Whipple procedure and its complications: what every

radiologist should know

Poster No.: C-0701

Congress: ECR 2012
Type: Educational Exhibit
Authors: 1 1 2
A. Burguete , J. Zabalza , M. M. Mendigana Ramos , I. Insausti ,
1

1 1 1
A. Sez de Ocriz Garca , J. L. Garca , F. J. Jimenez ;
1 2
Pamplona/ES, Etxauri/ES
Keywords: Pathology, Hemorrhage, Abscess, CT, Abdomen
DOI: 10.1594/ecr2012/C-0701

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Learning objectives

The knowledge of the normal postoperative anatomy after Whipple procedure with
CT allows the radiologist to make an accurate diagnosis of the complications after
pancreaticoduodenectomy.

Our purpose is to review the normal postoperative anatomy, potential complications and
patterns of recurrent disease in a multi-detector 64 row CT.

Background

Pancreaticoduodenectomy is indicated for resection of periampullary cancer and chronic

pancreatitis involving the head and uncinate process of the pancreas and it was
popularized by Whipple et al. It has been associated with high mortality and morbidity.
Nowadays the mortality has been reduced to a 4-5% but the morbidity still remains as
high as 35%.

The classic Whipple procedure involves resection of the head of the pancreas, the
duodenum, the proximal jejunum, the distal third of the stomach, and the lower half of
the common bile duct followed by pancreaticojejunostomy, hepaticoyeyunostomy and
gastroyeyunostomy.

Pancreatogastroanastomosis is an alternative for the reconstruction of the pancreatic

stump following a pancreatoduodenectomy (Fig. 1). Even though it was described in
1946, only in the last ten years has become popular. It seems that this modality
for pancreatic reconstruction is associated with a lower incidence of leakage at the
anastomotic site and lower morbi-mortality related to the procedure.

In this review all of the patients underwent pancreaticoduodenectomy with

pancreaticogastrostomy reconstruction.

Computed tomography is the imaging modality of choice in the follow-up of patients who
underwent pancreaticoduodenectomy. Interpretation of the CT scans depends on an
understanding of the normal postoperative appearance (Fig. 2), potential complications,
and patterns of recurrent disease and the purpose of this pictorial essay is to describe
all of them.

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Images for this section:

Fig. 1

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Fig. 2

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Imaging findings OR Procedure details

1. Normal postsurgical changes

Following pancreatoduodenectomy it is normal to see the following (Fig. 3):

- Ill-define increased attenuation in the peripancreatic fat planes and free fluid
collections. They are the most common findings, they are seen in 50% of patients.
Collections usually occur in the early postoperative period in the surgical bed, Morrison's
pouch, rigth paracolic gutter and at the anastomoses. These collections do not enhance
after contrast administration and are thin-walled or poorly delineated fluid collections.

- Free gas is a common finding.

- Pneumobilia is seen in 48-80% and it is specially diagnosed in the left liver lobe.

- Dilatation of intrahepatic bile duct is seen in 30% of patients.

- Reactive adenopathy: enlarged lymph nodes detected postoperatively simply reflect

an inflammatory response to the recent surgery. Stability or regression of the nodes on
follow up imaging confirms the diagnosis of reactive lymphadenopathy.

2. Early complications

- Postoperative abscess: they can occur anywhere in the abdomen and pelvis, common
sites are the surgical bed and subphrenic spaces (Fig. 4).

- Vascular complications: transient perfusion abnormalities within the liver are

commonly seen and they usually resolve on follow-up imaging (Fig. 5). Other vascular
complications are rare, but include hepatic artery injury, portal vein thrombosis, organ
ischaemia, and splenic infarction.

- Anastomotic leak: is the most commonly associated with mortality, it occurs in 18% of
patients and usually occurs in the first 1-2 weeks after surgery, any of the anastomoses
can fail. A definitive diagnosis is not possible unless a direct leak of oral contrast medium
is demonstrated. However an increase in the amount of the free gas, perianastomotic
fluid and ascities should suggest the diagnosis (Fig. 6).

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- Hemorrhage: is uncommon, is seen in less than 10% of patients but accounts for
11-38% mortality (Fig. 7).

- Acute pancreatitis: inflammatory changes or fluid collections in the left anterior

pararrenal space suggest acute pancreatitis of the remnant (Fig. 8), seen in 2-5% of
patients.

- Paralitic ileus: the reduction in bowel motility after pancreaticoduodenectomy is a

common finding (Fig. 9).

- Hepatic abcess or biloma: the bile ducts are very sensitive to ischemia, and violation
of the integrity of the intrahepatic bile ducts may result in hepatic abscess or intrahepatic
biloma (Fig. 10).

3. Late complications

- Recurrent disease: is a common finding, it can be found in 47% patients. Tumour can
recur locally in the surgical bed or at metastatic sites, usually liver or lung.

Recurrence in the surgical bed (Fig. 11) usually presents as abnormal soft-tissue material
related to the surgical site or cuffing retroperitoneal vascular structures. Early tumor
recurrence may be difficult to distinguish from inflammatory stranding, but invasion of the
fat between the mesenteric vessels and encasement of the vessels suggest recurrent
disease. Another CT finding is the bile ducts dilatation secondary to a recurrent neoplasm
which affects the bile limb.

Liver metastases (Fig. 12) generally appear as rounded hypodense masses best
visualized in the portovenous phase of enhancement.

Images for this section:

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Fig. 3

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Fig. 4

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Fig. 5

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Fig. 6

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Fig. 7

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Fig. 8

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Fig. 9

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Fig. 10

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Fig. 11

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Fig. 12

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Conclusion

CT is the imaging modality of choice in the follow-up of patients who underwent

pancreaticoduodenectomy.

Interpretation of the CT imaging depends on an understanding of the normal

postoperative appearance, potential complications, and patterns of recurrent disease.

Personal Information

References

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