1
|
Gaballah AH, Kazi IA, Zaheer A, Liu PS, Badawy M, Moshiri M, Ibrahim MK, Soliman M, Kimchi E, Elsayes KM. Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications. Radiographics 2024; 44:e230061. [PMID: 38060424 DOI: 10.1148/rg.230061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.
Collapse
Affiliation(s)
- Ayman H Gaballah
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Irfan A Kazi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Atif Zaheer
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Peter S Liu
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed Badawy
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mariam Moshiri
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed K Ibrahim
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Moataz Soliman
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Eric Kimchi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Khaled M Elsayes
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| |
Collapse
|
4
|
Cruz CJ, Kang I, Lee WJ, Kang CM. Laparoscopic pancreatic neck transection and double pancreatico-jejunostomy, an alternative surgical approach to chronic pancreatitis. Ann Hepatobiliary Pancreat Surg 2019; 23:291-294. [PMID: 31501821 PMCID: PMC6728246 DOI: 10.14701/ahbps.2019.23.3.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 01/28/2023] Open
Abstract
Chronic pancreatitis is a benign inflammatory process that results symptoms pertaining to loss of endocrine and exocrine function. Pain poses a great challenge in the management of CP and intractable pain represents the main indication for surgical intervention. Surgical options for CP ranges from pancreatic resection to pure drainage procedures. Herein, we present the case of 68 year-old female with recurrent abdominal pain due to chronic pancreatitis, who underwent successful laparoscopic pancreatic neck transection and double pancreatico-jejunostomy (duct-to-mucosa). Pre-operative imaging revealed a uniformly dilated pancreatic duct with encrusted pancreatic stone in the pancreatic head near the ampulla of Vater, with no inflammatory mass. Pre-operative laboratory work-ups were all normal. Pancreas texture was noted to be intermediate to soft. During pancreatic neck transection, there was spontaneous deviation of distal stump laterally leaving an ample space to accommodate jejunal loop. PD measured 8 mm. The standard duct to mucosa double layer simple interrupted suture was used for PJ anastomosis. There were no significant intra-operative events. No transfusion was required. Total operation time was 297 minutes, and it took 129 minutes for laparoscopic PJ completion. Immediate post-operative course was unremarkable. This case suggests laparoscopic double PJ can be an alternative surgical approach to reduce the pancreatic duct pressure in chronic pancreatitis. Based on accumulating experiences, long-term outcome also needs to be investigated to address potential role of this technique.
Collapse
Affiliation(s)
- Charles Jimenez Cruz
- Department of Surgery, Makati City Hospital, Makati City, Philippines.,Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Incheon Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| |
Collapse
|