AJR 2002; 179:1037-1041
© American Roentgen Ray Society
CT Findings in the Abdomen and Pelvis After Gastric Carcinoma Resection
Kyeong Ah Kim1,
Cheol Min Park1,
Sang Woo Park1,
Sang Hoon Cha1,
Hae Young Seol1,
In Ho Cha1 and
Ki Yeol Lee2
1 Department of Radiology, Medical Science Research Center, Korea University
Guro Hospital, 80, Guro-Dong, Guro-Ku, Seoul, 152-050, Korea.
2 Department of Radiology, Inje University Paik Hospital, 85, 2Ka, Jur-Dong,
Chung-Ku, Seoul, 100-032, Korea.
Received August 8, 2001;
accepted after revision March 26, 2002.
Address correspondence to C. M. Park.
Introduction
Gastric carcinoma is a common malignancy that results in significant
morbidity and mortality. Patients who have undergone gastric carcinoma
resection present challenging problems to their physicians. The radiologist is
frequently asked to define the postsurgical anatomy to assess the efficacy of
the procedures and to detect early and late postoperative complications. CT is
valuable for documenting normal postoperative anatomy, identifying
recurrences, evaluating anatomic relationships, and confirming the absence of
new lesions in the abdomen and pelvis after gastric carcinoma resection.
Compared with the large number of articles describing preoperative
assessment of gastric carcinoma, few reports have been published on the CT
findings in the abdomen and pelvis after gastric carcinoma resection. We
illustrate the CT findings of normal postoperative appearance, postoperative
complications, and tumor recurrence in the abdomen and pelvis.
CT Technique
In all patients, helical CT was performed with a single 20- to 25-sec
breath-hold using a slice collimation of 10 mm and a table pitch of 1:1. The
key to CT of the stomach is gastric distention, because wall thickening can be
simulated by underdistention. Each patient drank 200 mL of water just before
undergoing CT. Scanning was started 45 sec after the IV injection of 100-120
mL of nonionic contrast agent at a rate of 3 mL/sec.
Normal Postoperative Appearance
A variety of procedures are used to treat gastric carcinoma. Depending on
the location of the tumor, a subtotal or total gastrectomy or an
esophagogastrectomy may be performed.
Mild dilatation of the bile ducts without mechanical biliary obstruction
can be seen on follow-up CT after gastrectomy and vagotomy
(Fig. 1). This nonobstructive
biliary dilatation is possibly caused by altered biliary tract hormonal
response or sphincter of Oddi dysfunction. If a patient has no clinical
symptoms, no further evaluation is required. Surgical plications
(Fig. 2) may mimic masses; this
is a potential source of erroneous interpretation of local tumor recurrence in
the gastrointestinal tract.
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Fig. 1. —49-year-old woman with nonobstructive biliary dilatation
after esophagojejunostomy. Contrast-enhanced CT scan shows dilatation of
peripheral (thin arrows) and central (thick arrow) bile
ducts. No obstructing lesion was found in bile duct.
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Postoperative Complications
Anastomotic Leak and Abscess
Breakdown of a suture line and leakage occur at the anastomosis between the
stomach and the small bowel. CT may be needed to fully define the abscess
cavity (Fig. 3) and to direct
percutaneous drainage.
Afferent Loop Syndrome
Most cases of afferent loop syndrome are caused by mechanical obstruction
of the afferent loop from adhesions, kinking at the anastomosis, internal
hernia, stomal stenosis, malignancy, or inflammation surrounding the
anastomosis. CT plays a major role in the diagnosis of this entity, because
the clinical signs and symptoms are generally nonspecific. The CT finding is a
fluid-filled, dilated, transversely oriented portion of small bowel anterior
to the spine in the middle of the abdomen
[1]
(Fig. 4).
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Fig. 4. —63-year-old woman with afferent loop syndrome after Billroth
II operation. Contrast-enhanced CT scan shows massively dilated duodenum (D)
posterior to superior mesenteric artery (arrow) and anterior to
spine.
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Bezoar
Bezoar formation (Fig. 5) is
a complication of gastrectomy, particularly when gastectomy is combined with
vagotomy. Diminished peristalsis and absence of gastric acid allow poorly
chewed fibrous material to be retained and form a matted mass. This
complication should be suspected whenever radiologic findings show a large
discrete mass of food in the partially resected stomach of a fasting patient
[2].
Incisional Hernia
These hernias tend to occur during the first 4 months after surgery, a
critical period for the healing of transected muscular and fascial layers of
the abdominal wall. CT can show small defects in peritoneal and fascial layers
of abdominal wall through which the omentum or a "knuckle" of
intestine protrudes into the subcutaneous fat
[3]
(Fig. 6).
Esophageal Hiatal Hernia
Herniation of abdominal content through the esophageal hiatus above the
diaphragm (Fig. 7) is another
complication of gastric carcinoma resection.
Tumor Recurrence
Local Recurrence
Local recurrence of gastric carcinoma after surgery is defined as
histologic evidence of a tumor in the surrounding tissue of the resected
stomach. The most common sites of recurrence are in the area of the celiac
axis (Fig. 8) or hepatic
pedicle, followed by the anastomotic site
(Fig. 9) or gastric stump,
pancreas (Fig. 10), and
abdominal wall incision site
[4]
(Fig. 11).
Direct Extension
Tumor tissue may spread to adjacent organs via ligaments or peritoneal
reflections. The liver may be invaded via the gastrohepatic ligament, the
transverse colon via the gastrocolic ligament
(Fig. 12), and the pancreas
via the lesser sac.
Lymphatic Spread
Because of the abundant lymphatics in the stomach, lymph node metastases
are common in patients with gastric carcinoma. These patients may initially
have involvement of local nodes and, subsequently, regional or distant nodes
(Fig. 13).
Intraperitoneal Seeding
Intraperitoneal seeding may be manifested on CT scans as nodules, loculated
fluid collections, or irregular, beaded thickening and stranding of the
mesentery or omentum (Fig.
14A). The pouch of Douglas is the most dependent portion of the
peritoneal cavity and is a common site for drop metastases
(Fig. 14B).
Hematogenous Metastases
Because the venous return from the stomach is drained by the portal vein,
the liver is the most common site of bloodborne metastases. Less common sites
include the lungs, adrenal glands, kidneys, and bones.
Unusual Manifestations of Metastases
Ureteral Metastases
Most cases of ureteral metastases are associated with advanced gastric
carcinoma with multiple perigastric and paraaortic lymphadenopathy and diffuse
omental and mesenteric tumor infiltration. The CT findings are a thickened,
enhanced ureteral wall with periureteral infiltration
(Fig. 15), obstructive
hydronephrosis, and hydroureter
[5].
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Fig. 15. —49-year-old woman with metastatic linitis plastica of rectum
and Krukenberg's tumor of ovary. Patient underwent total gastrectomy for
signet ring cell—type gastric carcinoma. Contrast-enhanced CT scan shows
concentric thickening (arrow) of rectal wall with target sign and
infiltration into perirectal fat plane. Note right ovarian mass (K) and
ascites (a).
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Bowel Metastases
On helical CT, intestinal metastases from gastric carcinoma most commonly
show long segmental wall thickening (Fig.
16) with a thick inner enhancing layer
[6].
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Fig. 16. —67-year-old man with ureteral metastasis. Contrast-enhanced
CT scan shows thickened, enhanced right proximal ureteral wall with luminal
narrowing and periureteral infiltrations (arrows).
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Portal Vein Tumor Thrombosis
Gastric carcinoma should be considered a possibility in the diagnosis of
portal vein tumor thrombosis (Fig.
17), even if the serum 
-fetoprotein level is elevated and a
liver tumor is identified [7].
The portal tumor thrombus is presumed to have arisen from vascular invasion in
the primary foci of gastric carcinoma, and then to have permeated the portal
vein without invasion of the liver parenchyma.
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Fig. 17. —59-year-old man with portal vein tumor thrombosis.
Contrast-enhanced CT scan shows dilated, nonopacified main and right lobar
branches of portal vein (open arrows). Biopsy-proven multiple hepatic
metastases (solid arrows) are also present.
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