SF 8 - The postoperative abdomen: lost in translation?
1. To learn about the most common complications following abdominal surgery, either immediate or delayed.
2. To become familiar with the most common surgical procedures and to understand the mechanism of complications.
3. To be able to detect these complications with imaging methods, and to understand the principle of management, including conservative, interventional and/or surgical treatments.
Previous surgery is always a major difficulty when reporting on abdominal imaging. Some surgery is quite obvious, like hepatectomy or colectomy, some may be less apparent like by-pass, complex bowel surgery or even atypical liver resection. Knowledge of the exact surgical procedure is critical for the radiologist. This is even more true when looking for complications as some are quite specific. Differentiating fistulae, abscesses and bowel loops can be really challenging. Defining criteria for bowel obstruction is tricky. This session intends to clarify the most common clinical situations, allowing the radiologist to fully understand the specific situations and to enhance the dialogue with the surgeon.
1. To learn about the incidence of immediate postoperative inflammatory complications and their outcome.
2. To understand the surgical procedures that are most commonly exposed to inflammatory complications.
3. To be able to detect inflammation and abscesses and to identify direct and indirect signs of leakage.
4. To understand the discussion about treatment, conservative, surgical or interventional.
Postoperative complications can be general or specific to particular operations. Infections may occur in the operative site or organ, like wound infection, biliary infection or UTI and the peritoneum may be contaminated during or after surgery. Anastomotic leaks, traumatic organ injuries like lacerations and haematomas may develop to form abscesses. Abscesses can be categorised as intraperitoneal retro/subperitoneal or visceral. Pathways of infection are related to well-defined anatomical structures but may extend to contiguous structures and erode boundaries. In the early postoperative period, fever may be caused by tissue necrosis at the operation site. In a few days later sepsis, wound infection and abscess formation may start. Around 5 days after surgery anastomosis breakdown, fistula formation, wound infection and distant site infections may occur. Pelvic collections usually form in the first week, while subphrenic collections tend to form later. Inflammatory damage of vessels in the operation field often results in late postoperative bleeding. CT is the most widely used modality to detect postoperative conditions. Exams should be tailored to be able to demonstrate the altered anatomy, signs of peritonitis, possible source of leakage and collections. Imaging features of inflammatory complications and checklist of critical findings related to different abdominal and pelvic operations will be shown. The team of clinicians, surgeons and radiologists should always discuss treatment options and minimal invasive techniques are preferred; therefore, radiological intervention plays a major role. CT, US, EUS and image fusion (technical or cognitive) may help to guide the intervention.
1. To learn about the incidence of immediate postoperative vascular complications and their outcome.
2. To understand the surgical procedures that are most commonly exposed to vascular complications.
3. To be able to manage the diagnostic strategy using appropriate imaging modalities.
4. To understand the role of intervention.
Immediate vascular complications after abdominal surgery require early detection and treatment. Their incidence depends on different factors, including patient characteristics, complexity of surgery and surgeon’s learning curve. Transplantations are the surgical procedure most frequently affected by vascular complications in up to 20%. Imaging has a fundamental role in the postoperative period to screen for complications and to monitor the recovery process. Multidetector contrast material-enhanced computed tomography (MDCT) is the gold standard to detect immediate vascular complications. Delayed application of MDCT is leading to a higher patients mortality and morbidity. Accurate interpretation of postoperative findings requires that radiologists have sound knowledge and understanding of surgical procedures and related surgical anatomy. Most postoperative vascular complications provide a fertile ground for interventional radiology (IR), which can circumvent a major surgery on most occasions. The minimally invasive nature and lower morbidity associated with IR procedures make them preferable to similar surgical procedures.
1. To learn about the incidence of immediate and long-term intestinal obstruction after surgery and/or radiotherapy.
2. To understand the mechanism of obstruction related to previous surgery, including adhesion, volvulus, internal hernia and recurrence/complication of initial disease.
3. To be able to detect obstruction, characterise the mechanism and evaluate the severity.
4. To feed the discussion of conservative vs surgical treatment.
Post-operative complications, including gastrointestinal obstruction may be responsible for increasing morbidity and mortality. Recognition of early signs and identification of cause, location and type of immediate and late postoperative obstruction is a difficult task that may not be accurately accomplished by clinical examination. Imaging plays a paramount role in properly detecting and characterising such conditions, allowing for a timely and adequate treatment. Detection, diagnosis and differential diagnosis may be challenging because of the atypical postoperative anatomy and the effect of the underlying disease. Understanding their influence on imaging appearance is critical for correct diagnosis. Plain abdominal x-ray examination may be of little use in the immediate postoperative cases because of the commonly present paralytic ileus obscuring any characteristic signs and also not sufficiently accurate in most late postoperative cases. Barium examinations are usually not performed in acute abdominal conditions. Ultrasound does not play a significant role in the exploration of gastrointestinal pathology. Computed tomography with or without endoluminal contrast is the proper diagnostic modality to establish the definitive diagnosis; however, being familiar with typical signs of postoperative conditions (inflammation, infection, adhesion, dysfunction, volvulus, herniation, etc.) resulting in mechanical obstruction is mandatory to make an accurate and timely diagnosis.
1. To learn about the main surgical techniques of bariatric surgery and to understand the mechanism of the most common immediate and delayed complications.
2. To be able to identify the normal post-surgical appearance on imaging methods.
3. To detect the main complications associated with bariatric surgery on imaging methods.
Obesity is a disease that has reached epidemic proportions around the world. During the past 20 years bariatric surgery has become an increasingly popular form of treatment for morbid obesity. The most common bariatric procedures performed include laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy. Fluoroscopic upper gastrointestinal examinations and abdominal computed tomography (CT) are the major imaging tests used to evaluate patients after these various forms of bariatric surgery. We will illustarate the common bariatric surgical procedures, the imaging procedures accordingly to become familiar with the normal post-operative anatomy and to appreciate the role of imaging in the assessment of suspected immediate and long-term postoperative complications.