European Journal of Radiology 53 (2005) 341–352

The postoperative stomach

Courtney A. Woodfield, Marc S. Levine∗

Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA

Received 10 November 2004; received in revised form 14 December 2004; accepted 17 December 2004

Abstract

Gastric surgery may be performed for the treatment of a variety of benign and malignant diseases of the upper gastrointestinal tract,including peptic ulcers and gastric carcinoma. Radiographic studies with water-soluble contrast agents often are obtained to rule out leaks,obstruction, or other acute complications during the early postoperative period. Barium studies may also be obtained to evaluate for anastomoticstrictures or ulcers, bile reflux gastritis, recurrent tumor, or other chronic complications during the late postoperative period. Cross-sectionalimaging studies such as CT are also helpful for detecting abscesses or other postoperative collections, recurrent or metastatic tumor, or lesscommon complications such as afferent loop syndrome or gastrojejunal intussusception. It is important for radiologists to be familiar notonly with the radiographic findings associated with these various abnormalities but also with the normal appearances of the postoperatives omplications.T ing partialg he acute andc atients.©

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tomach on radiographic examinations, so that such appearances are not mistaken for pseudoleaks or other postoperative che purpose of this article is to describe the normal postsurgical anatomy after the most commonly performed operations (includastrectomy, esophagogastrectomy and gastric pull-through, and total gastrectomy and esophagojejunostomy) and to review thronic complications, normal postoperative findings, and major abnormalities detected on radiographic examinations in these p2005 Elsevier Ireland Ltd. All rights reserved.

eywords:Stomach surgery; Stomach postoperative diagnostic imaging; Stomach surgery complications; Stomach surgery normal findings

. Introduction

Gastric surgery often is performed for the treatment ofenign and malignant diseases of the upper gastrointesti-al tract. Postoperative radiographic examinations are ob-

ained in many of these patients to rule out leaks, obstruc-ion, or other abnormalities after surgery. It therefore ismportant for radiologists to be familiar with the normalostoperative findings as well as the complications asso-iated with gastric surgery and their radiographic appear-nces. This article reviews the major forms of gastric surgery,

he postoperative anatomy, associated complications, andhe normal postoperative findings and various abnormal-ties detected on radiographic examinations in these pa-ients.

∗ Corresponding author. Tel.: +1 215 662 6908; fax: +1 215 349 5925.E-mail address:marc.levine@uphs.upenn.edu (M.S. Levine).

2. Imaging techniques

The approach to imaging the postoperative stomachpends on the type of surgical procedure that has beenformed, the postoperative time period (i.e., early or late),the patient’s clinical status and presenting complaints. Ugastrointestinal contrast studies and CT are the primary iing tests used to evaluate the postoperative stomach, ofa complimentary fashion.

2.1. Upper gastrointestinal contrast examinations

When an anastomotic leak or staple line dehiscensuspected in the early or late postoperative periods, mosgeons will ask for an upper gastrointestinal study with wasoluble contrast material (e.g., diatrizoate meglumine anatrizoate sodium [Gastroview]; Mallinckrodt, St. Louis, Mas the initial imaging test[1]. The examination begins wiscout images of the lower chest and upper abdomen tsess the presence or absence of a dilated viscus, ex

720-048X/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.ejrad.2004.12.009

342 C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352

minal gas collections, free intraperitoneal air, or pneumato-sis as well as the location of surgical drains, clips, and su-tures. Scout images can be obtained in frontal and, if nec-essary, oblique positions (collimated and magnified on theregion of surgery), so that surgical material is not later mis-taken for a small anastomotic leak. If the type of surgeryis unknown, the pattern of surgical staples on the initialscout images can also help determine the operative proce-dure[2,3].

Water-soluble contrast material is recommended as theinitial contrast agent for the evaluation of upper gastroin-testinal leaks, as it has no known damaging effects on themediastinum or peritoneal cavity[4–7]. The patient ingeststhe contrast agent in the upright position to evaluate swal-lowing function and transit of contrast material from theesophagus into the stomach. The patient is then placed ina semi-recumbent position to ensure adequate coating of thepostoperative stomach, including all anastomoses and staplelines. If the patient is unable to drink, contrast material canalso be administered via a nasogastric tube or percutaneousgastrostomy tube.

The fluoroscopist initially should focus on anastomosesand staple lines (the most likely sites of perforation), ob-taining early spot images of these regions in order to avoidmissing a small leak. The position of the patient in which al rgeryp ro-p dingt dinga n-t enceo ual-i d byb froms or byf inumo

ate-r hasb ntrasta ablyb erties[ /v)b 0%,w ithw -l y tot d withw

riod( arer t up-p eval-u atoryc ratives 1 mg

Fig. 1. Leak from esophagojejunal anastomosis seen only with high-densitybarium. (A) Spot image from study with water-soluble contrast agent showstotal gastrectomy and esophagojejunostomy with contrast material in effer-ent loop of proximal jejunum and short, blind-ending jejunal stump. Alsonote possible tiny leak (arrow) from left lateral aspect of anastomosis. (B) Re-peat view with high-density barium shows definite tiny leak (white arrow)from left lateral aspect of esophagojejunal anastomosis as well as secondleak (black arrow) from right lateral anastomosis that was not visualizedwith water-soluble contrast agent.

versus 0.1 mg) to prevent rapid transit of barium and airthrough the gastric remnant into the small bowel, which canlimit the diagnostic value of this examination. When theprimary purpose of the study is to evaluate the postsurgi-cal anatomy, rule out obstruction, or assess the integrity of

eak is best visualized often depends on the type of suerformed (e.g., left posterior oblique position for a pylolasty). Small anastomotic leaks may appear as blind-en

racks or as self-contained extraluminal collections extenway from surgical anastomoses[8]. The presence of corast material in a surgical drain also indicates the presf a small leak, even when leaks are not otherwise vis

zed on these studies. Larger leaks may be manifesteroader channels of contrast material extending awayurgical anastomoses into peri-anastomotic collectionsree extravasation of contrast material into the mediastr peritoneal cavity[8].

If no leak is detected with water-soluble contrast mial, the study should be repeated with barium, whicheen found to be a better medium than water-soluble cogents for visualizing subtle postoperative leaks, presumecause of its greater radiodensity and adherence prop

4–7]. Recent work has shown that high-density (250%, warium is even more sensitive than low-density (60–10/v) barium for visualization of subtle leaks missed water-soluble contrast agents (Fig. 1) [9]. We therefore be

ieve that high-density barium should be given routinelhese patients to detect postoperative leaks not visualizeater-soluble contrast media.When symptoms develop in the late postoperative pe

i.e., more than 30 days after surgery) in patients whoeasonably mobile and cooperative, a double-contraser gastrointestinal study may be performed to betterate the gastric and esophageal mucosa for inflammhanges, strictures, or recurrent tumor. These postopetudies require a larger dose of intravenous glucagon (

C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352 343

gastric staple lines after gastric bypass surgery, however, asingle-contrast study remains the radiographic examinationof choice.

As in single-contrast upper gastrointestinal studies, thepatient initially ingests the high-density barium in the up-right position to evaluate for laryngeal penetration or as-piration, esophageal mucosal abnormalities, and transit ofbarium through the upper gastrointestinal tract. The patientis then positioned more horizontally and rotated to ensureadequate coating of gastric mucosal surfaces before obtain-ing double-contrast views of the stomach. Depending onthe type of surgery, the position in which the gastroentericand enteroenteric anastomoses are best visualized is vari-able. Prone positioning may be helpful for filling the effer-ent and afferent jejunal loops. Prone swallowing can also beperformed to better evaluate esophageal motility and disten-sibility.

2.2. Computed tomography

When patients develop generalized symptoms (e.g., ab-dominal pain) in the early or late postoperative periods, CTscans may be obtained with contiguous 5-mm axial sectionsfrom the lung apices or lung bases to the pubic symphysisafter administration of both oral and intravenous contrast ma-t of al r thanb detaila con-t ation,a f ex-t ibleo sug-g rwisem rentt rativep

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eval-u esti-n emp-t t in-g eala ob-t minf af-t ant oft h ina nge1 lin-e in)[

3. Types of gastric surgery

3.1. Partial gastrectomy

Partial gastrectomy with gastroduodenostomy or gastro-jejunostomy may be performed for treatment of benign andmalignant diseases of the stomach, such as gastric ulcers andgastric carcinoma. The site and extent of gastric resection de-pends on the nature and location of the lesion. Antrectomywith gastroduodenostomy can be used to treat refractory orcomplicated ulcers in the distal stomach, but this procedureis not often performed because of high rates of bile refluxacross the gastroduodenal anastomosis into the stomach. In-stead, surgery for ulcers in the distal stomach usually consistsof antrectomy and gastrojejunostomy. Subtotal gastrectomywith wide surgical margins of resection and gastrojejunos-tomy is the preferred surgery for distal gastric carcinomas[12].

3.1.1. Postoperative anatomyIn a partial distal gastrectomy with gastroduodenostomy

(Billroth I procedure), the connection between the stomachand duodenum is an end-to-end anastomosis using the entirefree edge of the stomach (Polya procedure) or a portion of thefree edge with closure of the remaining portion of the stom-a db stric

Fig. 2. Partial gastrectomy with gastroduodenostomy (Billroth I procedure).Spot image from double-contrast barium study shows widely patent gastro-duodenal anastomosis (arrows).

erial. If these patients have clinical signs or symptomseak, water-soluble contrast media should be used rathearium as the oral contrast agent. CT provides greaterbout the overall anatomy than upper gastrointestinal

rast studies and is better able to define the nature, locnd extent of postoperative collections. Small amounts o

raluminal fluid, contrast material, and air that are not visn fluoroscopic images can be readily detected on CT,esting the presence of a postoperative leak that otheight be missed. CT is also useful for evaluating recur

umor, metastases, wound complications, and postopeancreatitis[10].

.3. Nuclear medicine

Scintigraphic gastric emptying studies can be used toate postoperative motility disorders, including gastrointal stasis, dumping syndrome, and diarrhea. Gastric

ying studies may be performed by having the patienest a Tc-99m sulfur colloid-labeled liquid or solid mfter an overnight fast. Images of the stomach are

ained in the anterior and posterior projections every 15or 1 h after completion of a liquid meal and for 2 her completion of a solid meal. A time-activity curve chen be plotted to determine the half-emptying timehe stomach. Normally, liquids empty from the stomacn exponential fashion, with a half-time of 40 min (ra2–65 min), while solids empty from the stomach in aar fashion with a half-time of 90 min (range 45–110 m

11].

ch (Hofmeister modification) (Fig. 2). Trapping of ingestearium in the distorted folds and outpouchings of the ga

344 C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352

Fig. 3. Partial gastrectomy with gastrojejunostomy (Billroth II procedure).Spot image from double-contrast barium study shows widely patent gastro-jejunal anastomosis (arrows) with barium in afferent and efferent loops ofproximal jejunum.

remnant near the anastomosis occasionally may be difficultto distinguish from recurrent ulcers[13].

Partial distal gastrectomy with gastrojejunostomy (Bill-roth II procedure) is more commonly performed than a Bill-roth I procedure because of fewer complications related tobile reflux[14]. With this procedure, the entire free edge ofthe stomach (Polya procedure) or a portion of the free gas-tric edge (Hofmeister modification) is anastomosed to the je-junum via an end-to-side anastomosis (Fig. 3). With the latterprocedure, the oversewn edge of the gastric remnant may bemanifested by plication defects along both lateral margins ofthe gastrojejunal anastomosis, mimicking residual or recur-rent tumor on barium studies (Fig. 4). The gastrojejunostomycan be further classified as a loop type gastrojejunal anasto-mosis or as a Roux-en-Y type reconstruction. A Roux-en-Yreconstruction entails separating a segment of proximal je-junum from the remaining small bowel. The proximal end ofthe intact jejunum is anatomized in a side-to-end fashion tothe free edge of the stomach, and an end-to-side jejunojejunalanastomosis is created between the resected jejunal segmentand the more distal jejunum. This Roux-en-Y reconstructionis superior to the loop type gastrojejunal anastomosis becauseit decreases bile reflux from the small bowel into the stom-ach, thereby minimizing or preventing the development ofbile reflux gastritis in most patients[15].

nas-t tinu-o nump loop,w cre-t l tot typeg ic) orp olic

Fig. 4. Partial gastrectomy with plication defects at gastrojejunal anastomo-sis. Spot image from double-contrast barium study shows relatively symmet-ric plication defects (arrows) on both margins of gastrojejunal anastomosis.This finding should not be mistaken for recurrent tumor.

anastomosis often is preferred, as it results in a shorter affer-ent loop and, presumably, fewer postoperative complications[14]. However, an antecolic anastomosis may be favored inpatients with gastric carcinoma in order to avoid positioningthe gastrojejunal anastomosis in the lesser sac, where tumoris more likely to recur[10]. A loop-type gastrojejunal anas-tomosis extending from left to right (with the afferent loop tothe left and the efferent loop to the right) is characterized asisoperistaltic, as gastric and jejunal peristalsis are oriented inthe same direction, facilitating gastric emptying. Conversely,a gastrojejunal anastomosis extending from right to left (withthe afferent loop to the right and the efferent loop to the left)is characterized as antiperistaltic.

The postoperative anatomy of Billroth I and II procedures,including the gastric remnant, gastrojejunal anastomosis, andproximal small bowel, can all be visualized both on uppergastrointestinal contrast studies and CT. Although a BillrothI gastroduodenostomy may be difficult to recognize on CT,the afferent loop is readily identified posterior to the superiormesenteric vessels in patients with a Billroth II gastrojejunos-tomy[10]. Metallic sutures or staples in the subhepatic spacecan also be used to mark the location of the duodenal stumpon CT. However, the efferent jejunal loop is more difficultto identify because of its more variable and tortuous course[10].

33 seso unal,a denals pli-c ode-n alu-m pace

A loop type gastrojejunal anastomosis is created by aomosing the free end of the stomach to the side of a conus jejunal segment. The portion of the duodenum or jejuroximal to the anastomosis is described as the afferenthich carries potentially harmful bile and pancreatic se

ions toward the stomach. The portion of jejunum distahe anastomosis is described as the efferent loop. Loopastrojejunostomies can be positioned anterior (antecolosterior (retrocolic) to the transverse colon. A retroc

.1.2. Postoperative complications

.1.2.1. Acute.Leaks from any of the surgical anastomor suture lines (including the gastroduodenal, gastrojejnd jejunojejunal anastomoses and blind-ending duotump) account for most of the early postoperative comations after partial gastrectomy. Dehiscence of the dual stump is a particularly serious complication, as extrinal bile and pancreatic secretions in the peritoneal s

C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352 345

Fig. 5. Leak from gastrojejunal anastomosis after partial gastrectomy andgastrojejunostomy. Spot image from study with water-soluble contrast agentshows focal leak (black arrow) from left lateral aspect of gastrojejunal anas-tomosis into large gas-containing extraluminal collection (white arrows) inleft subphrenic space. (Note how gastric remnant is collapsed on this view).

may cause severe peritonitis[10]. Contrast studies can beused to detect and localize both large and small anastomoticleaks (Fig. 5). Findings on CT that suggest the presence ofa leak (even if one is not visualized directly) include pneu-moperitoneum, oral contrast material in an extraluminal lo-cation, and findings associated with an intraabdominal ab-scess (Fig. 6) [16]. In other patients, postoperative edema

Fig. 6. Secondary signs of leak from gastrojejunal anastomosis on CT afterp deratea ationo ater-s nasto-m

and spasm at the gastrojejunal or jejunojejunal anastomosesmay cause varying degrees of gastric outlet obstruction orsmall bowel obstruction that resolves spontaneously.

3.1.2.2. Chronic.One of the most common complicationsof a Billroth II partial gastrectomy in the late postoperativeperiod is postsurgical scarring at the gastrojejunal anastomo-sis, resulting in the development of anastomotic strictures,with varying degrees of gastric outlet obstruction. Such stric-tures can lead to bloating, nausea, and nonbilious vomiting.Barium studies and CT may reveal a markedly dilated gas-tric remnant containing large amounts of fluid and debris.When barium studies are performed, it is important to visu-alize anastomotic strictures in profile at fluoroscopy in orderto optimally assess their width and length. Because of overlapbetween the distal portion of the gastric remnant and prox-imal jejunum on frontal views, the strictures often are bestseen on steep oblique or lateral spot views. When anastomoticstrictures obstruct the gastrojejunal anastomosis, fluoroscop-ically or endoscopically guided dilation procedures can beperformed to relieve the obstruction without need for surgeryin most cases[17–19].

A Billroth II partial gastrectomy may be complicated byan “afferent loop syndrome,” defined as obstructive dilata-tion of the afferent loop of duodenum and proximal jejunum,w theo dialf icalt e isl bea e in-t ions,rd dio-g ms g oft p)s alsom % ofp g-n af-f tifiedi ilsc n-Yr

oje-j o biler fterp as-t ned,n eri-ai ee ofi ients[ e-v rted

artial gastrectomy and gastrojejunostomy. Unenhanced CT shows momount of extraluminal gas (arrowheads) and extraluminal high-attenural contrast material (arrows) in left upper quadrant. Study with woluble contrast agent (not shown) confirmed leak at gastrojejunal aosis.

ith accumulation of bile and pancreatic secretions inbstructed loop. Patients typically present with postpran

ullness, nausea, and bilious vomiting. With current surgechniques, the prevalence of the afferent loop syndromess than 1%[20]. Obstruction of the afferent loop cancute and complete or chronic and partial; causes includ

ernal small bowel hernias, anastomotic strictures, adhesecurrent tumor, and intraperitoneal metastasis[20–22]. Theilated afferent loop may not be visible on abdominal raraphs if the obstructed limb is filled with fluid. On bariutudies, delayed gastric emptying (with preferential fillinhe efferent loop and little or no filling of the afferent loohould suggest the diagnosis. However, the afferent loopay not be visualized on barium studies in as many as 20atients[23]. CT is the imaging modality of choice for diaosing an afferent loop syndrome; the dilated, fluid-filled

erent loop as well as the cause of obstruction can be idenn most cases (Fig. 7) [22,24,25]. Treatment usually entaonverting a simple loop gastrojejunostomy to a Roux-eeconstruction[14].

Chronic reflux of bile across gastrojejunal and jejununal anastomoses into the gastric remnant can lead teflux gastritis, which occurs in 5–15% of all patients aartial gastrectomy[26]. Edema and inflammation of the g

ric wall may be manifested on barium studies by thickeodular folds with or without associated ulcers in the pnastomotic region of the gastric remnant (Fig. 8). Surpris-

ngly, there is not a strong correlation between the degrnflammation and the degree of symptoms in these pat14]. If intractable epigastric pain or bilious vomiting delops, however, the Billroth II procedure can be conve

346 C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352

Fig. 7. Afferent loop obstruction after partial gastrectomy and gastrojejunos-tomy. Contrast-enhanced CT shows moderately dilated, fluid-filled duode-num (arrowheads) between aorta and superior mesenteric artery (small ar-row). Note how efferent loop is also mildly dilated (large arrow). This patienthad postsurgical adhesions (not visualized on image) causing afferent loopobstruction.

surgically to a Roux-en-Y reconstruction in order to divertbile and pancreatic secretions away from the gastric remnant[14].

Decreased or absent gastric acid secretion and gastric hy-pomotility after a partial gastrectomy and vagotomy can leadto retention of ingested fibrous material that coalesces to forma large mass, referred to as a gastric bezoar. Bezoars typi-cally appear on barium studies and CT as large intraluminalmasses with a mottled surface secondary to trapping of air

F tudys tomya

Fig. 9. Bezoar in gastric remnant. Contrast-enhanced CT shows dilated gas-tric remnant as a large, inhomogeneous mass (arrows) containing debris andmottled gas. This patient had a stricture at gastrojejunal anastomosis (notvisualized on image) after partial gastrectomy and gastrojejunostomy.

and contrast material in the crevices of the mass (Fig. 9). Be-zoars usually are freely mobile within the gastric remnant,enabling differentiation from gastric tumors, which are at-tached to the gastric wall. Smaller bezoars may float alongthe gastric air-fluid interface, appearing as round or ovoidfilling defects, and are lower in attenuation than particulatedebris and food in the stomach on CT[27]. Gastric outletobstruction is the major complication of gastric bezoars, butsmall bowel obstruction occasionally may occur if a bezoarpasses spontaneously into the small intestine. Gastric bezoarsoften can be treated by mechanical break-up at endoscopy,but surgery usually is required to relieve bezoar-related smallbowel obstructions[28].

Partial gastrectomies (Billroth I or II) for treatment ofpeptic ulcer disease may be complicated by anastomotic(marginal) ulcers, most commonly in the proximal jejunumabutting the anastomosis (Fig. 10) [29]. These marginal ulcerscan be difficult to differentiate from postsurgical jejunal out-pouchings on barium studies, so endoscopy may be requiredfor further evaluation[30]. Rigidity of the anastomosis, focaledema, and thickened gastric folds are secondary signs thatmay help differentiate these ulcers from postsurgical changesat the anastomosis[3]. Potential causes of recurrent ulcersafter partial gastrectomy include retained gastric antrum andgastrinomas[31].

stricc rrentt neali t tu-m eri-t s to thel umora y fo-c ke,u

ig. 8. Bile reflux gastritis. Spot image from double-contrast barium shows thickened, irregular folds in gastric remnant after partial gastrecnd gastrojejunostomy. (Arrow denotes gastrojejunal anastomosis).

Patients who have had a partial gastrectomy for gaancer are also at continued risk for developing recuumor. Local and regional lymphadenopathy and peritomplants are the two most common forms of recurren

or [32–34]. CT can be used to detect both nodal and poneal metastases as well as hematogenous metastaseiver, lungs, adrenals, kidneys, and bones. Recurrent tt the gastrojejunal anastomosis may be manifested bal thickening of the bowel wall on CT and by plaquelilcerative, or polypoid lesions on barium studies[3,13]. In-

C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352 347

Fig. 10. Marginal ulcer. Spot images from double-contrast barium studyshow marginal ulcer (arrow) in jejunum abutting gastrojejunal anastomosisafter partial gastrectomy and gastrojejunostomy.

filtrative tumors may be manifested on barium studies bynarrowing of the gastric remnant, which has straightened, ir-regular contours[13]. Whenever imaging tests raise concernabout the possibility of recurrent tumor in the gastric rem-nant, endoscopy and biopsy should be performed for a moredefinitive diagnosis.

Patients who have undergone a partial gastrectomy for be-nign disease, particularly peptic ulcer disease, are also at riskfor developing carcinoma in the gastric remnant 10 or moreyears after the original surgery. These “stump” carcinomastypically involve the distal aspect of the gastric remnant at ornear the gastrojejunal anastomosis[13,35,36]. Mucosal dam-age in the gastric remnant from chronic reflux of bile and pan-creatic secretions is thought to play a role in the developmentof stump carcinomas[37]. These tumors may appear on bar-ium studies as infiltrating, polypoid, ulcerative, or plaquelikelesions at or near the anastomotic margin (Fig. 11) [13].

Jejunogastric intussusception and gastrojejunal intussus-ception are rare complications after partial gastrectomy, witha reported incidence of only 0.1%[38]. In a jejunogastric in-tussusception, the efferent loop (rather than the afferent loop)usually intussuscepts into the gastric remnant. This intussus-ception can be visualized by a variety of imaging modalitiesincluding CT, ultrasound, and barium studies. On CT, a seg-ment of proximal jejunum, along with adjacent mesenteric fataO mayb rem-n mayb istalp t int

3

cer-v per-

Fig. 11. Carcinoma of gastric “stump.” Spot image from double-contrast bar-ium study shows irregular narrowing (white arrows) of lower end of gastricremnant due to carcinoma developing many years after partial gastrectomyand gastrojejunostomy. Also note narrowing (black arrows) of afferent andefferent loops of jejunum abutting anastomosis due to encasement by tumor.

formed for both benign and malignant diseases, most notablyesophageal and proximal gastric carcinomas[40]. This oper-ation may be done via a transthoracic or transhiatal approach.A right transthoracic esophagectomy often is performed fortumors arising from the upper two-thirds of the esophagus,while a left transthoracic esophagectomy is reserved primar-ily for tumors arising in the distal esophagus or at the gastriccardia[40]. A transhiatal esophagectomy without a thora-cotomy may also be performed for tumors of the thoracic orcervical esophagus[40]. No significant differences have beenfound in the 5-year survival rates after esophagogastrectomyand gastric pull-through performed via transthoracic andtranshiatal approaches[41].

3.2.1. Postoperative anatomyTransthoracic esophagogastrectomy using separate

right thoracotomy and abdominal incisions (Ivor Lewisesophagectomy) involves mobilization of the stomachthrough the esophageal hiatus of the diaphragm via an upperabdominal incision. The esophagus is resected through

nd vessels, is seen to extend into the gastric remnant[39].n barium studies, the intussuscepted loop of jejunume manifested by a coiled-spring defect in the gastricant [13]. Conversely, a gastrojejunal intussusceptione manifested on barium studies by narrowing of the dortion of the gastric remnant with a coiled-spring defec

he proximal jejunum abutting the anastomosis (Fig. 12).

.2. Esophagogastrectomy and gastric pull-through

Esophagogastrectomy with gastric pull-through and aical or intrathoracic esophagogastric anastomosis is

348 C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352

Fig. 12. Antegrade gastrojejunal intussusception. Spot image from bariumstudy shows narrowing (white arrow) of gastric remnant with coil-spring de-fect (black arrows) in proximal jejunum abutting gastrojejunal anastomosisdue to gastrojejunal intussusception.

a separate right thoracotomy, and an esophagogastricanastomosis is created at the level of the thoracic or cervicalesophagus.

In contrast, transhiatal esophagectomy involves mobiliza-tion of the stomach through a high upper abdominal inci-sion. The esophagus is dissected inferiorly via the abdominalincision and superiorly via a second cervical incision. Theesophagus is then transected proximally, and a high cervi-cal esophagogastric anastomosis is created[40]. A concomi-tant pyloroplasty or pyloromyotomy usually is performed forboth transthoracic and transhiatal esophagectomies to facili-tate gastric emptying.

3.2.2. Postoperative complications3.2.2.1. Acute.The most serious early complication afteresophagogastrectomy and gastric pull-through is a leak atthe esophagogastric anastomosis related to postoperative is-chemia or surgical technique[42]. Transhiatal esophagec-tomy is associated with a higher rate of anastomotic leaks,but these leaks typically occur in the neck, where they areless likely to cause mediastinitis or sepsis[43]. As a result,cervical leaks can be managed conservatively without needfor surgery in most cases. However, intrathoracic leaks atthe esophagogastric anastomosis frequently are complicatedby mediastinitis and sepsis; mortality rates as high as 60%h after

Fig. 13. Leak from esophagogastric anastomosis. Spot image from studywith water-soluble contrast agent after esophagogastrectomy and gastricpull-through shows focal leak from esophagogastric anastomosis into ex-traluminal collection (white arrows) at thoracic inlet. (Black arrow denotesesophagogastric anastomosis).

esophagogastrectomy[43]. As a result, early surgical repairof intrathoracic leaks generally is advocated.

Large or persistent pleural effusions, pneumomedi-astinum, and mediastinal widening, are all secondary signsof anastomotic leaks on chest radiographs[44]. Leaks fromthe esophagogastric anastomosis may be manifested on con-trast studies by blind-ending tracks, sealed-off extraluminalcollections, or free extravasation of contrast material into themediastinum (Fig. 13). Because these patients often have anend-to-side esophagogastric anastomosis, incomplete fillingof the proximal gastric pouch can be mistaken for a leak inthis region (Fig. 14A). Such pseudoleaks can be differenti-ated from true leaks by placing the patient in a recumbentor even a Trendelenberg position to obtain adequate fillingof the proximal gastric pouch (Fig. 14B). CT is also helpfulfor identifying the presence and extent of mediastinal abscesscollections resulting from such leaks (Fig. 15). Because of thehigh mortality rates associated with intrathoracic leaks fromthe esophagogastric anastomosis, many surgeons ask for rou-tine contrast studies 7–10 days after surgery in order to detectclinically silent leaks before oral feedings are initiated.

Other early complications after esophagogastrectomy in-clude obstruction at the esophagogastric anastomosis sec-ondary to postoperative edema and spasm and obstruction orleaks at the pyloromyotomy site. Extrinsic compression oft agealh layedg ors

ave been reported in patients with intrathoracic leaks

he intrathoracic stomach where it traverses the esophiatus of the diaphragm is also a frequent cause of deastric emptying (Fig. 16). The latter patients are at risk fwallowing dysfunction and subsequent aspiration[44–46].

C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352 349

Fig. 14. Pseudoleak from esophagogastric anastomosis. (A) Initial spot im-age from study with water-soluble contrast agent shows apparent extralumi-nal collection of contrast material (arrows) abutting esophagogastric anasto-mosis. (B) Repeat view after administration of barium with patient in recum-bent position shows end-to-side esophagogastric anastomosis (small arrows)with more complete filling of proximal pouch (large arrows) of intrathoracicstomach. This patient did not have a leak.

3.2.2.2. Chronic.Delayed postoperative complications af-ter esophagogastrectomy and gastric-pull through include al-kaline reflux esophagitis, benign anastomotic strictures frompostsurgical scarring or alkaline reflux esophagitis, recur-rent tumor, aspiration, and fistula formation between theesophagus and adjacent mediastinal structures secondaryto recurrent tumor or radiation therapy[44,47]. Anasto-motic leaks have also been reported in the late postoperativeperiod[47].

Alkaline reflux esophagitis may be manifested on double-contrast studies by mucosal nodularity, thickened folds, orulceration in the distal esophagus above the esophagogas-tric anastomosis. Anastomotic strictures typically appear onbarium studies as short, ringlike areas of narrowing at the

Fig. 14. (Continued.)

Fig. 15. Mediastinal abscess due to intrathoracic leak from esophagogastricanastomosis after esophagogastrectomy and gastric pull-through. Contrast-enhanced CT shows rim-enhancing extraluminal collection (large arrows) inright posterior mediastinum, containing fluid and gas. Note how collection isposterolateral to intrathoracic stomach (small arrow). Previous studies withwater-soluble contrast material showed a leak from right side of esopha-gogastric anastomosis as the cause of this collection.

350 C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352

Fig. 16. Narrowing of intrathoracic stomach by esophageal hiatus of di-aphragm. Right lateral spot image from barium study shows marked narrow-ing (arrow) of distal end of intrathoracic stomach where it crosses esophagealhiatus of diaphragm, causing delayed emptying of barium.

esophagogastric anastomosis (Fig. 17), whereas stricturesfrom alkaline reflux esophagitis appear as longer segments ofsmooth, tapered narrowing in the distal esophagus (Fig. 18).When strictures develop, a jet of barium sometimes can beseen streaming through the anastomosis into the intrathoracicstomach, also known as a “jet phenomenon,” an indirect signof narrowing at the esophagogastric anastomosis (seeFig. 17)[48].

In contrast, eccentric anastomotic narrowing with associ-ated mass effect should suggest recurrent tumor[44]. CT canalso be used to evaluate for local tumor recurrence as wellas distant metastases. Recurrent tumor may be manifested onbarium studies or CT by a soft tissue mass in the mediastinumcausing an extrinsic impression on the intrathoracic stomach[49].

3.3. Total gastrectomy and esophagojejunostomy

Total gastrectomy and esophagojejunostomy are per-formed for surgical treatment of both benign and malignantgastric diseases, including proximal gastric carcinomas andsevere gastric dysmotility[50,51]. The reported postopera-tive morbidity and mortality and 5-year survival rates of totalgastrectomy for gastric carcinoma are similar to those of par-tial gastrectomy[14,52].

3uity

m sto-m geonss from

Fig. 17. Benign stricture at esophagogastric anastomosis. Spot image frombarium study shows focal, symmetric narrowing (long arrow) at esopha-gogastric anastomosis due to postsurgical scarring. Note “jet” phenomenon(short arrows) due to streaming of barium through narrowed segment.

the jejunojejunal anastomosis to minimize reflux of bile andpancreatic secretions into the esophagus. A proximal jejunalpouch often is created near the esophagojejunal anastomo-sis[53]. Both the esophagojejunal anastomosis and proximalsmall bowel can be readily evaluated on barium studies. How-ever, barium often does not reflux across the enteric anasto-mosis, limiting visualization of the Roux limb. The esophago-jejunal anastomosis and proximal jejunal stump both can beidentified on CT.

3.3.2. Postoperative complications3.3.2.1. Acute.Anastomotic leaks and transient anastomoticnarrowing (usually related to postoperative edema andspasm) are the most common early complications after to-tal gastrectomy and esophagojejunostomy[8,54]. The preva-lence of anastomotic leaks ranges from 11–12%, and as manyas one-third result in postoperative deaths[8,54]. Anasto-motic leaks are most often located at the esophagojejunalanastomosis (Fig. 1) or, less commonly, at the jejunojejunalanastomosis or blind-ending jejunal stump[55].

.3.1. Postoperative anatomyAfter a complete gastric resection, intestinal contin

ost commonly is restored with a Roux-en-Y type anaosis between the esophagus and jejunum. Most sur

eparate the esophagojejunal anastomosis at least 40 cm

C.A. Woodfield, M.S. Levine / European Journal of Radiology 53 (2005) 341–352 351

Fig. 18. Alkaline reflux-induced stricture in distal esophagus. Spot imagefrom barium study shows smooth, tapered segment of narrowing (arrows)in distal esophagus above esophagogastric anastomosis after esophagogatrectomy and gastric pull-through.

3.3.2.2. Chronic.Delayed postoperative complications af-ter total gastrectomy and esophagojejunostomy includejejunoesophageal reflux (with or without alkaline refluxesophagitis), esophageal strictures, anastomotic narrowingsecondary to benign strictures or recurrent tumor, and af-ferent loop obstruction. Delayed anastomotic leaks may alsobe detected for the first time on contrast studies performed aslong as 7 months after surgery[8].

Reflux of bile and pancreatic secretions from the jejunuminto the esophagus can result in the development of severealkaline reflux esophagitis. Barium studies may reveal thick-ened, nodular folds or ulceration in the esophagus[8]. ARoux-en-Y reconstruction decreases reflux of bile into theesophagus but does not entirely eliminate this complication,so alkaline reflux esophagitis can also develop in these pa-tients[8,56].

Stricture formation at the esophagojejunal anastomosismay be caused by postsurgical scarring, alkaline refluxesophagitis, or recurrent tumor[50]. Benign strictures atthe esophagojejunal anastomosis typically appear on barium

studies as smooth, tapered segments of symmetric narrowing.In contrast, irregular, eccentric narrowing should be worri-some for recurrent tumor, necessitating endoscopy for fur-ther evaluation[8]. CT may also reveal recurrent tumor atthe esophagojejunal anastomosis (manifested by asymmetricwall thickening) or evidence of metastatic disease outside thegastrointestinal tract.

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