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.


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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