Imaging of Bariatric Surgery

Summarized by: Sakib Kazi, M.D.

Reviewed by: Prasaanthan Gopee-Ramanan, M.D.

Original publication details

Authors: Marc S. Levine , Laura R. Carucci

DOI: https://doi.org/10.1148/radiol.13122520

Reference: Levine, M. S., & Carucci, L. R. (2014). Imaging of bariatric surgery: normal anatomy and postoperative complications. Radiology, 270(2), 327–341.

Laparoscopic Roux en Y Gastric Bypass

Surgical anatomy

Stomach: partitioned into gastric pouch and excluded component

Jejunum: divided 25-30cm distal to ligament of Treitz

Distal limb → Gastrojejunal anastamosis 

Proximal limb → anastomosed to small bowel

Normal imaging

Upper GI Exam

Gastric pouch appears as small structure (volume 15-20 mL)

Gastrojejunal anastomosis should be visualized to estimate diameter

Inferior connection → seen on frontal views

Anterior or posterior connection → seen on steep oblique or lateral views 

Contrast material should pass freely into the Roux limb

Contrast material should opacify the small bowel past the jejunojejunostomy

Follow head of column of contrast to detect staple line breakdown, leaks, or strictures

Retrocolic Roux limb may have a short segment of circumferential narrowing which is not a stricture

Abdominal CT

Perform with both oral and IV contrast

Follow Roux limb course to jejunojejunal anastamosis 

Excluded stomach, which is normally collapsed, should be visualized

Complications

  • Commonly involve gastrojejunal anastomosis

    Less common sites: gastric pouch, blind-ending jejunal stump, jejunojejunostomy

    Routine upper GI examinations with water-soluble contrast 1-2 days post-op to rule out leaks

    High-density barium can be used to detect subtle leaks

    Scout images

  • Upper GI exam findings → focal narrowing of the gastrojejunal anastomosis; thickened, irregular folds in the Roux limb abutting the anastomosis

    Obstruction → dilated gastric pouch, delayed emptying of barium into Roux limb

  • Barium study findings → appear as discrete ulcer niches at gastrojejunal anastomosis

  • Acute

    Barium study findings → thickened, spiculated folds or thumb printing secondary to submucosal edema and hemorrhage

    CT findings → thickened jejunal wall, edema of mesentery, engorged mesenteric vessels

    Chronic

    Barium study findings → tubular narrowing with smooth contour, tapered margins, effaced folds

    CT findings → jejunal narrowing, bowel wall thickening, mucosal stratification

  • Type A

    Dilated alimentary limb and decompressed biliopancreatic limb

    Barium study findings → dilated Roux limb obstructed at/above jejunojejunostomy

    Type B

    Dilated biliopancreatic limb in closed-loop obstruction.

    CT findings → dilated, fluid-filled excluded stomach and biliopancreatic limb with a collapsed Roux limb

    Type C

    Small bowel channel obstruction distal to the jejunojejunostomy with dilation of Roux limb and biliopancreatic limb

  • Barium study findings → small bowel limbs entering and exiting hernia with retention of barium within the loops

    CT findings → suspect when cluster of small bowel loops seen in atypical location, especially left upper quadrant

  • Upper GI study findings → assess head of barium column to determine whether barium has emptied via gastrojejunal anastomosis of via dehisced portion of staple line to enter excluded stomach

Laparoscopic Adjustable Gastric Banding

Surgical anatomy

Gastric pouch → Silicone gastric band placed around stomach 2cm below gastroesophageal junction

Normal imaging

Upper GI Exam

Perform with oral water-soluble contrast to locate band relative to stomach, assess caliber of lumen and evaluate post-op leaks

Scout Image

locate band

Abdominal CT

With both oral and IV contrast material

Band can be identified around proximal stomach

Assess tubing and adjacent tissues

Complications

  • Barium study findings → excessive narrowing of lumen where it traverses the band, dilation of proximal stomach, slow emptying of barium

  • Barium study findings → concentric dilation of gastric pouch, esophageal dilation above pouch, normal to widened stoma

  • Abdominal radiograph findings → increased separation between gastric band and medial aspect of left hemidiaphragm, air-fluid level may be present

  • Upper GI study findings → contained or free extraluminal gas or fluid collections in left upper quadrant

  • Barium study findings → twisting of prolapsed stomach around band, narrowing and high grade luminal obstruction

  • Upper GI study findings → passage of barium around intraluminal position of band

Laparoscopic Sleeve Gastrectomy

Surgical anatomy

Greater curvature of fundus, body, proximal antrum of stomach resected

Normal imaging

Upper GI Exam

Long tubular gastric pouch

Abdominal CT

Narrowed tubular stomach, staple line along greater curvature, mesenteric fat present at site of resected stomach

Complications

  • Most commonly at proximal end of staple line near gastroesophageal junction

    Upper GI examination findings → extravasation of water-soluble contrast

    High-density barium to rule out subtle leaks

  • Barium study findings → focal strictures, narrowing with delayed barium emptying

  • Barium study findings → widening of gastric sleeve

Original paper

Citation


Levine, M. S., & Carucci, L. R. (2014). Imaging of bariatric surgery: normal anatomy and postoperative complications. Radiology, 270(2), 327–341.