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Imaging Findings in Roux-en-O and Other Misconstructions: Rare but Serious Complications of Roux-en-Y Gastric Bypass Surgery

¹ Department of Radiology, University of Chicago, 5841 S Maryland Ave., MC 2026, Chicago, IL 60637.
² Department of General Surgery, University of Chicago, Chicago, IL.

View larger version (22K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Schematic shows components of Roux-en-Y gastric bypass procedure.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —52-year-old woman with disconnected Roux-en-O misconstruction. Axial reconstruction CT scans show levels of gastric pouch (A), descending duodenum (B), and distal anastomosis (C). Enteric contrast medium administered orally opacifies markedly dilated gastric pouch (black asterisk, A), alimentary limb (short arrows, B and C), and extruded stomach and biliary limb (white asterisks). Common limb, beginning at supposed distal anastomosis (long arrow, C), distal small bowel, and colon (arrowheads B and C) are collapsed and gasless. At surgery, biliary limb was found to have been incorrectly anastomosed to gastric pouch, forming Roux-en-O loop that ran from gastric pouch to end blindly in excluded distal stomach. Distal portion of bowel is collapsed and gasless because common limb was completely disconnected from Roux loop.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —52-year-old woman with disconnected Roux-en-O misconstruction. Axial reconstruction CT scans show levels of gastric pouch (A), descending duodenum (B), and distal anastomosis (C). Enteric contrast medium administered orally opacifies markedly dilated gastric pouch (black asterisk, A), alimentary limb (short arrows, B and C), and extruded stomach and biliary limb (white asterisks). Common limb, beginning at supposed distal anastomosis (long arrow, C), distal small bowel, and colon (arrowheads B and C) are collapsed and gasless. At surgery, biliary limb was found to have been incorrectly anastomosed to gastric pouch, forming Roux-en-O loop that ran from gastric pouch to end blindly in excluded distal stomach. Distal portion of bowel is collapsed and gasless because common limb was completely disconnected from Roux loop.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —52-year-old woman with disconnected Roux-en-O misconstruction. Axial reconstruction CT scans show levels of gastric pouch (A), descending duodenum (B), and distal anastomosis (C). Enteric contrast medium administered orally opacifies markedly dilated gastric pouch (black asterisk, A), alimentary limb (short arrows, B and C), and extruded stomach and biliary limb (white asterisks). Common limb, beginning at supposed distal anastomosis (long arrow, C), distal small bowel, and colon (arrowheads B and C) are collapsed and gasless. At surgery, biliary limb was found to have been incorrectly anastomosed to gastric pouch, forming Roux-en-O loop that ran from gastric pouch to end blindly in excluded distal stomach. Distal portion of bowel is collapsed and gasless because common limb was completely disconnected from Roux loop.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Schematic shows disconnected Roux-en-O misconstruction. Biliary limb is incorrectly anastomosed to gastric pouch. Roux-en-O limb is completely disconnected from Roux-en-Y alimentary limb, resulting in complete mechanical bowel obstruction. Alimentary limb was oversewn in patient depicted in Figure 2A, 2B, 2C.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —60-year-old man with connected Roux-en-O misconstruction. Representative axial CT scan through upper abdomen shows nonspecific mild dilatation of upper abdominal bowel loops (thick arrows). Ileum (thin arrow) and colon (arrowheads) are unremarkable. Gastrojejunostomy tube placed in excluded gastric segment is partially evident within transverse duodenum.

View larger version (194K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —60-year-old man with connected Roux-en-O misconstruction. Patient was given medium-density barium in serial patient-controlled swallows during fluoroscopic observation. Early spot image of gastric pouch (thick arrow) shows patent proximal anastomosis (paired thin arrows) and normal-caliber alimentary limb (arrowheads). Small collection of contrast material lateral to pouch (single thin arrow) is residual contrast agent from earlier anastomotic leak that had healed.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —60-year-old man with connected Roux-en-O misconstruction. Fluoroscopic spot image of alimentary limb during initial filling shows normal bowel caliber. Mild indentation of alimentary limb as it goes through transverse mesocolon (arrow) is evident. Residual enteric contrast material from previous CT examination faintly opacifies colon.

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —60-year-old man with connected Roux-en-O misconstruction. Fluoroscopic spot image of distal alimentary limb shows mild to moderate dilatation of limb. Antegrade contrast flow is by gravity only with no peristaltic activity observed. Most contrast material has reached distal alimentary limb (arrowheads).

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —60-year-old man with connected Roux-en-O misconstruction. Fifteen-minute-delayed fluoroscopic spot image of alimentary limb shows retrograde peristalsis (arrows) with return of considerable amount of contrast material into dilated proximal alimentary limb (arrowheads). Fluoroscopy showed contrast material eventually reaching gastric pouch (not shown).

View larger version (26K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —Schematic shows connected Roux-en-O misconstruction. Biliary limb is anastomosed to gastric pouch instead of to distal end of Roux-en-Y limb. Proximal end of Roux-en-Y alimentary limb is anastomosed to biliary limb instead of to gastric pouch. Features may look anatomically correct on static images, but peristalsis in Roux limb connected to gastric pouch is reversed (thin arrows), causing functional obstructive symptoms.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —48-year-old woman with Roux limb inversion. Patient was given medium-density barium in patient-controlled boluses. Spot image from initial fluoroscopic examination shows alimentary limb is dilated (arrowheads) but more distal small bowel is of normal caliber (arrow). Fluoroscopic assessment shows no definable cause at transition point.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —48-year-old woman with Roux limb inversion. Radiograph 2 weeks after A shows persistence of contrast material in alimentary limb.

View larger version (185K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —48-year-old woman with Roux limb inversion. Follow-up fluoroscopic examination was performed after bowel preparation to clear contrast material from alimentary limb. Image obtained after administration of medium-density barium through jejunal tube shows biliary limb of normal caliber. Peristalsis is antegrade within biliary limb. At distal anastomosis, divergent flow of contrast material is evident antegrade into common limb (white asterisk) and retrograde into alimentary limb (black asterisk). Thin arrows indicate direction of peristalsis.

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —48-year-old woman with Roux limb inversion. Spot image obtained minutes after C shows continued abnormal retrograde peristalsis (arrow) diverting contrast material farther up alimentary limb.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6E —48-year-old woman with Roux limb inversion. After acquisition of D, patient was given water-soluble contrast material orally in patient-controlled boluses. Spot image shows dilated gastric pouch (thick arrow) and flaccid and featureless proximal alimentary limb (arrowheads). Peristalsis was initially antegrade (thin arrows).

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6F —48-year-old woman with Roux limb inversion. Fluoroscopic image shows that with full distention of alimentary limb by contrast material, abrupt reversal of peristalsis (arrow) is evident with return of contrast material to gastric pouch and subsequent marked patient emesis, essentially reproducing symptoms of food intolerance.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Roux limb inversion. Schematic shows normal configuration of free segment Roux-en-Y limb. Orientation of anatomic proximal (P) and distal (D) ends of free segment is maintained, so that peristalsis (arrows) is antegrade.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Roux limb inversion. Schematic shows orientation of anatomic proximal (P) and distal (D) ends of free segment are inverted before anastomosis. Anatomic distal end is anastomosed to gastric pouch, and anatomic proximal end is anastomosed to common limb. As with connected Roux-en-O, the features may look anatomically correct on static images, but peristalsis is reversed (arrows), causing functional obstructive symptoms.

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —51-year-old woman with short Roux limb misconstruction. For upper gastrointestinal examination, medium-density barium was administered through gastric tube in excluded gastric segment. Fluoroscopic image shows distal portion of stomach (asterisk) and biliary limb (arrowheads) are unremarkable. At distal anastomosis, preferential flow of contrast material into alimentary limb (white arrows) is evident with little contrast material passing distally into common limb (black arrow). Antegrade assessment of alimentary limb was limited owing to concomitant proximal anastomotic stenosis (not shown). At surgery, Roux limb measuring only 25 cm was identified. Short length allowed retrograde reflux, resulting in Roux-en-O physiologic characteristics.

View larger version (26K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —Short Roux limb misconstruction. Schematic shows all segments correctly oriented, but alimentary limb is abnormally short. Shortened length of Roux-en-Y limb allows random bile reflux up to gastric pouch (wavy arrows) despite normal antegrade peristaltic activity of alimentary limb (straight arrow).

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