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Jul09
CHRONIC PANCREATITIS: POSTOPERATIVE ANATOMY AND COMPLICATION
Surgical procedures are generally recognized by Pancreatologists as the most effective treatment for chronic pancreatitis in reducing acute exacerbations and chronic symptoms.Surgery performed for chronic pancreatitis can be classified as resection procedures or drainage jejunostomy.Types of pancreatic resection surgery include Whipple and Beger's procedures.Drainage pancreaticojejunostomy procedures include Puestow and Frey's operations.When the pancreatic duct in the body or tail is dilated beyond 6 mm, the puestow procedure is usually most effective.When disease occurs predominantly in the head of the pancreas, Frey's procedure is used.When there is a focal mass in the head without significant duct dilation, the whipple's procedure is most frequently done. Beger's procedure which preserves the duodenum, is also used as an alternative.
Several expected postoperative CT and MRI findings may be confused with disease.Periportal hepatic edema, which usually resolves in 1 month, and pneumobilia which usually persists, are seen universally.The afferent loop of the bowel that drains the pancreatic and biliary ducts may be edematous in the first 3 weeks.This appearance should not be mistaken for bowel ischemia or hemorrhage. The Roux loop may be mistaken for an abscess.In puestow procedure, the Roux loop lies between the stomach and the pancreatic body in the lesser sac and should not be misinterpreted as an internal hernia or pancreatic tumor.Transient fluid collections in the pancreatic and duodenal bed are common in the first month after surgery and do not need to be drained unless clinically indicated. Reactive lymphadenopathy is seen upto 2 months postoperatively.Perivascular cuffing around the celiac, hepatic, and mesentric arteries is seen upto 6 weeks after whipple and Beger's procedures.This finding can be mistaken for tumor recurrence.Mild pancreatic duct dilation is an expected postoperative appearance.After Frey's procedure, a large cavity may be seen in the pancreatic head and may possibly be mistaken for a pseudocyst or cystic neoplasm.Some errors can be avoided if postoperative anatomy is known to the radiologist.


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