CT Findings in the Abdomen and Pelvis After Gastric Carcinoma Resection
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1 CT Findings in the Abdomen and Pelvis After Gastric Carcinoma Resection Kyeong Ah Kim 1, Cheol Min Park 1, Sang Woo Park 1, Sang Hoon Cha 1, Hae Young Seol 1, In Ho Cha 1, Ki Yeol Lee 2 G astric carcinoma is a common malignancy that results in significant morbidity and mortality. Patients who have undergone gastric carcinoma resection present challenging problems to their physicians. The radiologist is frequently asked to define the postsurgical anatomy to assess the efficacy of the procedures and to detect early and late postoperative complications. CT is valuable for documenting normal postoperative anatomy, identifying recurrences, evaluating anatomic relationships, and confirming the absence of new lesions in the abdomen and pelvis after gastric carcinoma resection. Compared with the large number of articles describing preoperative assessment of gastric carcinoma, few reports have been published on the CT findings in the abdomen and pelvis after gastric carcinoma resection. We illustrate the CT findings of normal postoperative appearance, postoperative complications, and tumor recurrence in the abdomen and pelvis. CT Technique In all patients, helical CT was performed with a single 20- to 25-sec breath-hold using a slice collimation of 10 mm and a table pitch of 1:1. The key to CT of the stomach is gastric distention, because wall thickening can be simulated by underdistention. Each patient drank 200 ml of water just before undergoing CT. Scanning was started 45 sec after the IV injection of ml of nonionic contrast agent at a rate of 3 ml/sec. Normal Postoperative Appearance A variety of procedures are used to treat gastric carcinoma. Depending on the location Fig year-old woman with nonobstructive biliary dilatation after esophagojejunostomy. Contrast-enhanced CT scan shows dilatation of peripheral (thin arrows) and central (thick arrow) bile ducts. No obstructing lesion was found in bile duct. Pictorial Essay of the tumor, a subtotal or total gastrectomy or an esophagogastrectomy may be performed. Mild dilatation of the bile ducts without mechanical biliary obstruction can be seen on follow-up CT after gastrectomy and vagotomy (Fig. 1). This nonobstructive biliary dilatation is possibly caused by altered biliary tract hormonal response or sphincter of Oddi dysfunction. If a patient has no clinical symptoms, no further evaluation is required. Surgical plications (Fig. 2) may mimic masses; this is a potential source of erroneous Fig year-old man with surgical plications mimicking recurrent tumor. Contrast-enhanced CT scan shows polypoid elevation (arrow) at anastomosis. Received August 8, 2001; accepted after revision March 26, Department of Radiology, Medical Science Research Center, Korea University Guro Hospital, 80, Guro-Dong, Guro-Ku, Seoul, , Korea. Address correspondence to C. M. Park. 2 Department of Radiology, Inje University Paik Hospital, 85, 2Ka, Jur-Dong, Chung-Ku, Seoul, , Korea. AJR 2002;179: X/02/ American Roentgen Ray Society AJR:179, October
2 Kim et al. Fig year-old man with abscess of left subphrenic space after subtotal gastrectomy. Abscess (A) is limited by falciform ligament, which prevents spread to right subphrenic space. Fig year-old woman with bezoar in stomach remnant. Contrast-enhanced CT scan shows floating inhomogeneous mass with entrapped air (arrow). Fig year-old man with incisional hernia. Contrast-enhanced CT scan shows knucklelike portion of small bowel (arrows) protruding beneath healed midline incision. Fig year-old woman with tumor recurrence near celiac axis. Contrast-enhanced CT scan shows enlarged lymph nodes (arrows) surrounding celiac axis Fig year-old woman with afferent loop syndrome after Billroth II operation. Contrast-enhanced CT scan shows massively dilated duodenum (D) posterior to superior mesenteric artery (arrow) and anterior to spine. Fig year-old man with hiatal hernia after subtotal gastrectomy. Contrast-enhanced CT scan shows herniated gastric remnant (H) through esophageal hiatus above diaphragm. Fig year-old man with tumor recurrence at anastomosis site. Contrast-enhanced CT scan shows mucosal thickening and contrast enhancement at gastrojejunostomy site (arrows). AJR:179, October 2002
3 CT After Gastric Carcinoma Resection Fig year-old man with tumor recurrence in pancreas. Contrast-enhanced CT scan shows diffuse low-attenuation mass (arrows) that is infiltrating entire pancreas. Fig year-old woman with invasion of transverse colon via gastrocolic ligament. Contrast-enhanced CT scan shows irregular wall thickening (arrows) in transverse colon. Fig year-old woman with tumor recurrence along abdominal incision. Contrast-enhanced CT scan shows inhomogeneously enhancing mass (arrow) in anterior wall of abdomen. Fig year-old man with metastatic lymphadenopathy. Contrast-enhanced CT scan shows conglomerate lymphadenopathy (N) in left paraaortic area. Fig year-old man with peritoneal seeding. A, Contrast-enhanced CT scan reveals omental metastasis. Smudged omentum with small nodules and infiltrated fat (arrows) can be seen. B, Contrast-enhanced CT scan shows perirectal drop metastasis. Note well-enhancing tumor (arrows) in pouch of Douglas. A AJR:179, October 2002 B 1039
4 Kim et al. Fig year-old woman with metastatic linitis plastica of rectum and Krukenberg s tumor of ovary. Patient underwent total gastrectomy for signet ring cell type gastric carcinoma. Contrast-enhanced CT scan shows concentric thickening (arrow) of rectal wall with target sign and infiltration into perirectal fat plane. Note right ovarian mass (K) and ascites (a). interpretation of local tumor recurrence in the gastrointestinal tract. Postoperative Complications Anastomotic Leak and Abscess Fig year-old man with ureteral metastasis. Contrastenhanced CT scan shows thickened, enhanced right proximal ureteral wall with luminal narrowing and periureteral infiltrations (arrows). Breakdown of a suture line and leakage occur at the anastomosis between the stomach and the small bowel. CT may be needed to fully define the abscess cavity (Fig. 3) and to direct percutaneous drainage. Afferent Loop Syndrome Most cases of afferent loop syndrome are caused by mechanical obstruction of the afferent loop from adhesions, kinking at the anastomosis, internal hernia, stomal stenosis, malignancy, or inflammation surrounding the anastomosis. CT plays a major role in the diagnosis of this entity, because the clinical signs and symptoms are generally nonspecific. The CT finding is a fluid-filled, dilated, transversely oriented portion of small bowel anterior to the spine in the middle of the abdomen [1] (Fig. 4). Bezoar Bezoar formation (Fig. 5) is a complication of gastrectomy, particularly when gastectomy is combined with vagotomy. Diminished peristalsis and absence of gastric acid allow poorly chewed fibrous material to be retained and form a matted mass. This complication should be suspected whenever radiologic findings show a large discrete mass of food in the partially resected stomach of a fasting patient [2]. Incisional Hernia These hernias tend to occur during the first 4 months after surgery, a critical period for the healing of transected muscular and fascial layers of the abdominal wall. CT can Fig year-old man with portal vein tumor thrombosis. Contrast-enhanced CT scan shows dilated, nonopacified main and right lobar branches of portal vein (open arrows). Biopsy-proven multiple hepatic metastases (solid arrows) are also present. show small defects in peritoneal and fascial layers of abdominal wall through which the omentum or a knuckle of intestine protrudes into the subcutaneous fat [3] (Fig. 6). Esophageal Hiatal Hernia Herniation of abdominal content through the esophageal hiatus above the diaphragm (Fig. 7) is another complication of gastric carcinoma resection. Tumor Recurrence Local Recurrence Local recurrence of gastric carcinoma after surgery is defined as histologic evidence of a tumor in the surrounding tissue of the resected stomach. The most common sites of recurrence are in the area of the celiac axis (Fig. 8) or hepatic pedicle, followed by the 1040 AJR:179, October 2002
5 CT After Gastric Carcinoma Resection anastomotic site (Fig. 9) or gastric stump, pancreas (Fig. 10), and abdominal wall incision site [4] (Fig. 11). Direct Extension Tumor tissue may spread to adjacent organs via ligaments or peritoneal reflections. The liver may be invaded via the gastrohepatic ligament, the transverse colon via the gastrocolic ligament (Fig. 12), and the pancreas via the lesser sac. Lymphatic Spread Because of the abundant lymphatics in the stomach, lymph node metastases are common in patients with gastric carcinoma. These patients may initially have involvement of local nodes and, subsequently, regional or distant nodes (Fig. 13). Intraperitoneal Seeding Intraperitoneal seeding may be manifested on CT scans as nodules, loculated fluid collections, or irregular, beaded thickening and stranding of the mesentery or omentum (Fig. 14A). The pouch of Douglas is the most dependent portion of the peritoneal cavity and is a common site for drop metastases (Fig. 14B). Hematogenous Metastases Because the venous return from the stomach is drained by the portal vein, the liver is the most common site of bloodborne metastases. Less common sites include the lungs, adrenal glands, kidneys, and bones. Unusual Manifestations of Metastases Ureteral Metastases Most cases of ureteral metastases are associated with advanced gastric carcinoma with multiple perigastric and paraaortic lymphadenopathy and diffuse omental and mesenteric tumor infiltration. The CT findings are a thickened, enhanced ureteral wall with periureteral infiltration (Fig. 15), obstructive hydronephrosis, and hydroureter [5]. Bowel Metastases On helical CT, intestinal metastases from gastric carcinoma most commonly show long segmental wall thickening (Fig. 16) with a thick inner enhancing layer [6]. Portal Vein Tumor Thrombosis Gastric carcinoma should be considered a possibility in the diagnosis of portal vein tumor thrombosis (Fig. 17), even if the serum α-fetoprotein level is elevated and a liver tumor is identified [7]. The portal tumor thrombus is presumed to have arisen from vascular invasion in the primary foci of gastric carcinoma, and then to have permeated the portal vein without invasion of the liver parenchyma. References 1. Wise SW. Case 24: afferent loop syndrome. Radiology 2000;216: Smith CH, Gore RM. Postoperative stomach and duodenum. In: Gore RM, Levine MS, eds. Textbook of gastrointestinal radiology. Philadelphia: Saunders, 2000: Harrison LA, Keesling CA, Martin NL, Lee KR, Wetzel LH. Abdominal wall hernias: review of herniography and correlation with cross-sectional imaging. RadioGraphics 1995;15: Ha HK, Kim HH, Kim HS, Lee MH, Kim KT, Shinn KS. Local recurrence after surgery for gastric carcinoma: CT findings. AJR 1993;161: Choi HY, Cho KS, Lee MG, et al. Stomach cancer with ureteral metastasis: CT findings and mode of metastasis. J Korean Radiol Soc 1992;28: Jang HJ, Lim HK, Kim HS, et al. Intestinal metastases from gastric adenocarcinoma: helical CT findings. J Comput Assist Tomogr 2001;25: Araki T, Suda K, Sekikawa T, Ishii Y, Hihara T, Kachi K. Portal venous tumor thrombosis associated with gastric adenocarcinoma. Radiology 1990;174: AJR:179, October
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