Computed Tomography after Modified Whipple Procedure with Pancreatic Duct Occlusion

Transcription

1 Act Rdiologic ISSN: (Print) (Online) Journl homepge: Computed Tomogrphy fter Modified Whipple Procedure with Pncretic Duct Occlusion A. Aildgrd, F. Kolmnnskog, Ø. Mthisen & A. Bergn To cite this rticle: A. Aildgrd, F. Kolmnnskog, Ø. Mthisen & A. Bergn (1990) Computed Tomogrphy fter Modified Whipple Procedure with Pncretic Duct Occlusion, Act Rdiologic, 31:6, To link to this rticle: Pulished online: 04 Jn Sumit your rticle to this journl Article views: 34 Full Terms & Conditions of ccess nd use cn e found t

2 Actn Riicliologicii 31 (I9901 Fusc. 6 FROM THE DEPARTMENTS OF RADIOLOGY AND SURGERY, THE NATIONAL HOSPITAL. OSLO. NORWAY. COMPUTED TOMOGRAPHY AFTER MODIFIED WHIPPLE PROCEDURE WITH PANCREATIC DUCT OCCLUSION A. ABILDGAARD, F. KOLMANNSKOG, 0. MATHISEN nd A. BERGAN Astrct Eighty-two CT exmintions performed on 28 ptients who hd undergone modified Whipple procedure including pncretic duct occlusion were reviewed. Reduction of the ntero-posterior dimeter of the ody nd til of the pncretic remnnt ws oserved on consecutive scns in 8 ptients (29%). Decresing liver ttenution ws seen in 4 ptients (14%) postopertively. nd pseudocysts in the pncretic remnnt in 6 (21%). In 10 exmintions performed ecuse of suspected intrdominl scess postopertively, scess ws dignosed in 2 ptients. In 62 routine follow-up CT exmintions, significnt positive findings were dignosed in 5 ptients: tumor recurrence or metstses in 4, nd lrge pseuodocyst in one. CT is of vlue in the erly postopertive phse to revel postopertive complictions nd in the follow-up of ptients with specific symptoms indicting tumor recurrencc or metstscs. Key words: Pncres, CT; -, surgery; -, pseudocysts; pncretic duct, occlusion; Neoprcnc. Whipple pncreticoduodenectomy ws first reported in 1935 (19), nd hs ecome n estlished opertion for lesions in the perimpullry pncretic region (3). Severl modifictions of the opertion hve een introduced, including pylorus-preserving technique nd occlusion of the pncretic duct with foreign mteril (10, 13, 16). Computed tomogrphy (CT) following Whipple procedure is pplied to revel postopertive complictions or recurrent disese (2, 1 I, 18). At our hospitl modified Whipple procedure with pncretic duct occlusion using Neoprene hs een employed (5,9, 10, 13). The purpose of the present retrospective study ws to exmine the CT ntomy fter this procedure, nd to evlute the clinicl impct of CT in the erly nd lte postopertive follow-up in these ptients. Mteril nd Methods Between 1982 nd 1990, 28 ptients (13 femles nd 15 mles) were exmined y dominl CT from one week to 5 yers following modified Whipple procedure with pncretic duct occlusion. The men ge t opertion ws 54 yers (rnge 25-75). Twenty-seven ptients hd perimpullry neoplstic lesions, nd one, chronic pncretitis. The perimpullry cncers included 8 crcinoms nd 2 pudoms of the pncretic hed. 8 crcinoms nd one crcinoid of the ppill of Vter. 4 duodenl crcinoms, one duodenl leiom yosrcom, nd 3 cholngiocrcinoms. Eighty-two CT exmintions were performed, rnging from one to 8 exmintions in ech ptient (medin 3). The CT exmintions were performed with third genertion scnners (8 1 exmintions with Generl Electric Milwukee, IL, USA, nd one with Siemens Somtom DRH, Erlngen, Germny). Stndrd slice thickness ws 10 mm, nd scn intervl 10 to 20 mm. In 52 exmintions (63%) intrvenous injection of contrst medium (Isopque or Omnipque, Nycomed A/S. Oslo, Norwy) corresponding to pproximtely 17.5 to 35 g of iodine ws used. nd in 31 of these, slice series prior to contrst medium injection ws lso performed. The scns using intrvenous contrst medium were performed s dynmic incrementl studies, strting the scnning fter rpid injection of pproximtely hlf the mount of contrst medium, nd therefter injecting the rest slowly during the scnning. In 75 exmintions (91 %) orl contrst medium ws dministered, usully 750 to 1000 ml of diluted rium sulfte suspension (E-Z-CAT, E-Z-EM Inc., Westury, NY, USA). The Whipple procedure ws performed without ny pncreticojejunl nstomosis. Approximtely 50 percent of the stomch ws resected nd gstrojejunostomy ws done end-to-side. The hepticojejunostomy ws lso performed end-to-side. The gllldder ws removed. Accepted for puliction 17 August

3 580 A. ABILDGAARD ET AL. Tle 1 A.p. dimercv of pcincre/ic. hodv nd [il, nd the.p. dime/er qf /he Neoprme in the pncretic. duc/ mesurd / drflerenr lime inlervls ufrer ntodlfied Whipple operlion Time fter A.p. dimeter (mm) opertion Pncretic ody Pncretic til Neoprene (months) n min medin mx n min medin mx n min medin mx I I II I n= numer of exmintions. Whenever there ws more thn one exmintion for ny ptient in the sme time intervl the men vlues of the different exmintions were used in the clcultions. The remining pncretic duct ws injected with Neoprene (Fig. I), usully in n mount of 5 to 8 ml. The pncretic duct ws closed y purse-string suture, nd n omentl flp covered the resection line. The in vitro rdiogrphic ttenution of Neoprene in the fluent stte ws pproximtely 320 Hounsfield Units mesured in wter phntom. All CT scns were reviewed retrospectively, nd compred with the medicl records of the ptients. Whenever the pncretic residul could e clerly oserved, the ntero-posterior (.p.) dimeter of the pncretic ody ws mesured just to the left of the superior mesenteric rtery, nd the.p. dimeter of the pncretic til ws mesured 2 cm medil to the tip of the til (Fig. 2). The.p. dimeters were mesured perpendiculr to the long xis of the pncres. Exmintions showing tumor recurrence or pncretic pseudocysts were excluded from these mesurements. The.p. dimeter of the Neoprene in the pncretic duct ws mesured whenever the Neoprene ws clerly identified. The ttenution of the liver prenchym on non-contrst scns ws compred to the ttenution of lood in the lrge intrheptic vessels nd the prenchym of the right kidney. The men follow-up time fter opertion ws 21 months, rnging from 2.5 to 61 months. No ptient ecme dietic. All ptients received pncretic exocrine sustitution therpy. Four ptients (14%) with metstses hve died, etween 4 nd 17 months fter surgery. The CT exmintions were divided into three groups; 62 exmintions (76%) performed s routine follow-up exmintions in 21 ptients, 14 exmintions (17%) performed to clrify specific dignostic prolem in 8 ptients, nd 6 exmintions (7%) performed for monitoring chemotherpy for known liver metstses in 2 ptients. Fisher's exct test ws used nd p-vlues <0.05 were considered significnt. Results CT ntomy ufter. opertion. The results of mesuring the.p. dimeter of the pncretic ody nd til, nd the NEOPRENE PANCREATICREMNANT Fig. I. Schemtic drwing of modified Whipple procedure with injection of Neoprene in the pncretic duct. Fig. 2. Mesuring the size of the pncretic remnnt fter modified Whipple procedure with duct occlusion. A.p. dimeter of the ody nd til of the pncretic remnnt indicted (+). Neoprene (N) in pncretic duct. Neoprene in the pncretic duct, re listed in Tle I. A reduction in the sum of the dimeters of the pncretic ody nd til of 50 percent or more ws seen in 4 ptients (14%) when compring consecutive exmintions (Fig. 3). In nother 4 ptients size reduction of more thn 25 percent ws oserved. In 5 ptients (18%) with visile Neoprene in the first postopertive exmintions. the Neoprene ws not identifile t CT in lter exmintions (Fig. 4). The numer of exmintions in which different peripncretic vessels could e identified re listed in Tle 2.

4 CT AFTER PANCREATIC OPERATION AND DUCT OCCLUSION 58 1 Tle 2 Peripuncreulic vessels oserved on CT.folluning u modijied Whipple procedure. Esuminorions slioiiing drfinire /unwr ~I~IYJ/IWWI~/ of' one more of the vessels hw een e.wcluded Sup. mesent. Sup. mesent. Splenic Splenic Portl rtery vein rtery vein vein (A) No IVCM (n = 28) (B) Postcontrst exmintions (n= 18) I5 16 (C) Exmintions with oth pre- nd postcontrst series (n=3l) P-vlues (A) vs. (B) < 0.05 <O.OI < 0.05 <O.OI < 0.05 (A) vs. (C) < 0.05 < 0.05 < 0.05 <0.01 <O.OI (B) vs. (C) NS NS NS NS NS n = numer of exmintions. IVCM = intrvenous contrst medium. NS = Not significnt. Fig. 3. Decresing size of the pncretic remnnt on consecutive scns. ) Pncretic remnnt (P) without visile Neoprene 5 months fter opertion. ) Decresed size of the pncretic remnnt (P) 2 yers fter surgery. Fig. 4. Grdully reduced visiility of Neoprene in the pncretic duct. ) Neoprene in the pncretic duct 4 months fter opertion. Lrge (C) nd smll (+) pseudocysts in the pncretic til. ) No visile Neoprene 2 yers fter opertion. Reduced size of pseudocysts. A grdul reduction of the liver ttenution following surgery ws noted in 4 ptients on consecutive postopertive scns, or on comprison with preopertive exmintions (Fig. 5). The decresed ttenution ws first noticed etween 3 nd 8 months following the Whipple procedure. Gs in the intrheptic ile ducts ws oserved in 78 of the exmintions (95%). The gs ws usully locted in the left loe ner the hilus. Dilted intrdheptic or extrheptic ile ducts were not reveled in ny ptient. The exct loction of the hepticojejunostomy could not e determined in ny ptient. A nrrow zone with reduced ttenution surrounding the intrheptic prt of the inferior ven cv ws found in 6 ptients (21%) (Fig. 6). Three of these ptients lso hd preopertive CT performed in our hospitl. nd in one of these the zone of reduced ttenution ws lso seen preopertively. A similr zone surrounding the intrheptic portl venous rnches ws not recorded in ny ptient. Informtion gincd,from CT Positive CT findings in the 62 routine follow-up exmintions re listed in Tle 3. Locl tumor recurrence without ny other signs of metstses ws seen in one ptient (Fig. 7). There were two surgicl interventions sed on the CT findings in the routine exmintions. Lprtomy with liver iopsy confirmed liver metstsis from n insulom in one ptient, nd tretment with Interferon ws initited. In nother ptient with duodenl denocrcinom CT indicted possile liver metstsis, which, however, could not e confirmed y surgery. The equivocl findings in 2 other ptients were suspicion of lymph node metstses nd liver metstses, which were not confirmed on lter CT. In one ptient CT demonstrted pncretic pseudocyst with mximum dimeter of 17.5 cm. which ws drined using ultrsonic guidnce. The mylse concentrtion in the pseudocyst ws units per liter (reference vlue in serum units/l). None of the other pscudocysts. rnging in size from 1 to 6.5 cm, required therpy. The CT findings in the 14 exmintions ddressing specific clinicl prolem re listed in Tle 4. In one ptient sucutneous nd intrdominl scess nd in nother ptient intrperitonel fluid nd pelvic scess were surgiclly drined. No scess ws cliniclly or surgiclly dignosed in the follow-up fter the 6 negtive CT exmintions. In the 2 exmintions with equivocl CT findings. surgery ws performed shortly fter the CT exmintion, showing hemtom nd scess in one ptient, nd hemtom in the other.

5 ~ ~~ ~ ~~ ~ ~ 582 A. ABILDGAARD ET AL. Fig. 5. Decresing ttenution of the liver following modified Whipple procedure. ) Preopertive CT. The liver prenchym hs higher ttenution thn the spleen. ) Focl res of diminished ttenution of the liver 4 months fter opertion. Neoprene present in the pncretic duct. No signs of liver metstses were found in this ptient t follow-up one yer lter. Fig 6. A nrrow zone of reduced ttenution surrounding the intrheptic inferior ven cv seen fter modified Whipple procedure. Gs in the intrheptic ile ducts. Fig 7. Tumor recurrence fter modified Whipple procedure. ) Exmintion 2 months fter surgery showed no sign of recurrence (slice level shown is cudl to visile pncretic remnnt). ) Sme ptient, 1 I months postopertively. Tumor recurrence (+) cusing nterior displcement of superior mesenteric rtery nd nrrowing of inferior & cv (v). Tle 3 Positive CT findings in 62 postoperutive routine exuminutions prrfi~rnic~d on 21 ptients fter u modified Whipple opertion CT finding Tumor recurrence Tumor recurrence. liver- nd lymph node metstses Licer metstses Pncretic pseudocyst Equivocl No. of No. of exmintions ptients 2 I Lekge from the hepticojejunl or gstrojejunl nstomoses ws not oserved in ny CT exmintion, nd no exmintion ws performed ecuse of clinicl suspicion of such lekge. Discussion Our results indicte tht the size of the pncretic remnnt decreses mrkedly in some ptients following the modified Whipple procedure with duct occlusion, while re- Tle 4 CT,findings in 14 esminurions performed on 8 putients fter u modijied Whipple opertion lo clurily spec(fie dignosric prolem Indiction for CT findings CT exmintion Ascess Tumor Liver Norml Equirecurr. metsts. postop. vocl Suspicion of scess (n = 10) Suspicion of tumor recurrence or metstsis (n=4) n= numer of exmintions mining unchnged in others. Histologiclly. trophy of the exocrine pncretic prenchym hs een shown less thn 10 dys fter duct occlusion in dogs (lo), while preservtion of the endocrine function hs een demonstrted in humns (I. 6). The degree of size reduction postopertively possily reflects different degrees of firosis.

6 CT AFTER PANCREATIC OPERATION AND DUCT OCCLUSION 583 The grdully reduced visiility of the Neoprene in the pncretic duct seen in 5 ptients proly is cused y phgocytosis nd resorption. We find it less prole tht Neoprene should hve een dislodged from the pncretic duct, s we hve never identified Neoprene outside the duct system. Both pncretic nd non-pncretic perimpullry cncer hve tendency to spred loclly to lymph nodes (4). nd to oliterte the Ft plnes surrounding the celic trunk or the superior mesenteric rtery (8, 15). Therefore, identifiction of peripncretic vessels is importnt when looking for tumor recurrence or metstses. Our findings indicte tht the use of intrvenous contrst medium provides significntly etter identifiction of the peripncretic vessels on CT thn non-contrst enhnced scns. When exmining the liver prenchym for metstses, FOLEY (7) recommends oth non-contrst nd dynmic contrst enhnced scns in ptients with possile hypervsculr metstses. Perimpullry cncers in this ctegory include pncretic islet cell tumors nd crcinoid tumor. We noticed grdul reduction of the liver ttenution in 4 ptients (14%) following the modified Whipple procedure. The reson for the decresed ttenution is unknown. One my speculte if the reduced ttenution is ssocited with higher proportion of lipids in the prenchym, possily cused y different pttern of sorption from the intestine relted to the conversion to exocrine sustitution therpy, nd chnges in the pttern of ile secretion. This reduction in the liver ttenution my give flse-positive dignosis of liver metstses. As generl rule we recommend oth non-contrst nd dynmic incrementl scn series when liver metstses re suspected fter the modified Whipple procedure. Other uthors hve reported identifiction of the jejunl loop with the hepticojejunostomy or choledochojejunostomy on CT fter Whipple procedure (11, 18). We were not le to identify this loop ccurtely in ny ptient. We did not exmine the ptients in right lterl decuitus position, nor were spsmolytics dministered. In most ptients, however, we could clerly identify severl owel loops in the nstomotic re, which could definitely e differentited from tumor recurrence, metstses, scess, hemtom or other pthologicl expnsive lesions. Stisfctory contrst filling of the owel loops is proly more importnt thn the exct identifiction of the nstornosed jejunl loop. The zone of low ttenution surrounding the intrheptic portion of the inferior ven cv seen in 6 ptients might e relted to ltered lymphtic dringe from the liver (14). However, similr zones surrounding the portl rnches were not reveled in our ptients, in contrst to reported findings in ptients with heptic perivsculr lymph edem (12). In recent report on CT of the upper domen following Whipple procedure with pncreticojejunostomy, severl pthologicl fluid formtions surrounding the pncres were found, proly representing postopertive serum col- lections (2). With the modified Whipple procedure used in this series, no such peripncretic fluid collections were demonstrted. However, fter pncretic duct occlusion. pseudocyst formtion in the pncretic remnnt ws demonstrted in 6 out of 28 ptients (21%). Aprt from one uncomplicted ultrsoniclly guided dringe, the pseudocysts did not require therpy. Complictions relted to the pncreticojejunostomy following the trditionl Whipple procedure re mjor cuse of postopertive moridity nd mortlity (17). Compred to the seriousness of these complictions, the pseudocysts found fter pncretic duct occlusion seem to represent minor therpeutic prolem. Ascess formtion postopertively ws detected on CT in 2 ptients. The ility of CT to exclude postopertive scess, therey preventing n unnecessry lprotomy, is lso vlule. An dequte mount of contrst medium in the intestine prior to CT is importnt in this context. Our conclusion is tht CT is very useful for reveling or excluding suspected complictions in the erly postopertive phse following modified Whipple procedure with duct occlusion. In ptients with symptoms indicting tumor recurrence or metstses, CT is of mjor vlue in plnning pllitive tretment. Postopertive pncretic pseudocysts shown on CT re of little clinicl importnce if the pseudocysts do not rech considerle size. At present, the therpeutic consequences of detecting tumor recurrence or metstses from perimpullry cncer in n symptomtic ptient re limited. Therefore, routine long term follow-up with CT in these ptients might e of limited vlue. Requesf,for reprinfs: Dr. Andres Aildgrd. Rdiology Deprtment, Rikshospitlet. N-0027 Oslo 1, Norwy. REFERENCES I. BREKKE I. B., BERGAN A,, HEEN L. & FLATMAKK A.: Pncretic endocrine function fter duct occlusion in humns. Trnsplnt. Proc. 16 (1984) COOMBS R. J., ZEN J.. HOWARD J. M.. THOMFOKU N. R. & MERKICK H. W.: CT of the domen fter the Whipple procedure. Vlue in depicting postopertive ntomy, surgicl complictions, nd tumor recurrence. Am. J. Roentgenol. 154 (1990) CKIST D. W., SITZMANN J. V. & CAMERON J. L.: Improved hospitl moridity. mortlity. nd survivl fter the Whipple procedure. Ann. Surg. 206 (1987) CUBILL A. L.. FORTNER J. & FITZCEKALU P. J.: Lymph node involvement in crcinom of the hed of the pncres re. Cncer 41 (1978) DI CARLO V., CHIESA R., PONTIKOLI A. E. et l.: Pncretoduodenectomy with occlusion of the residul stump y Neoprene injection. World J. Surg. 13 (1989) DICARLO V.. CHIESA R., PONTIROLI A. E.. et l.: Intrductl injection of Neoprene to suppress ntive pncretic exocrine secretion in humns. Clinicl nd metolic evlution. Trnsplnt. Proc. 16 (1984) FOLEY W. D.: Dynmic heptic CT. Rdiology 170 (1989) FREENY P. C., MARKS W. M.. RYAN J. A. JK & TKAVEKSO L.

7 584 A. ABILDGAARD ET AL. W.: Pncretic ductl denocrcinom. Dignosis nd stging with dynmic CT. Rdiology 166 (1988), GALL F. P.. GEBHARDT C. & ZIRNGIBL H.: Chronic pncretitis. Results in I 16 consecutive, prtil duodenopncretectomies comined with pncretic duct occlusion. Hepto-Gstroenter (1982), GIBHAKDT C. & STOLTE M.: Pnkresgng-Occlusion durch Injektion einer schnellhrtenden Aminosurenlosung. Lngenecks Arch. Chir. 346 (1978), I. HEIKEN J. P.. BALFE D. M.. PICUS D. & SCHAKP D. W.: Rdicl pncretectomy. Postopertive evlution y CT. Rdiology 153 (1984), KOSLIN D. B.. STANLEY R. J., BERLAND L. L., SHIN M. S. & DALTON S. C.: Heptic perivsculr lymph edem. CT ppernce. Am. J. Roentgenol. 150 (1988). I I I. 13. LITTLE J. M., LAUEK C. & HOGG J.: Pncretic duct ostruction with n crylte glue. A new method for producing pncretic exocrine trophy. Surgery 81 (1977) MARINCHEK B.. BAKBIEK P. A,, BECKEK C. D., METTLEK D. & RUCHTI C.: CT ppernce of impired lymphtic dringe in liver trnsplnts. Am. J. Roentgenol. 147 (1986) MEGIBOW A. J., BOSNIAK M. A., AMBOS M. A. & BERANBAUM E. R.: Thickening of the celic xis nd/or superior mesenteric rtery. A sign of pncretic crcinom on computed tomogrphy. Rdiology 141 (1981), TKAVERSO L. W. & LONGMIKE W. P. JR: Preservtion of the pylorus in pncreticoduodenectomy. Surg. Gynecol. Ostet. 146 (1978) TREDE M. & SCHWALL G.: The complictions of pncretectomy. Ann. Surg. 207 (1988) VON VOGEL H., TODT H. C., KLAPDOR.. PFEIFFEK M. & BUUK- MAN R.: Computertomogrmm nch Pncresresektion. Z. Gstroenterol. 21 (1983) WHIPPLE A. 0.. PARSONS W. B. & MULLINS C. R.: Tretment of crcinom of the mpull of Vter. Ann. Surg. 102 (1935). 763.