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Surgery for Chronic Pancreatitis: Cross-Sectional Imaging of Postoperative Anatomy and Complications

¹ Department of Radiology, Indiana University Medical Center, 550 N University Blvd., UH 0279, Indianapolis, IN 46202.
² Department of Surgery, Indiana University Medical Center, Indianapolis, IN 46202.

View larger version (54K): [in a new window]   Fig. 1. —Diagram of pylorus-preserving Whipple procedure. Classic Whipple procedure is shown in inset: It entails radical dissection of pancreatic head, adjacent nodes, right half of omentum, gall bladder, common bile duct, and most or all of duodenum followed by gastrojejunostomy/duodenojejunostomy (green arrow), pancreaticojejunostomy (blue arrow), and hepaticojejunostomy (red arrow). (Courtesy of the Office of Visual Media, Indiana University)

View larger version (61K): [in a new window]   Fig. 2. —Diagram of Beger's procedure. Pancreatic body and most of head have been resected. Sleeve of pancreas is left with duodenum to preserve blood supply for latter. This procedure is technically harder to perform than Whipple procedure. Note pancreaticojejunostomy (red arrows) at two sites of Roux limb (green arrow). (Courtesy of the Office of Visual Media, Indiana University)

View larger version (117K): [in a new window]   Fig. 3. —Axial CT scan of 55-year-old man 2 weeks after Beger's procedure shows loop of small bowel (straight black arrows) between pancreatic tail (straight white arrow) and thin shell of pancreatic head (arrowheads). Roux limb shows wall thickening, which is a common early postoperative finding. Duodenum (curved black arrow) is preserved and contains nasojejunal tube. Fluid collection is seen adjacent to pancreatic tail (curved white arrow). Transient collections are common after such surgery and do not need to be drained unless clinically indicated.

View larger version (65K): [in a new window]   Fig. 4. —Diagram of Puestow procedure. Pancreas is filleted to expose main duct from neck to tail and ductal calculi are removed. Roux loop is anastomosed to "capsule" of pancreas with direct drainage of main and secondary pancreatic ducts into jejunum over 8- to 10-cm segment. Loop (arrows) lies anterior to pancreas. (Courtesy of the Office of Visual Media, Indiana University)

View larger version (117K): [in a new window]   Fig. 5A. —Anatomy after Puestow procedure in 46-year-old man with alcohol-induced chronic pancreatitis. Axial CT images show Roux (white arrows) intimately attached to anterior aspect of pancreatic head (arrowhead, A) and body and tail (black arrows, B). Note heavy calcification of pancreatic parenchyma consistent with chronic pancreatitis.

View larger version (110K): [in a new window]   Fig. 5B. —Anatomy after Puestow procedure in 46-year-old man with alcohol-induced chronic pancreatitis. Axial CT images show Roux (white arrows) intimately attached to anterior aspect of pancreatic head (arrowhead, A) and body and tail (black arrows, B). Note heavy calcification of pancreatic parenchyma consistent with chronic pancreatitis.

View larger version (64K): [in a new window]   Fig. 6. —Diagram of pancreas after Frey's procedure. Head of pancreas is cored out (blue arrow) and pancreaticojejunostomy is created via Roux loop (green arrows). Procedure is best performed in patients with duct dilation of head and body. (Courtesy of the Office of Visual Media, Indiana University)

View larger version (155K): [in a new window]   Fig. 7A. —39-year-old man after Frey's procedure. Axial CT (A) and coronal reformatted (B) images show that head of pancreas has been cored out leaving low-density cystic structure (black arrows). Rest of parenchyma is calcified and encircles low-density center (straight white arrows). Roux loop is seen as collapsed unopacified loop of bowel anterior to pancreas (arrowhead, A). Duodenum is intact (curved arrows).

View larger version (161K): [in a new window]   Fig. 7B. —39-year-old man after Frey's procedure. Axial CT (A) and coronal reformatted (B) images show that head of pancreas has been cored out leaving low-density cystic structure (black arrows). Rest of parenchyma is calcified and encircles low-density center (straight white arrows). Roux loop is seen as collapsed unopacified loop of bowel anterior to pancreas (arrowhead, A). Duodenum is intact (curved arrows).

View larger version (146K): [in a new window]   Fig. 8A. —CT scans obtained after Whipple procedure. Axial CT image of 77-year-old woman 8 days after Whipple procedure. Roux loop (arrows) is edematous.

View larger version (137K): [in a new window]   Fig. 8B. —CT scans obtained after Whipple procedure. Axial CT image of 62-year-old woman after Whipple procedure shows mild pancreatic duct dilation (white arrow), often seen after surgery. Roux jejunal loop extends to porta (black arrow) to allow drainage of common hepatic duct. Loop may be mistaken for fluid collection or abscess if type of surgery performed is not appreciated.

View larger version (142K): [in a new window]   Fig. 9A. —Postoperative CT appearance after Whipple and Puestow procedures. Axial CT scan of 65-year-old woman 5 weeks after Whipple procedure shows thick-walled fluid collection with enhancing rim (arrows). CT report called this "abscess." Such fluid collections, probably hematomas, are often seen in immediate aftermath of pancreatic surgery and do not need to be drained unless clinically indicated. Patient had no symptoms, such as fever, and was not treated. At follow-up clinic visit 4 months later, patient had good appetite and lack of symptoms.

View larger version (123K): [in a new window]   Fig. 9B. —Postoperative CT appearance after Whipple and Puestow procedures. Axial CT scan of 48-year-old man after Puestow procedure shows unopacified Roux loop (white arrow) anterior to tail of pancreas (black arrow) to which it is anastomosed. The postsurgical anatomy was not realized, and Roux loop was called "abscess."

View larger version (151K): [in a new window]   Fig. 10. —Axial CT scan of 31-year-old woman shows apparently solid mass, mistaken for tumor (white arrow), closely applied to anterior aspect of calcified pancreatic body and tail (black arrow). Patient had previously undergone a Puestow procedure, and the mass is simply the collapsed jejunal Roux loop. Delayed scan obtained in decubitus position with additional oral contrast material may be helpful to confirm that structure seen adjacent to pancreatic body after pancreaticojejunostomy is bowel and not tumor.

View larger version (186K): [in a new window]   Fig. 11A. —54-year-old man 16 days after Whipple procedure. Axial CT scans show soft-tissue cuff around celiac (white arrow, A) and superior mesenteric (black arrow, B) arteries. This finding is also seen with Frey's and Puestow procedures and distal pancreatectomy and probably represents postoperative perivascular edema or fibrosis. In absence of preoperative vascular cuffing, finding in first few months after surgery should not be regarded as suspicious for tumor presence. Note postoperative pneumobilia (arrowhead, A).

View larger version (184K): [in a new window]   Fig. 11B. —54-year-old man 16 days after Whipple procedure. Axial CT scans show soft-tissue cuff around celiac (white arrow, A) and superior mesenteric (black arrow, B) arteries. This finding is also seen with Frey's and Puestow procedures and distal pancreatectomy and probably represents postoperative perivascular edema or fibrosis. In absence of preoperative vascular cuffing, finding in first few months after surgery should not be regarded as suspicious for tumor presence. Note postoperative pneumobilia (arrowhead, A).

View larger version (158K): [in a new window]   Fig. 12. —Coronal T2-weighted MR image of 43-year-old man 3 months after undergoing Frey's procedure shows cystic area (white arrow) in head that corresponds to resected part of gland. Appearances were mistaken for cystic tumor because of lack of familiarity with surgical procedure. Note that common bile duct (black arrow) enters duodenum (arrowhead).

View larger version (174K): [in a new window]   Fig. 13. —Axial CT image of 53-year-old woman 5 weeks after distal pancreatectomy (spleen not removed) shows pseudoaneurysm of splenic artery (black arrow), which was surgically excised. Rest of artery (white arrow) is calcified. Note fluid collection around distal splenic artery (arrowhead). One reason for performing concomitant splenectomy is high incidence of splenic vessel damage during distal pancreatectomy.

View larger version (137K): [in a new window]   Fig. 14A. —50-year-old man 3 weeks after Whipple procedure. Axial CT image shows subtle pseudoaneurysm (arrow) of common hepatic artery.

View larger version (116K): [in a new window]   Fig. 14B. —50-year-old man 3 weeks after Whipple procedure. Contrast angiograms show pseudoaneurysm (arrow, B) occluded by coils placed distally (B) and proximally (C). Note replaced right hepatic artery (arrow, C), arising from superior mesenteric artery (arrowhead C).

View larger version (114K): [in a new window]   Fig. 14C. —50-year-old man 3 weeks after Whipple procedure. Contrast angiograms show pseudoaneurysm (arrow, B) occluded by coils placed distally (B) and proximally (C). Note replaced right hepatic artery (arrow, C), arising from superior mesenteric artery (arrowhead C).

View larger version (139K): [in a new window]   Fig. 15. —Axial CT scan of 39-year-old woman, obtained 21 months after Whipple procedure, shows distended loop of small bowel (black arrow). Note adjacent surgical clips (white arrows). Proximal small bowel (arrowhead) is not distended. Appearances are of blind pouch after side-to-side jejunojejunostomy.

View larger version (133K): [in a new window]   Fig. 16A. —Biliary dilation after Frey's procedure in two patients. Axial CT (A) and coronal reformatted (B) images in 43-year-old man 7 months after Frey's procedure show dilated common bile duct (CBD) (white arrows). There is abrupt cut off of distal CBD (arrowhead, B). Note low density in pancreatic head consistent with surgery (black arrow). No evidence of CBD malignancy was shown on endoscopic sonography and ERCP brushings. CBD stricture was thought to be ischemic in origin.

View larger version (136K): [in a new window]   Fig. 16B. —Biliary dilation after Frey's procedure in two patients. Axial CT (A) and coronal reformatted (B) images in 43-year-old man 7 months after Frey's procedure show dilated common bile duct (CBD) (white arrows). There is abrupt cut off of distal CBD (arrowhead, B). Note low density in pancreatic head consistent with surgery (black arrow). No evidence of CBD malignancy was shown on endoscopic sonography and ERCP brushings. CBD stricture was thought to be ischemic in origin.

View larger version (168K): [in a new window]   Fig. 16C. —Biliary dilation after Frey's procedure in two patients. Coronal T2-weighted MR image in 44-year-old woman 10 months after Frey's procedure shows dilated CBD with distal stricture (black arrow) close to ampulla. Note faint high density in pancreatic head consistent with cored-out center (white arrow). Subsequently patient underwent choledochojejunostomy; stricture was benign.

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