Postoperative State, Stomach and Duodenum

Michael P. Federle, MD, FACR

Key Facts

Imaging

Billroth 1 (B1) procedure
- Antrectomy with gastroduodenostomy
Billroth 2 (B2) procedure
- Distal gastrectomy with gastrojejunostomy
Surgery for gastric cancer
- May be some variant of B1 or B2, up to total gastrectomy
Complications include recurrent tumor and acute or chronic sequelae of surgery
Recurrent or new carcinoma
- Local, lymph node, peritoneal, hematogenous
Bezoar formation
- Conforms to shape of stomach, traps air within
Anastomotic leak
- CT may detect indirect signs of leaks missed on UGI series (up to 50% of cases)
Duodenal stump leakage
- Loculated collection of fluid in subhepatic space
- Rarely diagnosed on UGI
Jejunogastric intussusception
- Rare complication of B2 procedure
Afferent loop syndrome
- Obstruction of afferent loop at or near anastomosis → dilation of duodenum

Diagnostic Checklist

Upper GI series is 1st-line test for detecting mechanical complications of gastric surgery
CT is optimal test for general surveillance for postoperative complications
PET/CT is optimal imaging test for surveillance of recurrent gastric carcinoma
Abscessogram may identify leak as source of infection

(Left) Graphic depicts an isoperistaltic Billroth 2 gastrojejunostomy. The afferent limb

, comprised of the duodenum and a variable length of jejunum, carries pancreaticobiliary secretions toward the stomach, while the efferent limb

carries fluid and food downstream. (Right) Graphic depicts an antiperistaltic Billroth 2 procedure, in which the afferent loop

enters the anastomosis from a left-to-right direction. This procedure is intended to reduce the prevalence of bile gastritis

(Left) Film from a small bowel follow through shows evidence of a prior Billroth 2 procedure and complete obstruction of antegrade flow of barium in the mid jejunum

. At surgery, a phytobezoar was removed, which corresponded to the shape and size of the gastric remnant. (Right) Film from an upper GI series shows evidence of a prior Billroth 1 procedure, along with persistent filling defects within the stomach that conform to the shape of the stomach, a bezoar.

IMAGING

General Features

Many or most fluoroscopic exams of esophagus, stomach, and duodenum are now performed for patients who have surgically altered anatomy
Some procedures are so common they are discussed separately
- Postoperative state, esophagus
  - Includes esophagectomy with gastric pull-through
- Fundoplication complications
- Bariatric surgery
Goal for evaluating remaining procedures
- Define expected postoperative anatomy
- Describe imaging approaches to evaluation of postoperative patients
- Describe imaging and clinical findings for various complications

Surgical Procedures

Billroth 1 (B1) procedure
- Antrectomy with gastroduodenostomy
- Polya variation: Entire excised end of gastric stump is used for anastomosis
- Hofmeister: Only a portion (usually greater curvature portion) is used
Billroth 2 (B2) procedure
- Distal gastrectomy with gastrojejunostomy
  - Stomach may be anastomosed to Roux limb or loop of jejunum
  - Anastomosis is side-to-side
  - Variable length of duodenum and jejunum forms proximal or afferent loop
    - Carries pancreaticobiliary secretions toward stomach
  - Distal or efferent loop carries food and fluid downstream
  - Isoperistaltic anastomosis (right-to-left)
    - Afferent limb 1st contacts lesser curve side of anastomosis; efferent limb contacts distal side
  - Antiperistaltic (left-to-right)
    - Opposite configuration
  - Duodenal stump is closed by sutures
    - Usually filled with gas bubble on postoperative CT
    - Located in subhepatic space
  - Anastomotic loop may be brought to gastric remnant in antecolic or retrocolic position
    - Antecolic: Results in longer afferent loop
    - Retrocolic: Shorter afferent loop; considered more “physiological” and usually preferred
Surgery for gastric cancer
- Varies according to site and size of tumor
- May be some variant of B1 or B2, up to total gastrectomy
  - Gastrectomy usually results in creation of esophagojejunal anastomosis
- Usually involves extensive denervation of stomach
  - Alters gastric and intestinal motility and absorption