Small free fluid, edema, and fat stranding in surgical bed with reactive subcentimeter lymph nodes in mesentery


• Common complications
Abscess: Can be intrahepatic, in pancreatic bed, or in subphrenic, subhepatic, or retroperitoneal spaces
Gastrojejunostomy and hepaticojejunostomy leaks: Suspect when focal fluid collection or ectopic gas in close contiguity to anastomosis
Postoperative hemorrhage: May be due to bleeding from gastroduodenal artery stump or due to structural abnormality (e.g., pseudoaneurysm)
Anastomotic strictures: Suspect when progressive biliary or pancreatic ductal dilatation without obstructing tumor at anastomotic site



















IMAGING
General Features
• Best diagnostic clue
• Surgical procedure determined by location and type of pathology
Whipple procedure most commonly performed for tumors of pancreatic head, uncinate, and proximal neck
Central pancreatectomy performed for low-risk lesions (low malignant potential) in pancreatic neck/body
Enucleation performed for lesions with low malignant potential that are small and exophytic (often utilized for insulinomas)

– Classic Whipple procedure (pancreaticoduodenectomy) involves surgical removal of pancreatic head, gastric antrum, proximal duodenum, and gallbladder


CT Findings
• Normal findings immediately after Whipple procedure
Small free fluid, edema, and fat stranding in surgical bed with reactive subcentimeter lymph nodes in mesentery

• Complications
Pancreatic fistula
Abscess
Liver infarct
Postoperative hemorrhage
Portomesenteric venous thrombosis
Anastomotic strictures




– May be due to bleeding from gastroduodenal artery stump (first 24 hours after surgery) or due to structural abnormality (pseudoaneurysm, vascular erosion) usually after 5th postoperative day


CLINICAL ISSUES
Presentation
• Most common signs/symptoms
Pancreatic fistula defined as drain fluid amylase level 3x > serum amylase level on 3rd postoperative day (or > 50 cc amylase-rich fluid from drains per day)
Most common delayed complications following Whipple procedure include: Anastomotic stricture at biliary (8.2% at 5 years) or pancreatic (4.6% at 5 years) anastomosis, pseudocyst formation from pancreatic leak, and delayed gastric emptying (∼ 50%)


Natural History & Prognosis
• Whipple procedure morbidity and mortality have dramatically fallen
Mortality rate was once ∼ 25%, and is now 1-3%, despite pancreatic surgeries increasingly being performed for tumors previously considered unresectable

Treatment
• Pancreatic fistulas usually treated conservatively with drainage of fluid collections, antibiotics, and parenteral nutrition (surgery only considered for large pancreaticojejunal anastomotic dehiscence)
• Postoperative fluid collections (abscess or biloma), particularly when sizeable (> 3 cm), are usually treated with percutaneous drainage





























