Follow-up after Whipple operation by CT: techniques for the improvement of the afferent jejunal loop visualization and patterns of recurrence Poster No.: C-1971 Congress: ECR 2012 Type: Educational Exhibit Authors: I. S. Popovic S., D. Vasin, L. M. Lazic, J. Kovac, S. Jovanovic, 1 1 1 2 1 1 1 1 2 D. Masulovic, D. Saranovic ; Belgrade/RS, Beograd/RS Keywords: Pancreas, Biliary Tract / Gallbladder, Gastrointestinal tract, CT, Diagnostic procedure, Neoplasia DOI: 10.1594/ecr2012/C-1971 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 17
Learning objectives To enhance radiologists understanding of Whipple operation (cephalic pancreaticoduodenectomy) and anatomy after this kind of pancreatic surgery. To present the techniques for better visualization of the afferent jejunal loop by CT and typical patterns of tumor recurrence in patients who underwent Whipple operation (cephalic pancreaticoduodenectomy). Background Inadequate distension and incomplete filling of the afferent (billiary) jejunal loop with the orally given water or contrast, is the main problem in the interpretation of the CT exams in patients after Whipple operation. Collapsed afferent jejunal loop may be misinterpreted as the tumor recurrence at the site of the pancreaticojejunostomy, or the lymphadenopathy in the porta hepatis. We presented the postoperative CT findings of patients after the Whipple's operation (cephalic pancreaticoduodenectomy), performed for the pancreatic head cancer, or ampullary carcinoma. Technique of the Whipple's operation is described, and normal and pathological postoperative CT findings, which are characteristic for the immediate (early) and delayed (late) follow-up period, are presented. In addition, difficulties in differentiation of afferent jejunal loop from the recurrent tumor by CT are discussed, and references from the literature about the possibilities of successful visualization of the afferent jejunal loop are cited. Possible locations and CT appearances of the tumor recurrences are presented. An overview of the literature is provided. FOLLOW UP AFTER THE WHIPPLE'S PANCREATICODUODENECTOMY During the first three years after procedure is recommended CT examination every six months for detection possible local tumor recurrence, pathological change adjacent lymphatic nodes or evidence of distance metastasis. Imaging findings OR Procedure details Page 2 of 17
WHIPPLE'S PANCREATICODUODENECTOMY /WP/ Whipple's pancreaticoduodenectomy is the surgical procedure that combines the resection of the pancreatic head and the duodenum in block, including the gallbladder and part of the common bile duct, and involves formation of a number of anastomoses (gastrojejunostomy, pancreaticogastrostomy or pancreaticojejunostomy, hepaticojejunostomy or chledochojejunosotomy) (Fig. 1, 2, 3, 4). The most common indications for this operation are the neoplasm of the periampullary region (pancreatic head carcinoma, carcinoma of the papilla Vateri, distal common bile duct carcinoma, or the duodenal carcinoma). CT exams of 34 patients who underwent Whipple procedure were analyzed (20 male, 14 female; age: 58-67 years; 3 months - 10 years after the operation). Ct exams were performed on single-slice spiral CT (SSCT), after per os contrast /water/ was given, in porto-venous phase. 16 CT exams were performed using medicamentous hypotony performing following procedure: after ingestion of the 500 ml of water and intravenous injection of the 1 ml of the Buscopan (Hioscin-Butilbromid 20mg/1ml), patients laid in right lateral decubitus position for 10 minutes, than ingested additional 250 ml of water, and scanned. a. 8 patients, with hypotony, in right decubitus position / HRD/. /Fig. 5, Video 1 - Figure 11./. b. 8 patients, with hypotony, in supine position / HS/. /Fig. 6, Video 2 - Figure 12./. c. 18 patients without hypotony, in supine position /Control Group - CG/. /Fig. 7. Video 3 - Figure 13./. RESULTS The results are obtained by the average value of the width of afferent jejunal loop, measuring 2 cm from pancreatico-jejuno anastomose / Fig. 8/, and the average value of percentage of total length of afferent jejunal loop, visible by CT, depending of examination technique. HRD - 21mm, > 80% length of afferent jejunal loop was visible. HS - 15mm width, 40% length was visible, and CG - 8mm, < 20% jejunal loop was visible. Page 3 of 17
TUMOR RECURRENCE Potentially locations of tumor recurrence are: rest of pancreas, area of the head of the pancreas surgically removed, adjacent lymphatic nodes, around a mesenterial blood vessels /AMS, VMS/- perineural stream. Follow up CT examinations of our 34 patients shows a 16 patients with recurrent tumor /47%/: -12 patients /75%/ had pathological changed adjacent lymphatic nodes /Figure 9/. - 4 patients /25%/ had a perineural stream /Figure 10/. Images for this section: Page 4 of 17
Fig. 1: Anastomoses after WP (bd - billiary duct, B afferent (billiary) loop, P - rest of pancreas, R - Roux jejunal loop). Fig. 2: Pancreatico-jejuno anastomosis (arrow). Page 5 of 17
Fig. 3: Choledocho - jejuno anastomosis (arrow). Page 6 of 17
Fig. 4: Gastro - jejuno anastomosis (arrow) Page 7 of 17
Fig. 5: CT examination of 53-years old patient 2 years after WP /HRD/ - hypotony of afferent jejunal loop Page 8 of 17
Fig. 13: Video 3. CT examination - CG Page 9 of 17
Fig. 12: Video 2. CT examination - HS Page 10 of 17
Fig. 11: Video 1. CT examination - HRD Page 11 of 17
Fig. 10: Tumor reccurence - soft tissue density mass around the SMA /white arrow/. Metastatic changed lymphatic nodes /asterisk/ Page 12 of 17
Fig. 9: Tumor recurrence - metastatic changed lymphatic nodes on the place of the resected pancreatic head /white arrow/ and paraaortical /asteriks/. Afferent jejunal loop / open arrow heads/. Page 13 of 17
Fig. 8: Diameter of the afferent jejunal loop that was measured Page 14 of 17
Fig. 7: CT examination of 59-years old patient, 18 months after WP /CG/: Afferent jejunal loop or recurrence? Page 15 of 17
Fig. 6: CT examination of the 60 years old patient, 9 months after WP /HS/. Page 16 of 17
Conclusion The best CT visualisation of the afferent jejunal loop was made by combination of the medicamentous hypotony and right decubitus position of patient during the exam, after perorraly giving the water /negative contrast/. Tumor reccurence after Whipple pancreaticoduodenotomy is most common in the form of metastatic changed adjacent lymphatic nodes and perineural stream around the superior mesenteric artery. Personal Information References Imaging anatomy post pancreatic surgery P.A. Patel, M.B. Johnson, M.D. Patel, B. Stedman, C.N. Hacking, D.J. Breen; Southampton/UK - Johnson PT, CurryCA, Urban BA, Fishman EK. Spiral CT following the Whipple procedure:distinguishing normal postoperative findings from complications. J Comput Assist Tomogr.2002;26(6):956-961. Page 17 of 17