Pancreaticoduodenectomy: expected post-operative anatomy and complications

Abstract

Pancreaticoduodenectomy is a complex, high-risk surgical procedure performed for tumours of the pancreatic head and other periampullary structures. The rate of perioperative mortality has decreased in the past number of years but perioperative morbidity remains high. This pictorial review illustrates expected findings in early and late post-operative periods, including mimickers of pathology. It aims to familiarize radiologists with the imaging appearances of common and unusual post-operative complications. These are classified into early non-vascular complications such as delayed gastric emptying, post-operative collections, pancreatic fistulae and bilomas; late non-vascular complications, for example, biliary strictures and hepatic abscesses; and vascular complications including haemorrhage and ischaemia. Options for minimally invasive image-guided management of vascular and non-vascular complications are discussed. Familiarity with normal anatomic findings is essential in order to distinguish expected post-operative change from surgical complications or recurrent disease. This review summarizes the normal and abnormal radiological findings following pancreaticoduodenectomy.

Figure 1.

Diagrams of anatomy post pancreaticoduodenectomy (a) and post pylorus-preserving pancreaticoduodenectomy (b) with surgical anastomoses depicted. Intraoperative photographs from a standard pancreaticoduodenectomy delineate the three anastomoses: gastrojejunostomy (c), hepaticojejunostomy (d) and pancreaticojejunostomy (e).

Figure 2.

Acute deterioration Day 3 post surgery for pancreatic adenocarcinoma. CT shows an oedematous jejunal loop (arrow). This was mistaken for hypoenhancement and was reported as suspicious for ischaemia. Explorative laparotomy showed normally perfused bowel. Note the expected findings of a pancreatic stent (arrowhead) and a surgical drain (short arrow).

Figure 3.

Persistent vomiting Day 11 post surgery for pancreatic adenocarcinoma. Coronal CT shows distension of the residual stomach. Note the normal post-operative findings of pneumobilia (arrow) and oedematous jejunal loop.

Figure 4.

Fever, pain and leucocytosis Day 14 post surgery for pancreatic neuroendocrine tumour. Axial CT image shows a fluid collection (arrow) in the resection bed (a). A drainage catheter was placed using CT guidance and frank pus was drained. Coronal reformat from follow-up CT (b) shows satisfactory catheter position (arrow) with reduction in size of the collection.

Figure 5.

Two cases of complicated post-operative leaks; one of a pancreatic fistula and one of a biloma. Case 1: coronal CT reformat (a) shows a drainage catheter in a collection (arrow) inferior to the pancreaticojejunostomy. Tubogram through the drainage catheter (b) shows communication with the main pancreatic duct (arrow). Catheter fluid amylase was markedly elevated at 10,874 U/l consistent with a pancreatic fistula. Case 2: axial CT image shows a fluid collection (arrow) in the gallbladder fossa (c). Note the expected finding of a pancreatic stent (arrowhead). Percutaneous drainage of the collection was performed. Contrast injection through a percutaneous catheter tract via a sheath (d) shows communication to the central right hepatic duct (arrow). Contrast drains from this through the hepaticojejunostomy. Catheter fluid bilirubin was elevated at 10 mg dl⁻¹.

Figure 6.

Short history of anorexia, abdominal pain and rigors 9 years post surgery for duodenal adenocarcinoma. Axial CT image shows a bilobed thick walled fluid collection (arrow) in segments VIII and IVa of the liver. Ultrasound-guided drainage was performed, and frank pus was drained. Catheter fluid culture was positive for Escherichia coli.

Figure 7.

Cholangitis 6 months post surgery for pancreatic adenocarcinoma. Axial CT image (a) demonstrates dilatation of the afferent loop of the hepaticojejunostomy (aff), decompression of the efferent loop (arrow) and a soft-tissue mass at the hilum (asterisk). Image from percutaneous transhepatic cholangiogram (b) shows a similar appearance of biliary dilatation and distension of the afferent jejunal loop (arrow). The hepaticojejunostomy is patent and a catheter has been passed into the afferent loop. Despite multiple attempts, it was not possible to cannulate the efferent loop. A presumptive diagnosis of tumour recurrence in the efferent loop was made; the patient subsequently developed hepatic metastases. Palliative placement of an external biliary drain was performed.

Figure 8.

Recurrent cholangitis 3 years post surgery for pancreatic adenocarcinoma. Coronal MR cholangiopancreatography image (a) shows a stricture (arrow) of the common hepatic duct with associated intrahepatic duct dilatation. Image from percutaneous transhepatic cholangiogram (b) demonstrates balloon dilatation with waisting of the balloon (arrow) at the site of maximum stenosis. Post-dilatation cholangiogram demonstrated no residual stricture. The patient has not developed recurrent symptoms since the procedure.

Figure 9.

Hypotension and bleeding from surgical drain Day 20 post surgery for pancreatic adenocarcinoma. Axial image from arterial phase of CT angiogram shows active extravasation of contrast from a pseudoaneurysm at the site of the gastroduodenal artery stump (arrow). There is surrounding haematoma. Successful proximal coil embolization of the common hepatic artery was performed.

Figure 10.

A rim enhancing fluid collection lateral to the superior mesenteric vein was drained under CT guidance Day 8 post surgery for distal common bile duct cholangiocarcinoma. The catheter was accidentally displaced later on the ward and was manipulated back into the retroperitoneal collection using fluoroscopic guidance. Satisfactory repositioning is confirmed at follow-up CT. Subsequently, the catheter drained blood. A tubogram was performed that shows frank communication with the portal system (arrow), presumed to be related to injury at the time of catheter displacement. The catheter was clamped with intention for it to remain in situ indefinitely. It fell out at home 3 months later with no clinical sequelae.

Figure 11.

Critically unwell Day 19 post surgery for ampullary adenocarcinoma. Reformatted axial image (a) from a triphasic CT shows occlusion of the hepatic artery (arrow) and extensive portal venous gas. Coronal image (b) shows occlusion of the main portal vein (arrow) and parenchymal gas in Segment VI. The patient died shortly afterwards despite maximum ventilator and inotropic support.

Figure 12.

Two cases of stent migration. Case 1: axial CT image (a) shows a pancreatic stent (arrowheads) that has migrated through the pancreaticojejunostomy into the liver parenchyma resulting in abscess formation (arrow). A drainage catheter was placed within the collection using ultrasound guidance and frank pus was aspirated. Tubogram (b) performed at the end of the procedure outlines the abscess cavity and the pancreatic stent (arrow). Percutaneous retrieval of the stent was attempted but was unsuccessful. The patient developed hepatic metastases after a short interval and the drainage catheter was kept in situ while the patient received palliative chemotherapy. The patient died with the migrated stent and drainage catheter in situ. Case 2: reformatted coronal CT image (c) shows a migrated stent (arrowhead) adjacent to a 9-mm pseudoaneurysm related to a replaced right hepatic artery (arrow). The pseudoaneurysm was presumed to have developed as a result of the stent migration and was subsequently identified at formal angiography where coil embolization was successfully performed.