Impact of Interventional Radiology in Modern-Day Pancreatic Surgery

Abstract

Purpose To evaluate the role of interventional radiology (IR) in modern-day pancreatic surgery.

Methods Study design: An audit of prospectively maintained electronic medical records.

Duration of study: All patients who required image-guided interventions for postpancreatectomy complications from January 2014 to December 2019 were identified and reviewed.

Results Among 758 patients who underwent pancreatectomy, 206 (27.2%) developed complications. Of these, 46 patients (6%) experienced postpancreatectomy hemorrhage (PPH), with 30 patients (3.96%) requiring intervention; 13 patients (43.3%) underwent angioembolization, of whom 5 (38.46%) died due to causes unrelated to PPH, while 17 patients (56.7%) underwent surgical re-exploration. Although the 90-day mortality rates were not statistically significant, they appeared to be higher in the endovascular group (38.46 vs. 17.6%). Intra-abdominal fluid collections were observed in 173 patients (22.8%), with 147 (85%) undergoing image-guided interventions and 23 (13.3%) undergoing surgical re-exploration. The 90-day mortality rates were 6.12 and 21.7% in the IR and surgical groups, respectively. Biliary complications occurred in 31 patients (4%), of which 18 (58%) underwent image-guided intervention and 11 (35.5%) underwent surgical re-exploration. The 90-day mortality rates were 27.78 and 35.5% in the IR and surgical groups, respectively. Image-guided interventions successfully prevented re-exploration in 61.5% of PPH cases, 88.9% of biliary complications, and 99.3% of intra-abdominal fluid collections.

Conclusion IR procedures are safe and effective, and the synergistic role of the interventional radiologist provides a minimally invasive approach in the management of postpancreatectomy complications while reducing the need for re-exploration, thereby reducing the recovery time and preventing morbidity associated with re-exploration.

Keywords

postpancreatectomy complications - interventional radiology - image-guided interventions

Introduction

Pancreaticoduodenectomy (PD) remains the treatment of choice for patients with malignant and certain benign diseases of the pancreas and periampullary region.[1] Earlier pancreatic surgery was associated with high mortality and morbidity rates; however, with refinements in surgical techniques, the mortality rates have reduced considerably (less than 4%) in high-volume centers.[1] [2] [3] [4] [5] [6] Despite advancements in surgical techniques, morbidity continues to remain high, even in high-volume centers ranging between 30 and 50%.[1] [2] [3] [5] [7] [8] [9] [10] [11] [12] [13] Common complications include postoperative pancreatic fistula (POPF), intra-abdominal collections, delayed gastric emptying (DGE), while other less common but potentially fatal complications are postpancreatectomy hemorrhage (PPH), biliary leaks, and stricture.[1] [2] [7] [8] [13] [14] [15] [16] Early identification of these complications and appropriate management are vital for successful outcomes in postpancreatectomy patients.

In recent years, advancements in interventional radiology (IR) have led to the development of minimally invasive alternatives for the management of postpancreatectomy complications which have considerably reduced the need for emergency re-explorations.[1] [2] IR has demonstrated an increasing role in the successful early management of complications in a less invasive manner, that is, percutaneous image-guided drainage for intra-abdominal collections and POPF, percutaneous transhepatic biliary drainage (PTBD) for patients with biliary leak or stricture, and angioembolization for patients with PPH, thereby reducing the duration of hospital stay.[2]

Aims and Objectives

This study is aimed to evaluate the impact of IR in the management of postpancreatectomy complications in terms of preventing relook laparotomy and 90-day mortality rates.

Materials and Methods

This study included all patients who underwent pancreatic surgery from January 2014 to December 2019. After the approval by Institutional Review Board, a retrospective review of prospectively collected database identified 758 patients who underwent pancreatic surgery at Tata Memorial Hospital, Mumbai. All patients who required image-guided interventions were classified and analyzed.

All patients who developed postsurgical complications within 90 days of primary hospitalization were included. The complications were classified according to the International Study Group of Pancreatic Surgery (ISGPS).[17] [18] The 90-day mortality rate and the percentage of cases in which IR prevented re-exploration were determined.

Percutaneous Image-Guided Drainage for Intra-abdominal Collection and Postoperative Pancreatic Fistula

In patients with a high clinical index of suspicion of an abdominal collection, that is, deviation in the clinical course (fever, raised leukocyte count, DGE, abdominal pain, and tachycardia) or in cases with high-risk pancreatic anastomosis with an expected POPF, contrast-enhanced computed tomography (CECT) of the abdomen is performed to identify the presence and the site of collection. Significant fluid collection associated with POPF or an abscess is usually treated with percutaneous drainage under image guidance (as shown in [Fig. 1]).[19]

Fig. 1 Percutaneous drainage of postpancreatectomy collections. (A, B) Lesser sac collection using transhepatic approach, (C, D) gallbladder fossa collection, and (E, F) left subdiaphragmatic collection.

POPF remains the major contributor to morbidity and mortality following pancreatic surgery, occurring in 10 to 34% of patients undergoing pancreatic resections.[2] [20] POPF is defined as drain output of any measurable volume of fluid on or after postoperative day 3 with fluid amylase more than three times the serum amylase associated with a clinically relevant condition related directly to the POPF, which can originate from pancreaticoenteric or pancreaticogastric anastomosis after pancreatic head resection and of pancreatic remnant after distal pancreatectomy or enucleation.[12] [17] [18] [19] [20] A grading system is also established by the ISGPS which was revised in 2016, which stratified patients from a relatively benign clinical course (grade A—biochemical leak), moderately unwell patients requiring medical or minimally invasive intervention (POPF grade B), and critically ill patients, often with sepsis, requiring invasive intervention (POPF grade C).[10] [12] [17] [18] [20] [21] [22]

Ultrasound (USG)-guided percutaneous drainage is preferred, as it is easy to handle, widely available, and allows for real-time monitoring of the drain placement, while also being free from ionizing radiation. When the collection is located deep in the abdomen and is not well appreciated on USG, drainage can be performed under CT guidance. When the fluid collection is in challenging locations such as subdiaphragmatic, superior recess of lesser sac, juxtacaval areas, etc., techniques such as transhepatic, transthoracic, and hydrodissection can be utilized. The Seldinger technique is preferred for drainage of abdominal collections, as it allows highly accurate and safe placement of a drainage catheter.[2] Appropriate antibiotics based on cultures and sensitivity are administered to treat abdominal collection and to prevent abscess formation.

Percutaneous Transhepatic Biliary Drainage and Stenting for Bile Leak and Biliary Stricture

A bile leak is defined by the International Study Group of Liver Surgery as fluid with increased bilirubin concentration at least three times more than the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis.[23] Biliary leaks are managed by PTBD and/or placement of covered stent when clinically indicated (as shown in [Fig. 2]). Biliary access is obtained by puncturing a peripheral biliary radical under USG and/or fluoroscopy guidance. Covered stents are used across the site of leak, if the leak does not resolve after biliary diversion.[1] [2] [3] [7] [23] [24] Biliary strictures are managed by serial balloon dilatation and placement of larger biliary drainage catheter (as shown in [Fig. 3]).[1] [2] [7] [23] [25]

Fig. 2 Percutaneous transhepatic biliary drainage for bile leak. (A) right percutaneous cholangiogram demonstrating the biliary leak; (B, C) postbiliary stenting cholangiogram demonstrating complete exclusion of the biliary leak.

Fig. 3 Percutaneous transhepatic biliary drainage for anastomotic stricture. (A) right percutaneous cholangiogram demonstrating a HJ stricture with dilated biliary radicles. (B, C) Balloon plasty followed by biliary stenting across the HJ stricture to relieve the obstruction. HJ, hepaticojejunostomy.

Angiography and Embolization for Hemorrhage

Postoperative intra-abdominal hemorrhage is one of the most dreaded complications with a reported incidence of 1.5 to 15% and a reported mortality rate of 20 to 50%.[2] [3] [6] [7] [26] [27] [28] PPH is classified according to the ISGPS criteria and is defined as postoperative bleeding from the surgical site accompanied by a drop in hemoglobin of more than 3 g/dL with peripheral circulatory impairment requiring medical intervention.[2] [9] [27] [29] Early hemorrhage occurs within 24 hours and is generally due to technical failure or coagulopathy, whereas delayed or late PPH occurs after 24 hours and is often the result of multifactorial pathogenesis in which POPF plays an important role.[2] [6] [7] [27] [29] [30] Enzyme-rich peripancreatic collection can cause erosion of the vessel, resulting in the formation of a pseudoaneurysm, which can rupture, resulting in late hemorrhage.

In patients with suspected PPH, a triple-phase CT angiography is usually performed with iodinated contrast material to identify the source of bleeding and to plan the management. Selective angiography of the celiac axis and superior mesenteric artery is performed to identify active contrast extravasation or pseudoaneurysm (direct signs of active bleeding), spasm, and irregularity of a vessel (indirect signs of bleeding).[1] [2] [7] [26] [31] Permanent embolic agents such as detachable coils, liquid embolic agents (n-butyl cyanoacrylate glue [NBCA] glue), and polyvinyl particles are used to achieve hemostasis. Detachable coils are more radiopaque and facilitate precise positioning of the embolization coil in the target vessel. Liquid embolic agents such as NBCA or polyvinyl alcohol particles are used to achieve hemostasis in small distal vessels which cannot be catheterized (as shown in [Fig. 4]).[2] [6] [7] [9] [26] [31] [32] If the site of bleeding is located in the proximal large vessel such as superior mesenteric artery, common hepatic artery, or the celiac trunk, placement of stent graft across the site of bleeding is performed to preserve perfusion in distal vasculature (as shown in [Fig. 5]). Pseudoaneurysms that persist after endovascular embolization can be managed by percutaneous glue embolization.

Fig. 4 Case of carcinoma pancreas, status postrobotic-assisted classical Whipple's procedure. (A) SMA angiogram demonstrating pseudoaneurysm (black arrow) arising from replaced right hepatic artery; (B) embolization performed using 50% N-butyl cyanoacrylate glue; (C) postembolization SMA angiogram shows complete exclusion of the pseudoaneurysm.

Fig. 5 Case of periampullary carcinoma, status post-PPPD with hemorrhagic drain output. (A, B) Coeliac angiogram shows pseudoaneurysm arising from the GDA stump, which was successfully embolized using coils and stent graft. (C) Postembolization hepatic angiogram shows complete exclusion of pseudoaneurysm with good forward flow. GDA, gastroduodenal artery; PPPD, pylorus-preserving pancreaticoduodenectomy.

Venous Interventions

Mesenteric and portal vein thromboses and stenosis can be a relatively rare complication following pancreatic surgery, with portal vein resection being reported in up to 17% of cases.[33] [34] The development of venous thrombosis can lead to severe consequences, potentially causing intestinal ischemia, hepatic ischemia, ascites, and subsequently death.[35] CECT is the best modality to identify thrombus due to its high spatial resolution and is typically seen as a filling defect within the portal or superior mesenteric vein, better depicted in the portal venous phase.[33] [34] [35] As clinically indicated, portal vein thrombosis/stenosis can be managed by direct intravenous thrombolysis, mechanical thrombectomy, or venous stenting.[2] [9] [36] [37]

Venous thromboembolism (VTE) is a common complication and is a major source of postoperative morbidity and mortality. Risk factors include hypercoagulability and prolonged immobilization following pancreatic surgery. Primary thromboprophylaxis using low-molecular-weight heparin for up to 28 days after surgery and the use of thromboembolic deterrent stockings are valuable in reducing the risk of VTE.[38] Deep vein thrombosis is usually diagnosed on Doppler ultrasonography and can be managed by administration of therapeutic dose of anticoagulants and placement of inferior vena cava filter to prevent pulmonary embolism when clinically indicated.[38]

Image-Guided NGT/NJT Insertion for Delayed Gastric Emptying

DGE remains a common troublesome complication after PD, with a reported prevalence of 20 to 50%.[34] It has been defined by ISGPS as “the impossibility of resuming oral feeding after the first postoperative week or the prolonged use of a nasogastric aspiration tube.”[33] [34] [39] Risk factors include cholangitis, diabetes, and prior abdominal surgery.[34] Although the diagnosis is not based on imaging but on clinical symptoms, the presence of a severely distended stomach on CT scan is highly suggestive.[33] Symptomatic patients require fluoroscopy- or endoscopy-guided nasogastric/nasojejunal tube (NGT/NJT) insertion to decompress the gastric outlet obstruction and supplement enteral nutrition (as shown in [Fig. 6]). Most of the patients recover after a short period following NGT/NJT insertion.[32]

Fig. 6 Nasojejunal tube to relieve delayed gastric emptying postpancreatic surgery.

Results

A total of 758 patients underwent pancreatic surgery between January 2013 and December 2019, of which 206 patients (134 males and 72 females) developed complications. The demographic details, the type of pancreatic surgeries, and the pathological diagnosis are enlisted in [Table 1]. The age distribution of patients who developed complications following pancreatic surgery is illustrated in [Fig. 7].

Table 1 Patients' demographic profile and type of pancreatic surgery

Number of patients who underwent pancreatic surgery		758
Number of patients who developed complications		206
Gender		134:72 (M:F)
Mean age of patients who developed complications, y (SD)		53 (12.3)
Comorbidities (diabetes, hypertension, hypothyroidism, dyslipidemia, coronary artery disease, etc.)		No comorbidities: 114 One comorbidity: 45 Multiple comorbidities: 47
Type of surgery		Patients (n = 206)
A	Pancreatectomy	4% (8)
B	Pancreaticoduodenectomy	73.8% (152)
C	Enucleation	1% (2)
D	Pancreatectomy + vein resection	4.85% (10)
E	Multivisceral pancreatic surgery	16.5% (34)

Abbreviation: SD, standard deviation.

Fig. 7 A histogram showing age distribution of patients who developed complications following pancreatic surgery.

The postsurgical complications encountered include hemorrhage ([Table 2]), intra-abdominal collection ([Table 3]), POPF ([Table 4]), biliary leak/stricture ([Table 5]), vascular thrombosis, DGE, and pleural effusion. Comprehensive details about each complication and its corresponding management strategies are provided in the tables for clarity and reference.

Table 2 Summary of patients with PPH

PPH	Number of patients (%)
Suspected PPH	46/758 (6%)
Patients with PPH requiring intervention	30/758 (3.9%)
Angioembolization	13/30 (43.3%)
Surgical re-exploration	17/30 (56.7%)
90-day mortality rate in the surgical re-exploration group	3/17 (17.6%)
90-d mortality rate in IR group p-value, odds ratio (confidence interval)	5/13 (38.5%) 0.24, 2.92 (0.54–15.6)
90-day mortality rate in patients with PPH	8/46 (17.39%)
Details of angioembolization
Angioembolization	13/30 (43.3%)
Source	12: arterial, 1: venous
Successful embolization	8/13 patients (61.5%)
Re-exploration following angioembolization (all these five patients experienced complications that were beyond the scope of percutaneous image-guided intervention)	5/13 (38.4%)[a] HJ leak = 1, PJ leak = 1, jejunal perforation = 1, gangrenous appendix = 1, intestinal obstruction due to bands = 1 Two patients who had HJ/PJ leak expired
90-day mortality rate in patients who underwent angioembolization	5/13 (38.4%) Biliary sepsis and multiorgan failure (1), MI (1), hepatic decompensation (1), and major HJ/PJ leak (2)

Abbreviations: HJ, hepaticojejunostomy; IR, interventional radiology; PJ, pancreaticojejunostomy; PPH, postpancreatectomy hemorrhage.

^a All the five patients who underwent re-exploration had complications that were beyond the scope of management by percutaneous image-guided interventions.

Table 3 Summary of patients with intra-abdominal fluid collection

Intra-abdominal fluid collection	Number of patients
Total patients	173/758 (22.8%)
Patients with pancreatic fistula	152/173 (87.9%)
Image-guided intervention	147/173 (84.5%) (1 patient underwent surgical re-exploration following multiple percutaneous drainage procedure)
Percutaneous drainage	141/147 (95.9%)
Aspiration	6/147 (4.1%)
Surgical re-exploration	23/173 (13.3%)
Conservative management	3/173 (1.7%)
90-day mortality rate in the IR group	9/147 (6.12%)
90-day mortality rate in re-exploration group	5/23 (21.7%)
90-day mortality rate in patients with intra-abdominal fluid collection p-value, odds ratio (confidence interval)	14/173 (8.1%) 0.011, 4.26 (1.28–14.1)
Successful image-guided aspiration/drainage	146/147 (99.3%)
Number of drainages in a patient		Number of patients
1		115
2		20
3		7
More than 3		4

Abbreviation: IR, interventional radiology.

Table 4 Summary of patients with postoperative pancreatic fistula

Pancreatic fistula	Number of patients
Patients with pancreatic fistula	152/758 (20%)
Conservative management	9/152 (5.9%)
Percutaneous drainage	110/152 (72.36%)
Surgical re-exploration	33/152 (21.7%)
Surgical re-exploration following image-guided intervention	9/152 (5.92%)
Successful image-guided aspiration/ drainage	101/110 (91.8%)
90-day mortality rate in the IR group	3/110 (2.7%)
90-day mortality rate in re-exploration group	10/33 (30.3%)
90-day mortality rate in conservative group	1/9 (11%)
90-day mortality rate in patients with pancreatic fistula	14/152 (9.2%)

Abbreviation: IR, interventional radiology.

Table 5 Summary of patients with biliary complications

Biliary complications	Number of patients (%)
Bile leak and biliary stricture	31/758 (4%)
Biliary stricture	3/31 (9.68%) (all patients needed PTBD and biliary stenting)
Bile leak	28/31(90.3%)
Conservative management	2/28 (7.14%)
Image-guided intervention	18/31 (58%)
Percutaneous biliary drainage	10/28 (35.7%)—2 patients (7.14%) underwent re-exploration following biliary diversion
Biliary drainage and stenting	5/28 (17.85%)
Surgical intervention	11/31 (35.5%)
90-day mortality rate in the IR group p-value, odds ratio (confidence interval)	5/18 (27.78%) 1.00, 1.03 (0.19–5.5)
90-day mortality rate in surgical group	3/11 (27.27%)
90-day mortality rate in patients with biliary complications	8/31 (25.8%)
IR successful in preventing re-exploration	16/18 (88.9%)

Abbreviations: IR, interventional radiology; PTBD, percutaneous transhepatic biliary drainage.

The 90-day mortality rate in patients with PPH was higher in the endovascular group as compared to the surgical group. While PPH may have been a contributing factor, the causes of death were not directly related to PPH. There was no statistically significant difference in the 90-day mortality rate between IR and surgical groups in patients with PPH and biliary complications with p-values of 0.24 and 1, respectively. In patients with intra-abdominal collection, the 90-day mortality rate was four times higher in the surgical re-exploration group as compared to the IR group and was statistically significant with a p-value of 0.011.

Vascular Thrombosis

Two patients developed portal vein and portal vein graft thromboses, respectively, and were treated by mechanical thrombectomy and catheter-directed thrombolysis; however, both patients succumbed to death. The 90-day mortality rate among patients who developed portal vein thrombosis after pancreatic resection was 100% despite aggressive management. Three patients developed deep vein thrombosis of lower limbs and were managed conservatively by oral anticoagulation. No patient developed pulmonary thromboembolism in our study population.

Delayed Gastric Emptying

Eight percent of patients (61/758) developed DGE and required either NGT or NJT insertion. Most of the patients were managed with either intraoperative insertion of NGT/NJT or bedside insertion of NGT; however, few patients required endoscopy or image-guided insertion of NJT. No significant association was noted between intra-abdominal collections/POPF and DGE.

There was a significant increase in mortality rate in patients who had more than three complications following pancreatic surgery. The frequency of IR procedures performed on the patients is illustrated in [Fig. 8].

Fig. 8 A bar chart illustrating the frequency of IR procedures performed on the patients. IR, interventional radiology.

The 90-day mortality rate and the role IR played in preventing re-exploration are enlisted in [Table 6], and the ISGPS grading is enlisted in [Table 7].

Table 6 Summary of patients' 90-day mortality rate and the success of image-guided interventions in preventing re-exploration

Event	PPH	Biliary	Collection	DGE	Pleural effusion
90-day mortality rate in IR group p-value, odds ratio (confidence interval)	5/13 (38%)[a] 0.24, 2.92 (0.54–15.6)	5/18 (27.8%)[b] 1.00, 1.03 (0.19–5.5)	9/147 (6.1%) 0.011, 4.26 (1.28-14.1)	0/7 (0%)	1/7 (14.3%)[c]
90-day mortality rate in re-exploration group	3/17 (17.6%)	3/11 (27.3%)	5/23 (21.7%)	-–	–
90-day mortality rate	8/46 (17.39%)	8/31 (25.8%)	14/173 (8%)	5/61 (8.2%)[c]	1/8 (12.5%)
Success rates of IR procedures	8/13 (61.5%)	16/18 (88.9%)	146/147 (99.3%)	7/7 (100%)	7/7 (100%)

Abbreviations: DGE, delayed gastric emptying; IR, interventional radiology; PPH, postpancreatectomy hemorrhage.

^a Although PPH may have been a contributing factor, the causes of death in these patients are not directly related to PPH.

^b Only two deaths among patients with biliary complications in the IR group were attributed to biliary leaks. The remaining three deaths were caused by other unrelated factors.

^c The causes of death for the remaining patients were not linked to complications of interest, such as pleural effusion or DGE.

Table 7 Summary of ISGPS grading of postpancreatectomy complications

ISGPS	PPH (46)	Bile leak (28)	Collection (32)	POPF (152)	DGE (61)	DVT (3)	Pleural effusion (8)
Grade A			0	8 (5.26%)	15 (24.6%)
Grade B	17 (37%)	13 (46.4)	23 (71.9%)	106 (69.7%)	35 (57.4%)	1 (33.3%)	8 (100%)
Grade C	29 (63%)	15 (53.6%)	9 (28.1%)	38 (25%)	11 (18%)	2 (66.7%)

Abbreviations: DGE, delayed gastric emptying; DVT, deep vein thrombosis; IR, interventional radiology; ISGPS, International Study Group of Pancreatic Surgery; POPF, postoperative pancreatic fistula; PPH, postpancreatectomy hemorrhage.

Discussion

In recent decades, with advancements in surgical techniques, though the mortality rate associated with pancreatic surgery has decreased, morbidity rates continue to remain high.[1] [3] [7] [15] [32] [40] Many complications associated with pancreatic surgery are being successfully managed by minimally invasive IR techniques, thereby preventing morbidity associated with re-exploration. Interventional radiologists play a critical role in the management of patients with pancreatic and periampullary disease, seldom preoperatively and often postoperatively for the management of complications associated with pancreatic surgery.[1] [3] [7] [9] [32] Diagnosis of pancreatic neoplasm/peripancreatic mass infiltrating the pancreas is done preoperatively by percutaneous USG/CT-guided biopsy, thereby obviating surgery in certain benign pancreatic diseases. In selective patients, preoperative PTBD is done to relieve the obstructive jaundice so that neoadjuvant chemotherapy can be initiated to reduce the size of the tumor for optimal surgical results. PTBD and metallic stenting also play a role in the palliation of unresectable pancreatic tumors by relieving obstructive jaundice, thereby initiating chemotherapy. Most importantly, IR plays a critical role in the management of perioperative complications associated with pancreatic surgery.

The focus of this study was to establish the role of IR in the management of potentially life-threatening postpancreatectomy complications, thereby preventing re-exploration. In our study, out of 758 patients who underwent pancreatic surgery, 206 patients developed complications, of which 164 patients needed IR procedures for the management of complications.

The reported incidence of PPH in the literature ranges from 1.5 to 15%, and the mortality rate associated with PPH is high, ranging from 20 to 50%.[1] [2] [3] [6] [7] [9] [27] [28] In our study, the incidence of PPH requiring either surgical or image-guided intervention was 3.96% (30/758), and the 90-day mortality rate in patients with PPH was 17.39% (8/46). These results are comparable with other studies in the literature. The 90-day mortality rate among patients who underwent primary angioembolization for PPH is 38.46% (5/13) which is not statistically significant (p value - 0.24). The causes of death for these five patients included biliary sepsis with multiorgan dysfunction (one), myocardial infarction (one), hepatic decompensation (one), and major hepaticojejunostomy (HJ) and pancreaticojejunostomy (PJ) leaks (one each). Although PPH may have been a contributing factor, the causes of death were not directly related to PPH. Five patients (38.46%) underwent re-exploration following angioembolization in view of worsening clinical status due to HJ leak, PJ leak, jejunal perforation, gangrenous appendix, and intestinal obstruction due to Ladd's bands, respectively. All these five patients who underwent re-exploration were beyond the scope of management by IR. Overall, the mortality rates in patients with PPH remain high despite aggressive intervention. These patients also tend to have other associated complications and comorbidities which contribute to increased mortality and morbidity rates. IR played a pivotal role in 61.5% (8/13) of patients in preventing re-exploration.

The incidence of intra-abdominal fluid collection postpancreatectomy in our study was 22.8% (173/758), which is comparable with other studies in the literature (8–30%);[2] [3] [7] [8] [36] 87.8% (152/173) of patients had POPF; 91.84% (135/147) of patients who had intra-abdominal collections were successfully managed by IR, obviating the need for re-exploration. The 90-day mortality rate after primary percutaneous image-guided intervention was 6.12% (9/147) and after primary surgical re-exploration was 21.7% (5/23). Many of these patients who underwent percutaneous drainage had other complications and comorbidities, which increased the mortality risk. The 90-day mortality rate among patients who had intra-abdominal fluid collections and needed intervention was 8.1% (14/173).

The incidence of pancreatic fistula (PF) in our study was 20% (152/758), which is comparable to other studies in the literature (2–28%).[2] [12] [40] [41] This is obtained by meticulous examination of amylase levels in the abdominal fluid collection of all patients. The essential component of an anastomotic leak was the high amylase content (more than three times the upper normal serum value) in the drain fluid (of any measurable volume), at any time on or after the third postoperative day.[12] [17] [18] [19] [20] The International Study Group of Pancreatic Fistula definition also graded PF (grades A, B, and C) according to the clinical impact on the patient's hospital course and eventual outcome.[10] [12] [17] [18] [20] [21] [22] IR played a significant role in the management of patients with PF and had prevented re-exploration in 91.8% (101/110). The 90-day mortality rate in patients who underwent percutaneous drainage was 2.7% (3/110), and the 90-day mortality rate in patients who underwent primary surgical re-exploration was 30.3% (10/33).

The incidence of biliary complications seen in our study was ∼4% (31/758) and is comparable with other studies seen in the literature (3–22%).[1] [2] [3] [7] [25] [42] These patients tend to have other complications such as PF and intra-abdominal fluid collections; 9.6% (3/31) of the patients had biliary stricture and were managed successfully with biliary stenting. IR played a role in 88.9% (16/18) of patients with biliary complications in preventing re-exploration. The 90-day mortality rate among patients who underwent biliary diversion was 27.8% (5/18), and among patients who underwent surgical re-exploration was 27% (3/11). Overall, biliary leaks are associated with high mortality and morbidity rates, and early recognition of this condition is warranted.

Portal vein thrombosis was associated with a very high mortality rate (∼100%). Early recognition of this condition by portal vein Doppler/CECT of the abdomen and appropriate management using mechanical thrombectomy and/or catheter-directed thrombolysis is needed for successful outcomes.[9] [37] [38] Deep vein thrombosis of limbs was rarely seen in our study population due to the strict thromboprophylaxis followed in our institution, that is, compression stockings, early limb mobilization, and/or prophylactic anticoagulation. No patients had pulmonary thrombosis in our study population.

Less severe complications such as DGE, pleural effusion, and ascites may contribute to morbidity but seldom contribute to mortality and can be conveniently managed using image-guided intervention. IR plays an important role in the insertion of NJT under fluoroscopic guidance in patients with DGE, thereby promoting enteral feeding. In this study, no significant association was noted between patients with intra-abdominal fluid collection and DGE. With an increase in the number of complications, there was an increased risk of mortality, especially when the patient had more than three complications.

Conclusion

IR plays an important and crucial role in the management of complications following major pancreatic surgery. It provides a minimal invasive alternative to surgical re-exploration, reducing recovery time and preventing morbidity associated with re-exploration. Early recognition and prompt intervention are vital in patients with PPH, biliary leak, and portal vein thrombosis, as they are associated with high mortality and morbidity rates. Most patients with intra-abdominal fluid collection, POPF, PPH, pleural effusion, ascites, DGE, bile leaks and biliary stricture can be successfully managed with minimally invasive IR procedures, thereby minimizing the morbidity associated with re-exploration. In cases where re-exploration is necessary, it is often due to complications beyond the scope of percutaneous management. Despite the success of IR procedures, some patients may still require reoperation in situations such as anastomotic dehiscence, peritonitis, etc. Increased frequency of complications is associated with a higher risk of mortality. IR procedures are both safe and effective, and the synergistic role of interventional radiologists provides a minimally invasive approach to managing postpancreatectomy complications, significantly reducing the need for re-exploration.

Conflict of Interest

None declared.

Ethical Approval

For this type of study, formal consent is not required. The study was performed after approval from the Institutional Ethics Committee.

Informed Consent

For this type of study, informed consent is not required.

• References

• 1 Baker TA, Aaron JM, Borge M, Pierce K, Shoup M, Aranha GV. Role of interventional radiology in the management of complications after pancreaticoduodenectomy. Am J Surg 2008; 195 (03) 386-390 , discussion 390
• 2 Putzer D, Schullian P, Stättner S. et al. Interventional management after complicated pancreatic surgery. Eur Surg 2019; 51 (03) 105-113
• 3 Sohn TA, Yeo CJ, Cameron JL. et al. Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications. J Gastrointest Surg 2003; 7 (02) 209-219
• 4 Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993; 217 (05) 430-435 , discussion 435–438
• 5 Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 1987; 206 (03) 358-365
• 6 Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg 2019; 8 (02) 150-163
• 7 Mauri G, Mattiuz C, Sconfienza LM. et al. Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review. Insights Imaging 2015; 6 (02) 231-239
• 8 Reddy JR, Saxena R, Singh RK. et al. Reoperation following pancreaticoduodenectomy. Int J Surg Oncol 2012; 2012: 218248
• 9 Puppala S, Patel J, McPherson S, Nicholson A, Kessel D. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol 2011; 196 (01) 192-197
• 10 Shrikhande SV, Barreto G, Shukla PJ. Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy. Langenbecks Arch Surg 2008; 393 (01) 87-91
• 11 Penumadu P, Barreto SG, Goel M, Shrikhande SV. Pancreatoduodenectomy - preventing complications. Indian J Surg Oncol 2015; 6 (01) 6-15
• 12 Shrikhande SV, D'Souza MA. Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J Gastroenterol 2008; 14 (38) 5789-5796
• 13 Shukla PJ, Barreto G, Shrikhande SV. The evolution of pancreatoduodenectomy. Hepatogastroenterology 2011; 58 (109) 1409-1412
• 14 Shrikhande SV, Barreto SG, Somashekar BA. et al. Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration. Pancreatology 2013; 13 (01) 63-71
• 15 Lessing Y, Pencovich N, Nevo N. et al. Early reoperation following pancreaticoduodenectomy: impact on morbidity, mortality, and long-term survival. World J Surg Oncol 2019; 17 (01) 26-26
• 16 Winter JM, Cameron JL, Campbell KA. et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 2006; 10 (09) 1199-1210 , discussion 1210–1211
• 17 Bassi C, Dervenis C, Butturini G. et al; International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138 (01) 8-13
• 18 Bassi C, Marchegiani G, Dervenis C. et al; International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161 (03) 584-591
• 19 Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg 2014; 399 (07) 801-810
• 20 Pulvirenti A, Ramera M, Bassi C. Modifications in the International Study Group for Pancreatic Surgery (ISGPS) definition of postoperative pancreatic fistula. Transl Gastroenterol Hepatol 2017; 2 (12) 107-107
• 21 Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11: 105-118
• 22 Dhayat SA, Tamim ANJ, Jacob M. et al. Postoperative pancreatic fistula affects recurrence-free survival of pancreatic cancer patients. PLoS One 2021; 16 (06) e0252727
• 23 Koch M, Garden OJ, Padbury R. et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149 (05) 680-688
• 24 Herzog T, Belyaev O, Hessam S, Uhl W, Chromik AM. Management of isolated bile leaks after pancreatic resections. J Invest Surg 2014; 27 (05) 273-281
• 25 Angileri SA, Gorga G, Tortora S. et al. Biliary injuries after pancreatic surgery: interventional radiology management. Gland Surg 2019; 8 (02) 141-149
• 26 Limongelli P, Khorsandi SE, Pai M. et al. Management of delayed postoperative hemorrhage after pancreaticoduodenectomy: a meta-analysis. Arch Surg 2008; 143 (10) 1001-1007 , discussion 1007
• 27 Yekebas EF, Wolfram L, Cataldegirmen G. et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007; 246 (02) 269-280
• 28 Blanc T, Cortes A, Goere D. et al. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?. Am J Surg 2007; 194 (01) 3-9
• 29 Duarte Garcés AA, Andrianello S, Marchegiani G. et al. Reappraisal of post-pancreatectomy hemorrhage (PPH) classifications: do we need to redefine grades A and B?. HPB (Oxford) 2018; 20 (08) 702-707
• 30 Floortje van Oosten A, Smits FJ, van den Heuvel DAF, van Santvoort HC, Molenaar IQ. Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis. HPB (Oxford) 2019; 21 (08) 953-961
• 31 Schäfer M, Heinrich S, Pfammatter T, Clavien PA. Management of delayed major visceral arterial bleeding after pancreatic surgery. HPB (Oxford) 2011; 13 (02) 132-138
• 32 Sanjay P, Kellner M, Tait IS. The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy. HPB (Oxford) 2012; 14 (12) 812-817
• 33 Chincarini M, Zamboni GA, Pozzi Mucelli R. Major pancreatic resections: normal postoperative findings and complications. Insights Imaging 2018; 9 (02) 173-187
• 34 Lermite E, Sommacale D, Piardi T. et al. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol 2013; 37 (03) 230-239
• 35 Raman SP, Horton KM, Cameron JL, Fishman EK. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol 2013; 201 (01) 2-13
• 36 Zink SI, Soloff EV, White RR. et al. Pancreaticoduodenectomy: frequency and outcome of post-operative imaging-guided percutaneous drainage. Abdom Imaging 2009; 34 (06) 767-771
• 37 Quarrie R, Stawicki SP. Portal vein thrombosis: what surgeons need to know. Int J Crit Illn Inj Sci 2018; 8 (02) 73-77
• 38 Hanna-Sawires RG, Groen JV, Klok FA. et al. Outcomes following pancreatic surgery using three different thromboprophylaxis regimens. Br J Surg 2019; 106 (06) 765-773
• 39 Wente MN, Bassi C, Dervenis C. et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142 (05) 761-768
• 40 Yeo CJ, Cameron JL, Sohn TA. et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226 (03) 248-257 , discussion 257–260
• 41 Kazanjian KK, Hines OJ, Eibl G, Reber HA. Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 2005; 140 (09) 849-854 , discussion 854–856
• 42 Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z'graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003; 138 (12) 1310-1314 , discussion 1315

Publication History

Article published online:
01 May 2025