komplikasi anastomose usus halus

AJR:185, September 2005 671

AJR 2005; 185:671–681

0361–803X/05/1853–671

© American Roentgen Ray Society

Sandrasegaran et al.Small-Bowel Complications of Gastrointestinal Surgery

G a s t ro i n t e s t i n a l I m ag i n g • P i c t o r i a l E s s ay

Small-Bowel Complications of Major Gastrointestinal Tract Surgery

Kumaresan Sandrasegaran1

Dean D. Maglinte1

John C. Lappas1

Thomas J. Howard2

Sandrasegaran K, Maglinte DD, Lappas JC, Howard TJ

Received June 4, 2004; accepted after revision December 8, 2004.

1Department of Radiology, Indiana University Medical Center, UH Suite 0279, 550 N. University Boulevard, Indianapolis, IN 46202. Address correspondence to K. Sandrasegaran ([email protected]).

2Department of Surgery, Indiana University Medical Center, Indianapolis, IN.

OBJECTIVE. Gastrointestinal complications of major abdominal surgery often require ra-diologic assessment. The purpose of this article is to review the expected imaging findings andcomplications after commonly performed gastric and pancreatic surgery.

CONCLUSION. It is important to understand the postsurgical anatomy to avoid misin-terpreting an expected postoperative finding as a complication. Postoperative complicationscan be categorized as being related to adhesions, anastomosis, an enteric connection, and ab-normal bowel position.

bdominal, pancreatic, and gastricsurgeons perform increasinglycomplex procedures. The radiol-ogist is faced with CT or upper

gastrointestinal contrast studies in which theanatomy is difficult to discern and there isuncertainty whether a finding is an expectedpostoperative change or relates to a compli-cation. We retrospectively reviewed 377cases of complex abdominal surgery per-formed by gastric and pancreatic surgeons atour affiliated institutions between January2002 and August 2003. This pictorial essayshows the expected anatomy after com-monly performed procedures and the rangeof complications that might be seen on im-aging studies. For ease of categorization,postoperative small-bowel complicationsare classified as related to anastomosis, anenteric connection, abnormal bowel posi-tion, or adhesions.

Whipple ProcedureWhipple surgery is the only curative proce-

dure for carcinoma of the head of pancreas(Fig. 1). The survival rate is approximately30% 5 years after resection [1] and less than1% for those who do not qualify for the pro-cedure. It is important to appreciate postoper-ative anatomy to prevent overdiagnosingcomplications.

There are several normally expected CTfindings after the Whipple procedure. One isan afferent loop that is fluid filled and edem-atous and shows bright contrast enhancementin the first two postoperative weeks. This

finding should not be mistaken for an is-chemic or inflamed bowel or for fluid collec-tion (Fig. 1). Another finding is reactive lym-phadenopathy of up to 1.5 cm, which mightbe mistaken for a recurrent tumor [2]. Thisoccurs in the first month after Whipple andother pancreatic surgery. Third is perivascu-lar cuffing, which is commonly seen 1–2months after surgery and should not be mis-taken for recurrent tumor if preoperativescans did not show this finding. The celiacand superior mesenteric arteries are most af-fected and the common hepatic artery, less af-fected. Fluid collection in the duodenal bed inthe first 3 weeks after surgery is an expectedfinding. Unless there are clinical signs of in-fection, these collections need not be drained;they tend to be transient. Pneumobilia is apermanent feature after hepaticojejunostomy.Periportal edema is seen in the first 2 postop-erative weeks.

Puestow ProcedureIn cases of severe chronic pancreatitis,

end-to-end pancreaticojejunal anastomosis,such as in the Whipple procedure, is insuffi-cient to drain the pancreas. The Puestow pro-cedure (Fig. 2), a side-to-side longitudinalpancreaticojejunostomy, drains the pancre-atic duct directly into a jejunum loop [3]. InPuestow’s original description of the tech-nique, the spleen and distal pancreas were re-moved. The Roux loop in the Puestow proce-dure may be mistaken for a peripancreaticfluid collection if the nature of surgery is notappreciated.

A

Sandrasegaran et al.

672 AJR:185, September 2005

Bariatric Roux-en-Y Gastric Bypass Procedure

In the United States, more than 30% ofadults are obese; 2–3% of men and 6–7% ofwomen are morbidly obese [4, 5]. The Roux-en-Y gastric bypass procedure is the goldstandard for bariatric surgery (Fig. 3). Openand laparoscopic Roux-en-Y bypass proce-dures are associated with a 5–20% incidenceof complications [6]. An upper gastrointesti-nal contrast series is usually performed on thefirst postoperative day to detect gastrojejunalleak or obstruction. Understanding the post-operative anatomy is important to preventoverdiagnosis of complications (Fig. 4).

ComplicationsAnastomotic Complications

Anastomotic complications are the mostsignificant bowel-related complications. Theyoccur as a result of ischemia or suboptimal sur-gical technique, including staple gun failure,and account for most of the morbidity and mor-tality from the Whipple, Puestow, and Roux-

en-Y procedures. Anastomotic leak is found inup to 27% of patients having laparoscopicRoux-en-Y gastric bypass and, in our experi-ence, it is the most common postoperativecomplication of the Puestow procedure.

Stenosis—Symptomatic anastomotic steno-sis at the gastrojejunostomy site is found inapproximately 3–5% of patients having Roux-en-Y gastric bypass surgery [7, 8]. The inci-dence is higher in patients having a laparo-scopic Roux-en-Y bypass than in those havingan open procedure. Upper gastrointestinal con-trast series show delayed passage of contrastmaterial. On CT, a spherical pouch or air–con-trast level is suggestive of this diagnosis. An-other type of obstruction to gastric emptying isstenosis of the Roux limb at the site of meso-colonic tunneling in the Roux-en-Y bypassprocedure. This is usually caused by excessivestapling at the site of the mesenteric defect.

Ulcers—Anastomotic ulcers after gastricbypass procedures are common, with an inci-dence of 12–16% [9, 10]. An upper gas-trointestinal double-contrast barium series

may show these ulcers; however, the method isreported to have a sensitivity of only 50% com-pared with endoscopy [11]. In our experience,most stomal ulcers are visualized with modernfluoroscopic units and an adequate volume(100–200 mL) of barium for oral contrast.

Leak and perforation—Anastomotic leakor perforation is the most serious complica-tion of Roux-en-Y gastric bypass surgery. Itoccurs in 3–5% of patients and is usuallycaused by staple gun failure. The incidenceof leakage can be reduced by manually sew-ing the gastrojejunostomy [12, 13]. Thecomplication is evident in the first postoper-ative week. Although upper gastrointestinalstudies may show this leak (Fig. 5), the im-ages may be of poor quality because of thepatient’s size. It is our practice to obtain aCT scan with IV and positive oral (dilute wa-ter-soluble) contrast in any patient who hasunexplained fever, pain, or persistent nau-sea. Some anastomotic leaks are compli-cated by an enteroenteric, enterovesical, orenterocutaneous fistula (Fig. 5).

A B

Fig. 1—Whipple procedure.A, 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 gastrojejunos-tomy/duodenojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. (Used with permission of Visual Media, Indianapolis, IN)B, 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 nor-mal distal small bowel (curved arrow). Note normal-sized mesenteric nodes and stent at site of pancreaticojejunostomy (arrowhead).

Small-Bowel Complications of Gastrointestinal Surgery


A B

Fig. 2—Puestow procedure.A, 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)B, 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).

A B

Fig. 3—Roux-en-Y gastric bypass procedure.A, 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 jejunoje-junostomy, shown by linear sutures. (Used with permission of Visual Media, Indianapolis, IN)B, 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.(Fig. 3 continues on next page)



Afferent loop obstruction—Afferent loopobstruction occurs in 0.3% cases after gastro-enterostomy [14], including Billroth II sur-gery and the Whipple procedure. In Billroth II

surgery, the afferent limb is the duodenum; inpancreatic surgery, the Roux segment is theafferent limb (Fig. 1). Possible causes of ob-struction are adhesions, internal hernia, anas-

tomotic stenosis, stomal ulcer, recurrent tu-mor, and obturation from bezoar. Chronicpartial afferent-loop obstruction is termed“afferent loop syndrome.” Diagnosis is possi-

C

Fig. 3 (continued)—Roux-en-Y gastric bypass procedure.C, 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.

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 .

A B

Fig. 5—Anastomotic leak in 29-year-old woman.A, 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.B, 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).



ble but difficult to make with an upper gas-trointestinal series (Fig. 6). CT is the mostuseful imaging technique for diagnosis.

Enteric ConnectionEnteric-related complications are rare and

result from improper anatomic connection ofbowel loops. They are distinct from anasto-mosis-related complications.

Blind pouch syndrome—Side-to-sideanastomosis performed in Roux-en-Y gastricbypass surgery and after intestinal resectioncan result in an enlarged aperistaltic loop ofthe small bowel (Fig. 7). This enlarged loop istermed “blind pouch.” The blind pouches do

not form until approximately 4 months aftersurgery. These structures do not usually in-crease significantly in size after 12 months.Although often an incidental finding, blindpouch can lead to malabsorption, gastrointes-tinal bleeding, and bowel perforation [15]. Ifsymptoms are ascribed to the pouch, thepouch can be laparoscopically removed.

Short gut syndrome—Malabsorption canbe caused by inadequate length of function-ing small bowel after widespread small-bowel resection, such as in Crohn’s disease.The minimal length of small bowel (exclud-ing the duodenum) required to cope withoutparenteral nutrition or small-bowel trans-

plantation is estimated to be 100 cm. Patientswith a longer small bowel may also have di-gestive problems if the integrity of residualmucosa is impaired or the distal ileum hasbeen resected. Short gut syndrome can besimulated by inadvertent surgery when theileum is mistaken for the jejunum and a gas-troileostomy rather than a gastrojejunos-tomy is created (Fig. 8). This complication iseasily depicted by an upper gastrointestinalcontrast series. CT examination may showmultiple loops of nondistended jejunum thatare not opacified with oral contrast, whilethere is oral contrast in the stomach, ileum,and right colon.

A B

C

Fig. 6—Afferent loop obstruction in 50-year-old man.A, 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.B, 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).C, 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.



Altered Bowel PositionBowel position is usually altered as a con-

sequence of major abdominal surgery. How-ever, small bowel may become trapped inundesirable positions postoperatively. Thistype of complication includes hernia andintussusceptions.

Transmesenteric internal hernia—Trans-mesenteric hernia can occur in any proce-dure, including liver transplantation and gas-tric bariatric surgery, in which a Roux loop isfashioned. Transmesenteric hernias are morecommon after laparoscopic bariatric surgerythan after open surgery [16]. Transmesenterichernias occur through the tear in the mesoco-lon through which the Roux loop is brought

during a retrocolic anastomosis (Fig. 9). Thereported incidence of internal hernia is about2.5% [7, 16], and it generally involves theRoux loop. Antecolic placement of the Rouxloop does not lead to transmesenteric herniabut is complicated by a Petersen-type internalhernia in rare cases.

An upper gastrointestinal barium seriescould show the degree and location of small-bowel obstruction (Fig. 9) but is less useful indetermining the cause of obstruction. Thefinding of dilated proximal jejunum that re-mains fixed in a high position on erect viewssuggests internal hernia. CT is more helpfulin differentiating transmesenteric hernia (Fig.10) from mesocolic tunnel stenosis, stenosis

at the jejunojejunostomy, or adhesion-relatedsimple bowel obstruction. Appendix 1 showsfindings that indicate transmesenteric hernia.

There are no reports of a high frequency ofother types of internal hernia after abdominalsurgery. During diagnosis, it is important todistinguish an internal hernia from adhesivesmall-bowel obstruction. The former gener-ally requires emergency surgery [17].

External hernia—External hernias are an-other complication of gastrointestinal surgery.Ventral hernia is a major source of morbidityafter any major abdominal procedure. It ismore common after open Roux-en-Y gastricbypass surgery (incidence of up to 17%) thanafter a laparoscopic Roux-en-Y procedure. A

A

Fig. 7—Blind pouch.A, Diagram of formation of blind pouch after side-to-side enteroenterostomy. Dotted black line shows anatomy before development of blind pouch. Arrows show direc-tion of peristalsis. The blind pouch is filled rather than emptied by peristalsis. (Used with permission of Visual Media, Indianapolis, IN)B and C, 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.

B C



Richter hernia can occur at the site of the trocarafter laparoscopic procedures [18]. Parastomaland lumbar are other external hernias com-monly associated with abdominal surgery.

Intussusception—Intussusception accountsfor 5% of small-bowel obstruction in adults[19] and is more common in postoperative pa-tients. Possible causes include the presence of

foreign material, such as sutures and feedingtubes, and hyperperistalsis of bowel that hasbeen extensively handled [20]. CT appear-ances of these have been described [21].

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.

A B

Fig. 9—Transmesenteric hernia.A, 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)B, 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.



AdhesionsAdhesions are the most common cause of

bowel obstruction after surgery. The adhesionscan be symptomatic and nonobstructive. Ad-hesive small-bowel obstruction is classified assimple, closed loop, or strangulating.

Symptomatic, Without Overt ObstructionMore than 90% of patients who have had

abdominal surgery have enteric adhesions,even if there is no clinical obstruction [22]. Weroutinely find CT features that suggest adhe-sions in postoperative patients who report ab-dominal bloating or pain (Fig. 11) (Appendix2). These patients do not have high-gradesmall-bowel obstruction but may have inter-mittent or low-grade small-bowel obstruction,for which CT has poor sensitivity [23].

Adhesive Small-Bowel ObstructionThe diagnosis of adhesion-related small-

bowel obstruction is presumed on CT ifthere is a narrow zone of transition withoutan identifiable obstructive lesion. At our in-stitution, low-grade and partial high-gradeobstructions are treated by enteric decom-pression in which a long tube is placed underfluoroscopic guidance. Although these pa-tients rarely require surgery, those with com-plete, closed-loop, or strangulating obstruc-tion require emergent surgery. CT findingsof closed-loop (Appendix 3) and strangulat-ing obstruction (Appendix 4) are shown inFigures 12 and 13, respectively [24, 25].

SummaryIn conclusion, knowledge of complex ab-

dominal surgery is useful in differentiatingpostoperative anatomy from complications.When dealing with postoperative small-bowel obstruction, the radiologist should beable to diagnose less common types of ob-struction, such as afferent-loop, closed-loop,and strangulating obstruction, as well as un-usual causes such as internal hernia. This dis-crimination may be important in planningtherapy because even high-grade partial ad-

hesive obstructions are usually treated con-servatively, while obstructions with an inter-nal hernia or closed loop require surgery.

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APPENDIX 1: CT Findings of Transmesenteric Hernia (Fig. 10)

• Cluster of dilated loops of bowel anterior to stomach or transversecolon

• Deviation, crowding, or engorgement of mesenteric vessels as theypass between stomach and transverse colon

• Downward displacement of transverse colon or hepatic flexure• Close proximity of distal obstructed loop to site of mesenteric ves-

sel abnormalities• Fluid distention of obstructed loop with paucity of air

A

B C

Fig. 10—Transmesenteric hernia in 47-year-old woman.A and B, Axial CT images show dilated jejunal loops anteriorly (large white arrows). Mesenteric vessels supplying these loops curve (small black arrows, A) through trans-verse 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).C, Coronal reconstruction in same patient shows distended efferent loops (black arrow) lying above and depressing transverse colon (white arrow).



APPENDIX 2: CT Findings Suggesting Presence of Adhesions (Fig. 11)

APPENDIX 3: CT Findings of Closed-Loop Obstruction (Fig. 12)

• Acute angulation of small-bowel loops• Traction deformities• Stretching of loops; air trapped in valvulae conniventes• Asymmetric thickening of small-bowel wall• Small-bowel loops closely applied to anterior peritoneum• Thickening of anterior peritoneum

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 adhe-sion lysis with improvement of symptoms. K = superior pole of transplanted kidney.

• Distended fluid-filled loops• C or U segment if axial CLO• Radial distribution of loops in more oblique CLO• Two ends of distended loop come together

• Proximal bowel less distended than closed loop• Distal bowel nondistendedNote—CLO = closed-loop obstruction.

A B

Fig. 12—Closed-loop obstruction in 50-year-old man.A and B, 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.(Fig. 12 continues on next page)



APPENDIX 4: CT Findings in Strangulated Obstruction of Small Bowel (Fig. 13)

C D

Fig. 12 (continued)—Closed loop obstruction in 50-year-old man.C, Sagittal reconstruc-tion allows better appre-ciation of proximity of ends of closed loop (arrowheads).D, Coronal reconstruc-tion shows radial pattern of closed loop (white arrows). Distended bowel in left flank con-taining oral contrast on images A and D (black arrows) is jejunum, which lies proximal to closed loop. There is moderate ascites.

• Early SignsWall thickeningAscitesMesenteric vessel engorgementTarget or halo appearance due to submucosal edema

• Advanced IschemiaMesenteric vessel blurringHemorrhagic ascitesMesenteric or portal venous gasPneumatosisEnhancement of bowel wall on venous phase of IV contrastReduced enhancement of bowel wall on arterial phase of

IV contrast

A B

Fig. 13—Strangulating obstruction.A, 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.B, 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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