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Gastrointestinal Complications of Laparoscopic Roux-en-Y Gastric Bypass Surgery in Patients Who Are Morbidly Obese: Findings on Radiography and CT

¹ Department of Radiology, Division of Abdominal Imaging, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
² Present address: Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

View larger version (66K): [in a new window]   Fig. 1A. —Drawings of anatomy after Roux-en-Y gastric bypass surgery shows gastric pouch, excluded stomach, Roux loop, and distal jejunojejunal anastomosis (solid arrow). (Adapted with permission from [3]) In this illustration, Roux loop (R) has been passed through surgical defect in transverse mesocolon (open arrow) to lie in retrocolic retrogastric location. Sutures are used to close mesenteric defect. GP = gastric pouch, ST = excluded stomach.

View larger version (74K): [in a new window]   Fig. 1B. —Drawings of anatomy after Roux-en-Y gastric bypass surgery shows gastric pouch, excluded stomach, Roux loop, and distal jejunojejunal anastomosis (solid arrow). (Adapted with permission from [3]) In this modified illustration, no defect is created in mesocolon. Roux limb is antecolic and antegastric.

View larger version (132K): [in a new window]   Fig. 2. —44-year-old woman 24 hr after uncomplicated gastric bypass surgery. Upper gastrointestinal radiograph shows contrast material entering small gastric pouch (GP) and Roux loop (R) including "blind" end (R') to left of anastomosis. Note unopacified surgical drain (arrow).

View larger version (109K): [in a new window]   Fig. 3. —42-year-old woman 1 day after bypass surgery with small leak that resolved spontaneously in 10 days. Upper gastrointestinal radiograph shows extravasation of small amount of contrast medium (straight arrow) from gastrojejunal anastomosis. Note opacification of surgical drain (curved arrow). R = Roux loop, GP = gastric pouch.

View larger version (116K): [in a new window]   Fig. 4. —37-year-old woman 1 day after bypass surgery with small leak that required surgical repair. Upper gastrointestinal radiograph shows minimal pocket of extravasated contrast medium (open arrow) originating from gastric pouch (GP) or anastomosis with definite opacification of surgical drain (solid arrow).

View larger version (112K): [in a new window]   Fig. 5A. —42-year-old woman with abdominal pain and fever 4 days after bypass surgery. Imaging revealed large leak from gastrointestinal anastomosis that required surgical treatment. Upper gastrointestinal radiograph shows extravasation of contrast medium (solid arrows) from anastomosis (open arrow). R = Roux loop, GP = gastric pouch.

View larger version (161K): [in a new window]   Fig. 5B. —42-year-old woman with abdominal pain and fever 4 days after bypass surgery. Imaging revealed large leak from gastrointestinal anastomosis that required surgical treatment. Contrast-enhanced transverse CT scan reveals enteric contrast material extravasating (arrows) from gastric pouch (GP) and surrounding spleen.

View larger version (154K): [in a new window]   Fig. 6. —61-year-old woman with abdominal pain 1 day after bypass surgery. Transverse unenhanced CT scan shows distal excluded stomach (ST), barium-filled small-bowel loop, and extraluminal contrast material outlining inferior liver border (solid arrows) and peritoneum (open arrow).

View larger version (146K): [in a new window]   Fig. 7A. —32-year-old woman with fever and abdominal pain 10 days after bypass surgery. Imaging showed large gastrojejunal anastomotic leak and abscess. Abscess was drained with CT guidance. Upper gastrointestinal radiograph shows extravasation of contrast material (solid arrows) from gastrojejunal anastomosis with large amount of loculated extraluminal air (open arrow) adjacent to it. R = Roux loop, GP = gastric pouch.

View larger version (164K): [in a new window]   Fig. 7B. —32-year-old woman with fever and abdominal pain 10 days after bypass surgery. Imaging showed large gastrojejunal anastomotic leak and abscess. Abscess was drained with CT guidance. Unenhanced transverse CT scan shows contrast material in gastric pouch (GP) and large abscess (Ab) of lesser sac with small amount of contrast material lining its border (arrow).

View larger version (140K): [in a new window]   Fig. 8A. —60-year-old woman with abdominal pain and fever 18 days after bypass surgery. Small leak and fluid collection were seen on imaging. Both resolved spontaneously within 6 days. Upper gastrointestinal radiograph depicts contrast extravasation (arrow) from gastric pouch (GP) and formation of fluid collection containing air—fluid—contrast level (C). R = Roux loop.

View larger version (144K): [in a new window]   Fig. 8B. —60-year-old woman with abdominal pain and fever 18 days after bypass surgery. Small leak and fluid collection were seen on imaging. Both resolved spontaneously within 6 days. Transverse contrast-enhanced CT scan shows gastrojejunal anastomotic staple line (curved arrow) with adjacent fluid collection containing air—fluid level (straight arrow). ST = distal excluded stomach.

View larger version (130K): [in a new window]   Fig. 9. —45-year-old woman 1 day after uncomplicated bypass surgery. Oral contrast medium that refluxed up proximal jejunum into bypassed stomach (arrows) simulates leak. Only by positioning patient and observing flow of contrast material within stomach and duodenum could this complication be identified correctly. R = Roux loop, GP = gastric pouch.

View larger version (119K): [in a new window]   Fig. 10A. —52-year-old woman with abdominal pain and fever 4 days after bypass surgery. Intraabdominal abscess was detected at imaging. Upper gastrointestinal radiograph shows normal passage of contrast material through gastric pouch and gastrojejunal anastomosis. Air—fluid level (arrow) is seen lateral to gastric pouch (GP) with no evident extravasation of contrast material. R = Roux loop.

View larger version (155K): [in a new window]   Fig. 10B. —52-year-old woman with abdominal pain and fever 4 days after bypass surgery. Intraabdominal abscess was detected at imaging. Unenhanced transverse CT scan shows large fluid collection (Ab) adjacent to gastrojejunal anastomosis (arrowhead). Only by following anatomy on sequential images (not shown) could abscess be distinguished from excluded stomach.

View larger version (164K): [in a new window]   Fig. 11A. —59-year-old man with pain and fever 2 weeks after bypass surgery. Multiple abscesses, caused by leak, were successfully drained using percutaneous catheters. Unenhanced CT scan shows perihepatic fluid collection (Ab) containing air—fluid level. Second smaller collection (curved arrow) can be seen adjacent to gastrojejunal anastomosis (straight arrow).

View larger version (184K): [in a new window]   Fig. 11B. —59-year-old man with pain and fever 2 weeks after bypass surgery. Multiple abscesses, caused by leak, were successfully drained using percutaneous catheters. CT scan was obtained while large perihepatic collection was being drained, thus obviating surgery, with pigtail catheter (white arrow), which was placed using CT guidance. Second collection (C) is larger and was also drained using CT guidance (not shown). Black arrow indicates free intraperitoneal air.

View larger version (94K): [in a new window]   Fig. 12. —35-year-old woman with dysphagia and retching 2 months after bypass surgery. Upper gastrointestinal radiograph shows stricture (arrow) at gastrojejunal anastomosis with markedly dilated spherical gastric pouch (GP) but with passage of contrast material into Roux loop (R). Stricture was managed successfully with endoscopic balloon dilatation. E = esophagus.

View larger version (100K): [in a new window]   Fig. 13. —50-year-old woman with abdominal pain and distention 3 days after bypass surgery. Upper gastrointestinal radiograph shows cluster of dilated small-bowel loops in left upper abdomen (arrowheads). Large internal hernia through transverse mesocolon that was causing small-bowel obstruction was found at surgery.

View larger version (137K): [in a new window]   Fig. 14A. —41-year-old woman with abdominal pain and distention 34 days after bypass surgery. Bowel obstruction caused by transmesenteric internal hernia was detected on CT. Unenhanced CT scan shows dilated Roux loop (R) posterior relative to distal excluded stomach (ST). P = pancreatic head.

View larger version (130K): [in a new window]   Fig. 14B. —41-year-old woman with abdominal pain and distention 34 days after bypass surgery. Bowel obstruction caused by transmesenteric internal hernia was detected on CT. CT scan obtained more caudal than A shows herniated small-bowel cluster (SB) and engorged mesenteric vessels (arrows).

View larger version (105K): [in a new window]   Fig. 15. —46-year-old woman with pain and distention 18 months after bypass surgery. Transverse CT scan shows cluster of mildly dilated small-bowel segments (S) adjacent to left abdominal wall anterior to jejunojejunal anastomosis (curved arrow) with engorgement and crowding of mesenteric vessels (straight arrow). Internal hernia through small-bowel mesentery was diagnosis. More caudal section (not shown) revealed no omental fat between small-bowel cluster and abdominal wall.

View larger version (135K): [in a new window]   Fig. 16. —54-year-old woman with abdominal pain 9 days after bypass surgery. Unenhanced CT scan shows free intraperitoneal air (arrows) and markedly dilated distal stomach (ST). Perforation of distal stomach was repaired laparoscopically.

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