AJR 2005; 185:671-681
© American Roentgen Ray Society
Small-Bowel Complications of Major Gastrointestinal Tract Surgery
Kumaresan Sandrasegaran1,
Dean D. Maglinte1,
John C. Lappas1 and
Thomas J. Howard2
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.
Received June 4, 2004;
accepted after revision December 8, 2004.
Address correspondence to K. Sandrasegaran
(ksandras{at}iupui.edu).
Abstract
OBJECTIVE. Gastrointestinal complications of major abdominal surgery
often require radiologic assessment. The purpose of this article is to review
the expected imaging findings and complications after commonly performed
gastric and pancreatic surgery.
CONCLUSION. It is important to understand the postsurgical anatomy
to avoid misinterpreting an expected postoperative finding as a complication.
Postoperative complications can be categorized as being related to adhesions,
anastomosis, an enteric connection, and abnormal bowel position.
Introduction
Abdominal, pancreatic, and gastric surgeons perform increasingly
complex procedures. The radiologist is faced with CT or upper gastrointestinal
contrast studies in which the anatomy is difficult to discern and there is
uncertainty whether a finding is an expected postoperative change or relates
to a complication. We retrospectively reviewed 377 cases of complex abdominal
surgery performed by gastric and pancreatic surgeons at our affiliated
institutions between January 2002 and August 2003. This pictorial essay shows
the expected anatomy after commonly performed procedures and the range of
complications that might be seen on imaging studies. For ease of
categorization, postoperative small-bowel complications are classified as
related to anastomosis, an enteric connection, abnormal bowel position, or
adhesions.
Whipple Procedure
Whipple surgery is the only curative procedure for carcinoma of the head of
pancreas (Figs. 1A, and
1B). The survival rate is
approximately 30% 5 years after resection
[1] and less than 1% for those
who do not qualify for the procedure. It is important to appreciate
postoperative anatomy to prevent overdiagnosing complications.
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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)
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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).
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There are several normally expected CT findings after the Whipple
procedure. One is an afferent loop that is fluid filled and edematous and
shows bright contrast enhancement in the first two postoperative weeks. This
finding should not be mistaken for an ischemic or inflamed bowel or for fluid
collection (Figs. 1A, and
1B). Another finding is
reactive lymphadenopathy of up to 1.5 cm, which might be mistaken for a
recurrent tumor [2]. This
occurs in the first month after Whipple and other pancreatic surgery. Third is
perivascular cuffing, which is commonly seen 1-2 months after surgery and
should not be mistaken for recurrent tumor if preoperative scans did not show
this finding. The celiac and superior mesenteric arteries are most affected
and the common hepatic artery, less affected. Fluid collection in the duodenal
bed in the first 3 weeks after surgery is an expected finding. Unless there
are clinical signs of infection, these collections need not be drained; they
tend to be transient. Pneumobilia is a permanent feature after
hepaticojejunostomy. Periportal edema is seen in the first 2 postoperative
weeks.
Puestow Procedure
In cases of severe chronic pancreatitis, end-to-end pancreaticojejunal
anastomosis, such as in the Whipple procedure, is insufficient to drain the
pancreas. The Puestow procedure (Figs.
2A, and
2B), a side-to-side
longitudinal pancreaticojejunostomy, drains the pancreatic duct directly into
a jejunum loop [3]. In
Puestow's original description of the technique, the spleen and distal
pancreas were removed. The Roux loop in the Puestow procedure may be mistaken
for a peripancreatic fluid collection if the nature of surgery is not
appreciated.
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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)
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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).
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Bariatric Roux-en-Y Gastric Bypass Procedure
In the United States, more than 30% of adults are obese; 2-3% of men and
6-7% of women are morbidly obese
[4,
5]. The Rouxen-Y gastric bypass
procedure is the gold standard for bariatric surgery (Figs.
3A,
3B, and
3C). Open and laparoscopic
Roux-en-Y bypass procedures are associated with a 5-20% incidence of
complications [6]. An upper
gastrointestinal contrast series is usually performed on the first
postoperative day to detect gastrojejunal leak or obstruction. Understanding
the postoperative anatomy is important to prevent overdiagnosis of
complications (Fig. 4).
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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)
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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.
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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.
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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.
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Complications
Anastomotic Complications
Anastomotic complications are the most significant bowel-related
complications. They occur as a result of ischemia or suboptimal surgical
technique, including staple gun failure, and account for most of the morbidity
and mortality from the Whipple, Puestow, and Rouxen-Y procedures. Anastomotic
leak is found in up to 27% of patients having laparoscopic Roux-en-Y gastric
bypass and, in our experience, it is the most common postoperative
complication of the Puestow procedure.
Stenosis—Symptomatic anastomotic stenosis at the
gastrojejunostomy site is found in approximately 3-5% of patients having
Rouxen-Y gastric bypass surgery
[7,
8]. The incidence is higher in
patients having a laparoscopic Roux-en-Y bypass than in those having an open
procedure. Upper gastrointestinal contrast series show delayed passage of
contrast material. On CT, a spherical pouch or air-contrast level is
suggestive of this diagnosis. Another type of obstruction to gastric emptying
is stenosis of the Roux limb at the site of mesocolonic tunneling in the
Roux-en-Y bypass procedure. This is usually caused by excessive stapling at
the site of the mesenteric defect.
Ulcers—Anastomotic ulcers after gastric bypass procedures
are common, with an incidence of 12-16%
[9,
10]. An upper gastrointestinal
double-contrast barium series may show these ulcers; however, the method is
reported to have a sensitivity of only 50% compared with endoscopy
[11]. In our experience, most
stomal ulcers are visualized with modern fluoroscopic units and an adequate
volume (100-200 mL) of barium for oral contrast.
Leak and perforation—Anastomotic leak or perforation is the
most serious complication of Roux-en-Y gastric bypass surgery. It occurs in
3-5% of patients and is usually caused by staple gun failure. The incidence of
leakage can be reduced by manually sewing the gastrojejunostomy
[12,
13]. The complication is
evident in the first postoperative week. Although upper gastrointestinal
studies may show this leak (Figs.
5A, and
5B), the images may be of poor
quality because of the patient's size. It is our practice to obtain a CT scan
with IV and positive oral (dilute water-soluble) contrast in any patient who
has unexplained fever, pain, or persistent nausea. Some anastomotic leaks are
complicated by an enteroenteric, enterovesical, or enterocutaneous fistula
(Figs. 5A, and
5B).
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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.
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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).
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Afferent loop obstruction—Afferent loop obstruction occurs
in 0.3% cases after gastroenterostomy
[14], including Billroth II
surgery and the Whipple procedure. In Billroth II surgery, the afferent limb
is the duodenum; in pancreatic surgery, the Roux segment is the afferent limb
(Figs. 1A, and
1B). Possible causes of
obstruction are adhesions, internal hernia, anastomotic stenosis, stomal
ulcer, recurrent tumor, and obturation from bezoar. Chronic partial
afferent-loop obstruction is termed "afferent loop syndrome."
Diagnosis is possible but difficult to make with an upper gastrointestinal
series (Figs. 6A,
6B, and
6C). CT is the most useful
imaging technique for diagnosis.
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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.
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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).
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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.
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Enteric Connection
Enteric-related complications are rare and result from improper anatomic
connection of bowel loops. They are distinct from anastomosis-related
complications.
Blind pouch syndrome— Side-to-side anastomosis performed in
Roux-en-Y gastric bypass surgery and after intestinal resection can result in
an enlarged aperistaltic loop of the small bowel (Figs.
7A,
7B, and
7C). This enlarged loop is
termed "blind pouch." The blind pouches do not form until
approximately 4 months after surgery. These structures do not usually increase
significantly in size after 12 months. Although often an incidental finding,
blind pouch can lead to malabsorption, gastrointestinal bleeding, and bowel
perforation [15]. If symptoms
are ascribed to the pouch, the pouch can be laparoscopically removed.
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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)
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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.
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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.
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Short gut syndrome—Malabsorption can be caused by inadequate
length of functioning small bowel after widespread small-bowel resection, such
as in Crohn's disease. The minimal length of small bowel (excluding the
duodenum) required to cope without parenteral nutrition or small-bowel
transplantation is estimated to be 100 cm. Patients with a longer small bowel
may also have digestive problems if the integrity of residual mucosa is
impaired or the distal ileum has been resected. Short gut syndrome can be
simulated by inadvertent surgery when the ileum is mistaken for the jejunum
and a gastroileostomy rather than a gastrojejunostomy is created
(Fig. 8). This complication is
easily depicted by an upper gastrointestinal contrast series. CT examination
may show multiple loops of nondistended jejunum that are not opacified with
oral contrast, while there is oral contrast in the stomach, ileum, and right
colon.
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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.
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Altered Bowel Position
Bowel position is usually altered as a consequence of major abdominal
surgery. However, small bowel may become trapped in undesirable positions
postoperatively. This type of complication includes hernia and
intussusceptions.
Transmesenteric internal hernia—Transmesenteric hernia can
occur in any procedure, including liver transplantation and gastric bariatric
surgery, in which a Roux loop is fashioned. Transmesenteric hernias are more
common after laparoscopic bariatric surgery than after open surgery
[16]. Transmesenteric hernias
occur through the tear in the mesocolon through which the Roux loop is brought
during a retrocolic anastomosis (Figs.
9A, and
9B). The reported incidence of
internal hernia is about 2.5%
[7,
16], and it generally involves
the Roux loop. Antecolic placement of the Roux loop does not lead to
transmesenteric hernia but is complicated by a Petersen-type internal hernia
in rare cases.
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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)
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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.
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An upper gastrointestinal barium series could show the degree and location
of small-bowel obstruction (Figs.
9A, and
9B) but is less useful in
determining the cause of obstruction. The finding of dilated proximal jejunum
that remains fixed in a high position on erect views suggests internal hernia.
CT is more helpful in differentiating transmesenteric hernia (Figs.
10A,
10B, and
10C) from mesocolic tunnel
stenosis, stenosis at the jejunojejunostomy, or adhesion-related simple bowel
obstruction. Appendix 1 shows
findings that indicate transmesenteric hernia.
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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).
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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).
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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).
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There are no reports of a high frequency of other types of internal hernia
after abdominal surgery. During diagnosis, it is important to distinguish an
internal hernia from adhesive small-bowel obstruction. The former generally
requires emergency surgery
[17].
External hernia—External hernias are another complication of
gastrointestinal surgery. Ventral hernia is a major source of morbidity after
any major abdominal procedure. It is more common after open Roux-en-Y gastric
bypass surgery (incidence of up to 17%) than after a laparoscopic Roux-en-Y
procedure. A Richter hernia can occur at the site of the trocar after
laparoscopic procedures [18].
Parastomal and lumbar are other external hernias commonly associated with
abdominal surgery.
Intussusception—Intussusception accounts for 5% of
small-bowel obstruction in adults
[19] and is more common in
postoperative patients. Possible causes include the presence of foreign
material, such as sutures and feeding tubes, and hyperperistalsis of bowel
that has been extensively handled
[20]. CT appearances of these
have been described [21].
Adhesions
Adhesions are the most common cause of bowel obstruction after surgery. The
adhesions can be symptomatic and nonobstructive. Adhesive small-bowel
obstruction is classified as simple, closed loop, or strangulating.
Symptomatic, Without Overt Obstruction
More than 90% of patients who have had abdominal surgery have enteric
adhesions, even if there is no clinical obstruction
[22]. We routinely find CT
features that suggest adhesions in postoperative patients who report abdominal
bloating or pain (Fig. 11)
(Appendix 2). These patients do
not have high-grade small-bowel obstruction but may have intermittent or
low-grade small-bowel obstruction, for which CT has poor sensitivity
[23].
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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.
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Adhesive Small-Bowel Obstruction
The diagnosis of adhesion-related small-bowel obstruction is presumed on CT
if there is a narrow zone of transition without an identifiable obstructive
lesion. At our institution, low-grade and partial high-grade obstructions are
treated by enteric decompression in which a long tube is placed under
fluoroscopic guidance. Although these patients rarely require surgery, those
with complete, closed-loop, or strangulating obstruction require emergent
surgery. CT findings of closed-loop
(Appendix 3) and strangulating
obstruction (Appendix 4) are
shown in Figures 12A,
12B,
12C,
12D,
13A, and
13B, respectively
[24,
25].
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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.
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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.
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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.
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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.
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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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Summary
In conclusion, knowledge of complex abdominal surgery is useful in
differentiating postoperative anatomy from complications. When dealing with
postoperative small-bowel obstruction, the radiologist should be able to
diagnose less common types of obstruction, such as afferent-loop, closed-loop,
and strangulating obstruction, as well as unusual causes such as internal
hernia. This discrimination may be important in planning therapy because even
high-grade partial adhesive obstructions are usually treated conservatively,
while obstructions with an internal hernia or closed loop require surgery.
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