Postoperative defects of the stomach

Postoperative Defects of the Stomach By H. Joac~/t~ BURI-tENNE,M.D. F YOU KNO w YOUR MUSHROOMS, you can recognize a ehampignon anywhere (1,ig. 1). Surely, then, if you know gastric surgical procedures, you should be able to identify at least some of them radiographically. The importance is obvious: the scars and deformities of past surgery can closely simulate serious, presently active lesions. In the following discussion, a variety of these operations and their roentgen appearance is presented. The scar of a simple clos, re of a perforated gastric ulcer or of a local excision of a benign gastric lesion, is detected with difficulty roentgenographically on follow-up studies (Figs. 2 and 3). Oversewing an ulcer may result in a localized invagination of the gastric wall. Pastremoli noted a small figure 3 type defonnity-at the site of suture in 3 of 50 patients with surgical closure of a perforated ulcer 10. ~r Early postoperative studies showed a persistent crater of the sutured or invaginatcd ulcer to be responsible for a defect. These minor irregularities in the contour of the gastric wall disappear as time passes. Norberg reviewed over i00 ~a.'sos,- 5 years after simple closure of perforated peptic ulcer and was unable to detect any ror abnormality in a single case. is Weclgc a , d slee~;e resection involves a larger portion of the gastric wall and usually leaves a permanent deformity detectable on roentgen studies (Fig. 4), partic:t~larly if the g~.stric wall has been inverted with a two-layer closure, the surgical technique most commonly used for all types of gastrointestinal anastomoses, z'~ In effect, it is one outer laver of serosal sutures and one inner layer of sutl~rt's along the inverted mucosa /.Fig. 5). Because of the sequence of sut~ring ancl the surgical oric;ntation, the surgeon refers to two posterior layers and two anterior layers of sutures, us~ally interrupted. If one layer is done with continuous suturing, more pronounced deformity and contraction may result. 29 It is tl~e inversion of the gastrointestinal wall at the anastomosis that is responsil)le for the marginal (but really circular) filling defect seen roentgenogr~lphically. Gastrostomy ~suallv involves the anterior gastric wall close to the greater cur~'att~rc, which is art:ache.el to the anterior abdominal wall with a few sutures. Aft(,r the ('atheter is witllclrawn, the gastrostomy closes but the stomach remains attach,,cl to the abdominal wall. This anterior deviation is best seen radiograpl~i(,allv witl~ the patient in (,rc'ct lat(,ral position. Localizecl tenting may l~rsixt at th(: .t~:t.~trostomy site (Fig. 6). Cov~tra('tion of th(' .f~astric :~rvtrtvm ~n(l antropyloric muscular hypertrophy in patients with lcm~;-t(rrm ,,z,astroe~tero.s-tom?t we're first described by Wolf. ~-r.~ tlair (.t al. rel~ortc(1 13 lmtic'nts with surt~ical eonfirmatiov~ of these roentgen

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I~OSTOPEI'tATIVE DEFECTS

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findings 5 to 12 years after gastroenterostomy. I1 They discount the possibility o~ preexisting muscular hypertrophy by the higher incidence in the gastroenteros-

tomy group (13 of 132) than in randomly selected patients (21 of 6546). Localized deformity at the gastroesophageal junction varies with the different types of hiatus hernia repair. Hiatus hen~iorrhaphy involves approximation of

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Fig. 2.-Greater curvature defect :3 weeks after simple closure of a pedorated ulcer. This is a barium-filled surgical specimen of the stomach with gastroenterostomv after total gastreetomy." The inversion defect eot,ld not be detected on postol~ratire GI series.

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1 Fig. 3.-Surglcal sear. A. Irregular peristaltic contraction on greater curvature 2 years after local excision of leiomyoma. B. Barium-injected specimen after total gastrectomy for suspicion of carcinoma shows an area of fibrosis and thickening at the site of the previous surgery. (The pylorus has been retouched.)

the crura of the diaphragm at the hiatus With sutures passing from the medial crus through the muscular layer at the esophagogastrie junction to the lateral crus. The sutures often do not hold and various deformities result from recurrence of gastric hiatus hernia and scarring at the operative site (Fig. 7). Because deformity after hiatus hernia repair may simulate tumor, the advisability of routine postherniorrhaphy roentgen examination as a baseline study has been emphasized. 7

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Fig, 5.-Infolding at the gastroduodenostomy after resection and two-layer closure.

Fig. 6.-Localized tenting at gastrostomy site several years9 after withdrawal of the ga'strostomy catheter.

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Fig. 10.-The beagle ear sign (small arrows) after pyloroplasty. A and B. The greater cla'vature before and after surgery. C. Recurrent ulcer in another patient (large arrows).

Lateral roentgenograms show tile anterior deviation of the stomach due to gastropexy to the anterior abdominal wall in tile Nissen I procedure. The Nissen II techniqlle is primarily designed to prevent gastroesophagcal reflilx. The gastric fundus is plicate
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Fig. 1 l.--Three different types of lcsser curvature closure after partial gastric resection.

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Fig. 12.-Lesser curvature defect robsequent to gastroduodenmtomy and vagotomy. Clips indicate the lesser curvature closure adapted to the duodenal diameter.

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Fig. 18.-(;astrojejunal prolapse through the end-to-side gastrojejunostomy. The margins of the prolapsing mucosa at the stoma (arrows) are sceu in air (A) and barium contrast (B).

achalasia and consists of an anterior vertical incision of tile muscle at the cardia. Bulging mucosa at the point of incision may result in a pseudodiverticulum or pseudocrater s (Fig. 9A). In principle, pyloromyotomy (Fig. 9B) is tile same as esophagocardiomyotomy. Although the ,nuscular incision is also left open in this procedure, no pseudodiverticulum of the mucosa occurs. This operation (Ramstedt) is performed for hypertrophic plyoric stenosis. Narrowing of the pyloric canal typically persists on postoperative roentgen studies even though the gastric emptying is greatly improved. The decision to do a second operation should, therefore, never be based on the roentgen findings alone. 1 In one study of ~5:3 radiographic examinat!'ms, the pyloric deformity persisted in 13 per cent of medically or surgically treated patients, in some even after puberty, za The beas'te car sign may occur after the Heineke-Mikulicz pyloroplasty, ( Figs. 9C and 10). A longitudinal muscular incision on the anterior aspect of the pyloric ring is made anti the layers are closed in a vertical direction. The resulting pseudodiverticulum 4 with slight constriction on both its antral and dllodenal sides has since been confirmed in cadavar studies. ''4 Cincradiography is useful in differentiating postpyloropLasty pseudodivertfculum from l~lt:er crater. 2.u Recurrent ulcer can usually be recognized in the presence of pyloroplasty deformity 2s,:za (Fig. I012). Plication deject of the h:sser curvature is eornmonly seen after gastroduodenostomy and gastr~jcj~In~strm, y. This s~-calletl Ilolmeister de[t'r is dtw tc~ partial closure of the lesser curvature aspect of the cut end of the stomach in order to facilitate a stoma of no more than two or three f, ngerbreadtlas (Fig. 11 ). The twt~-laver closl,rc uf tlJ~. h:s:;er c,~rvature r~'slllts in a filling defect

190

II. JOACHIM BUI~IIENNE

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intussusception. A. Arrows indicate the racliolucent stripe bordering the rounded radiolucent filling defect in the gastric pouch caused by the doubled wall of the intussuscepted jejunum. B. Outlines indicate retrograde jejunogastric intussusception of the distal (efferent) jejunal limb."

proximal to the anastomosis which may extc3nd to the eardia (Fig. 12). If continuous suture is used, the lesser curvature closure may also result in a pseudodiverticulum deformity (Fig, 18). Plication defects after Hofmeister closure should not occur above tile carclia 19 (Fig. 14) or on the greater cu~'ature. s Postoperative baseline roentgen studies are always indicated and will avert later errors in interpretation. Early postoperative submucosal hemorrhage at the site of anastomosis may result in outlet obstruction. It must be differentiated from plication defect and jejunogastric intussusception. Intramural hematoma of this type usually subsides within I0 days (Fig. 15). Gastrojejunal.prolal~se may b~" the early stage of intussttsception. Prolapse involves the mucosal layer only, wtlereas intussusception indicates invagination of the entire wall of the viscus. Prolapse and intussusception may occur at any gastric anastomosis, with or without gastric resection, and may be antegrade or retrograde. Prolapse may be gastrojejunal l~ (Fig. 16) or gastroduodcnal.- and may be progressive zl and symptom~tic, la

191

I~OSTOPEBATIVE DEFECI'S

Intussusception is usually intermittent (Fig. I7). The antegrade intussusciptens is usually the distal (efferent) jejunal loop.~ A true s~rgical emergency exists if the retrograde jeiunogastric intussusception becomes incarcerated. Roentgen studies are diagnostic vehen they show enlarged valvulae conniventes of the intussusceptttm within the gastric pouch.

REFERENCES 1. Bishol~, H. G., and Hope, J. W,: Pylorie ficu]t~ de l'intcr|)ret~tion de ]a position du stenosis: postoperative roentgen studies and cardia aprils l'intervention de Nissen. Ann. their clinical significance. J. Pediat. 60:62, Radiol. 12:173, 1969. 13. LeVine, M., Boley, S. J., Mellins, l:I. 1962. 2. Bloch, C., and Wolf, B. S.: The gas- Z., and Schwartz, S. S.: Gastroiejunal mu.. troduodenai channel after pyloroplasty and cosal prolapse. R;~dio]ogy 80:30, 1063. vagotomy: a ci~eradiographic study. Radiol14. Nakayama, K.: Atlas of Gastrointesogy 84:43, 1965. tinal Surgery. Philadelphia, I,ippincott, 19{.~8. 3. Bradford, B., Jr., and Boggs, J. E.: 15. Norberg, P. B.: Results of the surgical Jejunogastric intussusception-an unusual treatment of perforated peptic ulcer: a clincomplication of gastric surgery. Arch. Surg. ical and roentgenological study. Acta Ch~'. 77:201, 1958. Scand. Suppl. 249:1, 1959. 4. Burhenne, H. I.: Roentgen anatomy 16. Pastremoli, A.: Osservasioni radioland terminology of gastric s~rgery. Amer. J. ogiche dopo intervento di sutura per uleera Roentgen. 91:731, 1964. gasfioduodenale perforata. Radiol. Med. 5. Burhenne, II. J.: The postoperative (Tori,m) 50:593, 1964. stomach. In ~lart~ttlis, A. R., and Bt;rhenne. 17. ~astrcmoli, A.: Sul significato delrimH. J. (Eds.): Alimentary Tract Roentgenol- magine di plus che talvolta :,i ris~xmtra dopo ogy, Vol. 1. St. Lo~s, Mosby, I967, p. 565. iniervento di sutura per ulcera gastroduo, 6. Cohen, W. N.: The fundoplication re- denale perforat;~. Minerva Radio]. 93:357, pair of sliding esophageal hiatus hernia: its 1904. roentgenographic al)pearance. Amer. J. ]8. Poppel. M. It.: (,~lstric inlussuscepRoentgen. 104:625. 1968. tions. Radiology 78:602. 1962. 7. Dietz, M. W.: Pseudot,moral post19. Pr6vot, R.: Uber Beutel, Tnschen und herniorrhaphy deformity. Amer. J. Itoentgen. Biirzel nm operierten Magen. R/JrdRenpraxis 107:81, 1969. 5- 101, 1933. 8. Fogel, M.: Rtintgenologische Ver~inde20. Reyelt, W. P., Jr.. and Anderson, A. rungen an der Kardiz n;~ch Osophzgofundoo A.: Rctrogracle jeiunog:istric tntus~~L~t:cption. stomie. Radiol. Clin. (Basel) 34:254, 1965. St~rg. f':)'nec. Obstet. 119:1305, 1904. 9. Glet~;on, ].. and Ellis, It.: Vagotomy 21. Sh;me, M. D., Amberg, J. I1., and and pyloroplasty: a eineradiographic study, Szemes. G.: Castrojejunal rnucosal prolap~ Amer. ]. Dig. Dis. 14:84, 1969. ;dter .,ul~t,~lai g~l~trect,ulj}.. C.dit'..~led. | 1 I: 10. Grimoud, M., Moreau. G., and Le- 177, 19619. mozy, J.: Le prolapsus post-op~'ratoire trans22,. Sire, G. i'. G.: (';a.~tro-duoden,tl muo anastomotique de la rnuqueuse gastrique. co,;;~l plolapse aflcr Billrolh I gilslrcclomy. Arch. Mal. Appear. Dig. 53:649, 196,1. Brit, Med. J. 1:I517, 1.960. 11. ltajdu, N., ltyde, 1.. :~n<| Ridtlell. V.: :23. S~einicke. O., ~nd l~t~el~gaard, M.: Antro-pyloric hypertrophy in palienls with Radiogr.lphic follow-up in hypertrophic longstanding g;~stro-enterostomie~. Brit. J. Radiol. 11 :-I.~. 196,~. treatment). Acta P~ledi;d. (Upp~) 49:4, 12. I.abrune, M., Fortier-13ea,lieu, M.. 19(}0. Tremhlay, D., and C,)idlu~t, D.: De la dif-

192 24. Toye, D. K. M., HUtton, I. F. K., and Williams, I. A:: Badiological anatomy after py!oroplasb/. Gut 11:358, 1970. 25. Williams, J. A., and Toye, D. K. M.: Recurrent ulcer after vagotomy and~pyloroplasty: the x-ray appearances and their value in diagnosis. Gut 11:405, 1970. 26. Wilson, W. J., and Weintraub, H. D.: The postpyloroplasty antrum. Amer. J. Roentgen. 96:408, 1966. 27. Wolf, B. S.: Multiple antral erosions

H. JOACHIM BUBHENNE with massive bleeding 11 years after gastroenterostomy for , hypertrophic pyloric stenosis of the newborn. Case 81. J. Mount Sinai Hosp. N.Y. 26:390, 1959. 28. Wolf, B. S.: Contracted autrnm 20 years post-gastroenterostomy. Case 82. J. Mount Sinai Hosp. N.Y. 28:40'2, 1959. 29. ZoLlinger, R. M., and Cutler, E. R.: Atlas of Surgical Operations, Vol. 1 (ed. 3). New York, Macmillan, 1961, p. 73.