Korean J Radiol.  2015 Apr;16(2):325-333. 10.3348/kjr.2015.16.2.325.

Mini-Gastric Bypass to Control Morbid Obesity and Diabetes Mellitus: What Radiologists Need to Know

• Park HJ
• Hong SS
• Hwang J
• Hur KY

• KMID: 2070176
• DOI: http://doi.org/10.3348/kjr.2015.16.2.325

Abstract

Laparoscopic mini-gastric bypass surgery is a safe and simple surgical intervention for treating morbid obesity and diabetes mellitus and is now being performed more frequently. Radiologists must be critical in their postoperative evaluation of these patients. In this pictorial review, we explain and illustrate the surgical technique, normal postoperative anatomy, and associated complications as seen on imaging examinations, including fluoroscopy and computed tomography.

Keyword

Mini-gastric bypass; Type 2 diabetes mellitus; Bariatric surgery; Diabetes surgery

MeSH Terms

Adult
Anastomotic Leak/epidemiology
Cholelithiasis/epidemiology
Constriction, Pathologic/epidemiology
Diabetes Mellitus/*therapy
Female
Fluoroscopy
Gastric Bypass/*methods
Hemorrhage/epidemiology
Humans
Laparoscopy
Male
Middle Aged
Obesity, Morbid/*surgery
Stomach/radiography/surgery
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Illustration of laparoscopic mini-gastric bypass. Mini-gastric tube is mounted parallel from angle of His to 2 cm proximal to pylorus along lesser curvature. Anchoring suture is used for acute angulation, and antecolic side-to-side gastro-jejunostomy is formed 200 cm distal to Treitz ligament. Bypassed segment is denoted by gray zone.

• 

  Fig. 2 Normal upper gastrointestinal series on postoperative day 1. A. No obvious contrast leakage or luminal narrowing is seen at side-to-side gastro-jejunostomy site (arrows). Afferent loop is not typically detected, and faint staple lines (arrowheads) are detected along gastric curvature. B. Image in another patient shows afferent loop (curved arrow) partially and multiple clips (arrows) with faint staple lines to prevent bleeding. E = efferent loop

• 

  Fig. 3 Computed tomography (CT) scans after mini-gastric bypass surgery. Cranial to caudal CT scans reveal remnant stomach (S) and bypassed segment (B). Gastro-jejunostomy (A) and distal loop (E) are anterior to transverse colon (C). Third duodenum (*) is marker to identify afferent loop. Staples for gastric separation are indicated by white arrows, and side-to-side gastro-jejunostomy is indicated by black arrow.

• 

  Fig. 4 Formation of hematoma in 31-year-old woman with decreased hemoglobin level. Pre-contrast computed tomography scans reveal high density fluid (arrows) (mean, 58 Hounsfield units) around remnant stomach (S) adjacent to staples without extravasation. Bleeding was spontaneously controlled. B = bypassed segment

• 

  Fig. 5 Anastomotic narrowing in 37-year-old man. A. Remnant stomach was distended on upper gastrointestinal series due to passage disturbance on postoperative day 1. String-like narrowing at gastro-jejunostomy (arrow) was probably caused by postoperative edema. Follow-up X-ray 4 hours later shows unimpeded passage of contrast agent into large intestine (not shown). B. Follow-up coronal computed tomography scan after 3 months reveals improvement in narrowing of gastro-jejunostomy (arrows) and no evidence of complications. E = efferent loop, S = remnant stomach

• 

  Fig. 6 Anastomotic stenosis in 49-year-old woman with postprandial abdominal pain 6 months postoperatively. Axial computed tomography scans reveal distension of remnant stomach (S) and narrowing of gastro-jejunostomy (arrows), suggesting anastomotic stenosis. B = bypassed segment

• 

  Fig. 7 Formation of abscess in 53-year-old woman with fever on postoperative day 15. Axial (A) and coronal (B) computed tomography scans show rim enhancement and loculated fluid (*) around pancreas with adjacent fat stranding. Percutaneous drainage with catheter produced odorous abscess. B = bypassed segment, S = remnant stomach

• 

  Fig. 8 Anastomotic leak in 46-year-old man with abdominal pain on postoperative day 7. A. Upper gastrointestinal series on postoperative day 1 shows edematous changes in gastro-jejunostomy (black arrows) without obvious contrast agent leak or passage disturbance. B, C. Axial (B) and coronal (C) computed tomography scans obtained on postoperative day 7 reveal air containing fluid (white arrows) adjacent to anastomosed site (black arrows) and ascites around lesion and left paracolic gutter. A = afferent loop, E = efferent loop, S = stomach

• 

  Fig. 9 Wound complications in 46-year-old man who underwent additional Roux-en-Y gastric bypass jejunostomy to treat leak. A. Computed tomography (CT) scan obtained on postoperative day 37 reveals direct connection (arrow) between remnant stomach and subcutaneous tissue, presenting as gastro-cutaneous fistula. Curved arrow = gastrojejunostomy. B. CT scan obtained on postoperative day 97 reveals wound dehiscence (arrows) and skin thickening. Intra-abdominal abscess (A) and mesenteric fat infiltration with peritoneal thickening are seen with secondary edematous changes in bowel loops. S = remnant stomach

• 

  Fig. 10 Marginal ulcer perforation in 65-year-old woman with sudden abdominal pain 1 year after surgery. Axial computed tomography scans reveal focal wall defect (arrows) in efferent loop (E) just below gastro-jejunostomy (A) with pneumoperitoneum (*), associated with edematous wall thickening in remnant stomach (S) as well as efferent loop with mesenteric haziness. B = bypassed segment

• 

  Fig. 11 Acute cholecystitis in 62-year-old woman with upper abdominal pain 1 year after surgery. A. Abdominal ultrasonography reveals sandy stones and sludge (curved arrow) in distended gall bladder (GB) with wall thickening. B. Computed tomography scan on same day shows distended GB with wall thickening and hyperemia (arrows) of adjacent liver.

• 

  Fig. 12 Spontaneous perforation in bypassed segment of 39-year-old man with generalized abdominal pain 8 months after surgery. Axial (A, B) and coronal (C) computed tomography scans show focal edematous wall thickening and suspicious wall defect (arrows) in upper greater curvature of bypassed gastric segment (B), which was away from staples, with abscess forming (*) around lesion, presumably peptic ulcer with perforation that was surgically proven. S = remnant stomach

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