which is required for adequate luminal distension. If the pa- tient’s weight exceeds the limit of the fluoroscopy table, the footboard can be removed so the patient can stand in the fluoroscopy unit; however, lacking hori- zontal images, the study will be limited. If the patient cannot stand, or their body girth prevents them from fitting under the fluoroscopy tower, the patient can drink the contrast, and then a supine abdominal radiograph can be obtained while the patient is lying on a stretcher. Although not ideal, this provides at least some information. Note that when performing esoph- agography or an upper GI fluoroscopy examination, the high frame rate/contin- uous fluoroscopy so critical to studying dysphagia with a modified barium swal- low study is not a concern; relative to the rapid movements involved in swallow- ing, movement/motility in the esophagus and stomach is much slower. Therefore, when performing these exams, the frame rate can be reduced, decreasing radiation exposure to the patient and to the fluo- roscopist while still obtaining the critical information. AR: How important is communica- tion between the radiologist and the bariatric surgeon? Dr. Grams: Communication be- tween the radiologist and the surgeon is crucial to maximizing the value of fluo- roscopy. For more common indications and procedures, the order tends to be straightforward, and the key then is the thoroughness of the reporting: every- thing that is evaluated needs to be spec- ified in the report, regardless of whether the findings are normal or abnormal. When the clinical question is more com- plicated, a consultation between the ra- diologist and surgeon and, in some cases, reviewing the images together, may be beneficial. So much clinical information is potentially obtainable from fluoros- copy of the upper GI tract, and it is vital to ensure that all of the information ob- tained in the fluoroscopy suite is trans- mitted to the surgeon, both before and after bariatric surgery. AR: Any concluding thoughts? Dr. Canon: Bariatric surgery is currently the most effective strategy for weight reduction in patients with obe- sity, a patient population that has risen dramatically in recent decades. A vari- ety of surgical techniques and imaging modalities are available to the abdom- inal radiologist to evaluate bariatric pa- tients before and after surgery. For the bariatric surgeon, preoperative upper GI fluoroscopic examination provides information that is critical to clinical decision-making. Postoperatively, these studies must be individually tailored to the patient, and defined by the anatomy and the clinical question. References 1. Sturm R, Ringel JS, Andreyeva T. Increasing obe- sity rates and disability trends. Health Aff (Millwood). 2004; 23:199-205. 2. CDC Website. Adult Obesity Facts. Available at: https://www.cdc.gov/obesity/data/adult.html; Ac- cessed December 7, 2019. 3. Kim DD, Basu A. Estimating the Medical Care Costs of Obesity in the United States: Systematic Review, Meta-Analysis, and Empirical Analysis. Value Health. 2016; 19:602-613. 4. Nudel J, Sanchez VM. Surgical management of obesity. Metabolism. 2019;92:206-216. 5. Carucci LR, Turner MA, Conklin RC, DeMaria EJ, Kellum JM, Sugerman HJ. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gas- trointestinal series. Radiology. 2006; 238:119-127. 6. ASMBS Website. Who is a Candidate for Bariat- ric Surgery? Available at: https://asmbs.org/patients/ who-is-a-candidate-for-bariatric-surgery. Accessed March 2, 2020. 7. ASMBS Website. Estimate of Bariatric Surgery Numbers, 2011-2018. Available at: https://asmbs. org/resources/estimate-of-bariatric-surgery-num- bers. Accessed December 7, 2019. 8. Levine MS, Rubesin SE, Laufer I. Barium studies in modern radiology: do they have a role? Radiol- ogy. 2009; 250:18-22. 9. Levine MS, Carucci LR. Imaging of bariatric sur- gery: normal anatomy and postoperative complica- tions. Radiology. 2014; 270:327-341. 10. Lim R, Beekley A, Johnson DC, Davis KA. Early and late complications of bariatric operation. Trauma Surg Acute Care Open. 2018;3: e000219. 11. American College of Radiology (ACR) Website. ACR Practice Parameter for the Performance of Esophagrams and Upper Gastrointestinal Examina- tions in Adults. Available at: https://www.acr.org/-/ media/ACR/Files/Practice-Parameters/UpperGIA- dults.pdf. Accessed March 2, 2020. 12. Levine MS, Carucci LR, DiSantis DJ, et al. Consensus Statement of Society of Abdominal Ra- diology Disease-Focused Panel on Barium Esoph- agography in Gastroesophageal Reflux Disease. AJR Am J Roentgenol. 2016; 207:1009-1015. 13. Kolakowski S Jr, Kirkland ML, Schuricht AL. Routine postoperative upper gastrointestinal series after Roux-en-Y gastric bypass: determination of whether it is necessary. Arch Surg. 2007;142: 930- 934; discussion 934. 14. Blachar A, Federle MP. Gastrointestinal com- plications of laparoscopic roux-en-Y gastric bypass surgery in patients who are morbidly obese: find- ings on radiography and CT. AJR Am J Roentgenol. 2002; 179:1437-1442.