Korean J Radiol.  2013 Jun;14(3):446-450. 10.3348/kjr.2013.14.3.446.

Modified Retroperitoneal Access for Percutaneous Intervention after Pancreaticoduodenectomy

• Pua U
• Quek LH

• KMID: 1705457
• DOI: http://doi.org/10.3348/kjr.2013.14.3.446

Abstract

Percutaneous access to the surgical bed after pancreaticoduodenectomy can be a challenge, due to the post-operative anatomy alteration. However, immediate complications, such as surgical bed abscess or suspected tumor recurrence, are often best accessed percutaneously, as open surgical or endoscopic approaches are often difficult, if not impossible. We, hereby, describe a safe approach that is highly replicable, in accessing the surgical bed for percutaneous intervention, following pancreaticoduodenectomy.

Keyword

Pancreaticoduodenectomy; Percutaneous; Retroperitoneal

MeSH Terms

Abscess/radiography/therapy
Bile Duct Neoplasms/pathology/radiography
Biopsy/methods
Catheterization/*methods
Cholangiocarcinoma/pathology/radiography
Drainage/instrumentation/*methods
Humans
Male
Middle Aged
Neoplasm Recurrence, Local/pathology/radiography
Pancreatic Diseases/radiography/therapy
*Pancreaticoduodenectomy
Postoperative Complications/radiography/*therapy
Radiography, Interventional/methods
Retroperitoneal Space

Figure

• 

  Fig. 1 Sixtyone year-old man with fever 7 days after pancreaticoduodenectomy. Contrast enhanced CT images (A) diagnostic (B) prior to drainage with patient in left decubitus position, shows abscess (*) in region of excised pancreatic head with overlying bowel loops and liver anteriorly. Planned trajectory in anterior pararenal space (white line) appeared narrow. (C) CT fluoroscopic image showing contrast-fluid hydrodissection (white arrows) widening space between right kidney and ascending colon to allow safe passage of needle. "Salinoma" was created by injecting contrast-fluid mixture continuously while advancing needle. (D) Contrast enhanced CT prior to drainage catheter removal, showing Cope loop of drainage catheter within surgical bed.

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  Fig. 2 Fiftyseven year-old man with suspicious lesion in surgical bed 3 years after pancreaticoduodenectomy. A. Contrast enhanced CT showed hypodense lesion in surgical bed, worrisome for tumor recurrence. Overlying bowel and vessels made anterior approach from biopsy unsuitable. Planned trajectory (white line) between segment VI of liver and right kidney is equivocal for needle passage without organ traversal. B. CT fluoroscopic image showing contrast-fluid hydrodissection (white arrows) used to create safe passage between liver and right kidney for guide needle. C. CT fluoroscopic image showing deployment of biopsy chamber into lesion (white arrow). Fine adjustments to biopsy location could be made by applying external torque on guide needle. Histology confirmed recurrent cholangiocarcinoma.

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