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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.
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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.)
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Mastalier B, Cauni V, Tihon C, Septimiu Petrutescu M, Ghita B, Popescu V, Andras D, Radu IM, Vlasceanu VG, Floroiu MF, Draghici C, Botezatu C, Cretoiu D, Varlas VN, Lazar AM. Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score. J Clin Med 2023; 12:6193. [PMID: 37834836 PMCID: PMC10573877 DOI: 10.3390/jcm12196193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.
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Affiliation(s)
- Bogdan Mastalier
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Victor Cauni
- Urology Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania;
| | - Constantin Tihon
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Septimiu Petrutescu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Bogdan Ghita
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Valentin Popescu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dan Andras
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Ion Mircea Radu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Vasile Gabriel Vlasceanu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Florian Floroiu
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Draghici
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Botezatu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dragos Cretoiu
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of Obstetrics and Gynaecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Department of Obstetrics and Gynaecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania
| | - Angela Madalina Lazar
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
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