AJR 2005; 184:1118-1127
© American Roentgen Ray Society
Surgery for Chronic Pancreatitis: Cross-Sectional Imaging of Postoperative Anatomy and Complications
Kumaresan Sandrasegaran1,
Dean D. Maglinte1,
Thomas J. Howard2 and
John C. Lappas1
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.
Received June 17, 2004;
accepted after revision September 15, 2004.
Address correspondence to K. Sandrasegaran
(ksandras{at}iupui.edu).
Abstract
OBJECTIVE. Surgery is increasingly undertaken for intractable
chronic pancreatitis. We evaluated the postsurgical anatomy and complications
of surgical options including Whipple, Puestow, Frey's, and Beger's
procedures.
CONCLUSIONS. Knowledge of postsurgical anatomy is important to avoid
misdiagnosing expected anatomy as complications on CT examinations. It is
important to carefully assess the upper abdominal arteries to detect subtle
but potentially lethal complications.
Introduction
The prevalence of chronic pancreatitis is approximately eight
individuals per 100,000 population
[1]. In our practice,
approximately one in 20 abdominopelvic CT examinations is performed for
diagnosing pancreatitis or its complications. Chronic pancreatitis is
associated with a spectrum of clinical and radiologic features. Structural
abnormalities include distention of the main and side ducts, ductal strictures
and calculi; fibrotic mass, particularly in the head; and extraglandular
abnormalities including pseudocysts. Exocrine and endocrine functional
deficiencies are common with disease progression. The quality of life in these
patients is impaired by chronic gnawing abdominal pain. Nerve ablation
procedures such as celiac plexus block produce variable success rates but do
not provide long-term pain relief
[2]. Surgical procedures are
generally recognized by pancreatologists as the most effective treatment of
chronic pancreatitis in reducing acute exacerbations and chronic symptoms.
Pain is abolished or significantly ameliorated in up to 70% of patients after
surgery [3]. The frequency of
acute events is reduced in nearly all patients
[1]. Surgery performed for
chronic pancreatitis can be classified as resection procedures or drainage
jejunostomy. Types of pancreatic resection surgery include Whipple and Beger's
procedures. Drainage pancreaticojejunostomy procedures include Puestow and
Frey's operations.
Surgical Procedures
The operative procedure selected often depends on the surgeon's expertise
and individual preference. Some criteria would generally favor one type of
surgery over another. When the pancreatic duct in the body or tail is dilated
beyond 6 mm, the Puestow procedure is usually the most effective surgery
[4]. When disease occurs
predominantly in the head, Frey's procedure is used. When there is a focal
mass in the head without significant duct dilation, the Whipple procedure is
most frequently used. Increasingly, Beger's procedure, which preserves the
duodenum, is used as an alternative.
We have retrospectively reviewed the postoperative appearances of 46
patients after surgery for chronic pancreatitis, including Whipple (n
= 18), Beger's (n = 5), distal pancreatectomy (n = 4),
Puestow (n = 5), and Frey's (n = 14) procedures. We did not
include patients who had pancreatic surgery for malignant disease. In this
pictorial essay, we present the anatomy, pitfalls in postoperative
interpretation, and complications seen after these procedures.
Whipple Procedure
The most common pancreatic resection surgery is the Whipple procedure
(Fig. 1), which is performed
for chronic pancreatitis with ductal strictures or amorphous inflammatory mass
in the head for which distinction from cancer cannot be made preoperatively.
However, many specialist pancreatic surgeons no longer consider this to be the
most appropriate surgery for chronic pancreatitis.
View larger version (54K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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)
|
|
Beger's Procedure
Beger's procedure is a less radical surgery with resection of the
pancreatic head and preservation of the duodenum (Figs.
2 and
3). After Beger's surgery, pain
relief is seen in up to 85% of patients at 5-year follow-up
[5,
6], but the postoperative
morbidity rate is 20%. A randomized study comparing Beger's and Whipple
procedures showed similar results at 6 months except for better pain tolerance
and glucose control in those treated with Beger's surgery
[7].
View larger version (61K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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.
|
|
Puestow Procedure
The Puestow procedure is a side-to-side longitudinal pancreaticojejunostomy
that drains the pancreatic duct directly into a loop of jejunum (Figs.
4,
5A, and
5B). This procedure is best
performed if the main pancreatic duct is significantly dilated, usually wider
than 6 mm.
View larger version (65K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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.
|
|
Frey's Procedure
Frey's procedure is a recently popularized procedure that combines partial
resection of the pancreatic head with a longitudinal jejunostomy (Figs.
6,
7A, and
7B). The morbidity rate of
Frey's procedure is approximately 9-22%
[6,
8,
9], well below that of the
Whipple procedure performed for chronic pancreatitis, for which the
complication rate is 30-40% [9,
10]. Frey's procedure is
contraindicated in the presence of duodenal or biliary stricture.
View larger version (64K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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).
|
|
Postoperative Findings
Several expected postoperative CT and MRI findings may be confused with
disease. Periportal hepatic edema, which usually resolves in 1 month, and
pneumobilia, which tends to persist, are universally seen. The afferent loop
of bowel that drains the pancreatic and biliary ducts may be edematous in the
first 3 weeks (Figs. 3,
8A, and
8B). This appearance should
not be mistaken for bowel ischemia or hemorrhage. The Roux loop may be
mistaken for an abscess (Figs.
8A,
8B,
9A, and
9B). In the Puestow procedure,
the Roux loop lies between the stomach and pancreatic body in the lesser sac
and should not be misinterpreted as an internal hernia (Figs.
5A, and
5B) or pancreatic tumor
(Fig. 10). This error is
avoided if the postoperative anatomy is known to the radiologist. Transient
fluid collections in the pancreatic and duodenal bed are common in the first
month after surgery and usually do not need to be drained (Figs.
3,
9A, and
9B). Reactive lymphadenopathy
measuring up to 1.5 cm in the short axis is seen up to 2 months
postoperatively. Perivascular cuffing around the celiac, hepatic, and superior
mesenteric arteries is seen up to 6 weeks after Whipple and Beger's procedures
(Figs. 11A, and
11B). This finding may be
mistaken for tumor recurrence. Mild pancreatic duct dilation is an expected
postoperative appearance (Fig.
8B). Duct dilation by 1 to 2 mm compared with preoperative studies
was seen in 12 of the 46 patients and did not correlate with subsequent
pancreatitis. After Frey's procedure, a large cavity may be seen in the
pancreatic head (Fig. 12), and
may possibly be mistaken for a pseudocyst or cystic neoplasm.
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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).
|
|
Complications
Although the operative procedures confer tremendous improvement in symptoms
and prevent deterioration in endocrine function, there is substantial early
morbidity. In our series, postoperative follow-up was available over a period
of 4-96 months (mean, 21.7 months). Major complications that required surgical
intervention or vascular embolization were uncommon (10.9%), whereas minor
complications were some-what more frequent (28.3%).
Arterial complications include pseudoaneurysm, stenosis, and dissection.
Detection of these complications requires thin overlapping slices, preferably
using MDCT, and meticulous attention to the main trunks and all branches of
the celiac and superior mesenteric arteries. In our experience, an early
arterial phase increases the sensitivity for detecting these lesions. Splenic
artery (Fig. 13) and common
hepatic artery (Figs. 14A,
14B, and
14C) pseudoaneurysms have
occurred after surgery. These aneurysms were treated with surgery or coil
embolization. Celiac artery stenosis may occur after pancreatic surgery and is
usually not treated unless there are attributable symptoms. Because of the
rich collaterals between the celiac and superior mesenteric arteries, isolated
vessel stenosis is usually asymptomatic. Portal vein thrombosis and splenic
infarction can occur either as a result of vessel trauma or from postoperative
pancreatitis.
View larger version (174K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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).
|
|
After any abdominal surgery, enteric leak, enterocutaneous fistula, and
small bowel obstruction may occur. These complications were not commonly seen
in our review patients. Only one patient had a major bowel complication: a
jejunocutaneous fistula after a Whipple procedure, which was treated
surgically. A late complication seen in one patient after a Whipple procedure
was the blind pouch syndrome (Fig.
15). The CT findings are fairly characteristic but may be mistaken
for abscess or small bowel obstruction.
View larger version (139K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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.
|
|
Pancreatic fistula and postoperative pancreatitis were seen in three
patients each. These responded to conservative therapy. Extrahepatic bile duct
dilation beyond 10 mm, unlike pneumobilia, is not an expected postoperative
finding. Biliary dilation was seen in two patients after Frey's procedure
(Figs. 16A,
16B, and
16C), thought to be due to
ischemia of the distal common bile duct.
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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 this window]
[in a new window]
[as a PowerPoint slide]
|
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.
|
|
Abscess can infrequently occur after pancreatic surgery and is usually
associated with anastomotic leaks or hemorrhage. An unusual complication seen
in one patient was an omental infarction, which was treated
conservatively.
Conclusion
Surgery is a last resort for patients with disabling chronic pancreatitis.
Improvement in symptoms and endocrine function occurs after surgery. However,
complications are common in the early postoperative period. Most complications
are minor and do not require surgical intervention. Knowledge of surgical
technique is important to prevent misdiagnosing postoperative anatomy for
disease. Systematic assessment of arterial and venous structures in the upper
abdomen should be performed to avoid missing subtle but potentially lethal
vascular complications.
References
- Nealon WH, Matin S. Analysis of surgical success in preventing
recurrent acute exacerbations in chronic pancreatitis. Ann
Surg 2001;233:793
-800[Medline]
- Warshaw AL, Banks PA, Fernandez-del Castillo C. AGA technical
review: treatment of pain in chronic pancreatitis.
Gastroenterology1998; 115:765
-776[Medline]
- Ihse I, Borch K, Larsson J. Chronic pancreatitis: results of
operations for relief of pain. World J Surg1990; 14:53
-58[Medline]
- Howell JG, Johnson LW, Sehon JK, Lee WC. Surgical management for
chronic pancreatitis. Am Surg2001; 67:487
-490[Medline]
- Beger HG, Schlosser W, Friess HM, Buchler MW. Duodenum-preserving
head resection in chronic pancreatitis changes the natural course of the
disease: a single-center 26-year experience. Ann Surg1999; 230:512
-519[Medline]
- Izbicki JR, Bloechle C, Knoefel WT, Kuechler T, Binmoeller KF,
Broelsch CE. Duodenum-preserving resection of the head of the pancreas in
chronic pancreatitis: a prospective, randomized trial. Ann
Surg 1995;221:350
-358[Medline]
- Buchler MW, Friess H, Bittner R, et al. Duodenum-preserving
pancreatic head resection: long-term results. J Gastrointest
Surg 1997;1:13
-19[Medline]
- Frey CF, Amikura K. Local resection of the head of the pancreas
combined with longitudinal pancreaticojejunostomy in the management of
patients with chronic pancreatitis. Ann Surg1994; 220:492
-504[Medline]
- Schafer M, Mullhaupt B, Clavien PA. Evidence-based pancreatic head
resection for pancreatic cancer and chronic pancreatitis. Ann
Surg 2002;236:137
-148[Medline]
- Sakorafas GH, Farnell MB, Nagorney DM, Sarr MG, Rowland CM.
Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105
patients. Arch Surg2000; 135:517
-523[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
