Imaging Pearls ❯ Pancreas ❯ Pancreatic Surgery
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- Key Points
• A personalized 3D-printed pancreatic cancer model provides more intuitive information than CT, allowing surgeons to better visualize the tumor’s location and relationship to neighboring organs.
• In particular, the survey score was higher among staff who performed the surgery than among residents.
• Individual patient pancreatic cancer models have the potential to be used for personalized patient education as well as resident education.
Use of individualized 3D‑printed models of pancreatic cancer to improve surgeons’ anatomic understanding and surgical planning
Chorog Song et al.
European Radiology https://doi.org/10.1007/s00330-023-09756-0 - Objectives Three-dimensional (3D) printing has been increasingly used to create accurate patient-specific 3D-printed models from medical imaging data. We aimed to evaluate the utility of 3D-printed models in the localization and understanding of pancreatic cancer for surgeons before pancreatic surgery. Conclusion The 3D-printed model of pancreatic cancer improved surgeons’ understanding of individual patients’ pancreatic cancer and surgical planning. Clinical relevance statement The 3D-printed model of pancreatic cancer can be created using a preoperative CT image, which not only assists surgeons in surgical planning but also serves as a valuable educational resource for patients and students.
Use of individualized 3D‑printed models of pancreatic cancer to improve surgeons’ anatomic understanding and surgical planning
Chorog Song et al.
European Radiology https://doi.org/10.1007/s00330-023-09756-0 - “The limitations of the present study are as follows. First, owing to technical limitations, the model is firm and stiff, which differs from the tactile sensation of actual biological tissue. There is still a lack of 3D printing technology for the formation of soft tissue structures. Therefore, when used as a preoperative simulation, there are disadvantages such as cutting and suturing, surgery, malleability, and a decrease in vitality, making it less competitive than augmented or virtual reality. Second, there was a small sample size of 10 patients and no direct survey of patients.”
Use of individualized 3D‑printed models of pancreatic cancer to improve surgeons’ anatomic understanding and surgical planning
Chorog Song et al.
European Radiology https://doi.org/10.1007/s00330-023-09756-0
- “The guideline conditionally recommends conventionally fractionated or stereotactic body radiation for neoadjuvant and definitive therapy in certain patients and conventionally fractionated regimens for adjuvant therapy. The task force suggests a range of appropriate dose-fractionation schemes and provides recommendations on target volumes and sequencing of radiation and chemotherapy. Motion management, daily image guidance, use of contrast, and treatment with modulated techniques are all recommended. The task force supported prophylactic antiemetic medication, and patients may also benefit from medications to reduce acid secretion.”
Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline
Manisha Palta et al.
Practical Radiation Oncology (2019) 9, 322-332 - “ The role of radiation in the management of pancreatic cancer is evolving, with many ongoing areas of active investigation. Radiation therapy is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is important that the nuances of available data are discussed with patients and families and that care be coordinated in a multidisciplinary fashion.”
Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline
Manisha Palta et al.
Practical Radiation Oncology (2019) 9, 322-332 - ”The role of radiation in the management of pancreatic cancer is evolving in the adjuvant, neoadjuvant, and definitive settings, as is the use of dose escalation and ablative RT, with advances in motion management, target delineation, treatment planning, and image guidance. The role of RT is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is critical that the nuances of available data are discussed with pa- tients and families and that care for patients with pancreatic cancer be coordinated in a multidisciplinary fashion.”
Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline
Manisha Palta et al.
Practical Radiation Oncology (2019) 9, 322-332
- “Radiologists can add value to the referring physician in the pre- and post-surgical evaluation of the pancreas by employing novel imaging techniques, such as 3D small FOV VR images and DECT. Additionally, structured reporting will allow complex and detailed findings often associated with such cases to be delivered to the referring physician in a clear and concise way, often improving patient management and potentially, outcomes.”
How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas Patel BN et al. Abdom Imaging (2015) 40:2932–2944 - “Higher pancreatic lesion conspicuity for both hypo- and hypervascular lesions can be achieved at lower monochromatic energy levels (i.e., 45–55 keV), which exploit higher image contrast at lower keV levels at the expense of image noise. Lower monochromatic energy level images can also increase conspicuity of small adenocarcinomas less than 3 cm in diameter.”
How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas Patel BN et al. Abdom Imaging (2015) 40:2932–2944 - Adenocarcinoma is the most common malignant tumor involving the ampulla. It is, however, an extremely rare malignancy, with age-standardized incidence rates of 0.6 per 100,000 in men and 0.4 per 100,000 in women. According to the various types of epithelium composing the ampullary region, adenocarcinomas can be subdivided into (a) intestinal-type cancers, (b) pancreatobiliary-type cancers, or (c) mixed intestinal and pancreatobiliary-type cancers. Tumors in the first category resemble tumors of the small bowel, colon, and rectum and can arise in adenomas. Pancreatobiliary-type carcinomas carry a worse prognosis.
MDCT and MRI of the ampulla of Vater (part I): technique optimization, normal anatomy,and epithelial neoplasms Alessandrino F et al. Abdom Imaging (2015) 40:3274–3291
- INTRODUCTION: Spleen-preserving left pancreatectomy (SPDP) with splenic vessels preservation (SVP) or without (Warshaw technique, WT) has been described with robotic, laparoscopy and open surgery. Nevertheless, significant data on medium- and long-term follow-up are still not available, since data in literature are scarce and the level of evidence is low.
CONCLUSIONS: WT is safe and feasible, even if there are not definitive evidences that demonstrate it is superior to classic SVP. RCTs are needed to determine advantages and disadvantages of WT compared to the classic SVP. Distal pancreatectomy with splenic preservation: A short-term outcome analysis of the Warshaw technique.
Boselli C et al. Int J Surg. 2015 Sep;21 Suppl 1:S40-3. doi: 10.1016/j.ijsu.2015.06.051. Epub 2015 Jun 26.
- “Abdominal aneurysms and pseudoaneurysms represent an important finding every emergency radiologist must detect. True aneurysms are usually incidental to the presenting complaint, whereas pseudoaneurysms are nearly always symptomatic.”
Review of visceral aneurysms and pseudoaneurysms. Lu M et al. J Comput Assist Tomogr. 2015 Jan-Feb;39(1):1-6. - Gastroduodenal (GDA) Artery Pseudoaneurysms: Etiology
- Iatrogenic injury (bx)
- Whipple procedure
- Pancreatitis
- Vasculitis
- “The Whipple procedure is associated with a unique set of common complications, including pancreatic fistula, postsurgical hemorrhage, postoperative pancreatitis, portomesenteric venous thrombosis, hepatic infarction, delayed gastric emptying and anastomotic strictures.”
CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications
Raman SP, Horton KM, Cameron JC, Fishman EK
AJR 2013;201:2-13 - “Early post-operative hemorrhage occurs within the first 24 hours after surgery and often results from active bleeding at the gastroduodenal artery (GDA) stump as a result of inadequate ligation during surgery.”
CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications
Raman SP, Horton KM, Cameron JC, Fishman EK
AJR 2013;201:2-13 - “Late post-operative hemorrhage occurs after 5 days and is usually secondary to a structural abnormality in the mesenteric vasculature. Although vascular erosions (usually the hepatic artery, celiac artery or splenic artery) and pseudoaneurysm formation can be underlying causes of this hemorrhage , the most common cause of late bleeding remains an abnormality of the GDA stump (either a pseudoaneurysm or active extravasation).”
CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications
Raman SP, Horton KM, Cameron JC, Fishman EK
AJR 2013;201:2-13 - Complications Following Whipple’s Procedure
- Pancreatic fistula
- Postoperative abscess
- Portal vein or SMV thrombosis
- Postoperative hemorrhage
- Pseudoaneurysm formation
- Hepatic ischemia or infarction
- Delayed gastric emptying
- Pancreatic or bile duct strictures
- Acute Peripancreatic Fluid Collection
1. Peripancreatic fluid collection
- Without an appreciable wall
- 1st 4 weeks after symptom onset
- Rich in pancreatic enzymes
- Conform to shape of the retroperitoneum
2. Conservative treatment if sterile
- Only rarely infected
- Pancreatic Surgeries
- Pancreatoduodenectomy (Whipple’s procedure)
- Central pancreatectomy
- Distal pancreatectomy
- Total pancreatectomy
- Puestow procedure
- Frey procedure - Whipples Procedure: Complications as Seen on CT
- Delayed gastric emptying (50% of patients)
- Gastric outlet obstruction
- Afferent loop syndrome
- Pancreatic fistulae (17%)
- Wound infection (9-10%)
- Abdominal abscess
- Intraabdominal bleed