Postoperative State, Stomach and Duodenum



Postoperative State, Stomach and Duodenum


Michael P. Federle, MD, FACR









(Left) Graphic depicts an isoperistaltic Billroth 2 gastrojejunostomy. The afferent limb image, comprised of the duodenum and a variable length of jejunum, carries pancreaticobiliary secretions toward the stomach, while the efferent limb image carries fluid and food downstream. (Right) Graphic depicts an antiperistaltic Billroth 2 procedure, in which the afferent loop image 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 image. 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

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Jun 8, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Postoperative State, Stomach and Duodenum

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