DOI:10.2214/AJR.07.2859
AJR 2008; 190:367-373
© American Roentgen Ray Society
Imaging Findings in Roux-en-O and Other Misconstructions: Rare but Serious Complications of Roux-en-Y Gastric Bypass Surgery
Myrosia T. Mitchell1,
Arunas E. Gasparaitis1 and
John C. Alverdy2
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.
Received July 12, 2007;
accepted after revision August 16, 2007.
Address correspondence to M. T. Mitchell
(myrosiam{at}gmail.com).
Abstract
OBJECTIVE. The purpose of this study was to present the clinical and
imaging findings of Roux-en-O and other misconstructions of Roux-en-Y gastric
bypass surgery. The more common complications of Roux-en-Y gastric bypass have
been described in the literature. Complications secondary to misconstructions
are rare and difficult to diagnose.
CONCLUSION. Roux-en-O or other misconstruction should be suspected
in patients with chronic bilious vomiting after Roux-en-Y gastric bypass when
no mechanical basis for obstruction can be identified. Fluoroscopic motility
assessment is often critical in the diagnosis of these misconstructions.
Keywords: complications • CT • fluoroscopy • gastric bypass surgery • gastrointestinal tract • misconstruction
Introduction
The prevalence of obesity has been steadily increasing since the 1950s
[1]. In the management of
morbid obesity, surgery has proved better than dieting and lifestyle
modifications. According to a National Institutes of Health Consensus
Conference in 1991, gastric bypass surgery is considered effective and
acceptable treatment [2]. For
weight reduction, the Roux-en-Y gastric bypass procedure is the most commonly
used surgical technique in North America
[3]. First described by
Wittgrove et al. [4] in 1994,
the operation involves construction of an approximately 20-mL gastric pouch
isolated from the distal portion of the stomach. The jejunum is transected
10–15 cm beyond the ligament of Treitz, and a 100-cm Roux-en-Y limb is
made and anastomosed to the gastric pouch
(Fig. 1). The more common
complications of Roux-en-Y gastric bypass have been described
[5,
6]. Complications secondary to
misconstruction are rare and difficult to diagnose
[7]. Misconstruction occurs
when the divided segments of small bowel are misidentified and anastomosed
incorrectly. We present our experience with a group of misconstructions we
have termed Roux-en-O misconstructions.
Materials and Methods
This study was conducted with institutional review board approval. A
retrospective review of our gastric bypass surgical patient database from 2002
to 2004 yielded the cases of four patients who had undergone Roux-en-Y gastric
bypass and had a preoperative diagnosis of Roux-en-O misconstruction. In three
patients, the diagnosis was suspected clinically because of the presence of
chronic bilious vomiting without radiologic evidence of mechanical common limb
obstruction. The fourth patient had chronic bilious vomiting with radiologic
evidence of complete bowel obstruction. In two cases, the diagnosis of
Rouxen-O misconstruction was confirmed at surgery; in the other two cases,
other types of misconstruction were identified. Clinical data were reviewed
for each patient.
Imaging evaluation consisted of fluoroscopic examination, CT, or both.
Fluoroscopic examinations were performed with either a remote radiofrequency
unit (D-340 Siregraph, Siemens Medical Solutions) or a conventional
radiofrequency unit (Sireskop SD, Siemens Medical Solutions). CT was performed
with one of two scanners (CTi helical, GE Healthcare; Brilliance, Philips
Medical Systems). Imaging findings were reviewed by two experienced
gastrointestinal attending radiologists (more than 10 years of experience
each) to confirm the accuracy of the original imaging interpretations. For
fluoroscopic examinations and for CT examinations, a consensus interpretation
was made regarding the surgical anatomic features, the loops delineated by
enteric contrast material, the presence or absence of bowel dilatation, and
any other pertinent pathologic findings. For fluoroscopic examinations, the
videotaped record of each study was reviewed in consensus for assessment of
bowel motility and evaluation of functional pathologic findings. There were no
discrepancies between the consensus retrospective interpretations and the
original radiology reports of these studies. The clinical data and imaging
findings were compared with the surgical findings.
Results
All four patients in this study had undergone surgery at hospitals other
than ours and had been transferred to our Center for the Surgical Management
of Obesity for management of chronic malnutrition and bilious vomiting. The
diagnosis of Roux-en-O misconstruction was not suspected before transfer. All
patients needed long periods of nutritional supplementation before undergoing
surgery for the misconstruction. During the 2002–2004 period,
approximately 400 Roux-en-Y gastric bypass operations had been performed at
our institution, and none of these operations was complicated by
misconstruction.
Disconnected Roux-en-O Miscontruction
A 52-year-old woman had undergone Roux-en-Y gastric bypass 3 months before
referral. Her postsurgical course had been complicated by vomiting and by
anastomotic dehiscence and leak, which were repaired 2 months after the
initial operation. The patient was referred to our facility because of
continued bilious vomiting. CT performed with IV and oral contrast media
showed the orally administered contrast agent opacifying dilated alimentary
and biliary limbs, contrast material reaching the excluded gastric lumen (Fig.
2A,
2B,
2C). The common limb and colon
were unopacified and gasless. Surgical exploration revealed a disconnected
Rouxen-O misconstruction (Fig.
3). The biliary limb had been incorrectly anastomosed to the
proximal gastric pouch, forming a Roux-en-O limb. The distal limb had been
reanastomosed to itself and was completely separated from the Roux-en-O limb.
The bilious vomiting resolved after surgical revision.
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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.
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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.
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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.
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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.
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Connected Roux-en-O
A 60-year-old man had undergone Rouxen-Y gastric bypass just over 1 year
before referral. He had a prolonged hospital stay because of multiple
postoperative complications, including anastomotic leak and septic shock. The
patient was referred to our facility for further management of the
complications, which included continued vomiting with oral and with
gastrojejunal tube feeding, necessitating total parenteral nutrition. We
suspected Roux-en-O misconstruction because the findings at multiple
endoscopic examinations showed bile in the alimentary Roux limb. Surgical
exploration was delayed nearly a year for management of the complications,
malnutrition, and newly detected rectal cancer.
During the management year, the patient underwent numerous imaging studies.
Every CT scan showed mild dilatation of the alimentary limb, but the distal
anastomosis, common limb, and colon appeared unremarkable
(Fig. 4A). An initial
fluoroscopic examination was performed 1 month after referral (not shown).
Contrast material was first administered through a gastric tube in the
excluded gastric segment. The scans showed a normal-caliber biliary limb with
normal antegrade peristaltic activity. Some angulation of loops was found near
the distal anastomosis, a finding compatible with nonobstructing adhesions.
Contrast material was then administered orally. The scans showed dilatation of
the alimentary limb tapering near the distal anastomosis but without a clear
cause. Peristalsis was considerably diminished but was thought to be overall
antegrade during that examination. Two subsequent fluoroscopic examinations of
the alimentary limb performed 4 and 10 months after referral had similar
anatomic findings, but the two studies had different motility findings (Figs.
4B,
4C,
4D,
4E). Oral contrast
administration showed abnormally diminished peristalsis in the alimentary limb
with antegrade passage by gravity only. A 15-minute delayed image was obtained
for one of the studies. The images showed retrograde passage of contrast
material to the gastric pouch. Abnormal retrograde peristaltic activity was
seen during the real-time examination.
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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.
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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.
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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.
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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).
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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).
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Surgical exploration revealed a connected type of Roux-en-O misconstruction
(Fig. 5). The biliary limb was
incorrectly anastomosed to the proximal gastric pouch. Unlike the findings in
the first patient, however, the Roux-en-O limb in this patient communicated
with the common limb. The bilious vomiting resolved after surgical
revision.
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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.
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Roux Limb Inversion
A 48-year-old woman had undergone Roux-en-Y gastric bypass approximately 7
months before referral. Chronic vomiting developed after surgery, and because
of this complication, the patient underwent four exploratory laparotomies at
hospitals other than ours. At the laparotomies, the patient successively
underwent cholecystectomy, revision of the Roux-en-Y gastric bypass,
jejunojejunostomy revision, and another anastomotic revision. She continued to
vomit bile despite ingesting nothing by mouth. She was referred to our
facility for further evaluation.
Initial fluoroscopic examination showed dilatation of the alimentary limb
with nondilated distal bowel but no definable cause at the transition point
(Fig. 6A). A radiographic
study 2 weeks later showed persistence of contrast material in the alimentary
limb (Fig. 6B). After bowel
preparation, another fluoroscopic study was performed with medium-density
barium administered through a gastric tube (Figs.
6C,
6D,
6E,
6F). This examination revealed
normal caliber of all small bowel segments and an unremarkable configuration
of the distal anastomosis with no evidence of mechanical obstruction. Motility
was abnormal, however, with preferential contrast flow into the alimentary
limb. Peristalsis within the alimentary limb was predominantly retrograde,
contrast material reaching the gastric pouch. A preoperative diagnosis of
Roux-en-O misconstruction was made.
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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.
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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.
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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.
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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).
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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.
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Surgical exploration revealed a limb inversion type of misconstruction
(Fig. 7A,
7B). It was determined that
during one of the revisions, a 150-cm Roux limb had been harvested in
isolation (both ends cut and separated from remaining small bowel) for use as
the alimentary limb. This Roux limb had a 180° twist in its mesentery, so
that when it was anastomosed to the stomach proximally and the common limb
distally, it was inverted and placed in an antiperistaltic orientation. The
entire limb was dilated with no evidence of mechanical obstruction. This
antiperistaltic orientation explains the proximal migration of bile over 150
cm to the gastric pouch, a distance too long for random migration. The
symptoms resolved after surgical revision of this faux O.
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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.
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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.
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Short Roux Limb
A 51-year-old woman had undergone Rouxen-Y gastric bypass approximately 1
year before referral. She did well for 6 months postoperatively, but then
presented with severe upper gastrointestinal bleeding due to an anastomotic
ulcer, for which the anastomosis was revised. After the revision, persistent
bilious vomiting and severe weight loss developed, and the patient was
referred to our facility.
Unenhanced CT performed as a localizing examination for an interventional
procedure showed normal-caliber bowel loops. Fluoroscopic examination with
contrast material administered through a gastric tube showed normal
peristaltic activity of the biliary limb but with preferential flow into the
alimentary limb rather than the common limb
(Fig. 8). Contrast material
ultimately refluxed proximally as far as the gastric pouch. Fluoroscopic
examination with an orally administered contrast agent showed a proximal
anastomotic stenosis that limited motility assessment of the pouch and the
immediately postanastomotic alimentary limb.
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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.
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Surgical exploration revealed an excessively short Roux limb, the
alimentary limb measuring only 25 cm from the proximal to the distal
anastomosis (Fig. 9). This
short length was believed to have allowed considerable bile reflux, causing an
anastomotic ulcer. Surgical revision of this faux O resulted in resolution of
the bile reflux and ulcers.
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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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Discussion
Gastric bypass surgery is becoming an increasingly popular option for
weight loss by morbidly obese patients. It is more effective than dieting for
substantial weight loss and for maintaining weight loss in this patient
population [2,
8]. Since its introduction in
1994, Roux-en-Y gastric bypass has become the most commonly used bariatric
procedure [3]. Anastomotic
stenoses and anastomotic leaks are the most common complications diagnosed
with imaging [5,
6]. These complications are
more likely to affect the proximal anastomosis and are usually easily
diagnosed with fluoroscopic examination. Less common complications include
abscess, bowel obstruction, hernia, and fistula
[7,
9].
Abscesses are well depicted with CT. Gastrogastric fistulas can be seen
with CT or fluoroscopic examination. Enterocutaneous fistulas are often late
complications of leaks and are also usually readily diagnosed with a
fluoroscopic examination. Ventral hernias are usually diagnosed with CT, and
internal hernias can be diagnosed with fluoroscopic examination or CT. All of
these complications can be identified on the basis of the presence of anatomic
distortion and discrete abnormalities visible on static images.
Misconstruction occurs when the divided segments of small bowel are
misidentified and anastomosed incorrectly. These complications are rare and
are difficult to diagnose because the orientation of bowel segments looks
completely normal on static images. Bowel dilatation is sometimes present but
is a nonspecific finding that can be caused by a variety of mechanical and
functional pathologic conditions. The diagnosis of misconstruction requires
careful monitoring of motility during fluoroscopy to identify the abnormal
peristaltic activity that characterizes these entities.
Roux-en-O misconstruction occurs when the proximal divided jejunum is
misidentified as the distal jejunum and is inadvertently anastomosed to the
gastric pouch instead of to the distal aspect of the jejunal Roux limb. This
misconstruction can occur in the primary operations or during surgical
revisions. Early postoperative foregut function may be normal with acceptable
tolerance of liquids and pureed foods. Chronic bilious vomiting is a
characteristic clinical presentation. Although bilious vomiting can occur with
any obstruction of the common limb, as in the case of the patient with a
disconnected Rouxen-O, the presence of this clinical symptom in the absence of
common limb obstruction should raise suspicion of misconstruction. Because of
the O-loop configuration of the misconstructed bowel, the normal peristaltic
activity of the loop directs the bilious duodenal succus into the alimentary
limb toward the gastric pouch and eventually causes bilious vomiting. Attempts
by the patient to eat distend the alimentary limb, further stimulating
retrograde peristalsis and exacerbating the bilious vomiting. Bowel dilatation
is variable. Fluoroscopic motility assessment should show preferential
diversion of biliary limb contents into the alimentary limb and retrograde
peristaltic activity of the alimentary limb. If not diagnosed early, Roux-en-O
misconstruction can lead to severe malnutrition because of the patient's
inability to keep food down.
Roux limb inversion usually occurs when the segments of small bowel are
transected at multiple points, resulting in a free segment that can be
anastomosed in an inverted antiperistaltic manner
[7,
10]. This problem is more
likely to occur during revision than in the primary surgical procedure. The
antiperistaltic orientation of the limb results in chronic vomiting and
intolerance of oral intake; feeding through a gastric tube in the excluded
stomach may be tolerated, however. Vomiting may be bilious, possibly because
of the proximity of this inverted segment to the distal anastomosis with the
biliary limb and the orientation of the distal anastomosis. The diagnosis can
be clinically difficult to make. On static images, this inverted alimentary
limb is often normal in caliber and appearance. Diagnosis depends on dynamic
fluoroscopic motility assessment. The antiperistaltic limb exhibits luminal
dilatation only after an adequate volume challenge of the lumen, at which
point dysfunctional retrograde peristalsis is stimulated and is
fluoroscopically apparent
[7].
Roux-en-Y gastric bypass operations can be performed with a short limb of
50–100 cm or a long limb of up to 150 cm
[11]. In patients with a body
mass index greater than 50, longer limb lengths are associated with greater
weight loss [12]. An
excessively short limb, as in the patient in whom the limb measured only 25
cm, can allow reflux of biliary contents to the level of the gastric pouch. In
our patient, this complication produced bile reflux gastritis and vomiting
that mimicked Roux-en-O misconstruction.
When gastric bypass patients present with obstructive symptoms,
consideration should be given to mechanical obstruction, dysmotility, and
misconstruction. Roux-en-O and other Roux-en-Y misconstructions should be
suspected in patients with chronic bilious vomiting after Roux-en-Y gastric
bypass in whom no mechanical basis for obstruction can be identified. The
diagnosis can remain elusive for many months after the initial procedure,
resulting in chronic malnutrition. Dynamic fluoroscopic assessment of bowel
motility is critical to the radiologic diagnosis of these entities. Imaging
findings can be misinterpreted if misconstruction is not considered.
Acknowledgments
We thank Lydia Johns, Department of Surgery, University of Chicago, for the
medical illustrations.
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Abstract
Introduction
