Top

Published in:

01-02-2018

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Authors: Nima Hafezi-Nejad, Elliot K. Fishman, Atif Zaheer

Published in: Abdominal Radiology | Issue 2/2018

Abstract

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Global Burden of Disease Cancer C, Fitzmaurice C, Dicker D, et al. (2015) The Global Burden of Cancer 2013. JAMA Oncology 1(4):505–527. https://doi.org/10.1001/jamaoncol.2015.0735 CrossRef

Lermite E, Sommacale D, Piardi T, et al. (2013) Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol 37(3):230–239. https://doi.org/10.1016/j.clinre.2013.01.003 CrossRefPubMed

Schafer M, Mullhaupt B, Clavien PA (2002) Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 236(2):137–148. https://doi.org/10.1097/01.SLA.0000022024.90584.E9 CrossRefPubMedPubMedCentral

Huttner FJ, Fitzmaurice C, Schwarzer G, et al. (2016) Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. The Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD006053.pub6

Wolfgang CL, Corl F, Johnson PT, et al. (2011) Pancreatic surgery for the radiologist, 2011: an illustrated review of classic and newer surgical techniques for pancreatic tumor resection. AJR Am J Roentgenol 197(6):1343–1350. https://doi.org/10.2214/AJR.10.5311 CrossRefPubMed

Patel NA, Maturen KE, Regenbogen SE, et al. (2017) Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features. Abdom Radiol (NY). https://doi.org/10.1007/s00261-017-1165-9

Seo JW, Hwang HK, Lee M, et al. (2017) Normal postoperative computed tomography findings after a variety of pancreatic surgeries. Korean J Radiol 18(2):299–308. https://doi.org/10.3348/kjr.2017.18.2.299 CrossRefPubMedPubMedCentral

Zaky AM, Wolfgang CL, Weiss MJ, et al. (2017) Tumor-vessel relationships in pancreatic ductal adenocarcinoma at multidetector CT: different classification systems and their influence on treatment planning. Radiographics 37(1):93–112. https://doi.org/10.1148/rg.2017160054 CrossRefPubMed

Vauthey JN, Dixon E (2009) AHPBA/SSO/SSAT consensus conference on resectable and borderline resectable pancreatic cancer: rationale and overview of the conference. Ann Surg Oncol 16(7):1725–1726. https://doi.org/10.1245/s10434-009-0409-5 CrossRefPubMed

10.

Chen FM, Ni JM, Zhang ZY, et al. (2016) Presurgical evaluation of pancreatic cancer: a comprehensive imaging comparison of CT versus MRI. AJR Am J Roentgenol 206(3):526–535. https://doi.org/10.2214/AJR.15.15236 CrossRefPubMed

11.

Park HS, Lee JM, Choi HK, et al. (2009) Preoperative evaluation of pancreatic cancer: comparison of gadolinium-enhanced dynamic MRI with MR cholangiopancreatography versus MDCT. J Magn Reson Imaging 30(3):586–595. https://doi.org/10.1002/jmri.21889 CrossRefPubMed

12.

Treadwell JR, Zafar HM, Mitchell MD, et al. (2016) Imaging tests for the diagnosis and staging of pancreatic adenocarcinoma: a meta-analysis. Pancreas 45(6):789–795. https://doi.org/10.1097/MPA.0000000000000524 CrossRefPubMed

13.

Koelblinger C, Ba-Ssalamah A, Goetzinger P, et al. (2011) Gadobenate dimeglumine-enhanced 3.0-T MR imaging versus multiphasic 64-detector row CT: prospective evaluation in patients suspected of having pancreatic cancer. Radiology 259(3):757–766. https://doi.org/10.1148/radiol.11101189 CrossRefPubMed

14.

Raman SP, Horton KM, Cameron JL, Fishman EK (2013) CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol 201(1):2–13. https://doi.org/10.2214/AJR.12.9647 CrossRefPubMed

15.

Mortele KJ, Lemmerling M, de Hemptinne B, et al. (2000) Postoperative findings following the Whipple procedure: determination of prevalence and morphologic abdominal CT features. Eur Radiol 10(1):123–128. https://doi.org/10.1007/s003300050017 CrossRefPubMed

16.

Zaheer A, Wadhwa V, Oh J, Fishman EK (2015) Pearls and pitfalls of imaging metastatic disease from pancreatic adenocarcinoma: a systematic review. Clin Imaging 39(5):750–758. https://doi.org/10.1016/j.clinimag.2015.04.017 CrossRefPubMed

17.

Tanaka N, Horiuchi A, Yokoyama T, et al. (2011) Clinical characteristics of de novo nonalcoholic fatty liver disease following pancreaticoduodenectomy. J Gastroenterol 46(6):758–768. https://doi.org/10.1007/s00535-011-0370-5 CrossRefPubMed

18.

McEvoy SH, Lavelle LP, Hoare SM, et al. (2014) Pancreaticoduodenectomy: expected post-operative anatomy and complications. Br J Radiol 87(1041):20140050. https://doi.org/10.1259/bjr.20140050 CrossRefPubMedPubMedCentral

19.

Berberat PO, Friess H, Kleeff J, Uhl W, Buchler MW (1999) Prevention and treatment of complications in pancreatic cancer surgery. Dig Surg 16(4):327–336CrossRefPubMed

20.

van Samkar G, Eshuis WJ, Lemmers M, et al. (2013) Value of scintigraphy for assessing delayed gastric emptying after pancreatic surgery. World J Surg 37(12):2911–2917. https://doi.org/10.1007/s00268-013-2219-y CrossRefPubMed

21.

Samaddar A, Kaman L, Dahiya D, Bhattachyarya A, Sinha SK (2015) Objective assessment of delayed gastric emptying using gastric scintigraphy in post pancreaticoduodenectomy patients. ANZ J Surg. https://doi.org/10.1111/ans.13360 PubMed

22.

Tamm EP, Jones B, Yeo CJ, Maher MM, Cameron JL (1995) Pancreaticogastrostomy and the Whipple procedure: radiographic appearance and complications. Radiology 196(1):251–255. https://doi.org/10.1148/radiology.196.1.7784577 CrossRefPubMed

23.

Raty S, Sand J, Nordback I (2007) Detection of postoperative pancreatitis after pancreatic surgery by urine trypsinogen strip test. Br J Surg 94(1):64–69. https://doi.org/10.1002/bjs.5572 CrossRefPubMed

24.

Machado NO (2012) Pancreatic fistula after pancreatectomy: definitions, risk factors, preventive measures, and management-review. Int J Surg Oncol 2012:602478. https://doi.org/10.1155/2012/602478 PubMed

25.

Bassi C, Dervenis C, Butturini G, et al. (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13. https://doi.org/10.1016/j.surg.2005.05.001 CrossRefPubMed

26.

Hamanaka Y, Nishihara K, Hamasaki T, et al. (1996) Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery 119(3):281–287CrossRefPubMed

27.

Hashimoto Y, Sclabas GM, Takahashi N, et al. (2011) Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. J Gastrointest Surg 15(12):2193–2204. https://doi.org/10.1007/s11605-011-1687-3 CrossRefPubMed

28.

Sugimoto M, Takahashi S, Kobayashi T, et al. (2015) Pancreatic perfusion data and post-pancreaticoduodenectomy outcomes. J Surg Res 194(2):441–449. https://doi.org/10.1016/j.jss.2014.11.046 CrossRefPubMed

29.

Yoon JH, Lee JM, Lee KB, et al. (2016) Pancreatic steatosis and fibrosis: quantitative assessment with preoperative multiparametric MR imaging. Radiology 279(1):140–150. https://doi.org/10.1148/radiol.2015142254 CrossRefPubMed

30.

Kim Z, Kim MJ, Kim JH, et al. (2009) Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study. HPB 11(3):215–221. https://doi.org/10.1111/j.1477-2574.2009.00011.x CrossRefPubMedPubMedCentral

31.

Kamal A, Singh VK, Akshintala VS, et al. (2014) CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. Abdom Imaging. https://doi.org/10.1007/s00261-014-0303-x

32.

Aube C, Lebigot J, Pessaux P, et al. (2003) Evaluation of the permeability of pancreaticogastric anastomoses (PGA) with dynamic magnetic resonance pancreatography after secretin stimulation (secretin MRCP). Abdom Imaging 28(4):563–570CrossRefPubMed

33.

Pessaux P, Aube C, Lebigot J, et al. (2002) Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation. J Am Coll Surg 194(4):454–462CrossRefPubMed

34.

Winter JM, Cameron JL, Yeo CJ, et al. (2008) Duodenojejunostomy leaks after pancreaticoduodenectomy. J Gastrointest Surg 12(2):263–269. https://doi.org/10.1007/s11605-007-0370-1 CrossRefPubMed

35.

Bhosale P, Fleming J, Balachandran A, Charnsangavej C, Tamm EP (2013) Complications of Whipple surgery: imaging analysis. Abdom Imaging 38(2):273–284. https://doi.org/10.1007/s00261-012-9912-4 CrossRefPubMed

36.

Scialpi M, Scaglione M, Volterrani L, et al. (2005) Imaging evaluation of post pancreatic surgery. Eur J Radiol 53(3):417–424. https://doi.org/10.1016/j.ejrad.2004.12.013 CrossRefPubMed

37.

Bassi C, Butturini G, Molinari E, et al. (2004) Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 21(1):54–59. https://doi.org/10.1159/000075943 CrossRefPubMed

38.

Wallace MJ, Choi E, McRae S, et al. (2007) Superior mesenteric artery pseudoaneurysm following pancreaticoduodenectomy: management by endovascular stent-graft placement and transluminal thrombin injection. Cardiovasc Intervent Radiol 30(3):518–522. https://doi.org/10.1007/s00270-006-0109-5 CrossRefPubMed

39.

Yoon W, Jeong YY, Shin SS, et al. (2006) Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 239(1):160–167. https://doi.org/10.1148/radiol.2383050175 CrossRefPubMed

40.

Willmann JK, Roos JE, Platz A, et al. (2002) Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol 179(2):437–444. https://doi.org/10.2214/ajr.179.2.1790437 CrossRefPubMed

41.

Smoot RL, Christein JD, Farnell MB (2006) Durability of portal venous reconstruction following resection during pancreaticoduodenectomy. J Gastrointest Surg 10(10):1371–1375. https://doi.org/10.1016/j.gassur.2006.09.001 CrossRefPubMed

42.

Ouaissi M, Sielezneff I, Pirro N, et al. (2008) Therapeutic anticoagulant does not modify thromboses rate vein after venous reconstruction following pancreaticoduodenectomy. Gastroenterol Res Pract 2008:896320. https://doi.org/10.1155/2008/896320 CrossRefPubMedPubMedCentral

43.

Zyromski NJ, Howard TJ (2008) Acute superior mesenteric-portal vein thrombosis after pancreaticoduodenectomy: treatment by operative thrombectomy. Surgery 143(4):566–567. https://doi.org/10.1016/j.surg.2007.10.020 CrossRefPubMed

44.

Kang MJ, Jang JY, Chang YR, Jung W, Kim SW (2015) Portal vein patency after pancreatoduodenectomy for periampullary cancer. Br J Surg 102(1):77–84. https://doi.org/10.1002/bjs.9682 CrossRefPubMed

45.

Miura F, Asano T, Amano H, et al. (2010) Eleven cases of postoperative hepatic infarction following pancreato-biliary surgery. J Gastrointest Surg 14(2):352–358. https://doi.org/10.1007/s11605-009-1089-y CrossRefPubMed

46.

Gaujoux S, Sauvanet A, Vullierme MP, et al. (2009) Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management. Ann Surg 249(1):111–117. https://doi.org/10.1097/SLA.0b013e3181930249 CrossRefPubMed

47.

Sugae T, Fujii T, Kodera Y, et al. (2012) Classification of the celiac axis stenosis owing to median arcuate ligament compression, based on severity of the stenosis with subsequent proposals for management during pancreatoduodenectomy. Surgery 151(4):543–549. https://doi.org/10.1016/j.surg.2011.08.012 CrossRefPubMed

48.

Antolovic D, Koch M, Galindo L, et al. (2007) Hepaticojejunostomy–analysis of risk factors for postoperative bile leaks and surgical complications. J Gastrointest Surg 11(5):555–561. https://doi.org/10.1007/s11605-007-0166-3 CrossRefPubMed

49.

Herzog T, Belyaev O, Hessam S, Uhl W, Chromik AM (2014) Management of isolated bile leaks after pancreatic resections. J Investig Surg 27(5):273–281. https://doi.org/10.3109/08941939.2014.916368 CrossRef

50.

Mathieu D, Vasile N, Fagniez PL, et al. (1985) Dynamic CT features of hepatic abscesses. Radiology 154(3):749–752. https://doi.org/10.1148/radiology.154.3.3969480 CrossRefPubMed

51.

Kato H, Isaji S, Azumi Y, et al. (2010) Development of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) after pancreaticoduodenectomy: proposal of a postoperative NAFLD scoring system. Journal of Hepato-Biliary-Pancreat Sci 17(3):296–304. https://doi.org/10.1007/s00534-009-0187-2 CrossRef

52.

Slezak LA, Andersen DK (2001) Pancreatic resection: effects on glucose metabolism. World J Surg 25(4):452–460. https://doi.org/10.1007/s002680020337 CrossRefPubMed

53.

Burkhart RA, Relles D, Pineda DM, et al. (2013) Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy. J Gastrointest Surg 17(3):451–460. https://doi.org/10.1007/s11605-012-2118-9 CrossRefPubMed

54.

Young SA, Sfakianakis GN, Pyrsopoulos N, Nishida S (2003) Hepatobiliary scintigraphy in liver transplant patients: the “blind end sign” and its differentiation from bile leak. Clin Nucl Med 28(8):638–642. https://doi.org/10.1097/01.rlu.0000079386.99870.3f PubMed

55.

Blair PS, Low G (2014) Biliary anastomotic leakage following orthotopic liver transplant: the use of primovist (gadoxetate disodium) as an intravenous mr cholangiography contrast agent for biliary leakage. J Clin Imaging Sci 4:75. https://doi.org/10.4103/2156-7514.148271 CrossRefPubMedPubMedCentral

56.

Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB (2007) Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 11(12):1704–1711. https://doi.org/10.1007/s11605-007-0369-7 CrossRefPubMed

57.

Bader TR, Braga L, Beavers KL, Semelka RC (2001) MR imaging findings of infectious cholangitis. Magn Reson Imaging 19(6):781–788CrossRefPubMed

58.

Arai K, Kawai K, Kohda W, et al. (2003) Dynamic CT of acute cholangitis: early inhomogeneous enhancement of the liver. AJR Am J Roentgenol 181(1):115–118. https://doi.org/10.2214/ajr.181.1.1810115 CrossRefPubMed

59.

Takano S, Ito Y, Oishi H, et al. (2000) A retrospective analysis of 88 patients with pancreaticogastrostomy after pancreaticoduodenectomy. Hepatogastroenterology 47(35):1454–1457PubMed

60.

Cevasco M, Rodriguez JR, Fernandez-del Castillo C (2008) Clinical challenges and images in GI: image 3. Pancreatic acinar cell carcinoma with subcutaneous fat necrosis. Gastroenterology 135(4):1054–1433. https://doi.org/10.1053/j.gastro.2008.08.032 CrossRefPubMed

61.

Chassagnon G, Metrard G, Besse H, Gauvain S (2014) 18F-FDG PET imaging in a patient with late omental infarction after treatment of pancreatic adenocarcinoma. Clin Nucl Med 39(6):567–569. https://doi.org/10.1097/RLU.0000000000000424 PubMed

62.

Javed AA, Bagante F, Hruban RH, et al. (2015) Postoperative omental infarct after distal pancreatectomy: appearance, etiology management, and review of literature. J Gastrointest Surg 19(11):2028–2037. https://doi.org/10.1007/s11605-015-2920-2 CrossRefPubMed

63.

Roeder F, Timke C, Uhl M, et al. (2012) Aggressive local treatment containing intraoperative radiation therapy (IORT) for patients with isolated local recurrences of pancreatic cancer: a retrospective analysis. BMC Cancer 12:295. https://doi.org/10.1186/1471-2407-12-295 CrossRefPubMedPubMedCentral

64.

Balaj C, Ayav A, Oliver A, et al. (2016) CT imaging of early local recurrence of pancreatic adenocarcinoma following pancreaticoduodenectomy. Abdom Radiol (NY) 41(2):273–282. https://doi.org/10.1007/s00261-015-0564-z CrossRef

65.

Lee ES, Lee JM (2014) Imaging diagnosis of pancreatic cancer: a state-of-the-art review. World J Gastroenterol 20(24):7864–7877. https://doi.org/10.3748/wjg.v20.i24.7864 CrossRefPubMedPubMedCentral

Title: Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection
Authors: Nima Hafezi-Nejad
Elliot K. Fishman
Atif Zaheer
Publication date: 01-02-2018
Publisher: Springer US
Published in: Abdominal Radiology / Issue 2/2018
Print ISSN: 2366-004X
Electronic ISSN: 2366-0058
DOI: https://doi.org/10.1007/s00261-017-1378-y

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Abstract

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 2/2018

Medical oncology and pancreatic cancer: what the radiologist needs to know

Rare pancreatic tumors

Assessment of iodine uptake by pancreatic cancer following chemotherapy using dual-energy CT

Characterizing indeterminate liver lesions in patients with localized pancreatic cancer at the time of diagnosis

Genetics of pancreatic cancer and implications for therapy

Utility of (18) F-FDG PET/CT and CECT in conjunction with serum CA 19-9 for detecting recurrent pancreatic adenocarcinoma

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page