European Radiology

, Volume 28, Issue 9, pp 3583–3590 | Cite as

Diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass: usefulness of systematically reviewing CT scans using ten signs

  • Jeannette C. EderveenEmail author
  • Marijn M. G. van Berckel
  • Saskia Jol
  • Simon W. Nienhuijs
  • Joost Nederend



To evaluate if systematically reviewing CT scans using ten signs leads to a better accuracy in diagnosing internal herniation (IH), compared to the original report. Also, the difference in accuracy was analysed between experience levels.


Patients were retrospectively included if they had undergone laparoscopic gastric bypass surgery between 2011 and 2014, and if additional radiological examination was performed for suspected IH between 2011 and 2016. Out of 1475 patients who had undergone laparoscopic gastric bypass surgery, 183 patients had one or more additional radiological examinations. A total of 245 CT scans were performed. All were reassessed by an abdominal radiologist, a radiology resident and intern. Assessment was done using ten signs from previous literature. Overall suspicion of IH was graded using a 5-point Likert scale. Accuracy was calculated using two-way contingency tables. Interobserver agreement was calculated using Fleiss’ kappa.


After 70 reoperations an IH was diagnosed in 48.6% (34/70). There was an increase in specificity for diagnosing IH with reoperation as reference from 52.8% (19/36; 95% CI 35.7–69.2%) in the original report to 86.1% (31/36; 95% CI 74.8–97.4%) for the radiologist (p = 0.002), 77.8% (28/36; 95% CI 64.2–91.4%) for the resident (p = 0.026) and 77.8% (28/36; 95% CI 64.2–91.4%) for the intern (p = 0.026). Interobserver agreement was good.


Systematically reviewing CT scans using a list of ten CT signs can improve specificity and thereby reduce unnecessary reoperations, especially in a high pre-test probability population. The tool can be easily taught to less experienced readers.

Key Points

Computed tomography is useful to diagnose internal herniation(IH) after gastric bypass surgery

Ten signs are described to improve CT diagnosis of IH

Systematically reviewing CT scans improves specificity

There is no difference in experience levels when using these ten signs


Multidetector computed tomography Gastric bypass Complications Sensitivity and specificity Hernia 



Body mass index


Internal herniation


Laparoscopic Roux-en-Y gastric bypass


Superior mesenteric artery



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is J. Nederend, MD, PhD.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was not required because the study was not performed on human subjects but only used previously collected data.


• retrospective

• diagnostic study

• performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Jeannette C. Ederveen
    • 1
    Email author
  • Marijn M. G. van Berckel
    • 2
  • Saskia Jol
    • 1
  • Simon W. Nienhuijs
    • 2
  • Joost Nederend
    • 1
  1. 1.Department of RadiologyCatharina HospitalEindhovenThe Netherlands
  2. 2.Department of SurgeryCatharina HospitalEindhovenThe Netherlands

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