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Small-Bowel Complications of Major Gastrointestinal Tract Surgery

¹ Department of Radiology, Indiana University Medical Center, UH Suite 0279, 550 N. University Boulevard, Indianapolis, IN 46202.
² Department of Surgery, Indiana University Medical Center, Indianapolis, IN.

View larger version (50K): [in a new window]   Fig. 1A —Whipple procedure. Diagram of anatomy after pylorus-preserving Whipple procedure in which cuff of duodenum is spared. Insert shows original Whipple procedure. The procedure entails radical dissection of pancreatic head, adjacent nodes, right half of omentum, gallbladder, common bile duct, and most or all of duodenum, followed by gastrojejunostomy/duodenojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. (Used with permission of Visual Media, Indianapolis, IN)

View larger version (172K): [in a new window]   Fig. 1B —Whipple procedure. Coronal reformat of isotropic source images in 64-year-old man 5 weeks after Whipple procedure shows edematous jejunal Roux loop (straight arrow). Compare with normal distal small bowel (curved arrow). Note normal-sized mesenteric nodes and stent at site of pancreaticojejunostomy (arrowhead).

View larger version (59K): [in a new window]   Fig. 2A —Puestow procedure. Diagram of anatomy after modified Puestow procedure. The pancreas is filleted to expose main duct from neck to tail, and ductal calculi are removed. Roux loop of jejunum is anastomosed to "capsule" of pancreas with direct drainage of main and secondary pancreatic ducts into lumen of jejunum over 8-10 cm segment. This procedure is best performed if main pancreatic duct is significantly (>6 mm) dilated. (Used with permission of Visual Media, Indianapolis, IN)

View larger version (132K): [in a new window]   Fig. 2B —Puestow procedure. Magnified view of axial CT image at level of upper abdomen in 67-year-old woman shows drainage jejunostomy Roux loop (black arrowheads) containing gas bubbles closely applied to anterior aspect of atrophic calcified pancreatic body (white arrow).

View larger version (56K): [in a new window]   Fig. 3A —Roux-en-Y gastric bypass procedure. Line diagram showing anatomy after Roux-en-Y gastric bypass procedure. In this procedure, 90% of stomach, entire duodenum, and proximal 30 cm of jejunum are excluded from digestion. Retrocolic version is demonstrated. Note short afferent loop at gastrojejunostomy, shown by circular staples. Duodenum is part of afferent loop at jejunojejunostomy, shown by linear sutures. (Used with permission of Visual Media, Indianapolis, IN)

View larger version (136K): [in a new window]   Fig. 3B —Roux-en-Y gastric bypass procedure. Upper gastrointestinal contrast image following Roux-en-Y gastric bypass procedure in 32-year-old woman shows esophagus (thin white arrow), gastric pouch (thick black arrow), short afferent loop (curved black arrow), and efferent loop (thick white arrows). Gastric remnant shows dilute contrast (curved white arrow) that has refluxed via duodenum from previous contrast study.

View larger version (130K): [in a new window]   Fig. 3C —Roux-en-Y gastric bypass procedure. Axial CT image of upper abdomen performed without IV contrast after Roux-en-Y gastric bypass procedure in 36-year-old woman shows small gastric pouch filled with dense, orally introduced contrast (black arrow). Adjacent, but surgically separated, is most of stomach, gastric remnant (white arrow). Surgical staples separating the two are seen (arrowhead). Dilute oral contrast in remnant has refluxed via duodenum. This should not be mistaken for direct leak from pouch (gastrogastric fistula), which will manifest with dense oral contrast in remnant without any in distal duodenum.

View larger version (148K): [in a new window]   Fig. 4 —Roux-en-Y gastric bypass procedure anatomy. Axial CT after the procedure in 48-year-old woman shows small pouch (straight white arrow) separated surgically from remnant (black arrow). Remnant was mistaken for abscess, and drainage catheter (curved arrow) was placed.

View larger version (136K): [in a new window]   Fig. 5A —Anastomotic leak in 29-year-old woman. Upper gastrointestinal contrast series after Roux-en-Y gastric bypass procedure shows edematous gastric pouch with leakage of contrast from gastrojejunal anastomotic site (black arrow) extending into left upper quadrant. There is also dense orally introduced contrast in gastric remnant (arrowhead) without contrast in the duodenum, indicating gastrogastric leak rather than retrograde reflux. Contrast is seen in transverse colon (white arrow) from previous upper gastrointestinal study.

View larger version (151K): [in a new window]   Fig. 5B —Anastomotic leak in 29-year-old woman. Axial CT of upper abdomen after Roux-en-Y gastric bypass procedure shows leak at gastrojejunostomy site complicated by abscess (black arrow). An enterocutaneous fistula is shown by a track of gas bubbles (arrowheads). Adjacent images (not shown) indicate gas bubbles are in a fistula and not small bowel. Leaked oral contrast is seen in open abdominal wound (white arrow).

View larger version (171K): [in a new window]   Fig. 6A —Afferent loop obstruction in 50-year-old man. Upper gastrointestinal contrast series after Whipple procedure shows dilation of afferent loop (white arrow) but not efferent loop (black arrow) or stomach (S). At surgery, the cause of the afferent-loop obstruction was found to be adhesions.

View larger version (114K): [in a new window]   Fig. 6B —Afferent loop obstruction in 50-year-old man. Axial CT image after Whipple procedure shows valvulae conniventes in uniformly dilated afferent loop (black arrows) confirming diagnosis of afferent-loop obstruction rather than pseudocyst. Back pressure from afferent-loop obstruction can cause biliary or main pancreatic duct dilation (not shown).

View larger version (127K): [in a new window]   Fig. 6C —Afferent loop obstruction in 50-year-old man. Coronal multiplanar reconstruction shows distended afferent loop (black arrows) well. Presence of dilated fluid-filled structure with caliber of more than 3.5 cm in periportal region extending transversely anterior to spine is highly diagnostic.

View larger version (48K): [in a new window]   Fig. 7A —Blind pouch. Diagram of formation of blind pouch after side-to-side enteroenterostomy. Dotted black line shows anatomy before development of blind pouch. Arrows show direction of peristalsis. The blind pouch is filled rather than emptied by peristalsis. (Used with permission of Visual Media, Indianapolis, IN)

View larger version (150K): [in a new window]   Fig. 7B —Blind pouch. Axial CT images of mid abdomen 10 months after multiple enteric resections for gastrointestinal stromal tumor in 51-year-old woman show right (white arrows) and left (black straight arrow, C) blind pouches. These are adjacent to surgical clips (arrowheads). There is no obstruction of proximal or intervening small bowel (curved arrows). CT findings are fairly characteristic and should not be mistaken for abscess or small-bowel obstruction. S = stomach.

View larger version (151K): [in a new window]   Fig. 7C —Blind pouch. Axial CT images of mid abdomen 10 months after multiple enteric resections for gastrointestinal stromal tumor in 51-year-old woman show right (white arrows) and left (black straight arrow, C) blind pouches. These are adjacent to surgical clips (arrowheads). There is no obstruction of proximal or intervening small bowel (curved arrows). CT findings are fairly characteristic and should not be mistaken for abscess or small-bowel obstruction. S = stomach.

View larger version (186K): [in a new window]   Fig. 8 —Short gut syndrome in 64-year-old man. Upper gastrointestinal contrast image shows only a few loops of small bowel between nasoenteric tube (white arrow) and ileocecal junction (black arrow). Patient had inadvertent gastroileostomy instead of gastrojejunostomy during Billroth II surgery. AC = ascending colon, DC = descending colon.

View larger version (63K): [in a new window]   Fig. 9A —Transmesenteric hernia. Diagram of sagittal anatomy after Roux-en-Y gastric bypass procedure and potential site of transmesenteric hernia. (Used with permission of Visual Media, Indianapolis, IN)

View larger version (127K): [in a new window]   Fig. 9B —Transmesenteric hernia. Upper gastrointestinal contrast image after Roux-en-Y gastric bypass procedure in 43-year-old woman shows distention of afferent (white arrow) and efferent (black arrow) with abrupt cutoff in mid efferent loop. Appearance is similar to mesocolic tunnel stenosis but more loops of distended efferent loops are seen, suggesting transmesenteric hernia, which was found at surgery.

View larger version (184K): [in a new window]   Fig. 10A —Transmesenteric hernia in 47-year-old woman. Axial CT images show dilated jejunal loops anteriorly (large white arrows). Mesenteric vessels supplying these loops curve (small black arrows, A) through transverse mesocolon (small white arrows). Transition is abrupt (arrowhead), in line with slightly thickened mesocolon and proximal to site of jejunojejunostomy, shown by surgical clips (large black arrow).

View larger version (182K): [in a new window]   Fig. 10B —Transmesenteric hernia in 47-year-old woman. Axial CT images show dilated jejunal loops anteriorly (large white arrows). Mesenteric vessels supplying these loops curve (small black arrows, A) through transverse mesocolon (small white arrows). Transition is abrupt (arrowhead), in line with slightly thickened mesocolon and proximal to site of jejunojejunostomy, shown by surgical clips (large black arrow).

View larger version (154K): [in a new window]   Fig. 10C —Transmesenteric hernia in 47-year-old woman. Coronal reconstruction in same patient shows distended efferent loops (black arrow) lying above and depressing transverse colon (white arrow).

View larger version (136K): [in a new window]   Fig. 11 —Nonobstructive symptomatic adhesions. Axial CT image in 59-year-old man with abdominal pain after renal transplant shows small bowel adherent to anterior peritoneum (white arrows) and kinking of bowel loop (arrowhead). There were no overt CT features of small-bowel obstruction. Patient subsequently underwent adhesion lysis with improvement of symptoms. K = superior pole of transplanted kidney.

View larger version (122K): [in a new window]   Fig. 12A —Closed-loop obstruction in 50-year-old man. Axial CT images show beaked appearance of distal and proximal ends of closed loop (arrowheads) as well as bowel wall thickening and increased enhancement, indicating impaired mesenteric venous return. Fluid-filled, distended small-bowel loops (white arrows, A) show radial distribution. Black arrow (A) = jejunum.

View larger version (118K): [in a new window]   Fig. 12B —Closed-loop obstruction in 50-year-old man. Axial CT images show beaked appearance of distal and proximal ends of closed loop (arrowheads) as well as bowel wall thickening and increased enhancement, indicating impaired mesenteric venous return. Fluid-filled, distended small-bowel loops (white arrows, A) show radial distribution. Black arrow (A) = jejunum.

View larger version (108K): [in a new window]   Fig. 12C —Closed-loop obstruction in 50-year-old man. Sagittal reconstruction allows better appreciation of proximity of ends of closed loop (arrowheads).

View larger version (130K): [in a new window]   Fig. 12D —Closed-loop obstruction in 50-year-old man. Coronal reconstruction shows radial pattern of closed loop (white arrows). Distended bowel in left flank containing oral contrast on images A and D (black arrows) is jejunum, which lies proximal to closed loop. There is moderate ascites.

View larger version (131K): [in a new window]   Fig. 13A —Strangulating obstruction. Axial CT after Whipple procedure in 68-year-old woman shows enhancing loop of jejunum in left flank (white arrows). Patient was found to have necrotic jejunum with closed-loop obstruction at surgery, which was performed 8 hours later.

View larger version (109K): [in a new window]   Fig. 13B —Strangulating obstruction. Axial CT in 63-year-old man 10 days after sigmoid colectomy shows mesenteric venous air (arrowheads). Patient died during emergency laparotomy and was found to have strangulating obstruction.

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