Chapter 42

Interventional radiology plays an important role in the treatment of patients with postoperative complications, decreasing morbidity, and mortality in many cases.

Abdominal abscesses can be treated by percutaneous drainage guided by computed tomography (CT) or ultrasound. It is an efficacious treatment, as long as adequate technique and patient selection are carefully performed.3,6 In obese patients, CT is usually better in visualizing the lesion and surrounding anatomy. The cutaneous entry site should be meticulously planned. In general, the shortest distance to the lesion should be traversed, obviously avoiding structures such as bowel, spleen, lung, and blood vessels. Coagulopathies, if present, should be corrected, and written informed consent should be obtained prior to the procedure.

Patients with leaks presenting insidious or minimal clinical findings usually can be treated nonoperatively, with antibiotics, maintenance of surgical drains (when present), with holding oral intake, and administration of total parenteral nutrition.3 CT should be performed on these patients. It can determine if there is any abdominal collection. Any suspicious fluid collection detected by CT should be promptly submitted to percutaneous aspiration and drainage.1,2,7 Catheter drainage may obviate surgery in many cases.

Patients with leaks, who exhibit hemodynamic instability, should undergo operative treatment. Inflammatory changes around the gastrojejunostomy and excluded stomach may significantly hamper the surgical access and treatment.3,4 These patients can also beneficiate from percutaneous drainage of fluid collections.

Fluid collections occur most frequently in the left upper abdomen, especially in the perisplenic area,6 but can also occur elsewhere in the abdomen and pelvis. Fluid collections may evolve into abscesses, and are not always related to anastomotic leaks.

Diagnostic puncture and aspiration guided by CT or ultrasound may be useful in distinguishing abscesses from other fluid collections. Hematomas usually present as high attenuation collections (60–80 HU). They are usually treated conservatively, or may be submitted to surgical drainage in case of large collections. They may become infected, and percutaneous puncture may be performed for diagnosis. Percutaneous drainage of hematomas is controversial, usually requiring longer drainage, bigger catheter size, and more catheter replacements due to drain obstruction.7

Acute postoperative distention of the excluded stomach may occur after gastric bypass surgery, usually due to adynamic ileus, edema, and obstruction at jejunojejunal anastomosis or small bowel obstruction. Marked distention of the excluded limb should be promptly diagnosed and treated, because excessive tension on the staple-line may result in free leak (Figure 42-1 a).

###### Figure 42–1.

Excluded stomach overdistention. (a) CT in early post-op period shows significant distention of excluded stomach, with air-fluid level (arrow). (b) Diagram of percutaneous gastrostomy.

The excluded segment of the gastrointestinal tract is not readily available for either mechanical, radiological, or endoscopic evaluation. CT scans must be obtained to evaluate ...

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