Contrast rule for post-surgical studies: Always use water-soluble contrast (Omnipaque 300) first for any anastomosis check where leak is possible. Follow with thin barium only if the water-soluble study is negative and better mucosal detail is needed. Never use barium as the first agent when anastomotic integrity is unknown.
Post-Esophagectomy Anatomy and Findings
Common procedures: Ivor Lewis esophagectomy (thoracic anastomosis at carina level), transhiatal esophagectomy (cervical anastomosis), McKeown (3-field — cervical anastomosis, abdominal and thoracic dissection).
Gastric conduit replaces the esophagus in most cases — pulled up through the posterior mediastinum with the gastric fundus becoming the neo-esophageal tip.
| Finding | Description |
|---|---|
| Anastomotic leak | Extravasation of contrast beyond luminal margin — document site (cervical vs. thoracic), extent, free vs. contained |
| Anastomotic stricture | Concentric narrowing at anastomotic site; common late complication; requires endoscopic dilation |
| Conduit redundancy | Tortuous or redundant conduit in the chest — can cause functional dysphagia |
| Intrathoracic herniation | Conduit herniating through hiatus alongside anastomotic site — unusual position |
| Delayed gastric emptying | Contrast pooling in conduit without passage to jejunum; pyloric dysfunction or denervation |
Anastomosis level predicts leak morbidity. Cervical anastomotic leaks are often contained in the neck and managed conservatively. Thoracic anastomotic leaks (Ivor Lewis) extend into the mediastinum — higher morbidity and mortality. Document whether leak is contained or communicates with mediastinum or pleural space.
Post-Whipple Anatomy and Findings
Anatomy: Pancreaticoduodenectomy removes the head of pancreas, duodenum, distal bile duct, and gallbladder. Three anastomoses in Child reconstruction (on a single jejunal limb): pancreaticojejunostomy → hepaticojejunostomy → gastrojejunostomy.
Pylorus-preserving Whipple (PP-PD): Pylorus and proximal duodenum retained — gastrojejunostomy replaced by duodenojejunostomy.
| Finding | Description |
|---|---|
| Delayed gastric emptying (DGE) | Most common complication; dilated gastric remnant with poor emptying; managed conservatively; may persist weeks |
| Gastrojejunostomy leak | Extravasation at anastomosis |
| Gastrojejunostomy stricture | Narrowing at anastomosis — late complication |
| Marginal ulcer | Peptic ulcer at or just distal to gastrojejunostomy; look for crater at anastomosis |
| Afferent limb obstruction | Biliopancreatic limb obstruction; dilated afferent limb visible on fluoroscopy; CT better for characterization |
Post-Roux-en-Y Gastric Bypass Anatomy and Findings
Anatomy: Small gastric pouch (15–30 mL) connected to Roux (alimentary) limb via gastrojejunostomy (GJ anastomosis). Jejunojejunostomy (JJ) ~75–150 cm distal reconnects alimentary limb to biliopancreatic limb. Excluded stomach, duodenum, and proximal jejunum are NOT opacified by oral contrast.
| Finding | Description |
|---|---|
| Stomal stenosis | GJ anastomosis <10 mm — most common indication for post-RYGB UGI; causes dysphagia, vomiting; treated with endoscopic balloon dilation |
| Anastomotic leak | Extravasation at GJ; surgical emergency in early post-op period |
| Marginal ulcer | Ulcer at or just distal to GJ on Roux limb side; may form GJ fistula |
| Internal hernia | NOT visible on fluoroscopy — if suspected, CT is required; presents with intermittent abdominal pain post-RYGB |
| Gastric pouch dilation | Late complication; pouch enlarges over time; less restriction |
Post-Nissen Fundoplication Anatomy and Findings
Anatomy: The gastric fundus is wrapped 360° around the distal esophagus and sutured to itself, creating a smooth extrinsic impression at the GEJ. The GEJ should be below the diaphragm.
| Finding | Description |
|---|---|
| Normal wrap | Smooth extrinsic impression on distal esophagus at GEJ level; slight narrowing expected; GEJ below diaphragm |
| Tight wrap | Significant narrowing at GEJ level; proximal esophageal dilation; dysphagia |
| Slipped/disrupted wrap | Wrap moves onto proximal stomach; recurrent reflux; "telescoping" appearance |
| Wrap herniation | Wrap and GEJ above diaphragm; common cause of post-fundoplication failure; wrap visible in chest |
| Gas-bloat | Inability to belch; functional — no specific fluoroscopic finding |
Reporting Checklist
- Procedure type: esophagectomy (approach) / Whipple / RYGB / Nissen / other
- Contrast used: water-soluble / thin barium
- Anastomosis site assessed: patent / leak (free vs. contained, location) / stricture
- Conduit/pouch: normal position / herniation / obstruction
- Emptying: adequate / delayed gastric emptying
- For RYGB: GJ anastomosis caliber (mm); stomal stenosis present/absent
- For Nissen: wrap position (above/below diaphragm); wrap intact/disrupted; GEJ level
- Communication to surgical team if leak identified
Common Pitfalls
| Pitfall | How to Avoid |
|---|---|
| Missing a small leak with water-soluble contrast | Small leaks may only be seen with thin barium (higher sensitivity); if clinical suspicion is high and water-soluble is negative, discuss with surgeon before switching to barium |
| Not knowing the surgical anatomy | Always review operative report and prior imaging before beginning — knowing the reconstruction type prevents misidentification of anatomy |
| Afferent limb vs. Roux limb | In Whipple, afferent limb contains bile and pancreatic secretions — does not normally fill with oral contrast; Roux limb fills. Know which limb should fill |
| Post-RYGB excluded stomach | The excluded stomach, duodenum, and proximal jejunum do not fill on oral contrast studies — do not mistake absence of filling for pathology |
| Wrap herniation missed | Must compare GEJ position to diaphragmatic hiatus on both PA chest scout and fluoroscopic lateral — wrap above diaphragm = failure |
Step-by-step fluoroscopy technique and systematic search patterns available in RadCall Pro.