The postsurgical pancreas

Abstract

Background Partial pancreatic resections are among the most complex surgical procedures in visceral tumor medicine and are associated with a high postoperative morbidity with a complication rate of 40–50 % of patients even in specialized centers.

Methods Description of typical surgical resection procedures and the resulting postoperative anatomy, typical normal postoperative findings, common postoperative complications, and radiological findings.

Results and conclusion CT is the most appropriate imaging technique for rapid and standardized visualization of postoperative anatomy and detection of clinically suspected complications after partial pancreatic resections. The most common complications are delayed gastric emptying, pancreatic fistula, acute pancreatitis, bile leakage, abscess, and hemorrhage. Radiologists must identify the typical surgical procedures, the postoperative anatomy, and normal postoperative findings as well as possible postoperative complications and know interventional treatment methods for common complications.

Key points: 

• Morbidity after pancreatic surgery remains high.

• CT is the best method for visualizing postoperative anatomy and is used for early detection of complications.

• Pancreatic fistula is the most common relevant complication after pancreatic resection.

• The ability of a center to manage complications is crucial to ensure the success of therapy.

Citation Format

• Fischbach R, Peller M, Perez D et al. The postsurgical pancreas. Fortschr Röntgenstr 2024; 196: 1037 – 1045

Keywords

pancreas - pancreatic resection - pancreaticoduodenectomy - pancreaticojejunostomy - postoperative complications - pancreas - CT-spiral - surgery - fistula - hemorrhage

Publication History

Received: 23 August 2023

Accepted: 20 December 2023

Article published online:
19 February 2024

• References

• 1 Keim V, Klar E, Poll M. et al. Postoperative Care Following Pancreatic Surgery. Dtsch Ärzteblatt Int 2009; 106: 789-794
• 2 Seufferlein T, Mayerle J, Böck S. et al. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. Z Gastroenterol 2022; 60: 991-1037
• 3 Nimptsch U, Krautz C, Weber GF. et al. Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated. Ann Surg 2016; 264: 1082-1090
• 4 Krautz C, Nimptsch U, Weber GF. et al. Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany. Ann Surg 2018; 267: 411-417
• 5 Alsfasser G, Leicht H, Günster C. et al. Volume – outcome relationship in pancreatic surgery. Br J Surg 2016; 103: 136-143
• 6 Mischinger H-J, Werkgartner G, Kornprat P. et al. Komplikationen in der Pankreaschirurgie. Wiener Klinisches Mag 2018; 21: 98-107
• 7 Bassi C, Dervenis C, Butturini G. et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13
• 8 Karim SAM, Abdulla KS, Abdulkarim QH. et al. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg 2018; 52: 383-387
• 9 Lermite E, Sommacale D, Piardi T. et al. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol 2013; 37: 230-239
• 10 Mortelé KJ, Lemmerling M, Hemptinne de B. et al. Postoperative findings following the Whipple procedure: determination of prevalence and morphologic abdominal CT features. Eur Radiol 2000; 10: 123-128
• 11 Yamauchi FI, Ortega CD, Blasbalg R. et al. Multidetector CT Evaluation of the Postoperative Pancreas. Radiographics 2012; 32: 743-764
• 12 Chincarini M, Zamboni GA, Mucelli RP. Major pancreatic resections: normal postoperative findings and complications. Insights Imaging 2018; 9: 173-187
• 13 Hüttner FJ, Fitzmaurice C, Schwarzer G. et al. Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2016; 2016: CD006053
• 14 Fahlbusch T, Luu AM, Höhn P. et al. Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy—analysis of 5,000 patients based on the German StuDoQ|Pancreas-Registry. Gland Surg 2022; 0 0–0
• 15 Klinkenbijl JHG, Schelling van der GP, Hop WCJ. et al. The Advantages of Pylorus-preserving Pancreatoduodenectomy in Malignant Disease of the Pancreas and Periampullary Region. Ann Surg 1992; 216: 142-145
• 16 Diener MK, Knaebel H-P, Heukaufer C. et al. A Systematic Review and Meta-analysis of Pylorus-preserving Versus Classical Pancreaticoduodenectomy for Surgical Treatment of Periampullary and Pancreatic Carcinoma. Ann Surg 2007; 245: 187-200
• 17 Guerrini GP, Soliani P, D’Amico G. et al. Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-Analysis. J Invest Surg 2016; 29: 175-184
• 18 Keck T, Wellner UF, Bahra M. et al. Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767). Ann Surg 2016; 263: 440-449
• 19 Mejia A, Shah J, Vivian E. et al. Outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing robotic (RPD) or open pancreaticoduodenectomies (OPD): a propensity score-weighted survival analysis. J Robot Surg 2023; 17: 1085-1096
• 20 Peng L, Lin S, Li Y. et al. Systematic review and meta-analysis of robotic versus open pancreaticoduodenectomy. Surg Endosc 2017; 31: 3085-3097
• 21 Nickel F, Haney CM, Kowalewski KF. et al. Laparoscopic Versus Open Pancreaticoduodenectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2020; 271: 54-66
• 22 Pędziwiatr M, Małczak P, Pisarska M. et al. Minimally invasive versus open pancreatoduodenectomy-systematic review and meta-analysis. Langenbecks Arch Surg 2017; 402: 841-851
• 23 Rooij de T, Hilst van J, Santvoort van H. et al. Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial. Ann Surg 2019; 269: 2-9
• 24 Raman SP, Horton KM, Cameron JL. et al. CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications. Am J Roentgenol 2013; 201: 2-13
• 25 Khalil JA, Mayo N, Dumitra S. et al. Pancreatic fistulae after a pancreatico‐duodenectomy: are pancreatico‐gastrostomies safer than pancreatico‐jejunostomies? An expertise‐based trial and propensity‐score adjusted analysis. Hpb 2014; 16: 1062-1067
• 26 Bassi C, Marchegiani G, Dervenis C. et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017; 161: 584-591
• 27 Yoshino J, Ban D, Ogura T. et al. The Clinical Implications of Peripancreatic Fluid Collection After Distal Pancreatectomy. World J Surg 2019; 43: 2069-2076
• 28 Yekebas EF, Wolfram L, Cataldegirmen G. et al. Postpancreatectomy Hemorrhage – Diagnosis and Treatment. Ann Surg 2007; 246: 269-280
• 29 Wente MN, Veit JA, Bassi C. et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20-25
• 30 Roulin D, Cerantola Y, Demartines N. et al. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 2011; 15: 1055-1062
• 31 Wolk S, Grützmann R, Rahbari NN. et al. Management of clinically relevant postpancreatectomy hemorrhage (PPH) over two decades – A comparative study of 1 450 consecutive patients undergoing pancreatic resection. Pancreatology 2017; 17: 943-950
• 32 Augustin AM, Fluck F, Bley T. et al. Endovascular Therapy of Gastrointestinal Bleeding. Fortschr Röntgenstr 2019; 191: 1073-1082
• 33 Shindo D, Yamamoto A, Amano R. et al. The findings of the contrast-enhanced CT and risk factors for hepatic infarction after pancreatoduodenectomy. Jpn J Radiol 2020; 38: 547-552