Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists

Abstract

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis.Teaching Points • Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%). • Multidetector CT is the mainstay technique to investigate suspected complications following PD. • Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings. • CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula. • Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

Bleeding complications after pancreatic surgery: interventional radiology management

“…When the patient is hemodynamically stable, it's generally recommended to perform abdominal and pelvic multidetector computer tomography (MDCT) angiography as soon as sentinel bleeding is observed, when sensitivity is highest (12,22,29,37,38). MDCT angiography can show the cause, nature and site of bleeding, being a fundamental tool as it can avoid or guide treatment (10,15,(39)(40)(41). Nonetheless, even if MDCT is performed, a clear bleeding site cannot be identified in many cases (1).…”

Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System

“…This group also clarified the definition of postoperative serum hyperamylasemia (POH), which had previously been confused with PPAP ( 10 ). The diagnostic criteria of PPAP ( 11 ) require three dimensions: sustained POH, clinical impacts relevant to PPAP, and radiologic features of acute pancreatitis ( 12 , 13 ). The grading system of PPAP is based on clinical impacts, including POH (biochemical change only), grade B (mild or moderate clinical impacts), and grade C (severe clinical impacts).…”

Biliary Fistula After Pancreaticoduodenectomy

“…благодаря прогрессу в области хирургической панкреатологии летальность после панкреатодуоденальной резекции (ПДР) сократилась с 16-25% в 90-х годах ХХ века [1] до 2-5% в настоящее время [1,2,3,4,5,6,7]. В передовых высокоспециализированных центрах госпитальная летальность после ПДР не превышает 1-1,5% [1,5,8].…”

“…по оценкам разных авторов? в 20-65% ПДР [1,2,3,4,5,6,7,8]. Наиболее грозными являются послеоперационная панкреатическая фистула (ПОПФ) и геморрагические осложнения, тогда как несостоятельность билиодигестивного анастомоза (БДА) характеризуtтся меньшей частотой встречаемости и более благоприятным прогнозом, в связи с чем в исследованиях билиарной фистуле (БФ) после ПДР уделяется меньше внимания [4,5,9,10,11,12,13].…”