PMC9276918_01
Preoperative imaging findings. (A) Phase III dynamic enhanced abdominal CT: Arrow 1 shows an intragallbladder hematoma, arrow 2 shows an intraduodenal hematoma, arrow 3 shows dilation of the main pancreatic duct, arrow 4 shows uneven enhancement of the head of the pancreas, suggestive of pancreatitis, and arrow 5 shows a retroperitoneal hematoma. (B) Phase III dynamic contrast-enhanced abdominal CT: Arrow 1 shows an intraintestinal hematoma, arrow 2 shows a retroperitoneal hematoma. (C) Abdominal MRI: Arrow 1 shows an intraduodenal hematoma, arrow 2 shows normal pancreatic tissue, and arrow 3 shows a retroperitoneal hematoma. (D) Abdominal MRI: This image shows a fully distended pancreatic duct.
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F1
The hematoma located in the duodenal intestinal canal, so the possibility of intestinal rupture was considered (Figures 1A,B). Dynamic hepatic MRI examination showed the formation of a very large retroperitoneal hematoma (acute-subacute stage), with adhesions to the pancreatic head and duodenum, unclear decomposability, and hematoceles in the bilateral paracolic sulcus (Figures 1C,D).
Results of previous imaging examinations at another hospital (A) (enhanced abdominal CT): Arrow 1 shows an enlarged gallbladder, arrow 2 shows patchy enhancement of the pancreatic head, and arrow 3 shows a significantly dilated main pancreatic duct. (B) Enhanced abdominal CT: Arrow 1 shows an enlarged gallbladder, arrow 2 shows patchy enhancement of the pancreatic head, suggestive of pancreatitis, and arrow 3 shows a rounded, low-density shadow of the pancreatic head, considered a pseudocyst. (C) Abdominal MRI: Arrow 1 shows a dilated common bile duct, arrow 2 shows an enlarged gallbladder, arrow 3 shows a pseudocyst of the pancreatic head, and arrow 4 shows full dilation of the main pancreatic duct. (D) Abdominal MRCP: Arrow 1 shows a dilated intrahepatic bile duct, arrow 2 shows an enlarged gallbladder, arrow 3 shows a dilated common bile duct, arrow 4 shows a pseudocyst of the pancreatic head, and arrow 5 shows a fully dilated main pancreaticduct.
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F2
A diagnosis of chronic pancreatitis with WON, dilatation of intrahepatic and extrahepatic bile ducts, and dilatation of the main pancreatic duct (Figures 2A-D) was made.
Intraoperative images. (A, B) A small amount of uncoagulated blood observed in the abdominal cavity after creating an incision in the peritoneum incision. (C) Hematocele below the hepatic margin observed during intraoperative exploration. (D) A dark blood clot in the posterior peritoneum of the duodenum.
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F3
Intraoperative exploration revealed intraabdominal bleeding (Figures 3A,B), serious abdominal adhesions, and a hematoma with a size and location in agreement with those observed on preoperative imaging. In the process of separating the adhesions after observing the very large retroperitoneal hematoma (Figure 3D) and removing a large number of blood clots, the outline of the pancreas became clear, and pancreatic duct expansion, with stones in the main pancreatic duct, and visible peripancreatic leakage were observed, as well as a pseudocyst of the head of pancreas that was closely related to the hematoma.
Postoperative histopathology results. (A) Arrow 1 shows the capsule of the cyst wall, arrow 2 indicates staining for the secretory protein from the cystic cavity and pancreatic juice, indicating organization, arrow 3 indicates a normal pancreatic gland structure, and arrow 4 indicates a normal residual epithelioid structure in the process of epithelial shedding (40x magnification). (B) Arrow 1 shows a normal residual epithelioid structure, arrow 2 shows epithelial detachment of the pancreas, arrow 3 shows the cystic cavity and its secreted proteins, pancreatic fluid and other tissues, arrow 4 shows a normal pancreatic duct structure, and arrow 5 shows a normal pancreatic gland structure (100x magnification).
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F4
Postoperative frozen pathology indicated atrophy of pancreatic glands, cord-like and slab-like proliferation of pancreatic islet cells, a small amount of residual epithelium in the cyst wall, hyperemia and edema under the pancreatic capsule, and infiltration of a large number of neutrophils, which are consistent with the diagnosis (Figures 4A,B).
Postoperative CT results. (A) Plain CT scan of the whole abdomen on the 3rd postoperative day. The arrow shows the pancreaticojejunostomy. (B) Full abdominal CT reexamination on day 3 postoperatively. The arrow showed the pancreaticojejunostomy. (C) Full abdominal CT reexamination on day postoperatively showing the entire pancreaticoduodenectomy area. (D) Plain CT scan of the whole abdomen on day 11 postoperatively. Arrow 1 shows the biliary and intestinal anastomosis, arrow 2 shows the indwelling open-field decompression tube intraoperatively, arrow 3 shows the pancreaticojejunostomy, and arrow 4 shows the indwelling three-cavity irrigation and drainage tube intraoperatively. (E) Plain CT scan of the whole abdomen 1 month after surgery showing no obvious abnormalities. (F) Plain CT scan of the whole abdomen 3 months after surgery indicating good recovery.
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F5
On the 3rd day after surgery, plain CT of the abdomen and pelvis showed multiple areas of exudation in the pelvic, a small protohematoma, and increased area of effusion around the liver and bilateral paracolic sulcus (Figures 5A,B). Reexamination of the abdomen and pelvic cavity by CT 11 days after surgery showed multiple areas of exudation around the duodenum compared with the previous scan, and the abdominal hematoma was smaller and less dense than before (Figure 5D). The results of regular follow-up and relevant examinations showed that the patient recovered well after surgery (Figures 5E,F), with a normal sleep and defecation.