CASE 18513 Published on 05.04.2024
0

Pancreatic leak secondary to pancreaticojejunostomy anastomotic dehiscence following Whipple procedure

Section

Abdominal imaging

Case Type

Clinical Case

Authors

Ibrahim M. Nadeem 1, Prasaanthan Gopee-Ramanan 1,2, Stefanie Y. Lee 1,2

1 Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

2 Department of Diagnostic Imaging, Juravinski Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada

Connected authors
Patient

77 years, male

Categories
Area of Interest Abdomen, Biliary Tract / Gallbladder, Pancreas ; No Imaging Technique
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Clinical History

A 77-year-old male with extrahepatic cholangiocarcinoma of the distal common bile duct underwent pancreaticoduodenectomy (Whipple procedure) and cholecystectomy. Past medical history was significant for prior CABG. The immediate postoperative course was complicated with protracted vomiting, inability to pass flatus, abdominal pain and distension, fever, leukocytosis, delirium, positive urinalysis, and hypoxic respiratory failure.

Imaging Findings

CT of the abdomen and pelvis with intravenous contrast in the portal venous phase was acquired on postoperative day 8. Imaging demonstrated dehiscence of the pancreaticojejunostomy anastomosis, with a fluid collection and locules of gas interspersed between the pancreatic and jejunal components. There were multiple adjacent collections extending from the pancreaticojejunostomy anastomosis. Fluid tracked inferiorly in the anterior pararenal space posterior to the SMA/SMV, with two partially organised retroperitoneal collections on either side of midline demonstrating posterior fascial enhancement. Fluid also tracked superiorly from the region of the pancreaticojejunostomy anastomosis into the periportal region, with an organised rim enhancing collection along the medial aspect of the caudate lobe.

The hepaticojejunostomy and gastrojejunostomy anastomoses were unremarkable. There was normal enhancement of the residual pancreas with pancreatic stent in situ.

There was small volume of fluid in the perihepatic region, perisplenic regions, paracolic gutters, and in the pelvis.

Discussion

Pancreaticoduodenectomy, also known as Whipple procedure, is a complex surgery performed for a range of indications involving the pancreas, duodenum, and/or the bile duct. The surgery involves resection of the pancreatic head, gastric antrum/pylorus, duodenum, proximal jejunum, common bile duct, and gallbladder, followed by the formation of the pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy anastomoses [1–3].

Whipple procedure is associated with significant postoperative morbidity [1,2]. Postoperative complications can be grouped by organ systems into pancreaticobiliary complications (i.e., pancreatic leak or ductal stricture), vascular complications (i.e., haemorrhage or vascular thrombosis), bowel complications (i.e., gastrojejunostomy anastomotic leak or bowel injury), and other (i.e., wound dehiscence) [2].

Imaging plays an important role in the assessment of postoperative complications. Contrast-enhanced CT in the portal venous phase is the usual initial imaging modality in the immediate postoperative setting due to its excellent spatial resolution, shorter imaging time, and visualisation of intraabdominal air. CT angiography can also be performed to detect vascular complications [2].

Pancreatic leak, also referred to as postoperative pancreatic fistula (POPF), refers to the leakage of pancreatic enzymes into the abdominal cavity, either due to leakage from the pancreaticojejunostomy anastomosis or from the pancreas [2,4]. Pancreatic leak has the potential to cause significant morbidity and mortality as leakage of pancreatic enzymes can trigger autodigestion of nearby structures, resulting in severe complications. In severe cases, pancreatic leak can result in sepsis, multiorgan failure, and death [2]. Pancreatic leaks following Whipple procedure have reported mortality rates ranging from 3–9% [4]. Factors that can increase the risk of pancreatic leak include advanced age, pathology of tumour, nutrition status, pancreatic duct size, intraoperative complications, and type of surgical technique [1,2].

Pancreatic leak is the most common cause of pathologic postoperative fluid collections, with reported incidences after Whipple procedure ranging from 6–14% [2]. Clinically, relevant pancreatic leak is defined as drain output with fluid amylase level greater than three times the normal serum amylase [2,5]. Pancreatic leak covers a spectrum of severities. Mild pancreatic leak is usually managed conservatively [2]. In severe cases, percutaneous drainage or repeat laparotomy may be warranted [2,3,5].

In this case, the patient was successfully treated with percutaneous drain insertion by the interventional radiology service. The lipase of the fluid collection was 194498 U/L, confirming the diagnosis of postoperative pancreatic leak secondary to pancreaticojejunostomy anastomotic dehiscence. According to the International Study Group for Pancreatic Fistula, findings are consistent with grade B POPF [5].

All patient data have been completely anonymised throughout the entire manuscript and related files.

Differential Diagnosis List
Pancreatic leak secondary to pancreaticojejunostomy anastomotic dehiscence following Whipple procedure
Intra-abdominal abscess
Haematoma
Seroma
Biloma
Acute pancreatitis
Bowel perforation
Final Diagnosis
Pancreatic leak secondary to pancreaticojejunostomy anastomotic dehiscence following Whipple procedure
Case information
URL: https://eurorad.org/case/18513
DOI: 10.35100/eurorad/case.18513
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 8. Axial (1a) and coronal images (1b) demonstrate dehiscence of the pancreaticojejunostomy anastomosis with a fluid collection and locules of gas interspersed between the pancreatic and jejunal components. The pancreatic duct stent is in situ. Pneumobilia is present, within normal limits.
IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 8. Axial (1a) and coronal images (1b) demonstrate dehiscence of the pancreaticojejunostomy anastomosis with a fluid collection and locules of gas interspersed between the pancreatic and jejunal components. The pancreatic duct stent is in situ. Pneumobilia is present, within normal limits.
IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 8. Axial (1a)
IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 8. Axial (1a) and coronal images (1b) demonstrate dehiscence of the pancreaticojejunostomy anastomosis with a fluid collection and locules of gas interspersed between the pancreatic and jejunal components. The pancreatic duct stent is in situ. Pneumobilia is present, within normal limits.
Figure 2

Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararenal space, posterior to the SMA/SMV, on either side of the midline. The collections demonstrate posterior fascial enhancement, but no circumferential rim enhancement. The sagittal image right of midline (2b) demonstrates the right retroperitoneal collection measuring 8.6 x 2.4 x 3.5 cm (CC x AP x TR), tracking inferiorly from the pancreaticojejunostomy anastomosis. The sagittal image le
Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararenal space, posterior to the SMA/SMV, on either side of the midline. The collections demonstrate posterior fascial enhancement, but no circumferential rim enhancement. The sagittal image right of midline (2b) demonstrates the right retroperitoneal collection measuring 8.6 x 2.4 x 3.5 cm (CC x AP x TR), tracking inferiorly from the pancreaticojejunostomy anastomosis. The sagittal image left of midline (2c) demonstrates the left retroperitoneal collection measuring 7.1 x 2.7 x 4.2 cm.
Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararenal space, posterior to the SMA/SMV, on either side of the midline. The collections demonstrate posterior fascial enhancement, but no circumferential rim enhancement. The sagittal image right of midline (2b) demonstrates the right retroperitoneal collection measuring 8.6 x 2.4 x 3.5 cm (CC x AP x TR), tracking inferiorly from the pancreaticojejunostomy anastomosis. The sagittal image le
Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararenal space, posterior to the SMA/SMV, on either side of the midline. The collections demonstrate posterior fascial enhancement, but no circumferential rim enhancement. The sagittal image right of midline (2b) demonstrates the right retroperitoneal collection measuring 8.6 x 2.4 x 3.5 cm (CC x AP x TR), tracking inferiorly from the pancreaticojejunostomy anastomosis. The sagittal image left of midline (2c) demonstrates the left retroperitoneal collection measuring 7.1 x 2.7 x 4.2 cm.
Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararena
Axial (2a) IV contrast-enhanced CT image of the abdomen demonstrates two retroperitoneal collections in the anterior pararenal space, posterior to the SMA/SMV, on either side of the midline. The collections demonstrate posterior fascial enhancement, but no circumferential rim enhancement. The sagittal image right of midline (2b) demonstrates the right retroperitoneal collection measuring 8.6 x 2.4 x 3.5 cm (CC x AP x TR), tracking inferiorly from the pancreaticojejunostomy anastomosis. The sagittal image left of midline (2c) demonstrates the left retroperitoneal collection measuring 7.1 x 2.7 x 4.2 cm.
Figure 3

Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collection medial to the caudate lobe measuring 6.1 x 7.5 x 3.1 cm. Bilateral pleural effusions are also partially visualised. The sagittal image right of midline (3c) demonstrates fluid and locules of gas from the region of the peripancreatic anastomosis tracking superiorly to the periportal region, in direct communication with the rim enhancing periportal fluid collection.
Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collection medial to the caudate lobe measuring 6.1 x 7.5 x 3.1 cm. Bilateral pleural effusions are also partially visualised. The sagittal image right of midline (3c) demonstrates fluid and locules of gas from the region of the peripancreatic anastomosis tracking superiorly to the periportal region, in direct communication with the rim enhancing periportal fluid collection.
Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collec
Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collection medial to the caudate lobe measuring 6.1 x 7.5 x 3.1 cm. Bilateral pleural effusions are also partially visualised. The sagittal image right of midline (3c) demonstrates fluid and locules of gas from the region of the peripancreatic anastomosis tracking superiorly to the periportal region, in direct communication with the rim enhancing periportal fluid collection.
Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collec
Axial (3a) and coronal (3b) IV contrast-enhanced CT images of the abdomen and pelvis demonstrate a rim enhancing fluid collection medial to the caudate lobe measuring 6.1 x 7.5 x 3.1 cm. Bilateral pleural effusions are also partially visualised. The sagittal image right of midline (3c) demonstrates fluid and locules of gas from the region of the peripancreatic anastomosis tracking superiorly to the periportal region, in direct communication with the rim enhancing periportal fluid collection.
Figure 4

CT-guided percutaneous drainage of the retroperitoneal collections adjacent to the pancreaticojejunostomy anastomosis was performed on postoperative day 10. The axial image demonstrates the tip of the drain in the periportal collection.
CT-guided percutaneous drainage of the retroperitoneal collections adjacent to the pancreaticojejunostomy anastomosis was performed on postoperative day 10. The axial image demonstrates the tip of the drain in the periportal collection.
Figure 5

Follow-up IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 84. The axial image demonstrates resolution of fluid collection and locules of gas between the pancreatic and jejunal components of the pancreaticojejunostomy anastomosis. The pancreatic stent is in situ.
Follow-up IV contrast-enhanced CT of the abdomen and pelvis in the portal venous phase was performed on postoperative day 84. The axial image demonstrates resolution of fluid collection and locules of gas between the pancreatic and jejunal components of the pancreaticojejunostomy anastomosis. The pancreatic stent is in situ.