Abdominal Imaging

, Volume 40, Issue 8, pp 2932–2944 | Cite as

How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas

  • Bhavik N. Patel
  • Rajan T. GuptaEmail author
  • Sabino Zani
  • R. Brooke Jeffrey
  • Erik K. Paulson
  • Rendon C. Nelson
Pictorial Essay


Disease involving the pancreas can be a significant diagnostic challenge to the interpreting radiologist. Moreover, the majority of disease processes involving the pancreas carry high significant morbidity and mortality either due to their natural process or related to their treatment options. As such, it is critical for radiologists to not only provide accurate information from imaging to guide patient management, but also deliver that information in a clear manner so as to aid the referring physician. This is no better exemplified than in the case of pre-operative staging for pancreatic adenocarcinoma. Furthermore, with the changing healthcare landscape, it is now more important than ever to ensure that the value of radiology service to other providers is high. In this review, we will discuss how the radiologist can add value to the referring physician by employing novel imaging techniques in the pre-operative evaluation as well as how the information can be conveyed in the most meaningful manner through the use of structured reporting. We will also familiarize the radiologist with the imaging appearance of common complications that occur after pancreatic surgery.


Pancreatic cancer CT/MR Imaging Value-based imaging 


Conflicts of Interest



  1. 1.
    Ansari D, Gustafsson A, Andersson R (2015) Update on the management of pancreatic cancer: surgery is not enough. World J Gastroenterol 21(11):3157–3165. doi: 10.3748/wjg.v21.i11.3157 PubMedCentralPubMedGoogle Scholar
  2. 2.
    Puleo F, Marechal R, Demetter P, et al. (2015) New challenges in perioperative management of pancreatic cancer. World J Gastroenterol 21(8):2281–2293. doi: 10.3748/wjg.v21.i8.2281 PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Donahue TR, Reber HA (2015) Surgical management of pancreatic cancer—pancreaticoduodenectomy. Semin Oncol 42(1):98–109. doi: 10.1053/j.seminoncol.2014.12.009 CrossRefPubMedGoogle Scholar
  4. 4.
    Greenblatt DY, Kelly KJ, Rajamanickam V, et al. (2011) Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol 18(8):2126–2135. doi: 10.1245/s10434-011-1594-6 CrossRefPubMedGoogle Scholar
  5. 5.
    Chernyak V, Flusberg M, Haramati LB, Rozenblit AM, Bellin E (2015) Incidental pancreatic cystic lesions: is there a relationship with the development of pancreatic adenocarcinoma and all-cause mortality? Radiology 274(1):161–169. doi: 10.1148/radiol.14140796 CrossRefPubMedGoogle Scholar
  6. 6.
    Tanaka M, Fernandez-del Castillo C, Adsay V, et al. (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12(3):183–197. doi: 10.1016/j.pan.2012.04.004 CrossRefPubMedGoogle Scholar
  7. 7.
    Yamauchi FI, Ortega CD, Blasbalg R, et al. (2012) Multidetector CT evaluation of the postoperative pancreas. Radiographics 32(3):743–764. doi: 10.1148/rg.323105121 CrossRefPubMedGoogle Scholar
  8. 8.
    Fidler JL, Fletcher JG, Reading CC, et al. (2003) Preoperative detection of pancreatic insulinomas on multiphasic helical CT. Am J Roentgenol 181(3):775–780. doi: 10.2214/ajr.181.3.1810775 CrossRefGoogle Scholar
  9. 9.
    King AD, Ko GT, Yeung VT, et al. (1998) Dual phase spiral CT in the detection of small insulinomas of the pancreas. Br J Radiol 71(841):20–23. doi: 10.1259/bjr.71.841.9534694 CrossRefPubMedGoogle Scholar
  10. 10.
    Hollett MD, Jeffrey RB Jr, Nino-Murcia M, Jorgensen MJ, Harris DP (1995) Dual-phase helical CT of the liver: value of arterial phase scans in the detection of small (<or = 1.5 cm) malignant hepatic neoplasms. Am J Roentgenol 164(4):879–884. doi: 10.2214/ajr.164.4.7726040 CrossRefGoogle Scholar
  11. 11.
    Bonaldi VM, Bret PM, Reinhold C, Atri M (1995) Helical CT of the liver: value of an early hepatic arterial phase. Radiology 197(2):357–363. doi: 10.1148/radiology.197.2.7480677 CrossRefPubMedGoogle Scholar
  12. 12.
    Foley WD, Mallisee TA, Hohenwalter MD, et al. (2000) Multiphase hepatic CT with a multirow detector CT scanner. Am J Roentgenol 175(3):679–685. doi: 10.2214/ajr.175.3.1750679 CrossRefGoogle Scholar
  13. 13.
    Francis IR, Cohan RH, McNulty NJ, et al. (2003) Multidetector CT of the liver and hepatic neoplasms: effect of multiphasic imaging on tumor conspicuity and vascular enhancement. Am J Roentgenol 180(5):1217–1224. doi: 10.2214/ajr.180.5.1801217 CrossRefGoogle Scholar
  14. 14.
    Murakami T, Kim T, Takamura M, et al. (2001) Hypervascular hepatocellular carcinoma: detection with double arterial phase multi-detector row helical CT. Radiology 218(3):763–767. doi: 10.1148/radiology.218.3.r01mr39763 CrossRefPubMedGoogle Scholar
  15. 15.
    Vargas R, Nino-Murcia M, Trueblood W, Jeffrey RB Jr (2004) MDCT in pancreatic adenocarcinoma: prediction of vascular invasion and resectability using a multiphasic technique with curved planar reformations. Am J Roentgenol 182(2):419–425. doi: 10.2214/ajr.182.2.1820419 CrossRefGoogle Scholar
  16. 16.
    Prokesch RW, Chow LC, Beaulieu CF, et al. (2002) Local staging of pancreatic carcinoma with multi-detector row CT: use of curved planar reformations initial experience. Radiology 225(3):759–765. doi: 10.1148/radiol.2253010886 CrossRefPubMedGoogle Scholar
  17. 17.
    Patel BN, Thomas JV, Lockhart ME, Berland LL, Morgan DE (2013) Single-source dual-energy spectral multidetector CT of pancreatic adenocarcinoma: optimization of energy level viewing significantly increases lesion contrast. Clin Radiol 68(2):148–154. doi: 10.1016/j.crad.2012.06.108 CrossRefPubMedGoogle Scholar
  18. 18.
    Deshmukh SD, Willmann JK, Jeffrey RB (2010) Pathways of extrapancreatic perineural invasion by pancreatic adenocarcinoma: evaluation with 3D volume-rendered MDCT imaging. Am J Roentgenol 194(3):668–674. doi: 10.2214/AJR.09.3285 CrossRefGoogle Scholar
  19. 19.
    Coursey CA, Nelson RC, Boll DT, et al. (2010) Dual-energy multidetector CT: how does it work, what can it tell us, and when can we use it in abdominopelvic imaging? Radiographics 30(4):1037–1055. doi: 10.1148/rg.304095175 CrossRefPubMedGoogle Scholar
  20. 20.
    Heye T, Nelson RC, Ho LM, Marin D, Boll DT (2012) Dual-energy CT applications in the abdomen. Am J Roentgenol 199(5 Suppl):S64–S70. doi: 10.2214/AJR.12.9196 CrossRefGoogle Scholar
  21. 21.
    Morgan DE (2014) Dual-energy CT of the abdomen. Abdom Imaging 39(1):108–134. doi: 10.1007/s00261-013-0033-5 CrossRefPubMedGoogle Scholar
  22. 22.
    Mileto A, Nelson RC, Paulson EK, Marin D (2015) Dual-energy MDCT for imaging the renal mass. Am J Roentgenol 204(6):W640–W647. doi: 10.2214/AJR.14.14094 CrossRefGoogle Scholar
  23. 23.
    Agrawal MD, Pinho DF, Kulkarni NM, et al. (2014) Oncologic applications of dual-energy CT in the abdomen. Radiographics 34(3):589–612. doi: 10.1148/rg.343135041 CrossRefPubMedGoogle Scholar
  24. 24.
    Megibow AJ, Sahani D (2012) Best practice: implementation and use of abdominal dual-energy CT in routine patient care. Am J Roentgenol 199(5 Suppl):S71–S77. doi: 10.2214/AJR.12.9074 CrossRefGoogle Scholar
  25. 25.
    Lin XZ, Wu ZY, Tao R, et al. (2012) Dual energy spectral CT imaging of insulinoma-value in preoperative diagnosis compared with conventional multi-detector CT. Eur J Radiol 81(10):2487–2494. doi: 10.1016/j.ejrad.2011.10.028 CrossRefPubMedGoogle Scholar
  26. 26.
    McNamara MM, Little MD, Alexander LF, et al. (2015) Multireader evaluation of lesion conspicuity in small pancreatic adenocarcinomas: complimentary value of iodine material density and low keV simulated monoenergetic images using multiphasic rapid kVp-switching dual energy CT. Abdom Imaging 40(5):1230–1240. doi: 10.1007/s00261-014-0274-y CrossRefPubMedGoogle Scholar
  27. 27.
    Macari M, Spieler B, Kim D, et al. (2010) Dual-source dual-energy MDCT of pancreatic adenocarcinoma: initial observations with data generated at 80 kVp and at simulated weighted-average 120 kVp. Am J Roentgenol 194(1):W27–W32. doi: 10.2214/AJR.09.2737 CrossRefGoogle Scholar
  28. 28.
    Miller FH, Rini NJ, Keppke AL (2006) MRI of adenocarcinoma of the pancreas. Am J Roentgenol 187(4):W365–W374. doi: 10.2214/AJR.05.0875 CrossRefGoogle Scholar
  29. 29.
    Low RN, Barone RM, Lacey C, et al. (1997) Peritoneal tumor: MR imaging with dilute oral barium and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT. Radiology 204(2):513–520. doi: 10.1148/radiology.204.2.9240546 CrossRefPubMedGoogle Scholar
  30. 30.
    Sahani DV, Kambadakone A, Macari M, et al. (2013) Diagnosis and management of cystic pancreatic lesions. Am J Roentgenol 200(2):343–354. doi: 10.2214/AJR.12.8862 CrossRefGoogle Scholar
  31. 31.
    Kim SH, Lee JM, Lee ES, et al. (2015) Intraductal papillary mucinous neoplasms of the pancreas: evaluation of malignant potential and surgical resectability by using MR imaging with MR cholangiography. Radiology 274(3):723–733. doi: 10.1148/radiol.14132960 CrossRefPubMedGoogle Scholar
  32. 32.
    Nealon WH, Walser E (2002) Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 235(6):751–758PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    Nealon WH, Walser E (2005) Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. Ann Surg 241(6):948–957 (discussion 957–960)PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Travis AR, Sevenster M, Ganesh R, Peters JF, Chang PJ (2014) Preferences for structured reporting of measurement data: an institutional survey of medical oncologists, oncology registrars, and radiologists. Acad Radiol 21(6):785–796. doi: 10.1016/j.acra.2014.02.008 CrossRefPubMedGoogle Scholar
  35. 35.
    Nougaret S, Reinhold C, Mikhael HW, et al. (2013) The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the “DISTANCE”? Radiology 268(2):330–344. doi: 10.1148/radiol.13121361 CrossRefPubMedGoogle Scholar
  36. 36.
    Larson DB, Towbin AJ, Pryor RM, Donnelly LF (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267(1):240–250. doi: 10.1148/radiol.12121502 CrossRefPubMedGoogle Scholar
  37. 37.
    Mitchell DG, Bruix J, Sherman M, Sirlin CB (2015) LI-RADS (Liver Imaging Reporting and Data System): summary, discussion, and consensus of the LI-RADS Management Working Group and future directions. Hepatology 61(3):1056–1065. doi: 10.1002/hep.27304 CrossRefPubMedGoogle Scholar
  38. 38.
    Schwartz LH, Panicek DM, Berk AR, Li Y, Hricak H (2011) Improving communication of diagnostic radiology findings through structured reporting. Radiology 260(1):174–181. doi: 10.1148/radiol.11101913 PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Brennan DD, Zamboni GA, Raptopoulos VD, Kruskal JB (2007) Comprehensive preoperative assessment of pancreatic adenocarcinoma with 64-section volumetric CT. Radiographics 27(6):1653–1666. doi: 10.1148/rg.276075034 CrossRefPubMedGoogle Scholar
  40. 40.
    Tamm EP, Silverman PM, Charnsangavej C, Evans DB (2003) Diagnosis, staging, and surveillance of pancreatic cancer. Am J Roentgenol 180(5):1311–1323. doi: 10.2214/ajr.180.5.1801311 CrossRefGoogle Scholar
  41. 41.
    Christians KK, Tsai S, Mahmoud A, et al. (2014) Neoadjuvant FOLFIRINOX for borderline resectable pancreas cancer: a new treatment paradigm? Oncologist 19(3):266–274. doi: 10.1634/theoncologist.2013-0273 PubMedCentralCrossRefPubMedGoogle Scholar
  42. 42.
    Al-Hawary MM, Francis IR, Chari ST, et al. (2014) Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the American Pancreatic Association. Gastroenterology 146(1):291–304 (e291). doi: 10.1053/j.gastro.2013.11.004 CrossRefPubMedGoogle Scholar
  43. 43.
    Brook OR, Brook A, Vollmer CM, et al. (2015) Structured reporting of multiphasic CT for pancreatic cancer: potential effect on staging and surgical planning. Radiology 274(2):464–472. doi: 10.1148/radiol.14140206 CrossRefPubMedGoogle Scholar
  44. 44.
    Al-Hawary MM, Francis IR, Chari ST, et al. (2014) Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 270(1):248–260. doi: 10.1148/radiol.13131184 CrossRefPubMedGoogle Scholar
  45. 45.
    Thoeni RF (2012) The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 262(3):751–764. doi: 10.1148/radiol.11110947 CrossRefPubMedGoogle Scholar
  46. 46.
    Morgan DE (2012) Imaging after pancreatic surgery. Radiol Clin North Am 50(3):529–545. doi: 10.1016/j.rcl.2012.03.004 CrossRefPubMedGoogle Scholar
  47. 47.
    Wolfgang CL, Corl F, Johnson PT, et al. (2011) Pancreatic surgery for the radiologist, 2011: an illustrated review of classic and newer surgical techniques for pancreatic tumor resection. Am J Roentgenol 197(6):1343–1350. doi: 10.2214/AJR.10.5311 CrossRefGoogle Scholar
  48. 48.
    Scialpi M, Scaglione M, Volterrani L, et al. (2005) Imaging evaluation of post pancreatic surgery. Eur J Radiol 53(3):417–424. doi: 10.1016/j.ejrad.2004.12.013 CrossRefPubMedGoogle Scholar
  49. 49.
    Roulin D, Cerantola Y, Demartines N, Schafer M (2011) Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 15(6):1055–1062. doi: 10.1007/s11605-011-1427-8 CrossRefPubMedGoogle Scholar
  50. 50.
    Poon RT, Fan ST (2008) Decreasing the pancreatic leak rate after pancreaticoduodenectomy. Adv Surg 42:33–48CrossRefPubMedGoogle Scholar
  51. 51.
    Zink SI, Soloff EV, White RR, et al. (2009) Pancreaticoduodenectomy: frequency and outcome of post-operative imaging-guided percutaneous drainage. Abdom Imaging 34(6):767–771. doi: 10.1007/s00261-008-9455-x CrossRefPubMedGoogle Scholar
  52. 52.
    Kaminsky PM, Mezhir JJ (2013) Intraperitoneal drainage after pancreatic resection: a review of the evidence. J Surg Res 184(2):925–930. doi: 10.1016/j.jss.2013.05.092 CrossRefPubMedGoogle Scholar
  53. 53.
    Ho CK, Kleeff J, Friess H, Buchler MW (2005) Complications of pancreatic surgery. HPB (Oxford) 7(2):99–108. doi: 10.1080/13651820510028936 PubMedCentralCrossRefGoogle Scholar
  54. 54.
    Rondelli F, Desio M, Vedovati MC (2014) Intra-abdominal drainage after pancreatic resection: is it really necessary? A meta-analysis of short-term outcomes. Int J Surg 12(Suppl 1):S40–S47. doi: 10.1016/j.ijsu.2014.05.002 CrossRefPubMedGoogle Scholar
  55. 55.
    Casadei R, Ricci C, Giampalma E, et al. (2014) Interventional radiology procedures after pancreatic resections for pancreatic and periampullary diseases. J Pancreas 15(4):378–382. doi: 10.6092/1590-8577/2198 Google Scholar
  56. 56.
    Wente MN, Veit JA, Bassi C, et al. (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142(1):20–25. doi: 10.1016/j.surg.2007.02.001 CrossRefPubMedGoogle Scholar
  57. 57.
    Yekebas EF, Wolfram L, Cataldegirmen G, et al. (2007) Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 246(2):269–280. doi: 10.1097/01.sla.0000262953.77735.db PubMedCentralCrossRefPubMedGoogle Scholar
  58. 58.
    Paraskevas KI, Avgerinos C, Manes C, Lytras D, Dervenis C (2006) Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism. World J Gastroenterol 12(37):5951–5958PubMedCentralPubMedGoogle Scholar
  59. 59.
    Tran KT, Smeenk HG, van Eijck CH, et al. (2004) Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 240(5):738–745PubMedCentralCrossRefPubMedGoogle Scholar
  60. 60.
    Machado NO (2012) Pancreaticopleural fistula: revisited. Diagn Ther Endosc . doi: 10.1155/2012/815476 PubMedCentralPubMedGoogle Scholar
  61. 61.
    House MG, Cameron JL, Schulick RD, et al. (2006) Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg 243(5):571–576 (discussion 576–578). doi: 10.1097/01.sla.0000216285.07069.fc PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Bhavik N. Patel
    • 1
  • Rajan T. Gupta
    • 1
    Email author
  • Sabino Zani
    • 2
  • R. Brooke Jeffrey
    • 3
  • Erik K. Paulson
    • 1
  • Rendon C. Nelson
    • 1
  1. 1.Department of RadiologyDuke University Medical Center, DUMCDurhamUSA
  2. 2.Department of SurgeryDuke University Medical Center, DUMCDurhamUSA
  3. 3.Department of RadiologyStanford Hospital & ClinicsStanfordUSA

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