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Internal (Petersen’s) hernia in Roux-en-Y gastric bypass. A 59-year-old female with intermittent abdominal pain after Roux-en-Y gastric bypass. A Coronal reformatted CT shows the jejunojejunal anastomosis (white arrow) in the right lower quadrant. B Axial CT image from the same scan as (A) shows twisting of the superior mesenteric vein (white arrows). C Coronal reformatted CT from 3 weeks prior shows the jejunojejunal anastomosis (white arrow) in the left upper quadrant, as expected. This was a symptomatic but nonobstructed Petersen’s hernia after retrocolic gastrojejunostomy, confirmed on surgery
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This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindicat...
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surgical techniques about pancreas anastomosis
Background:
Pancreaticoduodenectomy remains the gold standard for management of patients with pancreatic head and periampullary neoplasms. Despite the low mortality, overall morbidity remains high, principally due to the development of a clinically relevant postoperative pancreatic fistula (CR-POPF).
The aim of the present study is to compare rates...
Citations
... 1,[4][5][6][7] The reduction of POPF rates has been under intense investigation, and innovations in the surgical technique involving the drain of the main pancreatic duct into the alimentary tract. [8][9][10][11] The two major types of pancreaticojejunostomy (PJ) widely employed are the invagination and the duct-to-mucosa anastomosis. 9,12 Randomized controlled trials have failed to find significant differences in POPF rates between the two techniques. ...
Background:. Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients’ outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients’ outcome.
Methods:. The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed.
Results:. Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C).
Conclusion:. Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.
... Classic Whipple surgery is the standard PD procedure in which gastric antrum is removed, and the continuity of the intestinal loops is accomplished by three anastomoses to the proximal section of the jejunum. The three post-operative anastomoses include pancreaticojejunostomy (PJ), hepaticojejunostomy/choledochojejunostomy (HJ), and gastrojejunostomy (GJ) [6]. PD is used for tumors of the head, proximal neck, and the uncinate process [5]. ...
... Pre-operative CT examination with contrast enhancement is pivotal in selecting surgical candidates. Post-processing multiplanar reformatting and three-dimensional (3D) rendering are essential for the optimal assessment of the tumor, vascular involvement, and serves as a major determinant for selection of patients with resectable disease [6]. Multiple criteria have been introduced to identify clearly resectable stage I and II disease with the presence of a clear fat plane surrounding the vessel to borderline resectable stage III disease with tumor abutment of a major artery and resectable and reconstructable portovenous axis [6,8]. ...
... Post-processing multiplanar reformatting and three-dimensional (3D) rendering are essential for the optimal assessment of the tumor, vascular involvement, and serves as a major determinant for selection of patients with resectable disease [6]. Multiple criteria have been introduced to identify clearly resectable stage I and II disease with the presence of a clear fat plane surrounding the vessel to borderline resectable stage III disease with tumor abutment of a major artery and resectable and reconstructable portovenous axis [6,8]. Stage IV disease is defined by the presence of distant metastatic disease, and these patients are deemed unresectable. ...
Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.
