How To Treat Postoperative Complications Of Pelvic Surgery

Transcription

1 CT Findings of Postoperative Complications Following Pelvic Surgery Poster No.: C-1151 Congress: ECR 2013 Type: Educational Exhibit Authors: Y. H. Lee, E. J. Kang, D. M. Kang, K.-H. Yoon; Iksan/KR Keywords: CT, Pelvis, Abdomen, Surgery, Abscess, Fistula, Hemorrhage DOI: /ecr2013/C-1151 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 27

2 Learning objectives 1. To review the postoperative complications following pelvic surgery, according to various surgical techniques. 2. To illustrate the CT findings of various postoperative complications in abdominopelvic cavity. Background Surgical resection remains the treatment of choice in many malignant diseases of pelvic organs, such as uterus, ovary, ureter, bladder and rectum. The most common pelvic surgery is the cesarian section and second most common surgery is the hysterectomy. The other common surgery is the prostatectomy, cystectomy and lower anterior resection of the rectum. To treat oncologic diseases of pelvis, nowadays, various surgical techniques are performed such as laparotomy, laparoscopy, robot-assisted surgery, endorectal and transurethral surgery, which may lead to various complications in abdominopelvic cavity. Postsurgical complications may occur within a few days or weeks of surgery, or they may not occur for several months or even years. Multidetector computed tomography (MDCT) is the modality of choice for pre- and postoperative evaluation of various abdominopelvic diseases. The advantages of MDCT are shorter acquisition times, creation of thin sections on a routine basis in a singlebreathhold, retrospective calculation of thinner or thicker sections from the same raw data, and multiplanar planar image acquisition. Imaging findings OR Procedure details The early postoperative complications of pelvic surgery are surgical site infection, anastomotic leakage, obstructive ileus, hematoma, abscess, urinary tract injury,omental infarction, venous thrombosis, bowel ischemia, and acute subpritoneal fluid retension. Late postoperative complications are fistula formation, urinoma, lymphocele, pritoneal inclusion cyst, and endometriosis of abdominal wall. 1. Surgical Site Infection (Fig.1) Most frequent postoperative surgical complications Incidence : 2-25% Page 2 of 27

3 # Subcutaneous fat hazziess # Multiloculated cystic lesion with enhanced wall # abscess 2. Anastomosis Site Leakage (Fig.2) Incidence: 2.9%~15.3% Mortality : 1/3 after colorectal surgery is attributed to leaks # loculated fluid collections with air-fluid levels # extravasation of oral contrast materials 3. Subperitoneal Fluid Collection during Transurethral Surgery (Fig.3-5) Transurethral prostatectomy Transurethral resection of bladder tumor # Fluid infiltration and retension in pelvic extraperitoneal space (pre-, or paravesical space) and retroperitoneal space. 4. Bowel Obstruction (Fig.6) Small bowel obstruction is more common than large bowel obstruction. # can assess the severity of obstruction # dilated loops of small bowel proximal to the obstruction, predominantly central dilated loops # multiple air-fluid levels with different heights. 5. Hemorrhage and Hematoma (Fig.7) Page 3 of 27

4 Most common complication following gynecologic surgery # Acute hematoma: higher CT attenuated fluid collection # Active bleeding: active extravasation of contrast materials from the vessels. 6. Infection and Abscess (Fig.8) Infection and abscess formation can be a sequelae of hematoma or secondary to visceral injury of the bowel, ureter, or bladder # thick walled fluid density pelvic masses. # large amount of air: communication with the gastrointestinal tract 7. Bowel Perforation (Fig.9) Small bowel and the rectosigmoid colon are at risk for injury High incidence with adhesions from previous surgery, radiation therapy, PID, or endometriosis Most important complications of urologic surgery because it is potentially life threatening # loculated fluid collections with air-fluid levels # extravasation of oral contrast material 8. Urinary Tract Injury (Fig.10-11) Bladder laceration : most common injury Ureteral laceration: higher following radical hysterectomy with lymph node dissection # hydronephrosis due to ureteral obstruction Page 4 of 27

5 # extraluminal contrast materials leakage 9. Omental Infarction (Fig.12) Most cases of omental infarction are idiopathic, a small fraction # Triangular or oval area of heterogeneous fat attenuation, # Mass formation in the right middle or lower abdomen, in deep to the ventral abdominal wall, in anterior to the transverse colon, in anteromedial to the ascending colon. 10. Venous Thrombosis (Fig.13) Uncommon following laparoscopic surgery because of earlier mobilization, venous thrombosis and pulmonary embolism do occur following laparoscopic pelvic surgery # Focal filling defect in veins # Acute thrombus; increased venous diameter # Chronic thrombus: decreased venous diameter 11. Bowel Ischemia (Fig.14) Rare complication in pelvic surgery # bowel wall swelling and decreased enhancement # dilatation of bowels # gas in intestinal wall 12. Fistula (Fig.15-16) Page 5 of 27

6 Fistulous connections - vesicovaginal, rectovaginal (m/c), enterocutaneous, enterovesical, enteroenteral, enterovaginal, ureterovaginal # Tubular structure between uterus and other organ # Contrast material filled in vagina # Gas within the lumen of the bladder 13. Lymphocele (Fig.17-18) Frequently in resection of a large amount of lymphatic tissue Most lymphoceles are asymptomatic and resolve spontaneously without intervention # multiloculated cystic masses with thin septa 14. Peritoneal Inclusion Cyst (Fig.19) Occur in premenopausal women with a history of pelvic or abdominal surgery, trauma, PID, endometriosis Failure of the abnormal peritoneum to absorb fluid from the functioning ovaries # uni- or multiloculated cystic adnexal mass # ovary located either in the center or at the periphery 15. Abdominal Wall Endometriosis (Fig.20) More common following C/sec than after hysterectomy (less than 1%) Most common site of extrapelvic endometriosis is the abdominal wall # irregular structure and surface of the lesion Page 6 of 27

7 # homogenous and well enhancement of the mass in abdominal wall Images for this section: Fig. 1: 57-year-old male patient with prostate cancer. Robot assisted radical prostectomy were performed. Axial contrast-enhanced CT scan shows subcutaneous fat hazziness and abscess formation in lower anterior abdominal wall. Page 7 of 27

8 Fig. 2: 42-year-old man with rectal cancer and transverse colon cancer, total colectomy state. Axial contrast-enhanced CT scan shows multiple air bubble and fluid collection in anastomosis site, and large amount of air collection in pelvic cavity. Page 8 of 27

9 Fig. 3: 69-year-old man with prostate cancer, transurethral resection of prostate was done. Axial contrast-enhanced CT scan shows diffuse retroperitoneal fluid collection (a), and subperitoneal fluid collection (b) due to contrast leakage from bladder (c). Page 9 of 27

12 Fig. 6: 45-year-old female with uterine leiomyoma, partial mass excsion state. Axial contrast enhanced CT(a) shows distended large and small bowels loop, (b) show luminal narrowing of sigmoid colon (arrow). Page 12 of 27

13 Fig. 7: 47-year-old female with uterine myoma. Laparoscopy assisted hysterectomy was performed. Axial non-contrast CT scan shows heterogenous high attenuated fluid collection (arrows) in pelvic cavity. Page 13 of 27

14 Fig. 8: 70-year-old female with cervical cancer. Radical hysterectomy was performed. Axial contrast-enhanced CT scan shows low density fluid collection with enhancing thick wall (arrow) in pelvic cavity. Page 14 of 27

15 Fig. 9: 49-year-old man with bladder cancer. Cystectomy with neobladder reconstruction was performed. Axial contrast-enhanced CT scans show free air (arrowhead) and multfocal fluid collection with bowel wall thickening (arrow), in surgery small bowel perforation is detected. Page 15 of 27

16 Fig. 10: 52-year-old female with uterine adenocarcinoma. Laparoscopic assisted hysterctomy with BSO was performed. Portal phase image (a) shows fluid collection with peritoneal thickening, and delayed phase image (b) shows enhancement of pelvic fluid. suggested urine leakage and urinoma. Page 16 of 27

17 Fig. 11: 42-year-old female with cervical cancer. Robot assisted radical hysterectomy Axial contrast-enhanced CT scan shows contrast leakage to vagina due to lower ureter injury. Page 17 of 27

18 Fig. 12: 61-year-old woman with endometrial cancer. Robot assisted radical hysterectomy state. Axial contrast-enhanced CT scan shows Small non-enhancing nodular lesion (arrow) in left ovarian fossa, suggested focal omental infarction. Page 18 of 27

19 Fig. 13: 57-year-old mas with prostate cancer. Laparoscopic assisted radical prostatectomy was performed. Axial (a) and coronal (b) contrast-enhanced CT scan shows mild dilatated external iliac vein with focal filling defect (arrow. Page 19 of 27

20 Fig. 14: 42-year-old man with rectal cancer. Lower anterior resection state. Axial contrastenhanced CT scan shows decreased bowel wall enhancement of distal sigmoid colon (arrows) and sigmoid colon. Page 20 of 27

21 Fig. 15: 60-year-old man with rectal cancer. Robot assisted lower anterior resection state. Axial contrast-enhanced CT scan shows fistula between rectum and seminal vesicle with focal rectal wall defect (arrow) and abscess formation in perirectal space. Page 21 of 27

22 Fig. 16: 57-year-old man with bladder cancer, radical cystectomy state. Axial contrast-enhanced CT scan shows contrast leakage to colon and rectum, suggested ureteroenteric fistula. Page 22 of 27

23 Fig. 17: 37-year-old female with cervical cancer, radical hysterectomy state. Axial contrast-enhanced CT scan shows multiloculated fluid collection in left pelvic side wall. Page 23 of 27

24 Fig. 18: 64-year-old man with prostate cancer. Robot-assisted laparoscopic radical prostatectomy state. T2 weighted coronal image scan shows large cysic mass connecting to surgical field in right paravesical space. Fig. 19: 34-year-old woman with cystic pelvic mass after laparoscopic assisted subtotal hysterectomy. Endovaginal ultrasound and axial contrast-enhanced CT scan show large well defined cystic lesion confined in pelvic peritoneal space. Left ovary is located in the cystic lesion. Page 24 of 27

25 Fig. 20: 40-year-old female with palpable mass at lower abdominal wall. Previous cesarian section was done. Axial contrast-enhanced CT scan shows endometrosis (arrow) of right rectus muscle. Page 25 of 27

26 Conclusion MDCT is useful for evaluation of various early and delayed complications following pelvic surgery. We reviewed the CT finding of early complication (surgical site infection, anastomotic leakage, obstructive ileus, Hematoma, abscess, urinary tract injury, omental infarction, venous thrombosis, Bowel ischemia) and late complication (fistula, lymphocele, pelvic inclusion cyst, endometriosis of abdominal wall). The radiologist should be familiar with the various CT findings of post-operative complications after pelvic surgery for prevention and proper management of the severe complications. References 1. Paspulati RM, Dalal TA. Imaging of complications following gynecologic surgery. RadioGraphics 2010; 30: Eo H, Choi HJ, Kim SH, Jung SI, Park BK, Kim SH. Differentiation of Tuboovarian Abscess from Endometriosis: CT Indicators. J Korean Radiol Soc 2005;53: Kosugi C, Saito N, Kimata Y, Ono M, Sugito M, Ito M, et al. Rectovaginal fistulas after rectal cancer surgery: Incidence and operative repair by gluteal-fold flap repair. Surgery 2005 Mar;137(3): Li TC, Saravelos H, Richmond M, Cooke ID. Complications of laparoscopic pelvic surgery: recognition, management and prevention. Hum Reprod Update 1997 SepOct;3(5): Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg 2010; 4:5 6. Preidler KW, Steiner H, Sternthal HM, Primus G, Szolar D, Kern R. CT and ultrasonographic findings in a patient with endometriosis of the bladder after cesarean section. Eur. Radiol. 4, (1994) Page 26 of 27

27 7. Hammerstingl RM, Vogl TJ. Abdominal MDCT: protocols and contrast considerations. Eur Radiol 2005; Suppl 5: E78-E90 Personal Information Page 27 of 27