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DOI: 10.1148/rg.265055123
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Radiology of the Laparoscopic Roux-en-Y Gastric Bypass Procedure: Conceptualization and Precise Interpretation of Results1

Christopher D. Scheirey, MD, Francis J. Scholz, MD, Paresh C. Shah, MD, David M. Brams, MD, Brian B. Wong, MD and Michael Pedrosa, MD

1 From the Departments of Radiology (C.D.S., F.J.S., B.B.W., M.P.) and General Surgery (P.C.S., D.M.B.), Lahey Clinic, 41 Mall Rd, Burlington, MA 01805. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received May 19, 2005; revision requested July 29 and received October 3; accepted October 5. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  A gastric pouch (P) is created by dividing the stomach primarily along the lesser curvature.

 

Figure 2
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  		Figure 2.  The jejunum is divided 25–50 cm distal to the ligament of Treitz. The biliopancreatic limb (arrow) is temporarily excluded from the remainder of the small bowel. P = gastric pouch.

 

Figure 3
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  		Figure 3.  The Roux limb (R) is measured to 75–100 cm and attached to the biliopancreatic limb (arrow) with a side-to-side anastomosis. There are now three distinct portions of small bowel: the biliopancreatic limb, the Roux limb, and the common channel (arrowhead) distal to the anastomosis. P = gastric pouch.

 

Figure 4
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  		Figure 4a.  Frontal (a) and lateral (b) views show ante-colic-antegastric placement of the Roux limb (R), which is brought anterior to the transverse colon and stomach. P = pouch, black arrow = gastrojejunal anastomosis, white arrow in a = biliopancreatic limb, arrowhead in a = common channel.

 

Figure 4
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  		Figure 4b.  Frontal (a) and lateral (b) views show ante-colic-antegastric placement of the Roux limb (R), which is brought anterior to the transverse colon and stomach. P = pouch, black arrow = gastrojejunal anastomosis, white arrow in a = biliopancreatic limb, arrowhead in a = common channel.

 

Figure 5
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  		Figure 5a.  Frontal (a) and lateral (b) views show retro-colic-retrogastric placement of the Roux limb (R), which is tunneled posteriorly through a surgically created defect in the transverse mesocolon. P = pouch, black arrow = gastrojejunal anastomosis, white arrow in a = biliopancreatic limb, arrowhead in a = common channel.

 

Figure 5
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  		Figure 5b.  Frontal (a) and lateral (b) views show retro-colic-retrogastric placement of the Roux limb (R), which is tunneled posteriorly through a surgically created defect in the transverse mesocolon. P = pouch, black arrow = gastrojejunal anastomosis, white arrow in a = biliopancreatic limb, arrowhead in a = common channel.

 

Figure 6
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  		Figure 6a.  Normal findings at 24-hour postoperative UGI examination. Frontal (a) and oblique (b) images show the normal postoperative appearance of the pouch (thick white arrow), gastrojejunal anastomosis (black arrow), jejunal stump (arrowhead), and proximal Roux limb (thin white arrow).

 

Figure 6
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  		Figure 6b.  Normal findings at 24-hour postoperative UGI examination. Frontal (a) and oblique (b) images show the normal postoperative appearance of the pouch (thick white arrow), gastrojejunal anastomosis (black arrow), jejunal stump (arrowhead), and proximal Roux limb (thin white arrow).

 

Figure 7
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  		Figure 7a.  Displacement of breast tissue. (a) Postoperative UGI image obtained in a female patient with pendulous breasts shows underpenetration of the image. (b) UGI image obtained after superior displacement of the breast tissue by the patient shows a marked improvement in depiction of the postoperative appearance.

 

Figure 7
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  		Figure 7b.  Displacement of breast tissue. (a) Postoperative UGI image obtained in a female patient with pendulous breasts shows underpenetration of the image. (b) UGI image obtained after superior displacement of the breast tissue by the patient shows a marked improvement in depiction of the postoperative appearance.

 

Figure 8
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  		Figure 8.  Normal gastrojejunal anastomosis. CT scan shows an end-to-side gastrojejunal anastomosis (thin arrow), the gastric pouch (thick arrow), and the excluded stomach (arrowhead).

 

Figure 9
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  		Figure 9a.  Normal antecolic-antegastric Roux limb. CT scans displayed from cranial (a) to caudal (c) show the Roux limb (thick arrow in a and b) anterior to the excluded stomach (arrowhead in a) and colon (thin arrow in b). Arrows in c = sutures of the side-to-side enteroenteric anastomosis.

 

Figure 9
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  		Figure 9b.  Normal antecolic-antegastric Roux limb. CT scans displayed from cranial (a) to caudal (c) show the Roux limb (thick arrow in a and b) anterior to the excluded stomach (arrowhead in a) and colon (thin arrow in b). Arrows in c = sutures of the side-to-side enteroenteric anastomosis.

 

Figure 9
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  		Figure 9c.  Normal antecolic-antegastric Roux limb. CT scans displayed from cranial (a) to caudal (c) show the Roux limb (thick arrow in a and b) anterior to the excluded stomach (arrowhead in a) and colon (thin arrow in b). Arrows in c = sutures of the side-to-side enteroenteric anastomosis.

 

Figure 10
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  		Figure 10a.  Normal retrocolic-retrogastric Roux limb. CT scans (a obtained cranially to b) show the Roux limb (thick arrow) posterior to the excluded stomach (arrowhead) and colon (thin arrow).

 

Figure 10
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  		Figure 10b.  Normal retrocolic-retrogastric Roux limb. CT scans (a obtained cranially to b) show the Roux limb (thick arrow) posterior to the excluded stomach (arrowhead) and colon (thin arrow).

 

Figure 11
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  		Figure 11a.  Normal retrocolic-antegastric Roux limb. CT scans (a obtained cranially to b) show the Roux limb (thick arrow) anterior to the excluded stomach (arrowhead in a) and posterior to the colon (thin arrow).

 

Figure 11
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  		Figure 11b.  Normal retrocolic-antegastric Roux limb. CT scans (a obtained cranially to b) show the Roux limb (thick arrow) anterior to the excluded stomach (arrowhead in a) and posterior to the colon (thin arrow).

 

Figure 12
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  		Figure 12a.  Normal reflux up the biliopancreatic limb. (a, b) CT scans (a obtained cranially to b) show wide patency of the enteroenteric anastomosis (arrowhead in b) and reflux of contrast material up the biliopancreatic limb (arrow). (c) Image from a small bowel series, obtained in another patient, shows reflux of contrast material up the duodenum (arrows), through the pylorus, and into the excluded stomach.

 

Figure 12
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  		Figure 12b.  Normal reflux up the biliopancreatic limb. (a, b) CT scans (a obtained cranially to b) show wide patency of the enteroenteric anastomosis (arrowhead in b) and reflux of contrast material up the biliopancreatic limb (arrow). (c) Image from a small bowel series, obtained in another patient, shows reflux of contrast material up the duodenum (arrows), through the pylorus, and into the excluded stomach.

 

Figure 12
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  		Figure 12c.  Normal reflux up the biliopancreatic limb. (a, b) CT scans (a obtained cranially to b) show wide patency of the enteroenteric anastomosis (arrowhead in b) and reflux of contrast material up the biliopancreatic limb (arrow). (c) Image from a small bowel series, obtained in another patient, shows reflux of contrast material up the duodenum (arrows), through the pylorus, and into the excluded stomach.

 

Figure 13
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  		Figure 13.  Anastomotic leak in a 47-year-old woman 24 hours after surgery. UGI image shows contrast material from a large leak arising from the gastrojejunal anastomosis; the contrast material completely outlines the spleen. Emergent reexploration demonstrated an anastomotic leak, which was repaired.

 

Figure 14
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  		Figure 14a.  Gastrojejunal edema in a 33-year-old woman who was asymptomatic 24 hours after surgery. (a) Routine postoperative UGI image shows a marked delay in passage of contrast material through the narrowed gastrojejunal anastomosis (arrow). (b) UGI image obtained after 1 week of conservative management shows resolution of the edema, with rapid passage of contrast material into the Roux limb.

 

Figure 14
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  		Figure 14b.  Gastrojejunal edema in a 33-year-old woman who was asymptomatic 24 hours after surgery. (a) Routine postoperative UGI image shows a marked delay in passage of contrast material through the narrowed gastrojejunal anastomosis (arrow). (b) UGI image obtained after 1 week of conservative management shows resolution of the edema, with rapid passage of contrast material into the Roux limb.

 

Figure 15
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  		Figure 15a.  Gastrojejunal stricture in a 28-year-old woman with nausea and vomiting 1 month after surgery. (a) Image from the initial UGI examination shows tight narrowing of the gastrojejunal anastomosis (black arrow) and a rounded appearance of the gastric pouch (white arrow). (b) UGI image obtained 3 months after endoscopy and balloon dilation shows resolution of the anastomotic stricture (black arrow) and of the rounded pouch (white arrow).

 

Figure 15
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  		Figure 15b.  Gastrojejunal stricture in a 28-year-old woman with nausea and vomiting 1 month after surgery. (a) Image from the initial UGI examination shows tight narrowing of the gastrojejunal anastomosis (black arrow) and a rounded appearance of the gastric pouch (white arrow). (b) UGI image obtained 3 months after endoscopy and balloon dilation shows resolution of the anastomotic stricture (black arrow) and of the rounded pouch (white arrow).

 

Figure 16
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  		Figure 16.  Anastomotic stricture. Image from endoscopy shows a stricture at the anastomosis. Typically the first study performed in patients with symptoms of an anastomotic stricture, endoscopy is both diagnostic and therapeutic. (Courtesy of David L. Burns, MD, Lahey Clinic, Burlington, Mass.)

 

Figure 17
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  		Figure 17.  Widened gastrojejunal anastomosis in a 37-year-old woman with lack of satiety and suboptimal weight loss 1 year after surgery. Image from a double-contrast UGI study (prone drinking view) shows mild dilatation of the pouch (arrowhead) and a widened gastrojejunal anastomosis (white arrow) with rapid passage of contrast material into the Roux limb (black arrow). These findings were confirmed at surgery, and the bypass was revised.

 

Figure 18
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  		Figure 18a.  Gastrogastric fistula in a 47-year-old woman with insatiable appetite and weight gain 4 years after open Roux-en-Y gastric bypass. (a) UGI image shows contrast material opacifying the fundus (arrow) of the excluded stomach. (b) Image from the CT equivalent of a UGI examination shows oral contrast material (arrow) in the fundus of the excluded stomach. Note that no contrast material is seen in the body of the stomach; thus, this appearance does not represent normal reflux up the biliopancreatic limb.

 

Figure 18
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  		Figure 18b.  Gastrogastric fistula in a 47-year-old woman with insatiable appetite and weight gain 4 years after open Roux-en-Y gastric bypass. (a) UGI image shows contrast material opacifying the fundus (arrow) of the excluded stomach. (b) Image from the CT equivalent of a UGI examination shows oral contrast material (arrow) in the fundus of the excluded stomach. Note that no contrast material is seen in the body of the stomach; thus, this appearance does not represent normal reflux up the biliopancreatic limb.

 

Figure 19
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  		Figure 19.  Pouch-to-stump fistula in a 50-year-old woman with abdominal pain 11/2 years after surgery. UGI image shows a fistula (thin white arrow) between the pouch (black arrow) and jejunal stump (thick white arrow). The symptoms were not attributed to the fistula, and subsequent laparoscopy for evaluation of the pain revealed a previously undetected internal hernia.

 

Figure 20
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  		Figure 20.  Anastomotic ulcer. Image from endoscopy shows a large, white, fibrin-coated ulcer at the anastomosis. Ulcers can be difficult to diagnose with radiography. In general, they are diagnosed with endoscopy. (Courtesy of David L. Burns, MD, Lahey Clinic, Burlington, Mass.)

 

Figure 21
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  		Figure 21a.  Obstruction of the biliopancreatic limb in a 38-year-old woman with abdominal pain 1 week after surgery. (a, b) CT scans (a obtained cranially to b) show a nondistended, contrast material–filled antegastric Roux limb (arrow in a) but a distended, fluid-filled excluded stomach (arrowhead in a) and bilio-pancreatic limb (black arrow in b). The enteroenteric anastomosis (white arrow in b) was obstructed, presumably as a result of edema, and was subsequently decompressed with a percutaneous gastrostomy. (c) Follow-up CT scan obtained after percutaneous gastrostomy (arrow) shows a decompressed excluded stomach (arrowhead). The biliopancreatic limb obstruction due to enteroenteric anastomotic edema resolved without complication.

 

Figure 21
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  		Figure 21b.  Obstruction of the biliopancreatic limb in a 38-year-old woman with abdominal pain 1 week after surgery. (a, b) CT scans (a obtained cranially to b) show a nondistended, contrast material–filled antegastric Roux limb (arrow in a) but a distended, fluid-filled excluded stomach (arrowhead in a) and bilio-pancreatic limb (black arrow in b). The enteroenteric anastomosis (white arrow in b) was obstructed, presumably as a result of edema, and was subsequently decompressed with a percutaneous gastrostomy. (c) Follow-up CT scan obtained after percutaneous gastrostomy (arrow) shows a decompressed excluded stomach (arrowhead). The biliopancreatic limb obstruction due to enteroenteric anastomotic edema resolved without complication.

 

Figure 21
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  		Figure 21c.  Obstruction of the biliopancreatic limb in a 38-year-old woman with abdominal pain 1 week after surgery. (a, b) CT scans (a obtained cranially to b) show a nondistended, contrast material–filled antegastric Roux limb (arrow in a) but a distended, fluid-filled excluded stomach (arrowhead in a) and bilio-pancreatic limb (black arrow in b). The enteroenteric anastomosis (white arrow in b) was obstructed, presumably as a result of edema, and was subsequently decompressed with a percutaneous gastrostomy. (c) Follow-up CT scan obtained after percutaneous gastrostomy (arrow) shows a decompressed excluded stomach (arrowhead). The biliopancreatic limb obstruction due to enteroenteric anastomotic edema resolved without complication.

 

Figure 22
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  		Figure 22.  Perforation of the excluded stomach in a 28-year-old woman with tachycardia 1 day after surgery. CT scan of the thorax, obtained to evaluate for a pulmonary embolus, shows excessive free intraperitoneal fluid and air (arrow) without extraluminal contrast material. Arrowheads = enhancing, crescentic, atelectatic lung. Surgery revealed perforation of the excluded stomach adjacent to the suture line.

 

Figure 23
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  		Figure 23a.  Edema at the enteroenteric anastomosis in a 24-year-old woman with abdominal pain, nausea, and dehydration 5 days after surgery. (a) UGI image shows a distended Roux limb (white arrow) and an apparent transition point (black arrow) at the enteroenteric anastomosis. (b) CT scan shows narrowing at the enteroenteric anastomosis (arrow). The findings were believed to be a result of anastomotic edema, and the symptoms resolved with conservative management.

 

Figure 23
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  		Figure 23b.  Edema at the enteroenteric anastomosis in a 24-year-old woman with abdominal pain, nausea, and dehydration 5 days after surgery. (a) UGI image shows a distended Roux limb (white arrow) and an apparent transition point (black arrow) at the enteroenteric anastomosis. (b) CT scan shows narrowing at the enteroenteric anastomosis (arrow). The findings were believed to be a result of anastomotic edema, and the symptoms resolved with conservative management.

 

Figure 24
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  		Figure 24a.  Obstruction of the Roux limb by a bezoar in a 47-year-old man with nausea and vomiting 8 months after surgery. CT scans (a obtained cranially to b) show a bezoar (arrow in a) in the Roux limb with upstream dilatation (white arrow in b). The excluded stomach (arrowhead in b) was enhanced with contrast material via a previously placed gastrostomy tube (black arrow in b). The symptoms resolved with conservative management.

 

Figure 24
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  		Figure 24b.  Obstruction of the Roux limb by a bezoar in a 47-year-old man with nausea and vomiting 8 months after surgery. CT scans (a obtained cranially to b) show a bezoar (arrow in a) in the Roux limb with upstream dilatation (white arrow in b). The excluded stomach (arrowhead in b) was enhanced with contrast material via a previously placed gastrostomy tube (black arrow in b). The symptoms resolved with conservative management.

 

Figure 25
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  		Figure 25a.  Anastomotic obstruction from an internal hernia in a 23-year-old woman with pain, nausea, and vomiting 10 months after surgery. CT scans (a obtained cranially to b) show a dilated, fluid-filled excluded stomach and biliopancreatic limb (arrowheads) with a distended, contrast material–filled Roux limb (thick white arrows in b) and decompressed, clustered distal small bowel loops (thin white arrow in b). This appearance is consistent with obstruction at the anastomosis or in the common channel. Laparoscopy revealed an internal hernia at a small bowel mesenteric defect (black arrow in b).

 

Figure 25
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  		Figure 25b.  Anastomotic obstruction from an internal hernia in a 23-year-old woman with pain, nausea, and vomiting 10 months after surgery. CT scans (a obtained cranially to b) show a dilated, fluid-filled excluded stomach and biliopancreatic limb (arrowheads) with a distended, contrast material–filled Roux limb (thick white arrows in b) and decompressed, clustered distal small bowel loops (thin white arrow in b). This appearance is consistent with obstruction at the anastomosis or in the common channel. Laparoscopy revealed an internal hernia at a small bowel mesenteric defect (black arrow in b).

 

Figure 26
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  		Figure 26a.  Internal hernia at a small bowel mesenteric defect in a 51-year-old woman with abdominal pain 10 months after surgery. (a–c) CT scans displayed from cranial (a) to caudal (c) show distention of the Roux loop with a bezoar (white arrow in a, straight arrow in b); narrowing at the enteroenteric anastomosis (black arrow in a); an abrupt twist in the small bowel mesentery (curved arrow in b); edema of the small bowel mesentery (arrowheads in c); and venous engorgement (arrow in c). (d) Photograph obtained during laparoscopy shows engorged vessels and mesentery with a lymph fluid coagulum. An internal hernia at the small bowel mesenteric anastomosis caused a closed-loop obstruction and volvulus.

 

Figure 26
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  		Figure 26b.  Internal hernia at a small bowel mesenteric defect in a 51-year-old woman with abdominal pain 10 months after surgery. (a–c) CT scans displayed from cranial (a) to caudal (c) show distention of the Roux loop with a bezoar (white arrow in a, straight arrow in b); narrowing at the enteroenteric anastomosis (black arrow in a); an abrupt twist in the small bowel mesentery (curved arrow in b); edema of the small bowel mesentery (arrowheads in c); and venous engorgement (arrow in c). (d) Photograph obtained during laparoscopy shows engorged vessels and mesentery with a lymph fluid coagulum. An internal hernia at the small bowel mesenteric anastomosis caused a closed-loop obstruction and volvulus.

 

Figure 26
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  		Figure 26c.  Internal hernia at a small bowel mesenteric defect in a 51-year-old woman with abdominal pain 10 months after surgery. (a–c) CT scans displayed from cranial (a) to caudal (c) show distention of the Roux loop with a bezoar (white arrow in a, straight arrow in b); narrowing at the enteroenteric anastomosis (black arrow in a); an abrupt twist in the small bowel mesentery (curved arrow in b); edema of the small bowel mesentery (arrowheads in c); and venous engorgement (arrow in c). (d) Photograph obtained during laparoscopy shows engorged vessels and mesentery with a lymph fluid coagulum. An internal hernia at the small bowel mesenteric anastomosis caused a closed-loop obstruction and volvulus.

 

Figure 26
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  		Figure 26d.  Internal hernia at a small bowel mesenteric defect in a 51-year-old woman with abdominal pain 10 months after surgery. (a–c) CT scans displayed from cranial (a) to caudal (c) show distention of the Roux loop with a bezoar (white arrow in a, straight arrow in b); narrowing at the enteroenteric anastomosis (black arrow in a); an abrupt twist in the small bowel mesentery (curved arrow in b); edema of the small bowel mesentery (arrowheads in c); and venous engorgement (arrow in c). (d) Photograph obtained during laparoscopy shows engorged vessels and mesentery with a lymph fluid coagulum. An internal hernia at the small bowel mesenteric anastomosis caused a closed-loop obstruction and volvulus.

 

Figure 27
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  		Figure 27.  Closed-loop obstruction and internal hernia at the mesocolic window in a 43-year-old man with severe abdominal pain 2 years after surgery. Coronal thick-section average intensity projection image from contrast-enhanced CT shows a closed-loop obstruction of a short segment of the small bowel (arrow). Surgery revealed an internal hernia at the mesocolic window of a retrocolic and antegastric Roux limb with volvulus and closed-loop small bowel obstruction.

 

Figure 28
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  		Figure 28.  Hematoma in a 61-year-old woman with oliguria and a falling hematocrit 1 day after surgery. Nonenhanced CT scan shows high-attenuation material in the excluded stomach (arrowhead) and lesser sac (arrows). Surgery revealed 500 mL of intragastric blood and 150 mL in the lesser sac. No site of bleeding was found.

 

Figure 29
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  		Figure 29.  Abscess in a 49-year-old woman with fever and abdominal pain 18 days after surgery. CT scan shows a large abscess (arrow) posterior to the excluded stomach. Percutaneous drainage produced infected bloody fluid.

 




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