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Obese patients will have difficulty turning rapidly, especially owing to discomfort in the immediate postoperative period, and they may refuse to drink adequate amounts of contrast agent. Smith et al. recommend optimal patient positioning based on the staple geometry identified on the plain scout film of the abdomen (Table 3.4) [72]. Others prefer to start in the upright position if this is technically possible [73]. Smith and her colleagues have also stressed the following points: initial use of small quantities of water-soluble contrast, prompt filming of the first swallow without prolonged fluoroscopy, continued contrast administration only after the anatomy has been determined, and examination of the proximal and distal pouches if present [72,74].

CT imaging has been advocated as an effective method of evaluating the excluded stomach, which is difficult or impossible to visualize with oral contrast examinations [75]. If necessary, contrast medium may be injected percutaneously under CT guidance into the distal stomach [76,77].

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