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Imaging in Bariatric Surgery: A Guide to Postsurgical Anatomy and Common Complications

¹ Department of Radiology, University Hospital, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229-3900.
² Department of Surgery, University Hospital, University of Texas Health Science Center at San Antonio, San Antonio, TX.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Roux-en-Y gastric bypass. Artistic rendering of normal postsurgical anatomy shows retrocolic Roux limb (r), gastric pouch (gp), gastric remnant (gr), afferent limb (a), and small blind afferent limb (arrow).

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Roux-en-Y gastric bypass. Anteroposterior fluoroscopic spot image shows normal postoperative anatomy in 62-year-old woman after Roux-en-Y gastric bypass: gastric pouch (gp), Roux limb (r), small blind afferent limb (sa), gastrojejunal anastomosis (black arrow), and surgical drain (white arrow).

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Contrast-enhanced CT image in 38-year-old woman after Roux-en-Y gastric bypass shows normal postoperative anatomy: gastric pouch (gp), proximal Roux limb containing air (r), gastric suture line (black arrow), gastrojejunal anastomosis suture line (white arrow), gastric remnant containing fluid (gr), and small blind afferent limb (asterisk).

View larger version (57K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Laparoscopic adjustable gastric banding. Artistic rendering of normal postsurgical anatomy shows band around superior gastric body and connection to access port, which is placed subcutaneously. gp = gastric pouch, ds = distal stomach.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Laparoscopic adjustable gastric banding. Anteroposterior fluoroscopic spot image in 43-year-old woman after laparoscopic adjustable gastric banding shows normal postoperative anatomy. Note gastric pouch (gp), adjustable band with tubing (white arrows), gastric stoma (black arrow), and distal stomach (ds). Phi angle () is normal.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Vertical-banded gastroplasty (VBG). Artistic rendering of normal postsurgical anatomy shows creation of small gastric pouch (gp) by vertical stapling and application of polypropylene band through transgastric window (asterisk). ds = distal stomach.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Vertical-banded gastroplasty (VBG). Anteroposterior overhead image from fluoroscopy in 69-year-old woman after VBG shows normal postoperative anatomy, including gastric pouch (gp), gastric stoma (black arrow), distal stomach (ds), air-filled fundus (f), and suture line (white arrows).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Jejunoileal bypass. Artistic rendering of normal postsurgical anatomy shows creation of distal end-to-side jejunoileostomy (arrow) and resultant bypass of large portion of small bowel. Note ileum (i), proximal jejunum (j).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Jejunoileal bypass. Anteroposterior overhead image from fluoroscopy in 67-year-old woman after jejunoileal bypass shows normal postoperative anatomy, including gastric antrum (a), duodenal bulb (db), duodenum (d), jejunum (j), terminal ileum (t), cecum (c), and region of jejunoileal anastomosis (arrow).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —43-year-old man with gastrojejunal anastomotic leak 8 days after Roux-en-Y gastric bypass. Anteroposterior fluoroscopic spot image shows extravasated contrast material (white arrows), gastric pouch (gp), Roux limb (r) containing nasogastric tube, and gastrojejunal anastomosis (black arrow). Patient was observed and leak was sealed off without surgical intervention.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —43-year-old man with gastrojejunal anastomotic leak 8 days after Roux-en-Y gastric bypass. Sequential CT images show extravasated contrast material and air (arrows, B) tracking along surgical drain, air-fluid levels (arrows, C) anterosuperior to gastric pouch (gp), peripheral pneumoperitoneum (arrowheads), and refluxed contrast material in gastric remnant (gr). Nasogastric tube is seen in esophagus (e). Patient was observed and the leak sealed off without surgical intervention.

View larger version (178K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —43-year-old man with gastrojejunal anastomotic leak 8 days after Roux-en-Y gastric bypass. Sequential CT images show extravasated contrast material and air (arrows, B) tracking along surgical drain, air-fluid levels (arrows, C) anterosuperior to gastric pouch (gp), peripheral pneumoperitoneum (arrowheads), and refluxed contrast material in gastric remnant (gr). Nasogastric tube is seen in esophagus (e). Patient was observed and the leak sealed off without surgical intervention.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —Anteroposterior fluoroscopic spot image in 42-year-old woman after Roux-en-Y gastric bypass who had gastrojejunal anastomotic stricture secondary to early postoperative edema that resolved spontaneously shows severe narrowing of gastrojejunal anastomosis (arrow) and enlargement of gastric pouch (gp). Note short afferent portion of Roux limb (sa).

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —Contrast-enhanced CT image in 52-year-old woman after Roux-en-Y gastric bypass who had gastrojejunal anastomotic stricture secondary to adhesions. CT scan shows marked enlargement of gastric pouch (gp), which is compressing gastric remnant (white arrow). Note gastric staple line (black arrows). Diagnostic laparotomy confirmed findings. Adhesions were lysed and 10-French feeding tube was placed because of dysphagia due to multiple medical problems.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —55-year-old woman with jejunojejunal anastomotic stricture 1 week after Roux-en-Y gastric bypass surgery. Overhead image from fluoroscopic examination shows distention and opacification of Roux limb (r) and air distending afferent limb (a), which is partially coated with contrast material. Note air-distended gastric remnant (gr), gastric pouch (gp), and gastrojejunal anastomosis (arrow). Patient underwent percutaneous decompression and resolution of gastric remnant by interventional radiology department, which precluded surgery.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —55-year-old woman with jejunojejunal anastomotic stricture 1 week after Roux-en-Y gastric bypass surgery. CT scans show site of stricture at jejunojejunal anastomosis (arrow, C) and dilated proximal afferent loop (a), distended gastric remnant (gr), distended Roux limb (r), and normal-caliber distal jejunum (j). Percutaneous decompression of gastric remnant by interventional radiology department precluded surgery.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —55-year-old woman with jejunojejunal anastomotic stricture 1 week after Roux-en-Y gastric bypass surgery. CT scans show site of stricture at jejunojejunal anastomosis (arrow, C) and dilated proximal afferent loop (a), distended gastric remnant (gr), distended Roux limb (r), and normal-caliber distal jejunum (j). Percutaneous decompression of gastric remnant by interventional radiology department precluded surgery.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —38-year-old woman with partial gastrojejunal anastomotic obstruction secondary to stricture 3 weeks after Roux-en-Y gastric bypass.Fluoroscopic spot image taken 15 minutes after contrast administration shows distention of gastric pouch (gp) and severely delayed passage of contrast material past narrowed gastrojejunal anastomosis (arrow). Note Roux limb (r). Esophagogastroduodenoscopy confirmed findings, and uncomplicated balloon dilatation was performed.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —44-year-old woman with mesocolic window obstruction secondary to adhesions 5 weeks after Roux-en-Y gastric bypass.Overhead image from fluoroscopic examination shows dilatation of Roux limb (r) proximal to expected location of mesocolic window (arrow). Note gastric pouch (gp). Diagnostic laparotomy confirmed extensive circumferential adhesions constricting Roux limb at mesocolic window.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12 —32-year-old woman with obstruction secondary to mesocolic window hernia 4 weeks after Roux-en-Y gastric bypass.Overhead image from fluoroscopic examination shows distention and herniation of entire Roux limb (r) above expected region of mesocolic window, air-contrast levels (arrows), and distended gastric pouch (gp). Exploratory laparotomy confirmed complete herniation of Roux limb and jejunojejunal anastomosis through mesocolic window.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —41-year-old woman with transmesenteric herniation of distal small bowel (sb) through mesenteric defect at jejunojejunal anastomosis site (straight arrow, D) 6 year after Roux-en-Y gastric bypass. CT scans show associated mesenteric vessels are stretched and engorged (curved arrow, C and D). Obstruction of Roux limb (r) secondary to extrinsic compression by herniated small-bowel loops is also present. Note gastric pouch (gp) and gastric remnant (gr). Diagnostic laparoscopy confirmed CT findings. Herniated small bowel (sb) was viable, reduction was performed with atraumatic graspers, and responsible mesenteric defect was closed laparoscopically. ds = distal stomach.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —41-year-old woman with transmesenteric herniation of distal small bowel (sb) through mesenteric defect at jejunojejunal anastomosis site (straight arrow, D) 6 year after Roux-en-Y gastric bypass. CT scans show associated mesenteric vessels are stretched and engorged (curved arrow, C and D). Obstruction of Roux limb (r) secondary to extrinsic compression by herniated small-bowel loops is also present. Note gastric pouch (gp) and gastric remnant (gr). Diagnostic laparoscopy confirmed CT findings. Herniated small bowel (sb) was viable, reduction was performed with atraumatic graspers, and responsible mesenteric defect was closed laparoscopically. ds = distal stomach.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —41-year-old woman with transmesenteric herniation of distal small bowel (sb) through mesenteric defect at jejunojejunal anastomosis site (straight arrow, D) 6 year after Roux-en-Y gastric bypass. CT scans show associated mesenteric vessels are stretched and engorged (curved arrow, C and D). Obstruction of Roux limb (r) secondary to extrinsic compression by herniated small-bowel loops is also present. Note gastric pouch (gp) and gastric remnant (gr). Diagnostic laparoscopy confirmed CT findings. Herniated small bowel (sb) was viable, reduction was performed with atraumatic graspers, and responsible mesenteric defect was closed laparoscopically. ds = distal stomach.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13D —41-year-old woman with transmesenteric herniation of distal small bowel (sb) through mesenteric defect at jejunojejunal anastomosis site (straight arrow, D) 6 year after Roux-en-Y gastric bypass. CT scans show associated mesenteric vessels are stretched and engorged (curved arrow, C and D). Obstruction of Roux limb (r) secondary to extrinsic compression by herniated small-bowel loops is also present. Note gastric pouch (gp) and gastric remnant (gr). Diagnostic laparoscopy confirmed CT findings. Herniated small bowel (sb) was viable, reduction was performed with atraumatic graspers, and responsible mesenteric defect was closed laparoscopically. ds = distal stomach.

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —25-year-old woman with jejunojejunal intussusception just proximal to jejunojejunal anastomosis (straight arrows, A and C) 3 year after Roux-en-Y gastric bypass. CT scans show classic target sign involving distal Roux limb (r) and resultant mild dilatation of proximal portion (pr) of the Roux limb. Note gastric pouch (gp), gastric remnant (gr), gastric suture line (white arrows), and mesenteric vessels (curved arrow).

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —25-year-old woman with jejunojejunal intussusception just proximal to jejunojejunal anastomosis (straight arrows, A and C) 3 year after Roux-en-Y gastric bypass. CT scans show classic target sign involving distal Roux limb (r) and resultant mild dilatation of proximal portion (pr) of the Roux limb. Note gastric pouch (gp), gastric remnant (gr), gastric suture line (white arrows), and mesenteric vessels (curved arrow).

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14C —25-year-old woman with jejunojejunal intussusception just proximal to jejunojejunal anastomosis (straight arrows, A and C) 3 year after Roux-en-Y gastric bypass. CT scans show classic target sign involving distal Roux limb (r) and resultant mild dilatation of proximal portion (pr) of the Roux limb. Note gastric pouch (gp), gastric remnant (gr), gastric suture line (white arrows), and mesenteric vessels (curved arrow).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15 —42-year-old woman with gastric staple line disruption after Roux-en-Y gastric bypass.Oblique spot image from fluoroscopic examination shows air and contrast material in gastric remnant (gr). Note gastric pouch (gp) and Roux limb (r). Also note gastrojejunal anastomosis (arrows). Diagnostic laparotomy confirmed findings; adhesion lysis and staple line revision were performed.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16 —57-year-old woman with filling of oversewn jejunum after Roux-en-Y gastric bypass. Fluoroscopic image shows filling of short oversewn afferent jejunal limb (white arrows), gastrojejunal anastomosis (black arrow), gastric pouch (gp), and Roux limb (r). Note tip of nasogastric tube in proximal Roux limb and normal jejunal fold pattern.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17A —39-year-old man with abscess 21 days after laparoscopic adjustable gastric banding CT series shows intraabdominal abscess (a) tracking along band tubing (white arrows). Note adjustable gastric band (black arrows) and distal stomach (ds). At laparotomy, fistula between subcutaneous port site and lesser sac was found. Band and port were removed.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17B —39-year-old man with abscess 21 days after laparoscopic adjustable gastric banding CT series shows intraabdominal abscess (a) tracking along band tubing (white arrows). Note adjustable gastric band (black arrows) and distal stomach (ds). At laparotomy, fistula between subcutaneous port site and lesser sac was found. Band and port were removed.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —70-year-old man with stomal stenosis secondary to overinflation of laparoscopic adjustable gastric banding. Axial (A) and right anterior oblique slab reformatted (B) CT images show bulging band balloon (arrows, A) filled with radiopaque contrast material, distal stomach (ds), dilated gastric pouch (gp), and dilated distal esophagus (de). Band used was Swedish adjustable gastric band (SAG-BAND, Ethicon Endo-Surgery).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —70-year-old man with stomal stenosis secondary to overinflation of laparoscopic adjustable gastric banding. Axial (A) and right anterior oblique slab reformatted (B) CT images show bulging band balloon (arrows, A) filled with radiopaque contrast material, distal stomach (ds), dilated gastric pouch (gp), and dilated distal esophagus (de). Band used was Swedish adjustable gastric band (SAG-BAND, Ethicon Endo-Surgery).

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19 —43-year-old woman with dysphagia secondary to gastric stomal stenosis 4 years after laparoscopic adjustable gastric banding. Fluoroscopic spot image taken 20 minutes after contrast administration shows mildly distended gastric pouch (gp) with air-contrast level and delayed passage of contrast material into distal stomach (ds). Note esophageal reflux (er). Esophagogastroduodenoscopy confirmed findings, and uncomplicated stomal balloon dilatation and band volume adjustment were performed.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 20 —32-year-old man with stomal stenosis secondary to posterior band slippage 1 week after laparoscopic adjustable gastric banding.Fluoroscopic spot image shows air-contrast level in distended lateral eccentric gastric pouch (gp), severely narrowed stoma (arrow), and minimal contrast material distal to band. Phi angle () is greater than 90°. Diagnostic laparotomy confirmed findings. Band and port were removed and anterior gastric wedge resection was performed because of necrosis beneath band. ds = distal stomach.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 21 —Patient with disconnected connection tubing after laparoscopic adjustable gastric banding. Anteroposterior fluoroscopic image shows disconnection of gastric banding system (arrow) after blunt trauma. (Reprinted from Wiesner W, Schob O, Hauser RS, Hauser M. Adjustable laparoscopic gastric banding in patients with morbid obesity: radiographic management, results, and postoperative complications. Radiology 2000; 21:389-394 [64])

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 22 —Anteroposterior overhead image after injection of contrast material into port in patient with connection tubing leak after laparoscopic adjustable gastric banding. Note leak of contrast material at junction of port and connector tube (black arrows) and band in normal position (white arrow). = phi angle. (Reprinted from Mehanna MJ, Birjawi G, Moukaddam HA, Khoury G, Hussein M, Al-Kutoubi A. Complications of gastric banding: a radiological pictorial review. AJR 2006; 186:522-534 [24])

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 23A —51-year-old woman with vomiting secondary to severe gastric stomal stenosis 4 months after vertical-banded gastroplasty. Oblique fluoroscopic spot (A) and axial CT (B) images show enlarged gastric pouch (gp), distal stomach (ds), severe narrowing of stoma (white arrows), and esophageal reflux (black arrow, B).

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 23B —51-year-old woman with vomiting secondary to severe gastric stomal stenosis 4 months after vertical-banded gastroplasty. Oblique fluoroscopic spot (A) and axial CT (B) images show enlarged gastric pouch (gp), distal stomach (ds), severe narrowing of stoma (white arrows), and esophageal reflux (black arrow, B).

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 24A —39-year-old woman with gastric stomal stenosis and gastric diverticula 15 years after vertical-banded gastroplasty. Fluoroscopic spot images show delayed passage of contrast material into distal stomach (ds) and gastric pouch (gp) enlargement with air-contrast level. Note narrowed gastric stoma (white arrow), gastric pouch diverticula (arrowheads), and staple line (black arrows). Esophagogastroduodenoscopy confirmed findings and showed long-segment Barrett's esophagus. Uncomplicated gastric stoma balloon dilatation to 15 mm was performed.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 24B —39-year-old woman with gastric stomal stenosis and gastric diverticula 15 years after vertical-banded gastroplasty. Fluoroscopic spot images show delayed passage of contrast material into distal stomach (ds) and gastric pouch (gp) enlargement with air-contrast level. Note narrowed gastric stoma (white arrow), gastric pouch diverticula (arrowheads), and staple line (black arrows). Esophagogastroduodenoscopy confirmed findings and showed long-segment Barrett's esophagus. Uncomplicated gastric stoma balloon dilatation to 15 mm was performed.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 25 —37-year-old woman with complete gastric obstruction secondary to stomal food impaction 3 years after vertical-banded gastroplasty. Oblique fluoroscopic spot image 15 minutes after contrast administration shows gastric pouch (gp) enlargement with air-contrast level and dependent nonmobile filling defect (d). Esophagogastroduodenoscopy confirmed food lodged in stoma that was successfully removed. Stomal diameter was normal.

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