Early postoperative imaging after non-bariatric gastric resection: a primer for radiologists
Early postoperative imaging after non-bariatric gastric resection: a primer for radiologists
Massimo Tonolini 0
Elena Bracchi 0
0 Department of Radiology, BLuigi Sacco
1 University Hospital , Via G.B. Grassi 74, 20157 Milan , Italy
Surgical resection represents the mainstay treatment and only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Furthermore, other tumours and selected cases of nonmalignant disorders of the stomach may require partial or total gastrectomy. Often performed in elderly patients, gastric resection remains a challenging procedure, with significant morbidity (14-43% complication rate) and non-negligible postoperative mortality (approximately 3%). This paper provides an overview of contemporary surgical techniques for non-bariatric gastric resection, reviews and illustrates the expected postoperative imaging appearances, common and unusual complications after partial and total gastrectomy. Albeit cumbersome or unfeasible in severely ill or uncooperative patients, contrast fluoroscopy remains useful to rapidly check for anastomotic patency and integrity. Currently, emphasis is placed on multidetector CT, which comprehensively visualizes the surgically altered anatomy and consistently detects complications such as anastomotic leaks and fistulas, duodenal stump leakage, afferent loop syndrome, haemorrhages, pancreatic fistulas and portomesenteric venous thrombosis. Our aim is to help radiologists become familiar with early postoperative imaging, in order to understand the surgically altered anatomy and to differentiate between expected imaging
Gastrectomy; Complications; Anastomotic leakage; Contrast fluoroscopy; Computed tomography (CT)
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appearances and abnormal changes heralding iatrogenic
complications, thus providing a consistent basis for
correct choice between conservative, interventional or
surgical treatment.
Teaching points
Radical gastrectomy is associated with frequent
postoperative morbidity and non-negligible mortality.
In cooperative patients fluoroscopy allows checking for
anastomotic patency and leaks.
Multidetector CT with / without oral contrast
comprehensively visualizes the operated abdomen.
Awareness of surgically altered anatomy and expected
postoperative appearances is warranted.
Main complications include anastomotic and duodenal
leaks, haemorrhages and pancreatic fistulas.
Worldwide, gastric carcinoma (GC) represents one of
the leading cancers and accounts for over 900,000 new
cases and 723,000 deaths yearly [1]. GC shows
dramatic geographic variation, with the highest incidence in
China and Japan, parts of South America, Eastern
Europe and Russia. Conversely, in North America and
Europe this lethal disease has significantly declined
because of improved nutrition, food refrigeration,
eradication of Helicobacter pylori infection, decreasing tobacco
use and alcohol intake. Whereas in the far East early
GC detection through screening programs generally
allows curative treatment, in the rest of the world most
Fig. 1 Schematic representations of post-surgical anatomy: A) after total
gastrectomy with Roux-en-Y esophago-jejunostomy (EJS),
jejunojejunostomy (JJS) and blind-ending duodenal stump (d); alternative
technique with pouch (P) creation. Alimentary flow indicated by brown
GCs are diagnosed at an advanced stage, resulting in
dismal prognosis (27% 5-year survival rate) [1].
Resection with negative surgical margins represents
the mainstay treatment and only potentially curative
option for localized GCs, combined with adjuvant
chemotherapy or chemo-radiotherapy for disease stages IB and
higher. Radical gastrectomy remains a challenging
surgical procedure with significant postoperative morbidity
(14–43% complication rate) and mortality (0.8–12%,
mean 3%) [2–6].
Traditionally, early post- gastrectomy imaging was
limited to contrast fluoroscopy (CF) to assess
anastomotic patency and integrity. More recently, multidetector
CT is increasingly adopted to investigate most
postoperative abdominal conditions, to comprehensively
visualize the surgically altered anatomy and detect
iatrogenic complications. However, compared to the literature
about bariatric surgery imaging [7–9], few reports
describe CT techniques and expected and abnormal
appearances shortly after radical gastrectomy [10–12].
This paper provides an overview of contemporary
surgical techniques, reviews and illustrates the expected
postoperative imaging findings and complications after
partial and total gastrectomy, aiming to provide
radiologists with an increased familiarity in the interpretation of
early post-gastrectomy CT studies and, ultimately, to limit
iatrogenic morbidity.
Overview of gastrectomy techniques
Surgical exploration and aggressive resection of GC
with curative intent is undertaken unless medical
contraindications exist or preoperative imaging shows
metastatic spread or major vascular invasion. Surgical
approaches depend on tumour site and extension: tumours
arrow, bile flow in dark green. B) after subtotal gastrectomy with
smallsized gastric remnant (gr) connected to Roux-en-Y gastrojejunostomy
(GJS). C) after partial gastrectomy reconstructed with a Billroth II GJS
of the cardia, proximal and mid-body stomach require
total gastrectomy with removal of the entire stomach
along with terminal oesophagus and proximal
duodenum. Conversely, GCs of the distal body and antrum
may be treated by partial gastrectomy, with stapling
Fig. 2 In a 39-year-old male with endoscopic and bioptic diagnosis of
stomach adenocarcinoma, preoperative staging CT with oral water
distension (A) showed marked solid, enhancing mural thickening from
the gastric fundus along the greater curvature (thick arrow). On the fifth
postoperative day (POD) after uncomplicated total gastrectomy with
lymphadenectomy and splenectomy, contrast fluoroscopy (CF, B)
showed normally patent, thin EJS (arrowhead) with opacification of
jejunal limb and no anastomotic contrast medium leakage.
Corresponding expected postsurgical contrast-enhanced CT (C, D)
appearances at hospital discharge included stapled EJS (arrowheads)
without peri-anastomotic air or fluid, absent spleen without collections
in the surgical site
and division of the stomach at least 6 cm from any
macroscopic tumour [2–5, 13].
Radical gastrectomy is completed with splenectomy
and partial pancreatectomy in 17.5% and 7.1% of
patients, respectively. The extent of lymphadenectomy
remains controversial: compared to standard nodal
dissection of perigastric nodes along the lesser and greater
curvature, D2 lymphadenectomy is extended along the
celiac axis, left gastric, common hepatic and splenic
arteries. Gastric resection is sometimes performed to
treat uncommon stomach malignancies (gastrointestinal
stromal tumours, lymphomas or sarcomas) and selected
benign conditions such as refractory peptic ulcers. Very
recently, oncologic gastric surgery has also been
performed using laparoscopy, resulting in decreased
intraoperative blood loss and shorter hospital stays [2–5, 14,
15].
Following gastrectomy, the choice of digestive tract
anatomic reconstruction depends on the extent of resection. Most
total gastrectomies are reconstructed with Roux-en-Y
esophagojejunostomy (EJS), in which a jejunal limb is
brought up and re-anastomosed to the distal oesophagus and
to the closed duodenal stump (DS) (Fig. 1a). Whereas in
Fig. 4 In a 62-year-old male, CF performed five days after
uncomplicated partial gastrectomy showed opacified, moderately dilated
remnant stomach, slow transit of iodinated contrast through the GJS
(arrowheads) and opacified Roux-en-Y anastomotic recess (*)
Bhigh^ subtotal gastrectomy the small-sized gastric
remnant is connected to a Roux-en-Y gastrojejunostomy
(GJS) (Fig. 1b), Blow^ partial gastrectomy with
preservation of the gastric fundus may be reconstructed using a
Billroth II GJS (Fig. 1c) technique, with DS directly
connected to the remnant stomach. According to the
surgeon’s preference, anastomoses may be either hand-sewn
or stapled [5, 13, 16].
Fig. 3 In a 74-year-old male, preoperative CT (A) depicted a stricturing
carcinoma of the gastric body (thick arrow). Six days after uncomplicated
total gastrectomy with lymphadenectomy and splenectomy, CF (B)
visualized normally patent EJS (arrowhead) with a seemingly
extraluminal contrast medium accumulation (*) which corresponded to
anastomotic recess of the Roux-en-Y EJS at surgical correlation, a finding
which potentially mimics leakage if technical details are not known.
Corresponding expected postsurgical CT changes including air-filled
anastomotic recess (*), non-stapled EJS (arrowheads) with unremarkable
perianastomotic fat planes, no abnormal collections in the splenectomy
site
Fig. 5 A 63-year-old male underwent partial gastrectomy with Billroth II
reconstruction to relieve a large, non-malignant pyloric ulcer refractory to
medical therapy. Early postsurgical CF (A) showed mildly delayed transit
of iodinated contrast through the GJS (arrowhead), with fluid level in the
gastric remnant. Corresponding CT (B-D) appearances before discharge
included dilated remnant stomach (+) with ingested material, surgical
staples at the gastric resection site (arrow in B), expected imaging
appearance of the duodenal stump (DS, thin arrows in C, D) indicated
by a single metallic staple, without surrounding fluid or collections
Fig. 6 A 78-year-old male with antral gastric cancer underwent subtotal
gastrectomy with D2 lymphadenectomy and Billroth II reconstruction
and suffered from postoperative vomiting and fever. On 5th POD CF
(A) showed limited, slow transit through the GJS (arrowhead). On 9th
POD, unenhanced (B) and post-contrast (C-E) CT showed stapled gastric
What to expect after radical gastrectomy
The likelihood of postoperative morbidity is strongly
influenced by extended operation time, which acts as a
surrogate of challenging surgical manoeuvres. No
significant differences in complication rates exist with regard
to resection extension between total, proximal or distal
gastrectomy. Compared to open surgery, laparoscopic
and laparoscopic-assisted techniques are not associated
with significantly different morbidity, particularly
concerning pulmonary complications, anastomotic
leakage and intra-abdominal abscesses. Conversely,
splenectomy and pancreatectomy represent risk factors for
additional morbidity [2–5, 14, 15]. The effect of extended
lymphadenectomy remains controversial: several studies
showed that D2 nodal dissection is associated with
higher postoperative morbidity, reoperation rates and
mortality, specifically with increased likelihood of
pulmonary complications, wound infection, failed
anastomosis and pancreatic disorders [17, 18].
Similarly to other major abdominal surgeries,
respiratory problems including pleural effusion, atelectasis and
pneumonia commonly occur after oncologic gastrectomy,
resection site (arrows) and GJS (arrowheads), minimally dilated remnant
stomach (+), and a fluid collection (* in E) abutting the DS (thin arrow)
consistent with DS leakage, which was successfully managed
conservatively but required prolonged hospitalization
particularly in elderly men with chronic obstructive lung
disease [4, 19].
The most important specific post-gastrectomy
complications include anastomotic and DS leakage, pancreatic
fistula, acute pancreatitis and intra-abdominal
haemorrhage, and ultimately require reintervention in 25% of
cases, particularly because of leakage, abscesses and
bleeding. Anastomotic complications are most feared
and account for most of septic morbidity and mortality
[2–6, 20].
The commonest manifestations of intra-abdominal
complications include physical and laboratory
(leukocytosis, increasing C-reactive protein levels) signs of
sepsis within the first 7 to 10 postoperative days (PODs).
Bleeding is generally heralded by hypotension, dropping
haematocrit, blood from nasogastric or drainage tubes.
Most surgeons increasingly feel that abdominal pain and
physical findings are relatively insensitive and
increasingly rely on early postoperative imaging. When
discussing indication and timing of post-surgical studies,
asking the surgeon to draw the reconstructed anatomy
generally proves helpful to interpret fluoroscopic and
CT appearances [4, 21].
Fig. 7 A 76-year-old male with stricturing antro-pyloric carcinoma (thick
arrow) as preoperatively depicted by CT (A) underwent subtotal gastrectomy
with Roux-en-Y reconstruction. Early postoperative CF (B) showed little or
no transit through the GJS (arrowhead). On 8th POD during postoperative
sepsis, contrast-enhanced CT (C, D) showed normal stapled DS (thin arrows),
minimal fluid (*) in the cholecystectomy site. The patient then improved on
conservative therapy including gastric intubation. Subsequent endoscopy
showed ischaemic ulceration of the GJS. Repeated CT (E, F) three months
later showed circumferential mural thickening of the GJS (arrowheads) and
perianastomotic nodule (+) consistent with tumour recurrence
Fig. 8 In a 69-year-old woman with advanced carcinoma of the gastric
body, palliative total gastrectomy was performed. Five days after surgery,
CF (A) showed patent EJS with opacification of extensive anastomotic
leakage (*). A few days later, on conservative management,
contrastenhanced CT (B-D) showed bilateral pleural effusions and atelectasis
(B), patent EJS (arrowheads) and persistent leak (*)
Early post-gastrectomy imaging: techniques
and normal appearances
Fluoroscopic examination after oral administration of
watersoluble CM has been largely adopted to check for possible
anastomotic leakage. Albeit several institutions routinely
perform CF within five PODs, testing of anastomosis should
currently be obviated in asymptomatic patients [22, 23].
According to radiologist’s preference, either low-osmolar
iodinated CM or diatrizoate meglumine may be used, but the
latter is hyperosmolar and may induce pulmonary oedema if
aspirated [24, 25].
Rapid sequences in frontal and oblique views are
acquired during ingestion or sipping of CM via a straw,
with the patient standing or sitting on the fluoroscopy
table: unfortunately, CF is very cumbersome when the
recently operated patient is unable to cooperate or
cannot swallow [24]. Compared to the EJS, which is
generally recognized at the level or immediately below the
diaphragmatic hiatus (Figs. 2 and 3), the position of a
GJS is more variable and requires higher degrees of
left- or right-sided patient rotation (Figs. 4, 5 and 6).
Checklist for interpretation of early post-gastrectomy CT
Report pleuropulmonary changes at lung bases
Quantify free intraperitoneal air and/or fluid
Atelectasis, pneumonia, pleural effusion (see Fig. 8) or empyema (Fig. 14)
Discussion in text; see Fig. 10
Identify stapled or hand-sewn Gastric remnant generally indicated by staple line
- esophagojejunostomy (EJS) after total gastrectomy (Figs. 2 and 3) Efferent jejunal limb from EJS or GJS characterized by valvulae conniventes
- gastrojejunostomy (GJS) after partial gastrectomy (Figs. 5 and 6) and tubular configuration on coronal viewing
- look for localized air, fluid or haemorrhagic collections
adjacent to either EJS or GJS (Figs.11 and 12)
Identify the closed duodenal stump (DS)
- assess dilatation (Fig. 15)
- look for adjacent collections (Figs. 6 and 9)
Report presence and site of drainage tubes
DS generally recognized by a metallic staple at its blind end (Figs. 5, 6, 7 and 9)
Assess post-splenectomy or post-pancreatectomy status
Assess patency of splenic, portal and mesenteric veins
Exclude retained foreign bodies
If performed (see Figs. 2, 3 and 11)
For postoperative thrombosis, favoured by intra-abdominal sepsis
E.g. surgical sponges (indicated by thin hyperattenuating structures), bioabsorbable
haemostatic materials agents such as Gelfoam or Surgicel (which appear as
walled heterogeneous masses with internal Bmottled^ gas bubbles)
For abscess collections suggesting wound infection
After uncomplicated partial gastrectomy, delayed CM
passage through the GJS, incomplete emptying and fluid-fluid
level in the gastric remnant are fairly common, most usually
self-limiting and secondary to ileus or anastomotic oedema,
and generally do not represent a complication (Fig. 4);
however, in our experience anastomotic ulceration may have a
Fig. 9 An 81-year-old male with T3 N2 cancer of the lesser gastric curvature
(thick arrow) as preoperatively depicted by CT with oral water distension (A)
underwent total gastrectomy with Roux-en-Y reconstruction. On 9th POD CT
was performed because of bile from drainage: unenhanced (B) and post
contrast (C-F) scans with oral contrast showed normally opacified and patent
EJS (arrowheads) without evidence of anastomotic leak (note tip of surgical
drainage abutting the EJS in C). Abutting the stapled DS (thin arrows) a
non-capsulated fluid collection (*) corresponded to DS leakage which was
conservatively managed
similar appearance and may ultimately result in stricture
(Fig. 7) [5].
Albeit perianastomotic extravasation (Fig. 8) is nearly
100% specific for leakage, a pitfall of CF is represented
by misinterpretation of the anastomotic recess of an
endto-side reconstruction as extraluminal CM (Figs. 3 and 4)
[12].
Early post-gastrectomy CT
Fig. 10 A 77-year-old female with distal gastric carcinoma underwent
partial gastrectomy. Early postoperative CF (A) showed slow emptying of
gastric remnant through the GJS (arrowhead), without appreciable
extraluminal leaks. Six days later, the patient suffered from high fever:
contrast-enhanced CT (B-C) showed dilated remnant stomach (+),
absence of collections adjacent to the GJS (arrowheads in C and D), but
persistent intraperitoneal air and fluid consistent with peritonitis,
confirmed at surgical exploration: after redo anastomosis, the final status
of GJS (arrowhead) is shown in D
Anastomotic complications
Leakage resulting from breakdown of a suture line
secondary to either inadequate technique, excessive tension
or ischaemia, occurs after 3–4% of gastrectomies with
either hand-sewn and stapled anastomosis, generally as
an early complication within the first PODs;. Incidence
of leakage may reach 21% with routine use of CT.
Albeit variably symptomatic, anastomotic dehiscence
represents an independent predictor of survival with
10–20% associated mortality [2–4].
The fluoroscopic hallmark of anastomotic leak is
represented by CM extravasation adjacent to a GJS or EJS
(Fig. 8), with either contained collection or free
dispersal in the adjacent surgical cavity. However, since the
reported sensitivity varies in the range 22% to 67%,
negative CF findings do not rule out the possibility of
leakage (Fig. 10) [22].
As discussed above, the use of CT is favoured over CF in
uncooperative patients. Even without oral CM, CT is felt to be
superior to CF with 89.5% positive predictive value compared
to 40%, mostly because CT shows both the anastomosis and
Fig. 11 A 68-year-old male with recurrent gastric carcinoma on previous
Billroth II gastrectomy for peptic ulcer was treated with total gastrectomy.
Postoperative anemization required blood transfusions. On 12th POD,
contrast-enhanced CT (A, B) showed persistent intraperitoneal air, a
mixed attenuation collection (*) adjacent to the EJS (arrowheads),
consistent with anastomotic dehiscence, a subacute blood collection (+)
in the site of splenectomy. After percutaneous drainage, AL was treated
with positioning of a metallic stent (C) through the EJS. Persistent
leakage of oral iodinated contrast (*) at follow-up CF (D, E) led to
removal of the stent and positioning of a self-expanding stent (F)
the surrounding extraluminal compartment. On CT images the
EJS or GJS should be carefully scrutinized for focal
discontinuity and mural thickening. Since anastomotic dehiscence
leads to the extravasation of enteral material in the surgical
site, the most common appearance includes variably sized
airfluid collections, abscesses or inflammatory changes which
abut the EJS or GJS (Figs. 11 and 12) and tend to extend into
the lesser sac, left subphrenic, gastrohepatic and gastrosplenic
spaces [10–12].
Alternatively, anastomotic leak may sometimes appear
as generalized peritonitis with free fluid and
intraperitoneal air (Fig. 10). Suspicious findings which support a
diagnosis of visceral perforation over residual
postoperative air in the peritoneal cavity include persistence or
increase of pneumoperitoneum, particularly if abundant
(over 20 cm3) and occupying a single compartment. It
has been reported that persistent air after POD 5
associated with leukocytosis has 80% sensitivity for
identifying patients requiring re-operation [26, 27].
Albeit plain CT without enteral CM is rapidly
performed even in critically ill patients, according to some
reports positive oral CM improves the CT performance:
leakage is heralded by extraluminal CM collecting
nearby the EJS or GJS, or dissecting in the postoperative
neocompartment (Figs. 8 and 13) [10–12, 22, 23].
In the past, diagnosis of anastomotic dehiscence
warranted immediate surgical re-exploration with toilette,
closure of leakage or redo anastomosis, placement of
drainage tubes and enteral feeding. More recently, in
stable patients with contained leaks and no peritonitis,
non-operative management is increasingly considered:
endoscopic stenting (Fig. 11) is becoming the preferred
solution, and other options include endoscopic clipping
(Fig. 14) and percutaneous drainage of fluid collections.
Reoperation is currently reserved for wide dehiscence,
peritonitis or failure of nonoperative management [4,
12, 23].
Well-known to radiologists, fistulas represent abnormal
communications between the stomach and other
structures such as the skin, bronchial tree or pleural cavity,
which allow passage of enteral fluids. After
gastrectomy, subphrenic infection secondary to anastomotic leak
may occasionally be complicated by formation of
Fig. 12 An 81-year-old male with advanced, obstructing antral cancer
(thick arrow) as preoperatively depicted by CT (A) underwent palliative
partial gastrectomy with Roux-en-Y reconstruction. During prolonged
hospitalization the patient experience anemization and failure to thrive.
Early CF (not shown) showed slow transit through EJS. On 11th POD,
contrast-enhanced CT (B-D) showed some ingested materials in the
remnant stomach (+), stapled EJS (arrowheads), some residual
intraperitoneal air and fluid, inhomogeneous hypoattenuation of the 3rd
liver segment consistent with parenchymal infection
gastro-cutaneous, gastro-bronchial or gastro-pleural
(Fig. 14) fistulas, which represent rare occurrences
described in sparse case reports. Albeit CF studies may
show abnormal passage of CM through the fistula, CT
more effectively depicts associated changes and
consequences such as subphrenic abscess, pneumonia or
empyema (Fig. 14) [10, 11].
Anastomotic ulcers and strictures
Anastomotic ulcers may develop after gastrectomy, but are
unreliably depicted by imaging compared to endoscopy.
Ulcers plus ischemia and scar formation may ultimately lead
to the formation of an anastomotic stricture at the GJS (Fig. 7).
Anastomotic strictures develop in up to 3–4.4% of operated
patients, generally present weeks or months after surgery and
manifest with nausea, vomiting, dysphagia or post-prandial
pain [3].
Duodenal stump complications
The uncommon afferent loop syndrome generally occurs after
Billroth II reconstruction from obstruction of the afferent blind
DS by adhesions, internal hernia, intraluminal blood or
bezoar, anastomotic kinking, ulcer or stricture, and is heralded
by fluid-filled duodenal dilatation (Fig. 15) [10, 11].
Duodenal stump leakage
A potentially worrisome (6–11.7% mortality) complication of
Billroth II reconstruction, DS leakage occurs after 3% of
partial gastrectomies and corresponds to the spread of bile from
the blind-ending DS because of technical failure, ischemia or
distal obstruction, causing local and ultimately peritoneal
irritation [28]. Usual CT appearance includes a fluid collection
abutting the stapled DS and extending to the right sub-hepatic
or peripancreatic spaces (Figs. 6 and 9) [10, 11].
Currently, conservative treatment (parenteral nutrition,
antibiotics, octreotide, suction drains and percutaneous
drainage of abscesses) is successful in over 90% of cases;
Fig. 13 In a 76-year-old woman with T4 N2 gastric cancer, three days
after total gastrectomy unenhanced CT (A) showed minimal residual
pneumoperitoneum and extensive air (*) surrounding the EJS
(arrowheads). Repeated unenhanced CT with oral contrast
administration (B, C) showed patent EJS (arrowheads) and confirmed
circumferential anastomotic leakage (*), which was initially managed
conservatively but ultimately required reintervention with redo
anastomosis six days later because of failed clinical improvement and
progressive anemization
Fig. 14 A 59-year-old male with cardial carcinoma underwent total
gastrectomy. Early postoperative CF (A) showed patent EJS
(arrowhead) with perianastomotic contrast leakage (*) directed medially.
Bilateral pleural drainages were positioned to relieve minimal right
pneumothorax and left hydropneumothorax (B). On 10th POD
contrastenhanced CT with oral contrast (C, D) confirmed ample left-sided
hydropneumothorax with enhancing pleural surface. Extraluminal
contrast leakage (*) was seen both medially to the EJS (arrowheads)
and dependent in the left pleural empyema. Repeated CT obtained in
the right lateral decubitus position (E) before CT-guided pleural drainage
confirmed anastomotic fistula from the EJS (arrowhead) to the
hydropneumothorax, which was treated by endoscopic clipping
(arrowhead in F); note pleural pigtail drainage
reoperation is reserved for septic patients or failure of
conservative approach [4, 28].
Blood loss after gastrectomy may represent a
lifethreatening complication and generally results from
inadequate haemostasis, particularly ligation of small
feeding vessels. As it occurs at a staple line or
anastomosis, early postoperative haemorrhage is most usually
intraluminal rather than in the surgical site or peritoneal
cavity. Conversely, delayed bleeding is mostly due to
marginal anastomotic ulcers. CT findings include
intraluminal high-attenuation blood or clots in the bowel
(Fig. 15), sometimes extravascular CM Bblush^
corresponding to active bleeding. The latter sign and
endoscopically occult haemorrhage represent indications for
Fig. 15 A 72-year-old female with distal gastric carcinoma (thick arrow)
as preoperatively depicted by CT (A) underwent total gastrectomy. On
6th POD the patient suffered from persistent abdominal pain and
anemization. Postoperative CT (B-D) showed dilated fluid-filled
duodenum (+) up to stapled DS, consistent with afferent limb syndrome,
secondary to a large blood clot in the jejunum which was best seen as a
hyperattenuating intraluminal mass (*) on precontrast (D) scans. Surgical
reintervention was required to relieve obstruction
transarterial embolisation, particularly in patients unfit
for surgical reintervention [4, 29].
Pancreatic fistula and pancreatitis
Occurring after 7.6% of all gastrectomies, postoperative
pancreatic fistula corresponds to leaking pancreatic
secretions and develops secondary to resection or injury to
the pancreatic capsule. Fatty pancreas and pancreas
divisum are the key risk factors. The clinical and
laboratory diagnosis requires any measurable output from
peripancreatic drainage on or after POD 3 with amylase
content over three times the serum amylase;
alternatively pancreatic fistula is diagnosed at percutaneous
drainage or surgical reintervention [4, 30].
At CT, the usual appearance is a focal fluid collection in the
surgical bed, particularly in the lesser sac or adjacent to the
pancreas (Fig. 16). Currently, postoperative pancreatic
fistula is effectively managed nonsurgically until closure
with parenteral nutrition and percutaneous drainage of
dominant collections [31–33].
Alternatively, acute postoperative pancreatitis may
develop in the gland remnant after partial pancreatectomy,
and appears as segmental or diffuse enlargement with
Fig. 16 An 84-year-old male with lesser sac and pancreatic abscess (* in
A, B) from retroperitoneal perforation of pyloric peptic ulcer
(arrowheads) underwent emergency surgery, including subtotal
gastrectomy with Billroth II reconstruction. Note pancreatic parenchyma
(+), oedematous thickening of pylorus submucosa (thick arrows). On 7th
POD surgical revision was required due to DS biliary leakage, with
positioning of Kehr tube. Subsequently, on 20th POD follow-up CT (C,
D) showed minimal fluid adjacent to the drainage tube, consistent with
laboratory diagnosis of postoperative pancreatic fistula
peripancreatic inflammatory changes and fluid collections
extending to the retroperitoneal fasciae and the anterior
pararenal space [4].
Albeit CF may still be used as first-line imaging, multidetector
CT after radical gastrectomy increasingly allows
comprehensive visualization of the operated abdominal compartment and
provides a consistent basis for correct choice between
conservative, interventional or surgical treatment. In our experience,
early post-gastrectomy CT benefits from oral CM
administration if permitted by the patient’s conditions and cooperation.
Understanding the surgically altered anatomy and knowledge
of expected postoperative appearances is crucial to correctly
recognizing complications.
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