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Table 1 Checklist for interpretation of early CT after pancreatico-duodenectomy (PD)

From: Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists

Feature

Comments

Report pleuropulmonary changes (such as atelectasis, pneumonia, pleural effusion) at lung bases

Particularly common in elderly patients

Externally draining tubes present?

Use thick-slab maximum-intensity projection (MIP) reconstructions

Report presence, number, course and distal tip position

Identify

- pancreatic remnant (body and tail)

- main pancreatic duct (MPD)

- either pancreatico-jejunostomy (PJS) or pancreatico-gastrostomy (PGS)

Best visualised in oblique-coronal images

Assess calibre

Assess integrity, presence of internal or external trans-anastomotic stents

- mobilised jejunal limb

Identified by valvulae conniventes and tubular configuration on coronal images; mural oedema is generally normal

Identify

- hepatico-jejunostomy (HJS)

- either gastro-jejunostomy (GJS) or duodeno-jejunostomy (DJS)

- gastric dilatation

Pneumobilia and/or mild biliary tract dilatation are usually normal

Respectively after Whipple and pylorus preserving PD

Suggest delayed gastric emptying (optional fluoroscopy for confirmation)

Identify fluid collections and air

- surgical bed, abutting the PJS

- subhepatic/right-sided

- surrounding PR

- pneumoperitoneum/peritonitis

Report as consistent with a clinical/laboratory diagnosis of pancreatic fistula (fat stranding, mild non-demarcated fluid, small lymphadenopathies are usually normal)

Suggest bile leakage

Suggest acute pancreatitis

Mild residual air within 3 days is usually normal Persistent or abundant pneumoperitoneum, diffuse ascites, enhancing peritoneal serosa suggest peritonitis from major anastomotic leakage

Search for bleeding

- intraluminal in jejunum

- extraluminal

- hemoperitoneum

Use MIP reconstructions

Compare precontrast, arterial- and portal venous phase images

Always scrutinise the gastroduodenal artery “stump”

Assess patency of splenic, portal and mesenteric veins

For postoperative thrombosis, favoured by venous resections or graft insertion

Scrutinise laparotomic incision site

For fluid or abscess collections consistent with wound infection