Hemorrhagic Complications After Whipple Surgery: Imaging and Radiologic Intervention

Puppala, Sapna; Patel, Jai V.; McPherson, Simon; Nicholson, Anthony A.; Kessel, David

doi:10.2214/ajr.10.4727

Cited by 69 publications

(59 citation statements)

References 13 publications

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“…17–19 This great expertise, as well as that of the diagnostic radiologists, who have helped us identify patients and refine preoperative diagnosis, have fueled growth of the program, research opportunities, and better patient care.…”

Section: Discussionmentioning

confidence: 99%

Evolution of the Whipple procedure at the Massachusetts General Hospital

Castillo

Morales-Oyarvide

McGrath

et al. 2012

Surgery

208

127

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Background Since Allen O. Whipple published his seminal paper in 1935, the procedure that bears his name has been performed widely throughout the world and is now a common operation in major medical centers. The goal of this study was to investigate the evolution of pancreatoduodenectomy at the Massachusetts General Hospital (MGH). Methods We sought to identify all pancreatoduodenectomies performed at the MGH since 1935. Cases were obtained from a computerized database, hospital medical records, and the MGH historical archive. Demographics, diagnosis, intraoperative variables and short-term surgical outcomes were recorded. Results The first pancreatoduodenectomy at the MGH was carried out in 1941; since then, 2,050 Whipple procedures have been performed. Pancreatic ductal adenocarcinoma was the most frequent indication (36%). Pylorus preservation has been the most important variation in technique, accounting for 45% of Whipple procedures in the 1980s; observation of frequent delayed gastric emptying after this procedure led to decline in its use. Pancreatic fistula was the most frequent complication (13%). Operative blood replacement and reoperation rates have decreased markedly over time; the most frequent indication for reoperation was intra-abdominal bleeding. Mortality has decreased from 45% to 0.8%, with sepsis and hypovolemic shock being the most frequent causes of death. Mean duration of hospital stay has decreased from >30 to 9.5 days, along with an increasing readmission rate (currently 19%). Conclusion The Whipple procedure in the 21st century is a well-established operation. Improvements in operative technique and perioperative care have contributed in making it a safe operation that continues evolving.

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Section: Discussionmentioning

confidence: 99%

Evolution of the Whipple procedure at the Massachusetts General Hospital

Castillo

Morales-Oyarvide

McGrath

et al. 2012

Surgery

208

127

View full text Add to dashboard Cite

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“…8 Radiologists must be keenly aware of this and act immediately when patients develop signs of haemorrhage. CT angiography can demonstrate the cause, site and nature of bleeding.…”

Section: Vascular Complicationsmentioning

confidence: 99%

Pancreaticoduodenectomy: expected post-operative anatomy and complications

McEvoy¹,

Lavelle²,

Hoare³

et al. 2014

BJR

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Pancreaticoduodenectomy is a complex, high-risk surgical procedure performed for tumours of the pancreatic head and other periampullary structures. The rate of perioperative mortality has decreased in the past number of years but perioperative morbidity remains high. This pictorial review illustrates expected findings in early and late post-operative periods, including mimickers of pathology. It aims to familiarize radiologists with the imaging appearances of common and unusual post-operative complications. These are classified into early non-vascular complications such as delayed gastric emptying, post-operative collections, pancreatic fistulae and bilomas; late non-vascular complications, for example, biliary strictures and hepatic abscesses; and vascular complications including haemorrhage and ischaemia. Options for minimally invasive image-guided management of vascular and non-vascular complications are discussed. Familiarity with normal anatomic findings is essential in order to distinguish expected post-operative change from surgical complications or recurrent disease. This review summarizes the normal and abnormal radiological findings following pancreaticoduodenectomy.Pancreaticoduodenectomy was first performed in 1909 and was popularized by the American surgeon Allen Whipple, who refined the technique in the 1930s. Indications for the procedure include pancreatic head tumours, periampullary tumours, distal common bile duct tumours and chronic pancreatitis involving the pancreatic head. The mortality rate of the procedure has decreased from .20% to ,2% in high volume centres, making it a more attractive option now than it previously was. 1 However, perioperative morbidity rates remain high (30-40%). Many patients require post-operative imaging and radiologic intervention. Timely recognition of complications is important. EXPECTED POST-OPERATIVE FINDINGS AND MIMICKERS OF PATHOLOGYUnderstanding the surgical procedure and the expected postoperative findings is essential when interpreting imaging. The components of a standard pancreaticoduodenectomy are distal gastrectomy, duodenectomy, partial pancreatectomy, partial choledochectomy, cholecystectomy and proximal jejunectomy. A jejunal loop is mobilized up to the right upper quadrant and three anastomoses are formed: gastrojejunostomy, hepaticojejunostomy and pancreaticojejunostomy (Figure 1). Distal gastrectomy facilitates resection of nodes along the greater and lesser curves of the stomach, reduces delayed gastric emptying and theoretically reduces the risk of gastritis post-operatively.Pylorus-preserving pancreaticoduodenectomy, first described in 1944, 2 has gained popularity in the past two decades. It involves preservation of the stomach and proximal duodenum and formation of a duodenojejunostomy (Figure 1). There is debate in the literature regarding the advantage of pylorus-preserving pancreaticoduodenectomy compared with standard pancreaticoduodenectomy. Preservation of the distal stomach results in reduced frequency of dumping syndrome and...

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“…[3][4][5][6] Hemorrhage after pancreatic surgery is a less common but serious complication with an incidence of 1.5% to 15%. [7][8][9] Postoperative hemorrhage may result from insufficient intraoperative hemostasis, peptic ulcer, marginal ulcer, anastomotic dehiscence, or pseudoaneurysm rupture. 10 Hemorrhage from ruptured pseudoaneurysms is a rare entity, 11,12 however, it's usually massive, rapidly progressive, and life-threatening, which is associated with a high mortality rate of up to 54%.…”

Section: Introductionmentioning

confidence: 99%