PICTORIAL ESSAY

Roux-en-Y gastric bypass: major complications

Marina Andres,1 Marta Perez,1 Jose Roldan,1 Susana Borruel,1 Javier de la Cruz Vigo,2

Javier Azpeitia,1 Elena Alvarez,1 Roberto Carrera,1 Veronica Munoz1

1Department of Radiology, Hospital 12 de Octubre, Av Cordoba, Madrid, Spain2Department of Gastrointestinal Surgery, Hospital 12 de Octubre, Madrid, Spain

Abstract

Learning objectives: To describe normal anatomy ofRoux-en-Y gastric bypass (GBP) surgery. To know thespectrum of major complications, time of appearanceand imaging findings.Background: Roux-en-Y GBP surgery nowadays repre-sents a successful treatment of morbid obesity. FromJanuary 1999 to June 2005, 148 patients with Roux-en-YGBP surgery have been reviewed. Within a period of 24–72 h after surgery, upper gastrointestinal series wasperformed. The radiographic manifestations of normalanatomy and follow-up major complications are illus-trated in this pictorial essay. We compare the CT andother imaging findings with clinical and surgical findings.Imaging findings: A total of 14 follow-up major compli-cations occurred in 9 of 148 patients. Only 3 were earlycomplications, the other 11 were late and appearedbetween 1 month and 4 years. Imaging findings ofstomal stenosis, gastric staple line dehiscence, leaks,jejunal and gastric wall necrosis, small bowel obstructiondue to adhesions, loculated fluid collection and celiactrunk stenosis are illustrated.Conclusion: It is important for the radiologist to befamiliarized with the radiographic manifestations ofnormal anatomy and major complications after Roux-en-Y GBP. These may be life-threatening and usuallyappear as late complications. An adequate imagingtechnique and a prompt evaluation by the radiologistcan help to minimize them.

Key words: Morbid obesity—Roux-en-Y gastricbypass—Surgical anatomy—Major complications

Morbid obesity (MO) is a chronic disease with anincreasing prevalence. MO is defined as a body massindex (BMI) of 35 kg/m2 or 40 kg/m2 with and withoutcomorbidity, respectively [1]. Severe obesity is associatedwith several morbidities such as sleep apnea, hyperten-sion, coronary heart disease, type 2 diabetes, degenera-tive joint disease, some types of cancer and earlymortality.

The international criteria accepted for bariatric sur-gery after the failure of a non-surgical approach arethose patients with BMI > 40 kg/m2 or BMI 35–40 kg/m2 that are associated with some of the diseases men-tioned above [2].

Roux-en-Y GBP surgery nowadays represents a suc-cessful treatment for MO that achieves good long-termresults.

Therefore, it is very useful for the radiologist tounderstand the surgical techniques for MO treatment.

This pictorial essay reviews the normal anatomy ofRoux-en-Y gastric bypass (GBP) surgery, the spectrumof major complications, the time of appearance, andimaging findings.

Discussion

The Roux-en-Y GBP is a combination of restrictive-malabsorptive procedures, which allows a more persis-tent weight loss but has irreversibility as a drawback[5].

This bariatric procedure was first introduced byMason and Ito in 1967 and involves (a) the creation of asmall gastric pouch of 15–20 mL; (b) the division of thesmall bowel distal to the ligament of Treitz; and (c) thedistal segment is brought up to the pouch antecolic orretrocolic through the transverse mesocolon (Fig. 1) tocreate the gastrojejunostomy (<15 mm diameter); theRoux limb can be short (<100 cm) or long (>100 cm)and is connected as well as the biliopancreatic limb (thedefunctionalized stomach, duodenum and variablelength of jejunum), by either a stapled or a suturedjejunojejunostomy [3–5].Correspondence to: Marina Andres; e-mail: martape@ozu.es

ª Springer Science+Business Media, LLC 2007

Published online: 15 September 2007AbdominalImaging

Abdom Imaging (2007) 32:613–618

DOI: 10.1007/s00261-006-9086-z

From January 1999 to June 2005, 148 patients withRoux-en-Y GBP surgery have been reviewed. Within aperiod of 24–72 h after surgery, upper gastrointestinalseries (UGS) was performed in all of them before dis-charge (Fig. 2) to exclude anastomotic leaks.

The anatomy after Roux-en-Y GBP visualized by CTscans offers the possibility to depict more clearly theimportant structures (Fig. 3).

The radiographic manifestations of normal anatomyand follow-up major complications, which are those thatrequire surgical or radiologic intervention, are illustratedin this exhibit. We compare the CT and other imagingfindings with clinical and surgical findings.

A total of 14 follow-up major complications occurredin 9 of 148 patients. Only three were early complications,the other 11 were late complications and appeared be-tween 1 month and 4 years, most of them approximately1 year after surgery.

1. Stomal stenosis (n = 3). Stenosis of the gastric pouchoutlet was diagnosed between 1 month and 3 yearsafter surgery. All of them appeared as late complica-tions and were diagnosed by UGS which showed de-layed passage of a contrast material and were treatedby endoscopic dilatation (Figs. 4, 5).

2. Gastric staple line dehiscence (n = 2). When subopti-mal weight loss, sensation of satiety and emesis ap-pear, gastric staple line disruption must be suspected.This complication appeared 3 years after surgery (latecomplication). UGS was the method of choice for thediagnosis which was surgically proved and treated(Fig. 6).

3. Leaks (n = 2). UGS with water-soluble contrastmedium 24–72 h after surgery have an important rolein the depiction of extraluminal collections of thecontrast material from the gastrojejunal anastomosis(Fig. 7). CT is the other imaging method that permitsa prompt diagnosis; some investigators have reportedsurgically proven fistulas or leaks that were missed atUGS [1] and because of the potential complications,such as peritonitis, CT may be the best imagingmethod if fistula is suspected. The leaks to peritoneumwere repaired with the laparotomy approach.

4. Jejunal and gastric wall necrosis (n = 5). Several fac-tors may be the trigger of obstruction and secondarynecrosis: obstruction at enteroenterostomy due toedema, adhesions, or even internal hernias may causedistention and gastric, pancreatobiliary limb or jeju-nal wall necrosis (Figs. 8, 9), as well as staple linedisruption or leaks. Internal hernias usually develop

Fig 2. Schematic of Roux-en-Y GBPanatomy with corresponding appearance atupper GI study obtained with water-solublecontrast: 1 gastric pouch of 15–20 mL; 2staple line; 3 polypropylene band; 4 stapledgastrojejunostomy; 5 defunctionalizedstomach; 6 duodenum; 7 150 cm limbbypass; 8 blind loop; 9 Roux limb; 10 side toside anastomosis between distal small boweland Roux limb.

Fig 1. Schematic representation of Roux-en-Y Gastric bypass.

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later than adhesions with times of appearance re-ported of 289–825 days [1]. CT is the imagingmodality of choice and percutaneous decompressionmay be enough, whereas surgery is usually needed.

5. Loculated fluid collection (n = 1). These can be re-lated or unrelated to leaks (Fig. 10), secondary to thesurgical procedure. The time from surgery to diag-nosis is variable but most cases appear as early com-plications. CT plays an important role in the diagnosisand treatment as a drainage guidance.

6. Celiac trunk stenosis (n = 1). The median arcuateligament unites the diaphragmatic crura on eitherside of the aortic hiatus. It usually passes superior tothe origin of the celiac axis. Compression of the ce-liac axis by this ligament is referred to as celiac ar-tery compression syndrome or median arcuateligament syndrome, and it has been reported tocause intestinal angina (Fig. 11). This syndrome isnot a direct consequence of bariatric surgery, butsince the crura are outlined by fat, their position maybe influenced by the decrease in fat. The diagnosis ofceliac artery compression is traditionally made byusing conventional angiography, but thin-sectionmultidetector computed tomography and three-dimensional imaging techniques have the ability toobtain detailed images of the mesenteric vessels non-invasively [6–8].

Conclusion

It is important for the radiologist to be familiarizedwith the radiographic manifestations of normal anat-omy and major complications after Roux-en-Y GBP.These may be life-threatening and usually appear as latecomplications. An adequate imaging technique and aprompt evaluation by the radiologist can help to mini-mize them.

Fig 4. A 30-year-old woman with dysphagia and vomiting3 years after bypass surgery. Upper gastrointestinal radio-graph demonstrated a rounded and distended gastric pouch,stricture at gastrojejunal anastomosis (arrow) and delayedpassage of the contrast material. Endoscopic balloon dilata-tion was successfully used.

Fig 3. Transverse contrast-enhanced CTimages in a 37-year-old woman 1 month afterRoux-en-Y GBP. Patient presented withconstipation for a period of 10 days. Therewere no pathologic findings. A A small gastricpouch (red arrow) and defunctionalizedstomach (red star) and gastric staple linebetween them (white arrow). Blind loop(curved arrow). B Side to side anastomosis(black arrow) between Roux limb (yellowarrow) and gastric pouch. C Efferent loop thatis antecolic (passes through the transversemesocolon). D Decompressed horizontalduodenum (white star).

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Fig 6. A UGS obtained 3 years afterRoux-en-Y GBP in a 32-year-old woman.The patient presented with vomiting andintolerance to food. Adjacent to the Rouxlimb linear contrast images are seen(arrows). Gastric staple line dehiscence wasproved after laparotomy. B One year laterthe same patient with sensation of satiety.UGS shows disrupted staple line (blackarrow). Staple line (open arrow), small leak(white arrow), air image corresponding tothe excluded stomach (circle).

Fig 5. Upper GI series (UGS) in a 28-year-old woman withanastomotic stricture. A After swallowing sips, adequate passof barium meal to the gastric pouch (black arrow) can beseen. B Distention of gastric pouch and delayed passage ofthe contrast material, which makes the visualization of the

anastomosis between gastric pouch and Roux limb difficult.Staple line (arrows) and air–fluid level lateral to gastric pouchcorresponding to excluded stomach (large arrow). C Finally,the contrast material enters the Roux loop (red star) includingthe blind end (black star).

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Fig 8. Transverse enhanced CT scan 11 months afterRoux-en-Y GBP in a 24-year-old woman with acute gastricand pancreatobiliary limb distention who entered with perito-nitis. Surgery proved gastric and jejunal wall necrosis due toadhesions and required resection. A Staple line (arrow), Rouxlimb (open arrow), dilated excluded stomach with air in the

wall (red arrow). B Horizontal part of the duodenum (star),dilated jejunum as part of the pancreatobiliary limb (red star).C Ascending and descending colon (arrows), jejunojejunalanastomosis (curved arrow), non-distended Roux limb (blackarrow) and jejunum as part of the pancreatobiliary limb (redarrows).

Fig 7. A Control UGS after Roux-en-Y GBPin a 26-year-old man demonstrates a leak(open arrow) from the anastomosis.P = gastric pouch. R = Roux limb.D = Jackson–Pratt drain. B A 44-year-oldman with clinical deterioration 1 week afterbariatric surgery. UGS shows extravasation ofthe contrast material (open arrow) andsubphrenic extraluminal air adjacent to it(solid arrow). Staple line (curved arrow). Alarge hematoma in the lesser sac and a smallleak from the gastrojejunal anastomosis werefound at surgery.

Fig 9. Enhanced CT in a 29-year-old woman with abdominalpain. A and B CT scan shows the U-shaped loop (U) with fluidin the mesentery (F). The beak sign is seen at the obstructedsite (arrow). C Coronal reconstruction depicts the entire

U-shaped loop at the place of the jejunojejunal anastomosis(arrow). Surgery revealed a necrotized closed-loop smallbowel obstruction. Resection was required.

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References

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6. Horton KM, et al. (2005) Median arcuate ligament syndrome:evaluation with CT angiography. Radiographics 25:1177–1182

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Fig 10. A 58-year-old woman withabdominal pain and fever 11 days after thediagnosis and surgical treatment of a smallleak of the gastrojejunal anastomosis. AEnhanced transverse CT scan shows twofluid collections (F) containing air–fluid levels,one located in abdominal wall, the otheradjacent to gastrojejunal anastomosis (openarrow). B They were drained using CTguidance with a pig-tail catheter (arrow).

Fig 11. A Lateral and B left anterior oblique angiographyprojections in a 25-year-old woman 2 years after bariatricsurgery. The red arrows mark the focal narrowing in theproximal celiac axis, which has a characteristic hookedappearance that can help distinguish this condition from other

causes of celiac artery narrowing, such as atheroscleroticdisease. There were no pathologic findings in mesentericangiography. No collateral vessels were seen. C The com-plication was treated by balloon dilatation (the notch ismarked by the white arrow ).

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