Pancreaticoduodenectomy: expected post-operative anatomy and complications

Abstract

Pancreaticoduodenectomy is a complex, high-risk surgical procedure performed for tumours of the pancreatic head and other periampullary structures. The rate of perioperative mortality has decreased in the past number of years but perioperative morbidity remains high. This pictorial review illustrates expected findings in early and late post-operative periods, including mimickers of pathology. It aims to familiarize radiologists with the imaging appearances of common and unusual post-operative complications. These are classified into early non-vascular complications such as delayed gastric emptying, post-operative collections, pancreatic fistulae and bilomas; late non-vascular complications, for example, biliary strictures and hepatic abscesses; and vascular complications including haemorrhage and ischaemia. Options for minimally invasive image-guided management of vascular and non-vascular complications are discussed. Familiarity with normal anatomic findings is essential in order to distinguish expected post-operative change from surgical complications or recurrent disease. This review summarizes the normal and abnormal radiological findings following pancreaticoduodenectomy.Pancreaticoduodenectomy was first performed in 1909 and was popularized by the American surgeon Allen Whipple, who refined the technique in the 1930s. Indications for the procedure include pancreatic head tumours, periampullary tumours, distal common bile duct tumours and chronic pancreatitis involving the pancreatic head. The mortality rate of the procedure has decreased from .20% to ,2% in high volume centres, making it a more attractive option now than it previously was. 1 However, perioperative morbidity rates remain high (30-40%). Many patients require post-operative imaging and radiologic intervention. Timely recognition of complications is important. EXPECTED POST-OPERATIVE FINDINGS AND MIMICKERS OF PATHOLOGYUnderstanding the surgical procedure and the expected postoperative findings is essential when interpreting imaging. The components of a standard pancreaticoduodenectomy are distal gastrectomy, duodenectomy, partial pancreatectomy, partial choledochectomy, cholecystectomy and proximal jejunectomy. A jejunal loop is mobilized up to the right upper quadrant and three anastomoses are formed: gastrojejunostomy, hepaticojejunostomy and pancreaticojejunostomy (Figure 1). Distal gastrectomy facilitates resection of nodes along the greater and lesser curves of the stomach, reduces delayed gastric emptying and theoretically reduces the risk of gastritis post-operatively.Pylorus-preserving pancreaticoduodenectomy, first described in 1944, 2 has gained popularity in the past two decades. It involves preservation of the stomach and proximal duodenum and formation of a duodenojejunostomy (Figure 1). There is debate in the literature regarding the advantage of pylorus-preserving pancreaticoduodenectomy compared with standard pancreaticoduodenectomy. Preservation of the distal stomach results in reduced frequency of dumping syndrome and...

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

“…However, in the setting of PD surgery, most centres—including ours—discourage the use of oral CM, since it may cause beam-hardening artefacts and hamper detection of haemorrhage. Furthermore, recently operated patients are often unwell and not willing or able to swallow, particularly those with a distended stomach secondary to DGE [ 9 – 11 ].…”

“…5 b) should not be considered abnormal. Mild dilatation of the common hepatic duct requires correlation with laboratory tests [ 9 , 11 , 22 , 26 ].

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“…Unfortunately, interpretation of early postoperative CT imaging is generally challenging due to the surgically altered anatomy. Aiming to improve radiologists’ familiarity with postsurgical abdominal studies, this pictorial essay reviews and illustrates the expected postoperative CT appearances and the imaging features of typical and unusual post-PD complications [ 9 – 11 ].…”

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“…A repeat MRI 3 months after the modified-Whipple procedure found postsurgical changes with no concerning findings, acknowledging that normal postoperative findings may resemble pathological changes, such as fluid collection or ischaemia 6. Clinical follow-up confirmed there was no need for insulin or pancreatic enzymes and that she had recovered well physically with a return to normal activities.…”

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“…16,21 Although the largest existing case series of these operations supports a 30-day perioperative mortality of only 1.4%, *40% of these patients still sustain surgeryrelated morbidity, including delayed gastric emptying, pancreatic fistulae, bilomas, and biliary strictures. 22,23 Moreover, even after curative-intent surgery for PA and though new chemotherapeutics may offer prolonged survival, 24,25 a majority of PA patients undergoing curative-intent surgery still ultimately die of PA; historical data suggest that approximately four out of five of these patients have eventual progression of their cancer to stage IV disease, with a median postoperative survival of two years. 23,26 Beyond management of PA, morbidity and mortality for other upper GI cancers is similarly poor.…”