Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

Biodegradable biliary stents placement using a "kissing-stent" technique for management of a recalcitrant stricture post-live donor liver transplant

BACKGROUND

Biliary complications are common in pediatric liver transplant. Strictures resistant to interventional radiology procedures can be extremely challenging to manage and may result in the need of surgery or retransplantation.

METHODS

This case report illustrates the use of biodegradable stents post left lateral segment live donor liver transplant in a pediatric patient with a recalcitrant chronic stricture of the biliary-enteric anastomosis. The patient developed a high stricture requiring multiple interventions and eventual access of both the segment II and segment III ducts of the graft.

RESULTS

To ensure adequate biliary drainage, two biodegradable stents were deployed using a "kissing-stent" technique. The stents were successfully deployed and allowed the patient to remain free from an internal-external biliary drain for 11 months, with eventual redeployment of an additional biodegradable stent.

CONCLUSION

In patients with recalcitrant stenosis of the biliary anastomosis, biodegradable stents may provide durable drainage, optimizing graft function and delaying retransplantation in addition to keeping patients without external devices, thus improving quality of life.

Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist

Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.

Percutaneous Biliary Rendez-Vous to Treat Complete Hepatic-Jejunal Anastomosis Dehiscence after Duodeno-Cephalo-Pancreasectomy

Hepaticojejunostomy is an essential component of many surgical procedures, including pancreaticoduodenectomy. Biliary leaks after HJS represent a major complication leading to relevant clinical problems: the postoperative mortality rate could reach 70% for surgical re-intervention, whereas endoscopic management is technically difficult due to the postoperative anatomy. Interventional Radiology plays a pivotal role for these patients. The case of a percutaneous biliary rendez-vous procedure performed to treat an HJA dehiscence after duodeno-cephalo-pancreasectomy is presented, which is successfully guaranteed to avoid a new surgical approach.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I² = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I² = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I²= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I² = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I² = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage

BACKGROUND

Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication.

METHODS

All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage.

RESULTS

Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2).

CONCLUSION

Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.

Percutaneous trans-hepatic rescue and neo-creation of a post-surgical complete hepaticojejunostomy dehiscence

Biliary leakage complicating hepaticojejunostomy is a therapeutic dilemma for surgeons, gastroenterologist, and interventional radiologist. It is a major cause of postoperative morbidity. Percutaneous biliary intervention techniques have been developed for treating benign post-surgical biliary disease in patients not having severely compromised clinical conditions. Interventional radiology manoeuvres are especially indicated as the first line of treatment if endoscopic procedures are unfeasible for patients due to postsurgical anatomical modifications. We present a case of post-surgical complete hepaticojejunostomy dehiscence that was treated totally by percutaneous techniques with trans-hepatic rescue and hepaticojejunostomy neo-creation.

[Endovascular treatment of arterial bleeding after pancreatic surgery]

Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.

Emergency endovascular treatments for delayed hemorrhage after pancreaticobiliary surgery: indications, outcomes, and follow-up of a retrospective cohort

PURPOSE

To evaluate the outcomes of emergency endovascular treatments for delayed bleeding after pancreaticobiliary surgery.

METHODS

We retrospectively evaluated 21 patients (M:F = 13:8, median age = 64 years) undergoing 23 endovascular treatments, performed from 2010 to 2017 in a single center. Data collected were patient characteristics; surgery; pathology; incidence of postoperative pancreatic fistulas (POPF); bleeding signs on CT and angiography; damaged artery; endovascular tools used; technical and clinical success; intervals between surgery, endovascular treatment, and discharge; survival rates.

RESULTS

Sixteen patients had pancreatoduodenectomy, three hepaticojejunostomy, two distal pancreatectomy. Indications for surgery were mainly biliary (33%), pancreatic (19%), or duodenal (10%) malignancies. Seventeen patients had "grade C" POPF, three suffered a biliary leak, one had no POPF. Active bleeding was present in 17/23 CTs and in 22/23 angiographies, mostly from hepatic (43%), gastroduodenal (22%), and splenic (13%) arteries. The endovascular treatments were performed with coils (26%), glue (22%), stent-graft (22%), and their combinations (30%). Sixteen patients had a single endovascular treatment, one underwent a second embolization, three had subsequent surgery, one had repeat embolization followed by surgery. Relaparotomy rate was 19%. Median hospital stay was 37 days (range 12-75); median intervals among pancreaticobiliary surgery, endovascular treatment, and discharge were 21 (2-36) and 12 (8-47) days, respectively. We observed 4/21 intrahospital deaths (median: 31 days from endovascular treatment, 4-53); 1-year survival rate of discharged patients was 71%.

CONCLUSIONS

Endovascular treatment using embolization and/or stent-graft placement is a useful first-line intervention to halt postoperative hemorrhage after pancreaticobiliary surgery and decreases the need for urgent relaparotomy.

Natural history and therapeutic strategies of post-pancreatoduodenectomy abdominal fluid collections: Ten-year experience in a single institution

TRIAL DESIGN

The aim of this study was to identify independent risk factors for post-pancreatoduodenectomy (post-PD) abdominal fluid collections (AFCs) and evaluate our management protocol on it.

METHODS

A retrospective analysis of consecutive 2064 cases who underwent PD over the past decade in 1 single center was conducted. The patients were divided into AFCs and non-AFCs group. Univariable and multivariate logistic regression analysis was performed to identify independent risk factors of AFCs. The AFCs group was compared with the non-AFCs group with respect to the incidence of postoperative outcomes. The characteristics of AFCs were further analyzed in terms of clinical manifestations.

RESULTS

Two thousand sixty-four cases with pancreaticoduodenectomy were recruited and 15% of them were found AFCs. Diameter of main pancreatic duct ≤3 mm was found to be an independent predictor of AFCs (P < .001), along with soft pancreatic texture (P = .002), mesenterico-portal vein resection (P < .001), and estimated intraoperative blood loss >800 mL (P < .001). The incidence of mild complications was significantly higher in AFCs group than in non-AFCs group (34% vs 20%, P < .001), whereas no significant differences were noted in the rate of severe complications between these 2 groups (15% vs 15%, P = .939).

CONCLUSION

Enhanced drainage is recommended as an effective measure to decrease the incidence of severe complications caused by post-PD AFCs.

Bleeding complications after pancreatic surgery: interventional radiology management

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

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.

Unusual tumour ablations: report of difficult and interesting cases

Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.

Combined Endoscopic-Radiological Rendezvous for Distal Tail Postoperative Pancreatic Fistula (POPF)

Postoperative pancreatic fistula (POPF) with leakage of pancreatic juice is a rare, severe complication following pancreatic resection or, less commonly, splenectomy. Definitive treatment can require multidisciplinary approaches. We report a case of stenosis of the main pancreatic duct with distal tail GRADE C POPF, occurred after splenectomy for Hodgkin lymphoma, successfully treated with combined radiological-endoscopic approach.