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Gastrointestinal Imaging

E2644. Reviewing the NOTES: A Radiologist’s Guide for Imaging of Endoscopic Surgeries

Cruz A,  Rudd A,  Lall C,  Cohen A,  Chang K. University of California Irvine Health, Orange, CA

Address correspondence to A. Cruz (

Background Information: Endoscopic procedures are minimally invasive, and the amount of endoscopic procedures has expanded in recent years with a wide variety of endoscopic interventions as feasible treatment options for many different medical conditions. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has advanced the field of endoscopy with new techniques that offer less invasive alternatives to procedures previously performed only with laparoscopic or open surgical interventions. With an expanding field of endoscopy, radiologists should be aware of radiographic imaging findings of endoscopic procedures. This exhibit aims to provide an overview of certain endoscopic procedures, expected findings, and signs that may indicate a serious complication.

Educational Goals/Teaching Points: This exhibit will discuss imaging related to endoscopic procedures for a variety of medical conditions. The topics discussed will include basics of the procedure performed, expected imaging findings, and imaging of procedure-related complications. The procedures discussed cover endoscopic treatments for achalasia, gastroesophageal reflux disease (GERD), bariatric weight loss interventions, and mucosal lesions.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Endoscopic interventions are generally assessed after the procedure with single contrast esophagrams. This exhibit will primarily focus on fluoroscopic findings after endoscopy. In addition, CT and plain film findings are discussed and illustrated. Common findings after endoscopic procedures include minor pneumomediastinum and pneumoperitoneum, which can be concerning depending on clinical presentation and the amount of air present. Perforation and leaks are important imaging findings that may require intervention. Knowledge of the expected imaging findings and understanding of post-surgical anatomy is vital to the radiologist interpreting a study after a novel procedure. The procedures discussed in detail in this exhibit include per oral endoscopic myotomy (POEM), transoral incisionless fundoplication (TIF), intragastric balloons, transoral gastroplasty, and endoscopic clipping. POEM is a relatively new technique being used in the treatment of achalasia that entails dissection of the inner circular muscle of the esophagus. Endoscopic procedures for GERD include TIF, which is similar to a Nissen fundoplication. Intragastric balloons and transoral gastroplasty are being used as bariatric weight loss interventions, and both are aimed at creating a sensation of early satiety. Endoscopic clips are being used in closure of gastrointestinal mucosal lesions. At the completion of this exhibit, the participant will have a basic understanding of the technique of the procedures performed, endoscopic procedure anatomy, and expected and concerning imaging findings.

Conclusion: The field of endoscopy continues to expand with the advent of new procedures and treatment options performed in a minimally invasive fashion. This exhibit provides an overview of novel endoscopic procedures and a diagnostic approach for radiographic evaluation after these procedures.