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8 3D Modeling withCT
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pathology, while the use of new reconstruction techniques such as
volume rendering can be manipulated to orient the stomach, providing superior images compared to shaded surface display rendered images seen in early 3D imaging (CT gastroscopy).
Additionally, visualization of lesions in multiple planes with 3D CT
adds valuable perspective by enhancing depth perception and
improving the characterization of lesion morphology and spatial
relationship to adjacent structures [2].
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Gastric Cancer
CT imaging, in combination with endoscopic ultrasound (EUS),
is commonly utilized for the evaluation and staging of gastric cancers. While adequate stomach distention and the use of negative
intraluminal contrast agents have increased the diagnostic accuracy of CT, detection of gastric cancers with CT varies with the
stage of cancer, ranging between 90 and 100% for advanced gastric cancer [19]. In contrast, the accuracy of CT in diagnosing
early gastric cancers or depressed, endophytic lesions ranges from
20% with portal venous phase CT scan to 88% with arterial phase
imaging [19]. Additionally, both EUS and traditional CT scans
have been shown to be inaccurate in restaging of gastric cancer
after neoadjuvant chemotherapy.
The advantages of 3D CT can further improve the detection of
both early and advanced gastric tumors, with a reported diagnostic accuracy of 96% and 100%, respectively [20]. In patients with
early gastric cancer, studies have demonstrated a signicantly
higher detection rate (94%) with 3D CT imaging compared to
axial images alone [21]. 3D CT has also demonstrated high accuracy, sensitivity, and specicity in the staging assessment of
locoregional spread, nodal involvement, and distant metastases
[2]. In advanced gastric cancer, the use of 3D CT demonstrated
superior tumor staging accuracy over axial imaging alone [22].
While EUS has higher accuracy rates of T staging (87%), accurate
assessment of N stage is equivalent to 3D CT, which has reported
accuracy of 83% and 75% for tumor and nodal staging, respectively [20].
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More recently, tumor volumetric studies have further broadened the potential clinical applications of 3D CT in gastric cancer.
Tumor volume measurements on CT have demonstrated a strong
correlation with pathologic T and N stages for gastric cancer, both
in patients who have not received treatment and restaging following neoadjuvant chemotherapy [23, 24]. The utility of 3D CT
volumetry was further investigated in advanced gastric cancer
patients who underwent neoadjuvant chemotherapy. The study
showed that the percentage volume reduction rate of the primary
gastric tumor correlated highly with histopathologic tumor regression and can be used to predict tumor response to neoadjuvant
chemotherapy [25].
A. M. Kao and P. D. Colavita
Gastric Lymphoma
In patients with gastric lymphoma, CT scan remains the primary
imaging modality for the evaluation and staging. On CT imaging,
lymphomas can appear with nonspecic ndings of diffuse gastric wall thickening, inltrating lesions, or a polypoid mass.
Preservation of gastric distensibility and nodular thickening of the
gastric folds are features seen with lymphoma and can help differentiate them from adenocarcinoma. Other distinguishing features on CT imaging suggestive of lymphoma include
lymphadenopathy below the renal hilum.
Gastrointestinal Stromal Tumors (GISTs)
CT scan is the preferred diagnostic test of choice for GISTs, due
to the limited evaluation of submucosal pathology with traditional
upper endoscopy. GISTs often appear on CT as exophytic submucosal lesions in the gastric body or antrum, however, can also
present as an intraluminal mass. GISTs can grow to a large size,
with tumors frequently ranging between 3 and 10cm in size, and
heterogeneous enhancement can be seen in larger tumors due to
tumor necrosis. Similarly, mucosal ulceration can occur resulting
in CT ndings of extraluminal air or contrast within the lesion.
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101
Gastrectomy: Preoperative andPostoperative
Evaluation
The role of 3D CT in preoperative planning prior to gastric surgery has been described in patients with gastric cancer, as well as
the bariatric patient population [26–28]. Laparoscopic-assisted
gastrectomy is less invasive and now widely performed due to
benets in recovery time and quality of life; however, disadvantages of laparoscopy include the limited view of the entire stomach and increased operative time required to identify anatomic
vasculature. Several studies evaluating the utility of preoperative
3D CT in laparoscopic gastric cancer surgery describe its efcacy
in visualizing pertinent gastric vascular anatomy with 100% sensitivity in identifying the left and right gastric arteries [27]. 3D CT
also allowed for preoperative assessment of individual variation
in vasculature such as a replaced left hepatic artery, which can be
unintentionally ligated if misidentied intraoperatively, resulting
in postoperative liver dysfunction [26, 27]. In addition to vascular
anatomy, 3D CT can be used in gastric cancer surgery to simulate
the complex anatomical variations of the splenic hilum and assist
with lymph node dissection. Comparative studies of surgical outcomes with and without preoperative 3D CT simulation reveal
signicantly reduced operative time and blood loss with 3D CT
simulation, while other authors report a larger harvest of splenic
hilum (station 10) lymph nodes. Additionally, identication of the
caudal pancreatic artery or vein on 3D CT can increase the preservation of these vessels, which may prevent the development of
postoperative pancreatic stula [28].
CT is commonly obtained in the postoperative setting in
patients who have undergone partial or total gastrectomy. In gastric cancer patients, CT plays a role in surveillance and is used to
detect the presence of disease recurrence or progression to metastatic spread during the follow-up period. After bariatric surgery,
CT imaging can be used to evaluate the anastomosis after gastric
bypass and is frequently used to detect complications including
bleeding, perforation, or internal hernia [19, 29]. Similarly, 3D
CT after Roux-en-Y gastric bypass can be used to derive accurate
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A. M. Kao and P. D. Colavita
measurements of pouch volume, a key component of weight loss
after bariatric surgery [30]. In the acute postoperative setting, 3D
CT allows for immediate assessment of the anastomosis and
structural integrity of the pouch.
The clinical utility of multidetector CT may also include the
prediction of post-surgical weight loss after bariatric surgery, as
traditional methods of estimating gastric volume have been variable and often inaccurate. Multiple studies of 3D CT volumetry in
patients undergoing sleeve gastrectomy describe the feasibility
and accuracy of gastric volumetric measurements and have established their relationship with estimated weight loss [31, 32].
Pawanindra etal. used multidetector CT to calculate the volume
of the resected stomach in patients undergoing sleeve gastrectomy
and demonstrated a strong correlation with early postoperative
weight loss. Similar ndings were reported by Hanssen etal., who
used 3D CT to measure the volume of the postoperative gastric
remnant 6 months after surgery, showing a strong correlation
between remnant gastric volume> 100 mL and poor estimated
weight loss [31]. One recent study attempted to minimize the
varying degrees of gastric distention seen with heterogeneous CT
protocols showed gastric wall volume, rather than gastric luminal
volume, was the key indicator of weight loss 1year after sleeve
gastrectomy [32].
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Role oftheGastric Emptying
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Study
MichaelL.Williford andS.ScottDavis Jr.
Role ofaGastric Emptying Study
A gastric emptying study is a noninvasive method of obtaining an
objective measure of the rate of gastric emptying. The study can
be performed pre- or postoperatively and provides useful information that will help guide clinical decision-making. A nuclear
medicine study to describe gastric emptying was rst reported in
1966 [1]. Over time, the technology has evolved, and the study is
currently ordered to evaluate for both delayed and rapid gastric
emptying. A joint consensus statement was released in 2008 by
the Society of Nuclear Medicine and the American
Neurogastroenterology and Motility Society that provides the following framework for the performance and interpretation of a
gastric emptying study [2].
9
M. L. Williford
WakeMed Health and Hospitals, Raleigh, NC, USA
S. S. Davis Jr. (*)
Emory Endosurgery Unit, Department of Surgery, Emory University,
Atlanta, GA, USA
e-mail: sdavisj@emory.edu
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_9
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Patients are asked to discontinue medications that could affect
gastric motility, including prokinetic agents (e.g., metoclopramide),
anticholinergics, and opioids. The patients are then kept without
eating for 6h prior to the study. They are asked to eat a meal consisting of a low-fat solid (typically Tc-99 radiolabeled egg whites),
and this is often accompanied by specic volumes of toast, jam, and
water. Radiolabeled solids are most often used if there is a concern
for delayed gastric emptying, as emptying of liquids may be preserved in this condition. The meal must be nished within 10min.
A gamma camera is then used to obtain anterior and posterior
images of the stomach at the 0-, 1-, 2-, and 4-h time points. It is
important to reach the 4-h time point if the results are indeterminate, as a patient may have the appearance of normal gastric emptying initially, but the results at the later time points may be abnormal.
Delayed gastric emptying is consistent with >90% of the radiotracer present in the stomach at 1h, >60% at 2h, and >10% at 4h.
Rapid gastric emptying is consistent with <70% of the radiotracer
present in the stomach at 30min or <30% at 1h [3]. These normal
values were determined by analyzing the results of asymptomatic
volunteers.
M. L. Williford and S. S. Davis Jr.
Interpretation ofResults
The radiotracer counts will be analyzed and graphed over time. A
typical radiologist interpretation includes a calculated half-time
(the time at which 50% of the tracer has exited the stomach) and
the percentages of the tracer remaining at the 0-, 1-, 2-, and 4-h
time points. The following are actual patient vignettes with the
associated gastric emptying study images and interpretation based
on the above criteria.
Normal Gastric Emptying
Patient 1 is a 36-year-old woman with gastroparesis who originally underwent gastric stimulator placement in 2012. Her ability
to tolerate PO intake improved for several years, but in 2019 she
9 Role oftheGastric Emptying Study
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Fig. 9.1 Anterior and posterior projections of the radiotracer within the
stomach at various time points [4]
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Fig. 9.2 Amount of radiotracer remaining in the stomach over time
developed recurrent symptoms. Interrogation of her battery
revealed the need for replacement. She underwent battery replacement in January 2020, and the following images were obtained in
March 2020 (Fig.9.1).
The raw percentage empty values in the right upper corner of
the image (Fig.9.2) correspond with the 0-, 1-, 2-, and 4-h time
points. When compared to the normal values listed above, each of
these values remains within the expected range. Therefore, this
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