0:01

Okay, this is a case of Whipple

0:02

procedure, and we are trying to find

0:04

if there is any recurrence afterwards.

0:06

So, it's a routine surveillance scan.

0:09

So, as we go downwards, we can see here,

0:11

as soon as we reach the gastrohepatic

0:13

ligament, there is some soft tissue

0:16

in this location which should not be.

0:18

And then we see some of the dirtiness

0:20

of the fat in the same region.

0:23

And then, as soon as we reach the

0:26

bifurcation of the celiac trunk here,

0:31

we see some of the haziness of the soft tissue.

0:34

In this region, which has almost

0:36

reached the proximal portion before

0:40

the bifurcation of the celiac trunk.

0:42

So, this appearance

0:43

doesn't look good at all.

0:45

So, this patient has undergone a Whipple

0:47

procedure, and we can see this is the

0:49

remnant or residual pancreas which has

0:52

been anastomosed with the jejunum here.

0:54

So, this is basically a pancreaticojejunostomy

0:58

and as soon as we follow this jejunal

1:00

loop backwards, we can see this has been

1:02

anastomosed here with the hepatic duct.

1:04

So, this is the area of hepaticojejunostomy.

1:07

And as we follow the gastric lumen,

1:10

it has been anastomosed with this loop of the

1:12

jejunum here, that is, gastrojejunostomy.

1:16

This is the classical appearance of the

1:18

Whipple procedure, but we have to be very

1:20

cautious before the recurrence can occur

1:22

at the site of pancreatojejunostomy or

1:26

sometimes at the hepatojejunostomy if this

1:28

was a case of an infiltrative pancreatic

1:30

head tumor involving the lower end of the CBD.

1:32

So, these are the most common locations

1:34

we should be very alert to, because the

1:37

recurrences can occur in these locations.

1:39

In this particular case, the soft tissue

1:42

surrounding this area, surrounding the bifurcation

1:45

of the celiac trunk, they are not looking good.

1:47

So, let's go on the coronal

1:49

and see how it looks there.

1:52

So, if we follow the celiac trunk here,

1:54

we can see this soft tissue is actually

1:56

surrounding the entire undersurface.

1:58

It is encased, the undersurface,

2:01

so it is more than 180 degrees here.

2:03

So, going backwards.

2:04

It is actually encasing the

2:06

common hepatic artery as well.

2:07

So, this is the origin of

2:08

the common hepatic artery.

2:10

We see a lot of soft tissue here.

2:12

And that goes almost to the porta

2:14

hepatis, or the area where the jejunum

2:16

has been anastomosed to the porta hepatis.

2:20

And then we see the hepatojejunostomy,

2:22

which looks very clean, but there is

2:24

some dirtiness along the medial

2:25

aspect of the hepatojejunostomy as well.

2:28

But though that area looks slightly different

2:31

and away from the area we are seeing surrounding

2:34

the vessels or the site of pancreatojejunostomy.

2:39

So, we have high suspicion here that

2:41

tumor has recurred in the location where

2:43

the anastomosis has been performed in

2:45

the, between the pancreas and the jejunum.

2:48

And then this area looks relatively

2:51

clean, but there is some haziness in

2:52

the, uh, surrounding area of porta hepatis.

2:56

So before we move further, I will open high B

2:59

value DWI and see how it looks on high B value.

3:04

So going here we see like very low.

3:09

Hyperintensity in that area.

3:12

This is the pancreas coming backwards here.

3:15

So, overall the intensity is not

3:16

very striking on high B value DWI.

3:21

And let us quickly correlate with the ADC.

3:24

On ADC, it does not look

3:25

like very striking as well.

3:27

So now the question is basically is it really

3:29

recurrence or it is just scar tissue formed there.

3:32

But remember, scar tissue

3:34

will never cause encasement.

3:36

We have seen encasement in this particular case.

3:38

So that makes it suspicious

3:40

irrespectively, whether it is seen

3:42

on a DWI or ADC, or high B value or not.

3:46

So on pre-contrast, T1, we can find soft

3:50

tissue is still there, but it doesn't show

3:52

any different intensity compared to the

3:53

parenchyma or other tissues in the surrounding.

3:56

And then we see some high

3:58

T1-weighted intensities in the renal

4:01

cortex, which is basically some pious

4:03

or hemorrhagic cyst in the kidney.

4:06

So let's open the arterial

4:08

phase and see how it looks.

4:11

So same appearance here.

4:12

So the point here is, like, despite it did

4:14

not show any significant intensity on the

4:17

DWI or ADC, we see that this, this lesion

4:20

or whatever soft tissue we are seeing,

4:22

it is causing significant compromise of

4:25

the caliber of the common hepatic artery.

4:29

And the outline of this artery

4:31

looks very fuzzy and irregular.

4:34

And that is not a good sign,

4:35

because scarring will never do this.

4:37

Thank you.

4:38

And that soft tissue actually reaches to the

4:40

bifurcation as we saw earlier, almost to the

4:43

area where the splenic artery is arising.

4:47

And let's see how it looks on the venous phase.

4:50

So intensity overall did not change much.

4:52

If it is scar, it should enhance

4:54

more in the delayed phase.

4:55

So if we compare here with this area and

4:59

the fuzziness in the outline of the common

5:00

hepatic artery and no significant enhancement

5:03

in the delayed phase, keep the diagnosis

5:06

that's possibly going to be recurrence

5:09

in the area where it has been resected.

5:11

So recurrence in the

5:16

And we do not see any suspicious

5:17

lesion in the liver or spleen.

5:21

Just to make sure that we are not missing

5:22

anything else, I will go back to coronal

5:25

T2 and look everything very carefully

5:27

to find if we missed anything else.