Imaging the operated colon using water-enema multidetector CT, with emphasis on surgical anastomoses

Insights into Imaging, Apr 2018

Massimo Tonolini, Sonia Ippolito

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Imaging the operated colon using water-enema multidetector CT, with emphasis on surgical anastomoses

Imaging the operated colon using water-enema multidetector CT, with emphasis on surgical anastomoses Massimo Tonolini 0 1 Sonia Ippolito 0 1 0 Department of Radiology, BLuigi Sacco 1 Massimo Tonolini 2 University Hospital , Via G.B. Grassi 74, 20157 Milan , Italy Water-enema multidetector CT (WE-MDCT) provides a detailed multiplanar visualisation of mural, intra- and extraluminal abnormalities of the large bowel, relying on preliminary bowel cleansing, retrograde luminal distension, pharmacological hypotonisation and intravenous contrast enhancement. In patients with a history of colorectal surgery for either carcinoma or Crohn's disease (CD), WE-MDCT may also be performed via a colostomy, which allows depicting the anatomy and position of the residual large bowel and evaluates the calibre, length, mural and extraluminal features of luminal strictures. Therefore, WEMDCT may prove useful as a complementary technique after incomplete or inconclusive colonoscopy to assess features and suspected abnormalities of the surgical anastomosis, particularly when endoscopic or surgical interventions are being planned. This pictorial essay presents the WE-MDCT technique and pitfalls, the expected appearances after different colic surgeries and the imaging features of benign anastomotic disorders (fibrotic stricture, kinking, inflammatory ulcer) and of locally recurrent tumours and CD. Teaching points Water-enema multidetector CT (WE-MDCT) effectively visualises the operated colon Complementary to endoscopy, WE-MDCT may helpfully depict abnormalities of surgical anastomoses WE-MDCT allows assessment of strictures' features and abnormalities of the upstream bowel Technical pitfalls, normal postsurgical findings and benign anastomotic disorders are presented WE-MDCT allows detecting relapsing Crohn's disease, recurrent and metachronous tumours Computed tomography (CT); Colonoscopy; Colorectal surgery; Anastomosis; Stricture; Colorectal carcinoma; Crohn's disease Introduction Since the first description by Gossios et al. [ 1 ], water-enema multidetector CT (WE-MDCT) has developed into a technique dedicated to visualising the large bowel, which relies on a combination of preliminary bowel cleansing, retrograde fluid-attenuation luminal distension, pharmacological hypotonisation and intravenous contrast enhancement. Although relatively simple to perform and interpret, WEMDCT is increasingly considered the most accurate imaging technique to comprehensively stage colorectal carcinoma * (CRC) and has very high sensitivity (98.6–99%) for lesions measuring at least 1 cm and good agreement between CT features and histopathology [ 2–5 ]. Moreover, WE-MDCT has been effectively adopted to diagnose bowel endometriosis [ 6–8 ], colonic diverticular disease [9] and chronic inflammatory bowel diseases (IBD) [ 9–13 ]. Following colorectal surgery for either benign or malignant processes, optical colonoscopy remains the gold standard technique to assess the anastomotic site and residual large bowel and to identify recurrence of resected disease. However, in operated patients endoscopy is often hampered by postsurgical adhesions, sharp bowel angulations, bowel kinking, poor bowel preparation and anastomotic strictures (AS). WE-MDCT allows reliable measurement of the colonic wall thickness in normal and pathological conditions, and provides a detailed multiplanar assessment of mural, intra- and extraluminal abnormalities of the large bowel. Therefore, its use is appealing to investigate the operated colon, particularly after unsuccessful, incomplete or inconclusive endoscopy. Based upon personal experience at a tertiary hospital that performs IBD and oncologic surgery, this pictorial essay presents the WE-MDCT technique and pitfalls, the expected appearances after various colon surgeries and the imaging features of benign anastomotic disorders, recurrent tumours and Crohn’s disease (CD). Water enema multidetector CT technique and interpretation Acquisition technique Retrograde colonic distension is contraindicated in the presence of high-grade bowel obstruction, when a standard contrast-enhanced CT acquisition reliably investigates the site and cause of obstruction, thanks to the pre-existent bowel dilatation with intraluminal fluid. Before WE-MDCT, bowel cleansing is obtained using an iso-osmolar non-absorbable laxative solution (typically 4–6 doses of polyethylene glycol dissolved in 500 ml water per dose) the day before the examination, in association with a low-fibre diet for 3 days. Patients fast for 12 h after a liquid dinner the evening before the scheduled examination [ 9 ]. The patient is positioned on the CT scanner table and is instructed to turn to the left lateral decubitus. A lubricated enema tube is gently inserted into the rectum and connected to a bag that contains 1.5–2 l of warm tap water. Retrograde colonic distension through gravity is obtained within a few minutes and is stopped when the patient com (...truncated)


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Massimo Tonolini, Sonia Ippolito. Imaging the operated colon using water-enema multidetector CT, with emphasis on surgical anastomoses, Insights into Imaging, 2018, pp. 1-11, DOI: 10.1007/s13244-018-0612-7