AJR 2004; 183:141-143
© American Roentgen Ray Society
Narrowing of the Proximal Jejunal Limbs at Their Passage Through the Transverse Mesocolon: A Potential Pitfall of Laparoscopic Roux-en-Y Gastric Bypass
Theodore R. Smith1 and
Alan P. White2
1 Department of Radiology, The Albert Einstein College of Medicine of the
Montefiore Medical Center, J. D. Weiler Hospital, 1825 Eastchester Rd., Bronx,
NY 10461.
2 Department of Surgery, The Albert Einstein College of Medicine of the
Montefiore Medical Center, Bronx, NY 10461.
Received October 27, 2003;
accepted after revision December 1, 2003.
Address correspondence to T. R. Smith
(theodorersmith{at}aol.com).
Abstract
OBJECTIVE. We reviewed images obtained in patients who had recently
undergone laparoscopic Roux-en-Y gastric bypass procedures, noting
radiographic appearances and possible complications.
CONCLUSION. In five (45%) of 11 patients, we observed a focal area
of circumferential narrowing of the proximal jejunal Roux-en-Y loop. This
narrowing corresponded to the site of multiple circumferential sutures from
the edge of the hiatus created in the transverse mesocolon to the serosa of
the traversing jejunal Roux-en-Y loop as the latter courses superiorly to join
the gastric pouch. This narrowing should not be confused with localized
ischemia or another disease process.
Introduction
Morbid obesity with its associated medical problems, such as hypertension,
diabetes, and shortened lifespan, is a prevalent condition that has been
growing in incidence since 1960
[1]. For those patients who
have failed to achieve and maintain weight loss through dietary and medical
management, bariatric surgery is being increasingly used
[2]. Among the various surgical
options, laparoscopic Roux-en-Y gastric bypass (LRGB) has become a favored
technique. It results in greater weight loss
[3] and improvement in
comorbidities and in quality of life, and it reduces recovery time and the
incidence of perioperative complications
[4,
5]. LRGB has also become a
favored procedure at our hospital, with a gastrointestinal series being
routinely performed after the surgery. On several such studies, over a short
period of time, a persistent segmental narrowing of the upper jejunal
Roux-en-Y limb was noted (Figs.
1A,
1B,2A,
2B,3A,
3B). This finding prompted a
review of gastrointestinal series that were performed in 11 consecutive
patients soon after LRGB procedures.
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Fig. 1A. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 62-year-old woman 1 day after laparoscopic
Roux-en-Y gastric bypass. Persistent circumferential nonobstructive narrowing
(arrow) at proximal Roux-en-Y jejunal loop corresponds to site of
passage through transverse mesocolon.
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Fig. 1B. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 62-year-old woman 1 day after laparoscopic
Roux-en-Y gastric bypass. Persistent narrowing point (arrow), with
intact mucosa, corresponds to suturing of transverse mesocolon to jejunal
serosa. Solid arrowhead indicates gastric pouch; open arrowhead indicates
gastric pouch–jejunum anastomosis.
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Fig. 2A. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 42-year-old woman 14 days after
laparoscopic Roux-en-Y gastric bypass. Nonobstructive circumferential
narrowing of proximal limb of Roux-en-Y jejunal loop (arrows) is
observed at site of created transverse mesocolon opening.
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Fig. 2B. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 42-year-old woman 14 days after
laparoscopic Roux-en-Y gastric bypass. Persistent narrowing (arrows)
is seen.
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Fig. 3A. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 34-year-old woman 1 day after laparoscopic
Roux-en-Y gastric bypass. Some dilatation is seen in Roux-en-Y upper jejunal
limb proximal to circumferential narrowing (arrow) at created hiatus
in transverse mesocolon.
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Fig. 3B. —Radiographs from gastrointestinal series with water-soluble
Gastrografin ([diatrizoate meglumine and diatrizoate sodium solution USP] 120
mL, Bracco Diagnostics) obtained in 34-year-old woman 1 day after laparoscopic
Roux-en-Y gastric bypass. Persistence of narrowing is noted at same point
(arrow) as in A.
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Subjects and Methods
Gastrointestinal series were performed in 11 consecutive patients who had
undergone Roux-en-Y gastric bypass 1–14 days after the procedure
(postoperative day 1, seven patients; postoperative day 2, three patients; and
postoperative day 14, one patient.). The patients (10 women and one man)
ranged in age from 32 to 62 years (average age, 44.5 years; median age, 43
years).Water-soluble Gastrografin ([diatrizoate meglumine and diatrizoate
sodium solution USP] 120 mL, Bracco Diagnostics) was used, and fluoroscopic
and overhead images were obtained. All cases were reviewed by an attending
radiologist.
Results
In five (45%) of the 11 cases, a circumferential narrowing of the upper
Roux-en-Y jejunal limb was observed at its passage through the transverse
mesocolon, with intact mucosa and mild or no luminal dilatation proximal to
the narrowing. No significant obstruction to flow was seen at the created
hiatus. One patient subsequently had a small-bowel obstruction more distal to
the created opening.
Discussion
In LRGB, a proximal gastric pouch with a capacity of approximately
15–30 mL is formed and isolated from the remaining bypassed stomach. The
pouch is approximately 5 cm distal to the gastroesophageal junction and is
anastomosed to a proximal Roux-en-Y ascending jejunal limb of approximately
75–150 cm from the site where the limb is brought through the transverse
mesocolon, posterior to the colon and stomach
[6]. The other Rouxen-Y jejunal
limb is anastomosed side by side to the more distal jejunum, thereby bypassing
a good portion of the latter. The surgically created opening in the transverse
mesocolon is usually formed in an avascular area, just lateral to the middle
colic artery. Because of the potential risk of internal bowel herniation
through the opening, sutures are placed from the transverse mesocolon to the
serosa of the ascending traversing jejunal limb passing through that opening
circumferentially from approximately the 10-o'clock to the 3-o'clock position
[7]. These sutures are thought
to produce the circumferential irregular narrowing that has been noted on our
postoperative contrast-enhanced studies.
The chief potential complications of LRGB include obstruction, leakage at
anastomotic sites, herniation, pouch breakdown, and, rarely, intussusception
[8]. The radiographic
appearance of upper gastrointestinal findings in patients after LRGB has been
studied in detail and reported in large series. In a study of 463 patients,
Blachar et al. [2] found a 10%
overall rate of complications, which the investigators divided into major
(those requiring intervention) and minor (those that resolved spontaneously):
4.5% with bowel obstructions (14 internal hernias and nine small-bowel
adhesions), 3.0% major leaks, 2.8% minor leaks, 3.2% with anastomotic
strictures, one gastro-gastric fistula, and one gastrocutaneous fistula. The
time to onset of complications ranged from 1 to 825 days (median, 15 days)
after the procedure. Another study recently reported two cases of chronic
ischemia–related abnormalities of the jejunal anastomotic limb in
patients who had undergone LRGB
[9].
One school of thought believes that performing gastrointestinal series is
not efficacious without a specific clinical symptomatic indication
[10]. However, as in the
series by Blachar et al. [2],
all our patients except one were routinely studied within 1–2 days (one
patient, 14 days) after LRGB with water-soluble-contrast–enhanced
gastrointestinal series, primarily to check for leakage, delayed gastric pouch
emptying, stricture, small-bowel obstruction, or herniation. (We used
Gastrografin in case peritoneal spillage occurred.) Of the relatively small
number of eleven patients, five (45%) exhibited a circumferential irregular
narrowing with intact mucosal appearance, corresponding to the point at which
the upper jejunal Roux-en-Y limb passed through and was sutured to the
transverse mesocolon. Because there was no clinical indication, almost none of
these patients were followed up with subsequent gastrointestinal series or CT
examinations. Therefore, this radiographic finding, which to our knowledge has
not previously been described, should be recognized as a frequently observed
appearance after LRGB and should not be confused with an abnormal submucosal
process such as localized ischemia.
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Abstract
Introduction
