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Figure 3.43. Whipple procedure. (A) CT scan at the level of the pancreas after Whipple procedure showing the gastrojejunal and pancreaticojejunal anastomoses. A nasogastric tube is present. (B) CT scan of a different patient after Whipple procedure showing a stent in the pancreatic duct and an external biliary drain in place.

Figure 3.43. Whipple procedure. (A) CT scan at the level of the pancreas after Whipple procedure showing the gastrojejunal and pancreaticojejunal anastomoses. A nasogastric tube is present. (B) CT scan of a different patient after Whipple procedure showing a stent in the pancreatic duct and an external biliary drain in place.

will show stability or regression over time. Unfilled loops of bowel may simulate adenopathy as well. Increased attenuation of the fat in the surgical bed and surrounding the mesenteric vessels is also an expected postoperative finding, which may persist for up to a year after surgery and should not be confused with tumor infiltration.

The remaining pancreas is often atrophic, and mild dilatation of the pancreatic duct is common. A soft tissue defect at the pancreaticoje-junostomy site may be seen secondary to invagination of the pancreas into the bowel loop (the so-called dunking procedure) and may simulate tumor recurrence or intussusception (Fig. 3.44). Bluemke et al. reported thickening of the gastric antrum and proximal duodenum in 64% of patients undergoing the pylorus-preserving Whipple procedure with adjuvant chemotherapy and radiation therapy [42]. These findings were thought to be secondary to the radiation therapy and should not be attributed to metastatic disease.

The most common complication and the leading cause of perioperative mortality following the Whipple procedure is related to leakage or breakdown of the pancreaticojejunostomy. Unfortunately, this anastomosis is the most difficult to visualize with contrast. Trerotola et al. have suggested a preferred method of fluoroscopic visualization of this region by injection of the biliary stent or T tube in a shallow Trendelenburg or left posterior oblique position [45].

Liver infarction is not unusual in patients who have undergone resection of the portal vein and/or superior mesenteric vein, with an incidence of 70% reported in one series [39]. In the later postoperative period, recurrent disease, either in the pancreatic bed or in the liver, is best identified on CT imaging. Recurrent tumor in the region of the surgical bed and liver metastases commonly develop, and the survival rate for pancreatic cancer remains dismal (Fig. 3.45).

Figure 3.44. Whipple procedure with dunking. Supine film from an upper GI series showing a defect at the pancreaticojejunostomy site from invagination of the pancreas into the bowel.
Figure 3.45. Whipple procedure with recurrent tumor. Supine film from an upper GI series performed 4 months after surgery shows partial gastric outlet obstruction and irregular narrowing of the gastrojejunal anastomosis from recurrent tumor.

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