EURORAD ESR

Case 14809

State-of-the-art endoscopic treatment of walled-off postnecrotic pancreatic collection

Author(s)
Tonolini Massimo, M.D.1; Gambitta Pietro, M.D.2

"Luigi Sacco" University Hospital,
Radiology (1) and Endoscopy (2) Departments
Via G.B. Grassi 74 20157 Milan, Italy;
Email:mtonolini@sirm.org
 
Patient
male, 37 year(s)
 
 
  • Figure 1
    Plain abdominal radiographs
     

    Upright (a) and supine (b) radiographs showed a large, ovoid-shaped demarcated opacity (*), centrally located in the upper abdomen. Note metallic clips from previous cholecystectomy, paucity of bowel gas.

     
    Area of Interest: Pancreas; Imaging Technique: Plain radiographic studies; Procedure: Drainage; Special Focus: Cysts;

    Upright (a) and supine (b) radiographs showed a large, ovoid-shaped demarcated opacity (*), centrally located in the upper abdomen. Note metallic clips from previous cholecystectomy, paucity of bowel gas.

     
    Area of Interest: Pancreas; Imaging Technique: Plain radiographic studies; Procedure: Drainage; Special Focus: Cysts;
     
     
  • Figure 2
    Pre- and postcontrast multidetector CT
     

    Unenhanced (a,b) images confirmed a large (approx.20x12 cm) fluid-attenuation collection (*) centered in the pancreatic region, with some solid dependent debris (+ in b). Note metallic clips from previous...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Unenhanced (a,b) images confirmed a large (approx.20x12 cm) fluid-attenuation collection (*) centered in the pancreatic region, with some solid dependent debris (+ in b).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    The vast, internally nonenhancing postnecrotic pancreatic collection (*) exerted mass effect with compression and dislocation of the stomach and splenoportal venous system.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Albeit images from previous CT studies were unavailable, residual enhancing pancreatic regions (black arrowheads) were recognisable at the head (g) and tail (h), both compressed by the postnecrotic collection.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Albeit images from previous CT studies were unavailable, residual enhancing pancreatic regions (black arrowheads) were recognisable at the head (g) and tail (h), both compressed by the postnecrotic collection.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;
     
     
  • Figure 3
    Postprocedural plain abdominal radiograph

    Radiographically the nasocystic drainage tube (thick arrows) and pigtail stents (arrows) are recognised, crossing through the short but wide (16x20mm) transmural metal gastrocystic stent (thin arrow).

     
    Area of Interest: Pancreas; Imaging Technique: Plain radiographic studies; Procedure: Drainage; Special Focus: Cysts;
     
     
  • Figure 4
    Repeated contrast-enhanced multidetector CT 8 days after Fig.3
     

    After treatment, the postnecrotic pancreatic collection (*) showed marked size decrease (approx.12x4 cm) and mixed gaseous and fluid content. Note nasocystic tube (thick arrow), thickened adjacent posterior wall of...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    After treatment, the postnecrotic pancreatic collection (*) showed marked size decrease (approx.12x4 cm) and mixed gaseous and fluid content. Note nasocystic tube (thick arrow), thickened adjacent posterior wall of...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Focused coronal (c), sagittal (d) images and maximum-intensity projection (MIP, e) reconstruction showed short, wide metallic stent (thin arrows) and nasocystic tube (thick arrows) through the cystogastrostomy.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Focused coronal (c), sagittal (d) images and maximum-intensity projection (MIP, e) reconstruction showed short, wide metallic stent (thin arrows) and nasocystic tube (thick arrows) through the cystogastrostomy.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    Maximum-intensity projection (MIP) reconstruction showed short, wide metallic stent (thin arrows) through the cystogastrostomy, and nasocystic tube (thick arrows) with distal extermity in the treated collection.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;
     
     
  • Figure 5
    Follow-up contrast-enhanced multidetector CT 1 month after Fig.4
     

    The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;

    The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Drainage; Special Focus: Cysts;
     
     
  • Figure 6
    Repeated endoscopic treatment
     

    The last therapeutic session included repositioning of nasocystic tube (thick arrow in b), and trans-Wirsung drainage. Note pigtail stents (arrows) through the cystogastrostomy.

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Drainage; Special Focus: Cysts;

    The last therapeutic session included repositioning of nasocystic tube (thick arrow in b), and trans-Wirsung drainage. Note pigtail stents (arrows) through the cystogastrostomy.

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Drainage; Special Focus: Cysts;
     
     
Upright (a) and supine (b) radiographs showed a large, ovoid-shaped demarcated opacity (*), centrally located in the upper abdomen. Note metallic clips from previous cholecystectomy, paucity of bowel gas.
 
Upright (a) and supine (b) radiographs showed a large, ovoid-shaped demarcated opacity (*), centrally located in the upper abdomen. Note metallic clips from previous cholecystectomy, paucity of bowel gas.
 
Unenhanced (a,b) images confirmed a large (approx.20x12 cm) fluid-attenuation collection (*) centered in the pancreatic region, with some solid dependent debris (+ in b). Note metallic clips from previous cholecystectomy.
 
Unenhanced (a,b) images confirmed a large (approx.20x12 cm) fluid-attenuation collection (*) centered in the pancreatic region, with some solid dependent debris (+ in b).
 
Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid dependent debris (+ in b). Note metallic clips from previous cholecystectomy.
 
Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid dependent debris (+ in b).
 
Portal-venous phase enhanced images (c...h) confirmed vast, internally nonenhancing pancreatic collection (*), with predominantly fluid attenuation, discernible peripheral wall (arrowheads), a septum and solid dependent debris (+ in b).
 
The vast, internally nonenhancing postnecrotic pancreatic collection (*) exerted mass effect with compression and dislocation of the stomach and splenoportal venous system.
 
Albeit images from previous CT studies were unavailable, residual enhancing pancreatic regions (black arrowheads) were recognisable at the head (g) and tail (h), both compressed by the postnecrotic collection.
 
Albeit images from previous CT studies were unavailable, residual enhancing pancreatic regions (black arrowheads) were recognisable at the head (g) and tail (h), both compressed by the postnecrotic collection.
 
Radiographically the nasocystic drainage tube (thick arrows) and pigtail stents (arrows) are recognised, crossing through the short but wide (16x20mm) transmural metal gastrocystic stent (thin arrow).
 
After treatment, the postnecrotic pancreatic collection (*) showed marked size decrease (approx.12x4 cm) and mixed gaseous and fluid content. Note nasocystic tube (thick arrow), thickened adjacent posterior wall of gastric antrum (+) with submucosal oedema.
 
After treatment, the postnecrotic pancreatic collection (*) showed marked size decrease (approx.12x4 cm) and mixed gaseous and fluid content. Note nasocystic tube (thick arrow), thickened adjacent posterior wall of gastric antrum (+) with submucosal oedema.
 
Focused coronal (c), sagittal (d) images and maximum-intensity projection (MIP, e) reconstruction showed short, wide metallic stent (thin arrows) and nasocystic tube (thick arrows) through the cystogastrostomy.
 
Focused coronal (c), sagittal (d) images and maximum-intensity projection (MIP, e) reconstruction showed short, wide metallic stent (thin arrows) and nasocystic tube (thick arrows) through the cystogastrostomy.
 
Maximum-intensity projection (MIP) reconstruction showed short, wide metallic stent (thin arrows) through the cystogastrostomy, and nasocystic tube (thick arrows) with distal extermity in the treated collection.
 
The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after necrosectomy, best depicted in MIP reconstruction (c).
 
The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after necrosectomy, best depicted in MIP reconstruction (c).
 
The treated postnecrotic pancreatic collection (*) showed mild increase of size and wall thickness, mostly fluid-attenuation content. Note pigtail stents (arrows) positioned through the cystogastrostomy after necrosectomy, best depicted in MIP reconstruction (c).
 
The last therapeutic session included repositioning of nasocystic tube (thick arrow in b), and trans-Wirsung drainage. Note pigtail stents (arrows) through the cystogastrostomy.
 
The last therapeutic session included repositioning of nasocystic tube (thick arrow in b), and trans-Wirsung drainage. Note pigtail stents (arrows) through the cystogastrostomy.
 
 
 
Home Search Sections Teaching Cases History FAQ Case Archives Contact Login Disclaimer Imprint Switch to MOBILE version
View desktop version