Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy. Ann Surg. 2012;256:139-145. [PMID: 22609844 DOI: 10.1097/sla.0b013e318256c32c]

Preoperative body composition measured by bioelectrical impedance analysis can predict pancreatic fistula after pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) remains one of the most severe complications after pancreatic surgery. The methods for predicting pancreatic fistula are limited. We aimed to investigate the predictive value of body composition parameters measured by preoperative bioelectrical impedance analysis (BIA) on the development of POPF.

METHODS

A total of 168 consecutive patients undergoing pancreatic surgery from March 2022 to December 2022 at our institution were included in the study and randomly assigned at a 3:2 ratio to the training group and the validation group. All data, including previously reported risk factors for POPF and parameters measured by BIA, were collected. Risk factors were analyzed by univariable and multivariable logistic regression analysis. A prediction model was established to predict the development of POPF based on these parameters.

RESULTS

POPF occurred in 41 of 168 (24.4%) patients. In the training group of 101 enrolled patients, visceral fat area (VFA) (odds ratio [OR] = 1.077, P = 0.001) and fat mass index (FMI) (OR = 0.628, P = 0.027) were found to be independently associated with POPF according to multivariable analysis. A prediction model including VFA and FMI was established to predict the development of POPF with an area under the receiver operating characteristic curve (AUC) of 0.753. The efficacy of the prediction model was also confirmed in the internal validation group (AUC 0.785, 95% CI 0.659-0.911).

CONCLUSIONS

Preoperative assessment of body fat distribution by BIA can predict the risk of POPF after pancreatic surgery.

The safety and efficacy of stapler method for transection of the pancreatic parenchyma during pancreatoduodenectomy (STRAP-PD trial): study protocol for a randomized control trial

BACKGROUND

Pancreaticoduodenectomy is a highly difficult and invasive type of gastrointestinal surgery. Prevention of postoperative pancreatic fistula is important, and this may be possible by the stapler method.

METHODS

STRAP-PD is a single center randomized controlled trial. We compare a method of transecting the pancreatic parenchyma in pancreaticoduodenectomy using a surgical stapler device with a conventional transecting method using energy devices (e.g., scalpel, ultrasonic coagulator and incision devices). Patients with soft pancreas who are scheduled to undergo pancreaticoduodenectomy are randomized to arm A (conventional method) or arm B (stapler method). We aim to examine the safety and usefulness of dissection by the automatic suture device, with attention to the rate of pancreatic fistula ISGPF grade B or C and to postoperative complications. This is a single-center randomized study, which began in September 2023 at Wakayama Medical University Hospital.

DISCUSSION

Pancreatic parenchymal transection is typically performed either by direct incision using a scalpel or by employing energy devices such as ultrasonic coagulating cutting devices during pancreaticoduodenectomy. In a prospective pilot study, we conducted pancreatic parenchymal transection in 20 consecutive normal pancreatic cases during pancreaticoduodenectomy, observing postoperative pancreatic fistula grade B in one case (5%). Traditional methods involving scalpel incision or the use of ultrasonic coagulating cutting devices have been historically favored but perceived as technically challenging, and they have been reliant upon the surgeon's skill. Notably, relatively high incidences of postoperative pancreatic fistula among patients with soft pancreas have also been observed. Our proposed stapler method may therefore be a useful method responsible for reducing the development of pancreatic fistula. This method would be as part of minimally-invasive surgery for pancreaticoduodenectomy. It uses an endoscopic linear stapler to cut the pancreatic parenchyma, so it is likely to be more convenient than conventional methods and can be used universally. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry, UMIN000052089. the Registration Date on 1st September 2023.

Severity of hyperechoic pancreas on preoperative ultrasonography: high potential as a clinically useful predictor of a postoperative pancreatic fistula

PURPOSE

This study aimed to evaluate the effectiveness of using the severity of hyperechoic pancreas (HP) observed on preoperative ultrasonography (US) as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF).

METHODS

A retrospective study was conducted with 94 patients who underwent pancreatectomy between April 2006 and March 2021. The severity of HP on US was classified into two categories (normal to mild vs. moderate to severe [obvious HP]). Multiple preoperative and intraoperative parameters were analyzed to predict CR-POPF.

RESULTS

Out of the 94 patients, CR-POPF occurred in 21 (22%) patients, and obvious HP was observed in 30 (32%). Univariate analysis revealed that moderate to severe HP (obvious HP) was significantly associated with an increased incidence of CR-POPF (P<0.001). Factors such as the absence of pancreatitis, a small main pancreatic duct (<3 mm), intraoperative soft pancreas, increased body mass index, and lower pancreatic attenuation and attenuation index were also associated with CR-POPF (all P<0.05). Multivariate analysis showed that obvious HP and soft pancreatic texture were independent predictors of CR-POPF, with odds ratios of 11.53 (P=0.001) and 14.12 (P=0.003), respectively. The combination of obvious HP and soft pancreatic texture provided the most accurate prediction for CR-POPF.

CONCLUSION

The severity of HP, as observed on preoperative US, was significantly associated with CR-POPF. Severe HP may serve as a clinically useful predictor of POPF, especially when evaluated alongside the intraoperative pancreatic texture.

Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk.

METHODS

Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139).

RESULTS

We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF.

CONCLUSION

Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.

Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score

BACKGROUND

High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications.

METHODS

A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents.

RESULTS

Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01).

CONCLUSION

A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy

OBJECTIVE

Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF).

METHODS

Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C).

RESULTS

A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008).

CONCLUSIONS

Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.

Body composition analysis using convolutional neural network in predicting postoperative pancreatic fistula and survival after pancreatoduodenectomy for pancreatic cancer

PURPOSE

To evaluate whether body composition measurements acquired using convolutional neural networks (CNNs) from preoperative CT images could predict postoperative pancreatic fistula (POPF) and overall survival (OS) after pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

257 patients (160 men; median age [interquartile range], 67 [60-74]) who underwent pancreaticoduodenectomy for PDAC between January 2013 and December 2017 were included in this retrospective study. Body composition measurements were based on a CNN trained to segment CT images into skeletal muscle area, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Skeletal muscle area, VAT, and SAT were normalized to height square and labeled as skeletal muscle, VAT, and SAT indices, respectively. The independent risk factors for clinically relevant POPF (grade B or C) were determined using a multivariate logistic regression model, and prognostic factors for OS were assessed using Cox proportional hazards regression analyses.

RESULTS

After pancreatioduodenectomy, 27 patients developed POPF grade B or C (10.5 %, 27/257). The VAT index (odds ratio [OR] = 7.43, p < 0.001) was the only independent prognostic factor for POPF grade B or C. During the median follow-up period of 23 months, 205 (79.8 % [205/257]) patients died. For prediction of OS, skeletal muscle index (hazard ratio [HR] = 0.58, p = 0.018) was a significant factor, along with vascular invasion (HR = 1.85, p < 0.001) and neoadjuvant therapy (HR = 0.58, p = 0.011).

CONCLUSIONS

A high VAT index and a low skeletal muscle index can be utilized in predicting the occurrence of POPF grade B or C and poor OS, respectively.

The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study

The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p < 0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.

Pancreatic Ductal Adenocarcinoma: Update of CT-Based Radiomics Applications in the Pre-Surgical Prediction of the Risk of Post-Operative Fistula, Resectability Status and Prognosis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors.

METHODS

The PubMed database was searched for papers published in the English language no earlier than January 2018.

RESULTS

We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective.

CONCLUSIONS

It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.

Development of a Nomogram to Predict Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy on the Basis of Visceral Fat Area and Magnetic Resonance Imaging

BACKGROUND

The aim of this study was to develop a nomogram to predict the risk of developing clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) using preoperative clinical and imaging data.

METHODS

The data of 205 patients were retrospectively analyzed, randomly divided into training (n = 125) and testing groups (n = 80). The patients' preoperative laboratory indicators, preoperative clinical baseline data, and preoperative imaging data [enhanced computed tomography (CT), enhanced magnetic resonance imaging (MRI)] were collected. Univariate analyses combined with multivariate logistic regression were used to identify the independent risk factors for CR-POPF. These factors were used to train and validate the model and to develop the risk nomogram. The area under the curve (AUC) was used to measure the predictive ability of the models. The integrated discrimination improvement index (IDI) and decision curve analysis (DCA) were used to assess the clinical feasibility of the nomogram in relation to five other models established in literature.

RESULTS

CT visceral fat area (P = 0.014), the pancreatic spleen signal ratio on T1 fat-suppressed MRI sequences (P < 0.001), and CT main pancreatic duct diameter (P = 0.001) were identified as independent prognostic factors and used to develop the model. The final nomogram achieved an AUC of 0.903. The IDI and DCA showed that the nomogram outperformed the other five CR-POPF models in the training and testing cohorts.

CONCLUSION

The nomogram achieved a superior predictive ability for CR-POPF following PD than other models described in literature. Clinicians can use this simple model to optimize perioperative planning according to the patient's risk of developing CR-POPF.

A novel prediction model of pancreatic fistula after pancreaticoduodenectomy using only preoperative markers

BACKGROUND

Since clinically relevant postoperative pancreatic fistula (CR-POPF) can cause intra-abdominal hemorrhage and abscesses, leading to surgery-related deaths after pancreaticoduodenectomy (PD), its preoperative prediction is important to develop strategies for surgical procedures and perioperative management. This study aimed to establish a novel prediction model for CR-POPF using preoperative markers.

METHODS

On a training set of 180 patients who underwent PD at the Yamaguchi University Hospital, a combination of CR-POPF predictors were explored using the leave-one-out method with a unique discrete Bayes classifier. This predictive model was confirmed using a validation set of 366 patients who underwent PD at the Osaka University Hospital.

RESULTS

In the training set, CR-POPF occurred in 60 (33%)　of 180 patients and 130 (36%)　of 366 patients in the validation set using selected markers. In patients with pancreatic ductal adenocarcinoma (PDAC), the main pancreatic duct (MPD) index showed the highest prognostic performance and could differentiate CR-POPF with 87% sensitivity and 81% specificity among 84 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index-based model for 130 PDAC samples were 93% and 87%, respectively. In patients with non-PDAC, the MPD index/body mass index (BMI) combination showed the highest prognostic performance and could differentiate CR-POPF with 84% sensitivity and 57% specificity among 96 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index/BMI-based model for 236 non-PDAC samples were 85% and 53%, respectively.

CONCLUSION

We developed a novel prediction model for pancreatic fistulas after PD using only preoperative markers. The MPD index and MPD index/BMI combination will be useful for CR-POPF assessment in PDAC and non-PDAC samples, respectively.

Fatty pancreas was associated with a higher acute pancreatitis Systemic Inflammatory Response Syndrome score at hospital admission

BACKGROUND

Pancreatic fat infiltration was shown to be linked with acute pancreatitis and probably its severity. These interesting findings merit more investigation to elucidate the effect of fatty pancreas on acute pancreatitis severity.

METHODS

We performed a retrospective study of patients hospitalized with documented acute pancreatitis. Pancreatic fat was determined according to pancreas attenuation on computed tomography. Patients were divided into two groups, with and without fatty pancreas. The Systemic Inflammatory Response Syndrome (SIRS) score was compared.

RESULTS

Overall, 409 patients were hospitalized with acute pancreatitis. Among them, 48 patients had fatty pancreas (group A), vs. 361 patients who did not (group B). The mean ± SD age in group A was 54.6 ± 21.3, vs. 57.6 ± 16.8 in group B ( P  = 0.51). Patients in group A, had a significantly higher rate of fatty liver, as compared to group B (85.4% vs. 35.5%, P  < 0.001). There was no significant difference in the medical history among the two groups. Fatty pancreas was associated with more severe acute pancreatitis as assessed by SIRS score at admission. The mean ± SD of SIRS score was significantly higher in group A (0.92 ± 0.87), as compared to 0.59 ± 0.74 in group B ( P  = 0.009). Positive SIRS score was present in a significantly higher proportion of patients with fatty pancreas (25%), as compared to only 11.4% in group B ( P  = 0.02).

CONCLUSION

The occurrence of acute pancreatitis with higher SIRS score was significantly associated with fatty pancreas. Fatty pancreas may represent a predictor of acute pancreatitis severity.

Radiological parameters to predict pancreatic texture: Current evidence and future perspectives

Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management, thereby minimizing postoperative morbidity. Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease. However, radiological evaluation of pancreatic texture, an important determinant of pancreatic fistula, has not been widely used to predict the risk of postoperative pancreatic fistula. Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture. Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies. With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies, elastography is emerging as a promising tool for predicting pancreatic texture. Also, recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function. Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis, facilitating early intervention. The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences. However, multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.

Automated whole-volume measurement of CT fat fraction of the pancreas: correlation with Dixon MR imaging

OBJECTIVES

This study aimed to assess the feasibility of pancreatic steatosis quantification by automated whole-volume measurement of the fat fraction of the pancreas on CT in comparison to MRI using proton-density fat fraction (PDFF) techniques.

METHODS

Fifty-nine patients who underwent both CT and MRI were analyzed. Automated whole-volume measurement of pancreatic fat on unenhanced CT was performed by a histogram analysis with local thresholding. Three sets of CT fat volume fraction (FVF) (%) values with thresholds of -30 Hounsfield unit (HU), -20 HU and -10 HU were compared to MR-FVF (%) values measured on a PDFF map.

RESULTS

The median -30 HU CT-FVF, -20 HU CT-FVF, -10 HU CT-FVF and MR-FVF values of the pancreas were 8.6% (interquartile range (IQR), 11.3), 10.5% (IQR, 13.2), 13.4% (IQR, 16.1) and 10.9% (IQR, 9.7), respectively. The -30 HU CT-FVF (%), -20 HU CT-FVF (%) and -10 HU CT-FVF (%) of the pancreas showed a significant positive correlation with the MR-FVF (%) of the pancreas (ρ = 0.898, p < 0.001, ρ = 0.905, p < 0.001, ρ = 0.909, p < 0.001, respectively). The -20 HU CT-FVF (%) displayed reasonable agreement with the MR-FVF (%) with a low absolute fixed bias (mean difference, 0.32%; limit of agreement from -10.1 to 10.7%).

CONCLUSION

The automated whole-volume measurement of the CT fat fraction of the pancreas using the threshold CT attenuation value of -20 HU may be a feasible, non-invasive, and convenient technique for quantifying pancreatic steatosis.

ADVANCES IN KNOWLEDGE

CT-FVF value of the pancreas had a positive correlation with the MR-FVF value. The -20 HU CT-FVF may be a convenient technique for quantifying pancreatic steatosis.

External pancreatic ductal stenting in minimally invasive pancreatoduodenectomy: How to do it?

It has been shown that external pancreatic ductal stenting (EPDS) can reduce the incidence of clinically relevant postoperative pancreatic fistula. Although studies have described EPDS in open pancreaticoduodenectomy (PD), EPDS in minimally invasive PD has not been reported yet. Thus, the objective of this study was to describe the technique of EPDS in minimally invasive PD. The procedure was performed either laparoscopically or using a robot. Once PD was completed, key steps included triple enterotomy, threading of silk-suture through all enterotomies and exteriorization, completing posterior layer of pancreaticojejunostomy (PJ), railroading stent through preplaced silk-suture, intubation of stent into the pancreatic duct, completion of PJ, followed by hepaticojejunostomy and parietalization of jejunum at the stent exit site. EPDS in PD through a minimally invasive approach can be performed safely in selected cases with either a small-sized pancreatic duct or a soft pancreas.

Visceral Obesity as a Predictor of Postoperative Complications After Pancreaticoduodenectomy

INTRODUCTION

Obesity is associated with increased morbidity and mortality post surgery. The measurement of visceral obesity can predict postoperative outcomes after pancreaticoduodenectomy.

METHODS

This is a prospective observational study. Visceral obesity was calculated by measuring the fat thickness in the retro-renal area by using a computed tomography scan. Visceral obesity was defined as retro-renal fat thickness (RRFT) of ≥ 2 cm. Patients were divided into two groups: Group-A (RRFT < 2 cm, non-obese) and Group-B (RRFT > 2 cm, obese). Demographic, clinical, and intraoperative variables were correlated with postoperative outcomes.

RESULTS

Fifty-six patients were included in the study. Thirty-two patients were included in Group-A, and 24 patients were included in Group-B. The two groups had comparable outcomes. A total of 21 patients in Group-A (65.62%) and 17 patients in Group-B (70.83%) had comorbidities, including diabetes mellitus, hypertension, and coronary disease (p=0.680). American Society of Anesthesiologists (ASA) grading was comparable (p=0.927). BMI was also comparable (p=0.354). Type of pancreaticoduodenectomy, pancreatic texture, pancreatic duct diameter, and technique of pancreaticojejunostomy anastomosis were comparable. The mean operative time was longer in Group-B (362 ± 36.2 min vs. 298 ± 45.2 min) (p=0.001). Intraoperative blood loss was more in Group-B (312 ± 36.8 ml vs. 267 ± 23.7 ml) (p=0.001). The rates of postoperative pancreatic fistula and delayed gastric emptying were comparable (p=0.402 and p=0.134, respectively). The length of hospital stay was longer in patients in Group-B (p=0.004). There was one death in Group-B (obese group).

CONCLUSION

Visceral obesity is a risk factor for postoperative complications after a pancreaticoduodenectomy.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF.

METHODS

We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF.

RESULTS

In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group.

CONCLUSION

Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

BACKGROUND

No studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ).

METHODS

The medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF.

RESULTS

Of 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas.

CONCLUSIONS

Pancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.

A new fistula risk score using sarcopenic obesity and subcutaneous fat area for predicting postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/PURPOSE

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy and current predictors of POPF are inadequate. We developed a new fistula score to more accurately predict POPF.

METHODS

We retrospectively reviewed 169 patients who underwent pancreaticoduodenectomy between January 2010 and August 2021 at our institution and examined patients' risk factors according to the occurrence of grade B/C POPF. Muscle and fat were assessed on preoperative computed tomography images and cutoff values were determined by receiver operating characteristic curve analysis.

RESULTS

Grade B/C POPF occurred in 38 (22.5%) patients. Multivariate analysis of patients' risk factors revealed that sarcopenic obesity (odds ratio [OR] 2.94; p = .033), L3 subcutaneous fat area (SFA) ≥ 98.0 cm² (OR 2.69; p = .049), and soft pancreatic texture (OR 27.5; p = .002) were independent risk factors of grade B/C POPF occurrence. In addition, a new fistula risk score based on these factors revealed that 63.6% of patients with high scores developed grade B/C POPF, while those with negligible or low scores did not.

CONCLUSIONS

A new fistula risk scoring system based on sarcopenic obesity, SFA, and pancreatic texture may accurately predict POFP.

Histological pancreatic findings correlate with computed tomography attenuation and predict postoperative pancreatic fistula following pancreatoduodenectomy

BACKGROUND

Although a soft pancreas is a widely-accepted reliable risk factor for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD), there is no established preoperative evaluation of pancreatic texture.

METHODS

Two hundred thirty-seven patients who underwent PD with histological pancreatic assessment were retrospectively enrolled. The degree of fibrosis and fatty infiltration was scored histologically as seven grades and five grades, respectively. Computed tomography (CT) attenuation of the pancreas was measured on preoperative unenhanced CT images. Correlations between the CT attenuation of the pancreas and the histological pancreatic findings, and the development of POPF were analyzed.

RESULTS

The fibrosis grade was significantly higher for hard pancreas than for soft pancreas (p < 0.001), whereas the fatty infiltration grade was similar between the two types (p = 0.161). CT attenuation of the pancreas was inversely correlated with both fibrosis grade (Spearman's rank correlation coefficient ([r] = -0.609, p < 0.001) and fatty infiltration grade (r = -0.382, p < 0.001). Multivariate analysis showed that body mass index ≥25 kg/m² (odds ratio [OR]: 5.64, p < 0.001) and fibrosis grade ≤2 (OR: 18.0, p < 0.001) were independent risk factors for clinically significant POPF.

CONCLUSION

Histological pancreatic texture can be evaluated with CT attenuation and might be helpful in preoperatively predicting the development of POPF after PD.

Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?

BACKGROUND

The commonly used predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) have subjective assessment components and can be used only in the postoperative setting. Also, the available objective predictors based on preoperative cross-sectional imaging were not prospectively studied.

AIM

To evaluate the accuracy of the pancreatic attenuation index (PAI) and pancreatic enhancement ratio (PER) for predicting CR-POPF following PD and its correlation with pancreatic fat fraction and fibrosis.

METHODS

A prospective observational study included patients who underwent PD for benign and malignant pathology of the periampullary region or pancreatic head between February 2019 and February 2021. Patients undergoing extended or total pancreatectomy and those with severe atrophy of pancreatic tissue or extensive parenchymal calcifications in the pancreatic head and neck precluding calculation of PAI and PER were excluded from the study. Preoperatively PAI was measured in the neck of the pancreas by marking regions of interest (ROI) in the non-contrast computed tomography (CT), and PER was measured during the contrast phase of the CT abdomen. Also, the fibrosis score and fat fraction of the pancreatic neck were assessed during the histopathological examination. Demographic, clinical and preoperative radiological indices (PAI, PER) were evaluated to predict CR-POPF. Preoperative pancreatic neck CT indices were correlated with the histopathological assessment of fat fraction and fibrosis.

RESULTS

Of the 70 patients who underwent PD, 61 patients fulfilling the inclusion criteria were included in the analysis. The incidence of CR-POPF was 29.5% (18/61). PAI had no association with the development of CR-POPF. Of the preoperative parameters, PER (mean ± standard deviation [SD]) was significantly lower in patients developing CR-POPF (0.58 ± 0.20 vs 0.81 ± 0.44, P = 0.006). The area under the curve for the PER was 0.661 (95%CI: 0.517-0.804), which was significant (P = 0.049). PER cut-off of 0.673 predicts CR-POPF with 77.8% sensitivity and 55.8% specificity. PAI and PER had a weak negative correlation (Strength-0.26, P = 0.037). Also, PER showed a moderately positive correlation with fibrosis (Strength 0.50, P < 0.001). Patients with CR-POPF had a significantly higher incidence of the intraabdominal abscess (50% vs 2.3%, P < 0.001), delayed gastric emptying (83.3% vs 30.2, P < 0.001), and prolonged mean (± SD) postoperative hospital stay (26.8 ± 13.9 vs 9.6 ± 3.6, P = 0.001).

CONCLUSION

PER exhibited good accuracy in predicting the development of CR-POPF. PER additionally showed a good correlation with PAI and fibrosis scores and may be used as an objective preoperative surrogate for assessing pancreatic texture. However, ROI-based PAI did not show any association with CR-POPF and pancreatic fat fraction.

Uniting epidemiology and experimental models: pancreatic steatosis and pancreatic cancer

Research from epidemiologic studies and experimental animal models provide insights into the role of pancreatic steatosis in the development of pancreatic cancer. Epidemiologic data demonstrate that pancreatic steatosis is widely prevalent and significantly associated with both development and progression of pancreatic cancer. By focusing on current experimental models, this review elucidates potential cellular mechanisms underlying not only the pathophysiology of pancreatic steatosis itself, but also the pathogenesis behind pancreatic steatosis's role in changing the tumour microenvironment and accelerating the development of pancreatic cancer. This review further explores the impact of bariatric surgery on pancreatic steatosis and pancreatic cancer. Synthesizing knowledge from both epidemiologic studies and experimental animal models, this review identifies gaps in current knowledge regarding pancreatic steatosis and its role in carcinogenesis and proposes future research directions to elucidate the possible mechanisms underlying other obesity-associated cancers.

Distal Pancreatectomy for Pancreatitis in the Modern Era

INTRODUCTION

Distal pancreatectomy has not been well examined in the modern era to guide management for pancreatitis. We evaluated this heterogeneous group and the preoperative factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF).

METHODS

Patients undergoing distal pancreatectomy at a single academic institution from August 2012 to January 2020 were evaluated. Univariate and multivariate logistic regressions were conducted between preoperative factors and CR-POPF.

RESULTS

One hundred and thirty patients underwent distal pancreatectomy. Indication for operative management included chronic pancreatitis and/or pseudotumor in 24.6% (n = 32), disconnected left pancreatic remnant in 31.5% (n = 41), chronic distal pseudocyst in 20.8% (n = 27), and distal necrosis in 13.8% (n = 18). Significant complications (Clavien-Dindo grade ≥ III) were seen in 34% of patients. After surgery, 34.2% developed diabetes, 40% had persistent opioid use, and 22.3% had CR-POPF. In multivariate analysis, male sex was significantly associated with CR-POPF (odds ratio 3.1, P = 0.037), and having a preoperative, therapeutic endoscopic retrograde cholangiopancreatography was protective (odds ratio 0.28, P = 0.020).

CONCLUSIONS

Distal pancreatectomy is undertaken in pancreatitis with high morbidity. Female sex and preoperative, therapeutic endoscopic retrograde cholangiopancreatography were significant protective factors for CR-POPF. The natural history of this approach is relevant for those with distal pancreatitis failing medical management.

Impact of Fatty Pancreas on Postoperative Pancreatic Fistulae: A Meta-Analysis

Background

Soft pancreas is widely recognized as an important risk factor for the development of postoperative pancreatic fistula (POPF). Although fatty pancreas (FP) has not been formally defined as a cause of pancreatic fistula, existing research has shown that it can increase the incidence of POPF by increasing pancreatic tenderness; therefore, it may be a potential risk factor. This study aimed to discern whether FP was associated with POPF.

Method

Two reviewers independently performed literature searches from five electronic databases. According to the established inclusion criteria, we extracted necessary data from the studies that met the criteria for further analysis. We pooled the odds ratios (ORs) from individual studies using a random-effects model to investigate the associations between POPF and the prognosis of FP.

Result

A total of 11 studies involving 2484 individuals were included. The pooled prevalence of POPF was 18% (95% CI: 12-24%). Body mass index (BMI) was associated with a significantly increased risk of POPF (OR=3.55; 95% CI: 1.83, 6.86; P=0.0002; I²=0). FP was obviously associated with the occurrence of POPF (OR=3.75; 95% CI: 1.64, 8.58; P=0.002; I²=78).

Conclusion

FP is closely associated with the development of POPF, and the early identification of these high-risk patients can help to reduce the incidence of POPF.

Systematic Review Registration

The Registration URL link is (https://www.crd.york.ac.uk/PROSPERO/). The ID is "CRD42021265141".

Evolving pancreatic cancer treatment: From diagnosis to healthcare management

The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.

Estimation of pancreatic fibrosis and prediction of postoperative pancreatic fistula using extracellular volume fraction in multiphasic contrast-enhanced CT

OBJECTIVE

To investigate the diagnostic performance of the extracellular volume (ECV) fraction in multiphasic contrast-enhanced computed tomography (CE-CT) for estimating histologic pancreatic fibrosis and predicting postoperative pancreatic fistula (POPF).

METHODS

Eighty-five patients (49 men; mean age, 69 years) who underwent multiphasic CE-CT followed by pancreaticoduodenectomy with pancreaticojejunal anastomosis between January 2012 and December 2018 were retrospectively included. The ECV fraction was calculated from absolute enhancements of the pancreas and aorta between the precontrast and equilibrium-phase images, followed by comparisons among histologic pancreatic fibrosis grades (F0‒F3). The diagnostic performance of the ECV fraction in advanced fibrosis (F2‒F3) was evaluated using receiver operating characteristic curve analysis. Multivariate logistic regression analysis was used to evaluate the associations of the risk of POPF development with patient characteristics, histologic findings, and CT imaging parameters.

RESULTS

The mean ECV fraction of the pancreas was 34.4% ± 9.5, with an excellent intrareader agreement of 0.811 and a moderate positive correlation with pancreatic fibrosis (r = 0.476; p < 0.001). The mean ECV fraction in advanced fibrosis was significantly higher than that in no/mild fibrosis (44.4% ± 10.8 vs. 31.7% ± 6.7; p < 0.001), and the area under the receiver operating characteristic curve for the diagnosis of advanced fibrosis was 0.837. Twenty-two patients (25.9%) developed clinically relevant POPF. Multivariate logistic regression analysis demonstrated that the ECV fraction was a significant predictor of POPF.

CONCLUSIONS

The ECV fraction can offer quantitative information for assessing pancreatic fibrosis and POPF after pancreaticojejunal anastomosis.

KEY POINTS

• There was a moderate positive correlation of the extracellular volume (ECV) fraction of the pancreas in contrast-enhanced CT with the histologic grade of pancreatic fibrosis (r = 0.476; p < 0.001). • The ECV fraction was higher in advanced fibrosis (F2‒F3) than in no/mild fibrosis (F0‒F1) (p < 0.001), with an AUC of 0.837 for detecting advanced fibrosis. • The ECV fraction was an independent risk factor for predicting subclinical (odds ratio, 0.81) and clinical (odds ratio, 0.80) postoperative pancreatic fistula.

Establishment of risk prediction model of postoperative pancreatic fistula after pancreatoduodenectomy: 2016 edition of definition and grading system of pancreatic fistula: a single center experience with 223 cases

Objective

To establish a risk prediction model for pancreatic fistula according to the pancreatic fistula standards of the 2016 edition.

Methods

Clinical data from 223 patients with PD admitted to Tianjin Third Central Hospital from January 2016 to December 2020 were retrospectively analyzed. Patients were divided into modeling (January 2016 to December 2018) and validation (January 2019 to December 2020) sets according to the time of admission. The risk factors for postoperative pancreatic fistula (POPF) were screened by univariate and multivariate logistic regression analyses, and a risk prediction model for POPF was established in the modeling set. This score was tested in the validation set.

Results

Logistic regression analysis showed that the main pancreatic duct index and CT value were independent risk factors according to the 2016 pancreatic fistula grading standard, based on which a risk prediction model for POPF was established. Receiver operating characteristic curve analysis showed that the area under the curve was 0.775 in the modeling set and 0.848 in the validation set.

Conclusion

The main pancreatic duct index and CT value of the pancreas are closely related to the occurrence of pancreatic fistula after PD, and the established risk prediction model for pancreatic fistula has good prediction accuracy.

Nonalcoholic fatty pancreas disease: An emerging clinical challenge

Nonalcoholic fatty pancreas disease (NAFPD) is an emerging disease that has gained an increasing amount of attention in recent years. It describes fat accumulation in the pancreas with insignificant alcohol consumption, but the pathogenesis is largely unknown. A wide range of terms have been used to describe the phenomenon of pancreatic fat accumulation, but NAFPD remains an under-recognized and non-independent disorder. Obesity, age, sex, race, and unhealthy lifestyle are established independent risk factors for NAFPD, which is strongly associated with metabolic syndrome, type 2 diabetes, pancreatitis, pancreatic fistula, pancreatic cancer, and nonalcoholic fatty liver disease. At present, imaging techniques are common diagnostic aids, but uniform criteria and consensus are lacking. Therapeutically, healthy diet, weight loss, and exercise are the mainstays to reduce pancreatic fat accumulation. It can be seen that there is a limited understanding of NAFPD at this stage and further exploration is needed. Previous studies have revealed that NAFPD may directly affect diagnosis and clinical decision-making. Therefore, exploring the pathophysiological mechanism and clinical associations of NAFPD is a major challenge for researchers and clinicians.

The Relationship Between Visceral Obesity and Post-operative Complications: A Meta-analysis

BACKGROUND

Body composition can have important influence on surgical outcome. There is substantial literature examining sarcopenia, however much less in known about the impact of fat. Visceral fat area (VFA) is a reliable measures of fat distribution that can be quantified with CT scan. The aim of this study is to determine the impact of VFA to predict complications and mortality after emergent or elective surgery.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed in accordance with the Preferred.

Postoperative pancreatic fistula affects recurrence-free survival of pancreatic cancer patients

PURPOSE

Postoperative pancreatic fistula (POPF) with reported incidence rates up to 45% contributes substantially to overall morbidity. In this study, we conducted a retrospective evaluation of POPF along with its potential perioperative clinical risk factors and its effect on tumor recurrence.

METHODS

Clinical data on patients who had received pancreatoduodenectomy (PD), distal pancreatectomy (DP), or duodenum-preserving pancreatic head resection (DPPHR) were prospectively collected between 2007 and 2016. A Picrosirius red staining score was developed to enable morphological classification of the resection margin of the pancreatic stump. The primary end point was the development of major complications. The secondary end points were overall and recurrence-free survival.

RESULTS

340 patients underwent pancreatic resection including 222 (65.3%) PD, 87 (25.6%) DP, and 31 (9.1%) DPPHR. Postoperative major complications were observed in 74 patients (21.8%). In multivariable logistic regression analysis, POPF correlated with body mass index (BMI) (p = 0.025), prolonged stay in hospital (p<0.001), high Picrosirius red staining score (p = 0.049), and elevated postoperative levels of amylase or lipase in drain fluid (p≤0.001). Multivariable Cox regression analysis identified UICC stage (p<0.001), tumor differentiation (p<0.001), depth of invasion (p = 0.001), nodal invasion (p = 0.001), and the incidence of POPF grades B and C (p = 0.006) as independent prognostic markers of recurrence-free survival.

CONCLUSION

Besides the known clinicopathological risk factors BMI and amylase in the drain fluid, the incidence of POPF correlates with high Picrosirius red staining score in the resection margins of the pancreatic stumps of curatively resected pancreatic ductal adenocarcinoma (PDAC). Furthermore, clinically relevant POPF seems to be a prognostic factor for tumor recurrence in PDAC.

Reappraisal of clinical indication regarding total pancreatectomy: can we do it for the risky gland?

BACKGROUND

Although total pancreatectomy (TP) is performed at an increasing rate at major pancreatic centers, there is still debate regarding its indications and outcomes. This study aims to analyze the indications and outcomes of TP using our retrospective data.

METHODS

We conducted a retrospective study on patients who underwent TP between January 2009 and December 2019 at two academic hospitals using data collected. Preoperative data, including demographics and clinical picture, operative details, and postoperative data, were collected and analyzed. Conventional indications of TP included positive margin on the neck, lesion of the central part of the pancreas, and diffuse lesions of the whole pancreas. The classification of the risky gland included pancreas remnants, which had higher risk for pancreaticoenterostomy after pancreatic head resection.

RESULTS

During the study periods, a total of 72 TP were performed for benign and malignant pancreatic diseases. After excluding six TP undergone due to trauma or complication after partial pancreatectomy, 64 patients were grouped into 47 patients with existing conventional indications and 17 patients with predicted risky anastomosis. There was no significant difference in clinical data and surgical results between the conventional indication group and the risky gland group. Thirty-day major morbidity and mortality was 9.4% and 0%, respectively. Ninety-day mortality rate was 1.4% (n=1, conventional group), with the median follow-up length of 21.5 months. Overall 5-year survival rate was 67.7% for the total participants: 87.5% for the risk gland group and 57.9% for the conventional group. There was no significant difference in between the two groups.

CONCLUSIONS

Total pancreatectomy appears to be a viable option for risky glands in terms of surgical safety.

The role of acinar content at pancreatic resection margin in the development of postoperative pancreatic fistula and acute pancreatitis after pancreaticoduodenectomy

BACKGROUND

A fatty infiltration of the pancreas has been traditionally regarded as the main histological risk factor for postoperative pancreatic fistula, whereas the role of the secreting acinar compartment has been poorly investigated. The aim of this study was to evaluate the role of acinar content at pancreatic resection margin in the development of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis after pancreaticoduodenectomy.

METHODS

Data from 388 consecutive patients who underwent pancreaticoduodenectomy (2018-2019) were analyzed. Pancreatic section margins were histologically assessed for acinar, fibrosis, and fat content. Acinar content was categorized using median and third quartile as cut-offs. Univariate and multivariable analysis of possible predictors of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis were performed.

RESULTS

Acinar content was <60% in 166 patients (42.8%), ≥60% and ≤80% in 156 patients (40.2%), and >80% in 66 patients (17.0%). The rate of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis was significantly higher in patients with acinar content >80% (39.4% and 33.3%, respectively) as well as in those with acinar content ≥60% and ≤80% (36.5% and 35.3%, respectively), compared with patients with acinar content <60% (10.2% and 5.4%, respectively) (P < .001). Acinar content was identified as an independent predictor of clinically relevant postoperative pancreatic fistula (≥60% and ≤80%, odds ratio 2.51, P = .008; >80%, odds ratio 2.93, P = .010) and clinically relevant postoperative acute pancreatitis (≥60% and ≤80%, odds ratio 9.42, P < .001; >80%, odds ratio 10.16, P < .001).

CONCLUSION

An acinar content at pancreatic resection margin ≥60% is associated to an increased risk of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis. Fat content was associated neither with clinically relevant postoperative pancreatic fistula nor with clinically relevant postoperative acute pancreatitis.

The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve

BACKGROUND

In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.

METHOD

Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44).

RESULTS

In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III-IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m², and patients operated in the third period.

CONCLUSION

This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

Traditional and Novel Adiposity Indicators and Pancreatic Cancer Risk: Findings from the UK Women's Cohort Study

(1) Background: We studied the association of both conventional (BMI, waist and hip circumference and waist-hip ratio) and novel (UK clothing sizes) obesity indices with pancreatic cancer risk in the UK women's cohort study (UKWCS). (2) Methods: The UKWCS recruited 35,792 women from England, Wales and Scotland from 1995 to 1998. Cancer diagnosis and death information were obtained from the National Health Service (NHS) Central Register. Cox's proportional hazards regression was used to evaluate the association between baseline obesity indicators and pancreatic cancer risk. (3) Results: This analysis included 35,364 participants with a median follow-up of 19.3 years. During the 654,566 person-years follow up, there were 136 incident pancreatic cancer cases. After adjustments for age, smoking, education and physical activity, each centimetre increase in hip circumference (HR: 1.03, 95% CI: 1.01-1.05, p = 0.009) and each size increase in skirt size (HR: 1.12, 95% CI: 1.02-1.23, p = 0.041) at baseline increased pancreatic cancer risk. Baseline BMI became a significant predictor of pancreatic cancer risk (HR: 1.04, 95% CI: 1.00-1.08, p = 0.050) when latent pancreatic cancer cases were removed. Only baseline hip circumference was associated with pancreatic cancer risk (HR: 1.03, 95% CI: 1.00-1.05, p = 0.017) when participants with diabetes at baseline were excluded to control for reverse causality. (4) Conclusion: Hip circumference and skirt size were significant predictors of pancreatic cancer risk in the primary analysis. Thus, hip circumference is useful to assess body shape relationships. Additionally, standard skirt sizes offer an economical and objective alternative to conventional obesity indices for evaluating pancreatic cancer risk in women.

Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy

PURPOSE

This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3).

METHODS

A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients.

RESULTS

The incidence rates of CR-POPF, severe complications (Clavien-Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%.

CONCLUSIONS

A simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.

Perioperative acinar cell count method works well in the prediction of postoperative pancreatic fistula and other postoperative complications after pancreaticoduodenectomy

BACKGROUND

Earlier we have shown that high frequency of acinar cells in the pancreatic transsection line predicts postoperative pancreatic fistula after pancreaticoduodenectomy (PD). Acinar cell count method (ACM) is fast to perform during operation. In this study our aim was to validate the accuracy of ACM to compare it with other published risk prediction methods.

METHODS

87 patients who underwent PD without any trial including perioperative medications were collected from a single hospital. Data on demographics, surgical details, postoperative complications clinically relevant pancreatic fistulae (CR-POPF) and clinically relevant Clavien-Dindo complications (CR-CDC) were registered. Thirteen previously published risk prediction methods were included in the comparison, such as pancreatic duct diameter, palpable texture of pancreas, Braga score (BC), Fistula Risk Score, Modified Fistula Risk Score, Alternative Fistula Risk Score and multiple radiological parameters. ROC-curves were calculated to compare sensitivity and specificity for identifying high risk patients for CR-POPF and CR-CDC.

RESULTS

The three most accurate risk prediction methods for CR-POPF were ACM (sensitivity 88.9%, specificity 52.6%; p = 0.043), BC (87.5%, 56.6%; p = 0.039) and visceral fat area to subcutaneous fat area ratio (75.5%, 80.0%; p = 0.032). In predicting CR-CDC the three most accurate methods were ACM (73.9%, 56.2%; p = 0.033), BC (68.4%, 59.5%; p = 0.036) and TPAI (78.3%, 41.7%; p = 0.012).

CONCLUSION

ACM was shown to be as good as the more complicated risk scoring methods in the prediction of CR-POPF. It was good also in predicting all clinically relevant complications. ACM is easy to use during operation and can be recommended as a routine risk prediction method.

Significant association between the preoperative erythrocyte mean corpuscular volume and infectious complications after pancreaticoduodenectomy

PURPOSE

An organ/space surgical site infection reportedly develops in 20% of patients who undergo pancreaticoduodenectomy (PD). The present study aimed to identify the predictors for developing severe infectious complications after PD.

METHODS

We retrospectively reviewed the records of 115 consecutive patients who underwent PD at Ehime University Hospital between January 2013 and January 2020. Severe infectious complications were defined as Clavien-Dindo classification grade ≥ III postoperative complications related to bacterial or fungal infections, including clinically relevant postoperative pancreatic fistula (CR-POPF). The patient characteristics, blood chemistry data, body composition data and operative data were evaluated as potential predictors of severe infectious complications. We also evaluated the erythrocyte indices, such as the mean corpuscular hemoglobin, the mean corpuscular hemoglobin concentration, and the mean corpuscular volume (MCV).

RESULTS

Among 115 patients, 25 (21.7%) developed severe infectious complications, which included 20 (17.4%) cases of CR-POPF. According to multivariate analyses, MCV > 97.4fL, C-reactive protein (CRP) > 1.2 mg/dL and diameter of main pancreatic duct < 5 mm were independent predictors of severe infectious complications (odds ratio, 13.891, 7.356 and 4.676, respectively, 95% confidence interval, 3.457-55.815, 1.868-28.964 and 1.391-15.716, respectively).

CONCLUSION

Preoperative high MCV/CRP values and a small main pancreatic duct are predictive factors associated with severe infectious complications after PD.

Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system.

AIM

The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF.

METHODS

All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed.

RESULTS

Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%.

CONCLUSION

Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.

Toward a Routine Assessment of Visceral Adipose Tissue Volume from Computed Tomographic Data

OBJECTIVE

The study's aim was to determine to what extent total visceral adipose tissue (VAT) volume (V_VAT-T ) measured from segmented VAT areas (A_VAT ) on all axial computed tomography (CT) sections (thickness of 5 mm) between the diaphragm and pelvic floor can be predicted by the A_VAT of commonly selected landmark sections in patients with overweight or obesity.

METHODS

A total of 113 patients (31 females, 82 males) with images of full abdominopelvic coverage and proper image quality were included (BMI = 25.0-64.1 kg/m² , 29.5 ± 4.9 kg/m² ). Linear regression between A_VAT and V_VAT-T (reference) was used to determine approximate equations for VAT volume for all parameters (single sex, different anatomical landmarks or lumbar intervertebral disc spaces, one or five axial sections). Agreement was evaluated by the multivariate coefficient of determination and by the SD of the percentage difference (s_d% ) between the estimated VAT volume on one or five sections and V_VAT-T .

RESULTS

The V_VAT-T was 0.9 to 8.4 (3.8 ± 2.2) L for females and 2.7 to 11.7 (5.6 ± 2.1) L for males. Best agreement was found at L2-3 (s_d%  = 14.3%-15.5%) for females and at L1-2 or L2-3 (11.7%-12.4%) for males. Agreement at the umbilicus or the femoral heads was poor (20.2%-57.9%). Segmentation of one or five sections was substantially faster (11/70 seconds) than whole-abdomen processing (15 minutes).

CONCLUSIONS

V_VAT-T can be rapidly estimated by VAT segmentation of axial CT sections at sex-specific lumbar intervertebral disc spaces.

Assessment of Preoperative Clinicophysiologic Findings as Risk Factors for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Objective

Postoperative pancreatic fistula (POPF) is one of the severe complications that develop after pancreaticoduodenectomy (PD). This study aimed to assess the utility of preoperative clinicophysiologic findings as risk factors for POPF after PD.

Summary of Background Data

We enrolled 350 patients who underwent PD between 2007 and 2012 at Tokyo Women's Medical University.

Methods

In total, 350 patients who underwent PD between 2007 and 2012 were examined retrospectively. All patients were classified into 2 groups as follows: group A (no fistula/biochemical leak group, 289 patients) and group B (grade B/C of POPF group 61 patients). Variables, including operative characteristics, length of stay in hospital, morbidity, mortality, and data regarding preoperative clinicophysiologic parameters, were collected and analyzed as predictors of POPF for univariate and multivariate analyses.

Results

There were 213 male and 137 female patients. The mean age was 65.4 years (range, 21–87 years). Univariate analysis showed that sex (P = 0.047), amylase level (P = 0.032), prognostic nutritional index (PNI; P = 0.001), and C-reactive protein/albumin ratio (P = 0.005) were independent risk factors for POPF. In contrast, multivariate analysis showed that sex (P = 0.045) and PNI (P = 0.012) were independent risk factors for POPF.

Conclusions

Our results show that PNI (≤48.64 U/mL) and male sex were risk factors for POPF after PD, and especially, PNI can be suggested as an effective biomarker for POPF.

Study Protocol of the PreFiPS Study: Prevention of Postoperative Pancreatic Fistula by Somatostatin Compared With Octreotide, a Prospective Randomized Controlled Trial

Background: Pancreatic fistula (PF), i. e., a failure of the pancreatic anastomosis or closure of the remnant pancreas after distal pancreatectomy, is one of the most feared complications after pancreatic surgery. PF is also one of the most common complications after pancreatic surgery, occurring in about 30% of patients. Prevention of a PF is still a major challenge for surgeons, and various technical and pharmacological interventions have been investigated, with conflicting results. Pancreatic exocrine secretion has been proposed as one of the mechanisms by which PF occurs. Pharmacological prevention using somatostatin or its analogs to inhibit pancreatic exocrine secretion has shown promising results. We can hypothesize that continuous intravenous infusion of somatostatin-14, the natural peptide hormone, associated with 10–50 times stronger affinity with all somatostatin receptor compared with somatostatin analogs, will be associated with an improved PF prevention.

Methods: A French comparative randomized open multicentric study comparing somatostatin vs. octreotide in adult patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy with or without splenectomy. Patients with neoadjuvant radiation therapy and/or neoadjuvant chemotherapy within 4 weeks before surgery are excluded from the study. The main objective of this study is to compare 90-day grade B or C postoperative PF as defined by the last ISGPF (International Study Group on Pancreatic Fistula) classification between patients who receive perioperative somatostatin and octreotide. In addition, we analyze overall length of stay, readmission rate, cost-effectiveness, and postoperative quality of life after pancreatic surgery in patients undergoing PD.

Conclusion: The PreFiPS study aims to evaluate somatostatin vs. octreotide for the prevention of postoperative PF.

Computed Tomography Assessment of Fat Distribution and Staple-Line Leak Risk After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) has become the most frequent bariatric procedure and staple-line leak represents its most feared complication. Visceral obesity, a core component of the metabolic syndrome, has been associated with worst postoperative outcomes after various abdominal surgical procedures, and can be estimated by computed tomography (CT). The aim of this study was to assess the impact of radiologically determined visceral obesity in the risk of staple-line leak after SG.

MATERIAL AND METHODS

A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Several anthropometric variables were measured on a preoperative CT scan. Multivariate analysis was performed to determine preoperative risk factors for staple-line leak.

RESULTS

During the study period, 377 patients were included in the analysis. The median BMI was 39.7 kg/m² (36.5-43.5) and 8 patients (2.1%) presented a gastric leak. After multivariate analysis, visceral obesity defined by visceral fat area (VFA)/body surface area (BSA) ≥ 85 cm²/m² was the only independent predictive factor for gastric leak (OR = 5312).

CONCLUSION

CT scan-assessed visceral obesity defined by a VFA/BSA ratio ≥ 85 cm²/m² is associated with an increased risk of gastric leak after SG. Preoperatively radiological examination in patients suspected of visceral obesity would be useful to optimize preoperative management.

Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy

Background

Clinically relevant postoperative pancreatic fistula (CR-POPF) continues to be a major contributor to morbidity after pancreaticoduodenectomy (PD), but it remains unclear what risk factors can precisely predict the development of CR-POPF after laparoscopic pancreatoduodenectomy (LPD). We thus aimed to identify the risk factors for predicting CR-POPF after LPD.

Methods

A total of 388 consecutive patients who underwent LPD at our institution between July 2014 and December 2018 were identified. All data, including pre-, intra-, and postoperative risk factors associated with CR-POPF defined by the International Study Group of Pancreatic Fistula, were collected retrospectively. To evaluate the predictive performance of the risk factor models, areas under the receiver operating characteristic curve (ROC) were determined.

Results

CR-POPF was observed in 31 patients (8.0%) with significant association observed with body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), intra-abdominal fat thickness, main pancreatic duct width, soft pancreatic texture, operative time, underlying pathology, and albumin (Alb) on postoperative days (POD) 1­–3. Multivariate analyses revealed that VFA >82 cm² [odds ratio (OR) =11.088; P=0.029], main pancreatic duct width <3 mm (OR =7.701; P=0.001), soft pancreatic texture (OR =12.543; P=0.022), and operative time >320 min (OR =6.061; P<0.001) were independent risk factors for CR-POPF after LPD. Areas under the ROC curve (AUC) analysis revealed the pancreatic texture was the strongest single predictor (AUC =0.854) of CR-POPF, and pancreatic texture + pancreatic duct width was the best two-predictor model (AUC =0.904). Meanwhile, our findings indicated an association between the TFA >221 cm² (OR =8.637; P=0.001) and VFA >82 cm² (OR =7.009; P<0.001) with soft pancreatic texture.

Conclusions

Soft pancreatic texture, VFA >82 cm², main pancreatic duct width <3 mm, and operative time >320 min were independent predictive risk factors of CR-POPF for LPD.

Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.

Retrorenal fat predicts grade C pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula after pancreaticoduodenectomy is one of the most severe complications with mortality rates as high as 45%, and the prediction of most severe form of fistula (grade C) is crucial for successful management of patients who are to undergo cephalic pancreatoduodenectomy. It has been found that the amount of abdominal fat may predict grade C postoperative pancreatic fistula. In this study, we analysed the value of retrorenal fat thickness in the prediction of grade C pancreatic fistula.

METHODS

A total of 140 patients who underwent pancreaticoduodenectomy were retrospectively analysed. Retrorenal fat thickness and intra-abdominal fat, expressed as total fat area, visceral fat area and subcutaneous fat area, were determined from computed tomography slices using the known range of attenuation values (-190 to -30). Blood loss, operating time, pancreatic texture and main pancreatic duct diameter as well as body mass index were also analysed.

RESULTS

Retrorenal fat thickness (P = 0.0004), duct diameter (P = 0.0008), subcutaneous fat area (P = 0.023) and total fat area (P = 0.014) were found to be significant predictors of grade C pancreatic fistula.

CONCLUSION

Although retrorenal fat tissue thickness may seem robust, it is a simple measure that can be used to predict the most severe grade of pancreatic fistula after pancreaticoduodenectomy.

Preoperative assessment of patient comorbidities before left colectomy: Comparison between ASA performance status scale and a new computed tomography physical status score

PURPOSE

To compare a newly developed preoperative computed tomography physical status (CT-PS) score with the American Society of Anesthesiology performance status (ASA-PS) scale in the assessment of patient preoperative health status and stratification of perioperative risk before left colectomy.

MATERIALS AND METHODS

Preoperative chest-abdomen-pelvis CT examinations of patients who were scheduled to undergo elective laparoscopic left colonic resection for cancer in two centers were reviewed by two radiologists blinded to clinical data for the presence of several key imaging features in order to assess general, cardiac, pulmonary, abdominal, renal, vascular and musculoskeletal status. CT examinations of patients from center 1 were used to build a CT-PS score to predict ASA-PS≥III. CT-PS score was further validated using an external cohort of patients from center 2.

RESULTS

During a 2-year period, 117 consecutive patients (63 men, 54 women; mean age, 65±13 [SD] years; age range: 53-90 years) who underwent laparoscopic left colectomy for cancer in center 1 (66 patients, building cohort) and center 2 (51 patients, validation cohort) were retrospectively included. Ninety-one percent of patients were ASA-PS 1-2. Overall postoperative morbidity was 23% and severe morbidity 12%. The area under the receiver operating characteristic curve of CT-PS score was 0.968 (95% CI: 0.901-1.000) in the building cohort and 0.828 (95% CI: 0.693-0.963) in the validation cohort. The optimal thresholds yielded 87% (95% CI: 83-91%) sensitivity and 100% (95% CI: 91-100%) specificity in the building cohort and 75% (95% CI: 69-81%) sensitivity and 83% (95% CI: 77-88%) specificity in the validation cohort for the prediction of ASA-PS.

CONCLUSION

Preoperative chest-abdomen-pelvis CT thoroughly and wisely read is highly accurate to differentiate patients with ASA-PS I/II from those with ASA-PS III/IV before left colectomy.

[Predictors of external pancreatic fistulae after pancreatic resection]

Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.

The ratio of abdominal depth to body mass index is a preoperative predictor of postoperative complications after laparoscopic pancreaticoduodenectomy: a retrospective propensity score matched analysis

BACKGROUND

Postoperative complication rates after laparoscopic pancreaticoduodenectomy (LPD) remain high despite improvements in perioperative management. Measurements on computed tomography imaging of intra-abdominal tissue have not been thoroughly investigated as predictors of mortality and morbidity following LPD. The aim of this study was to assess whether the ratio of abdominal depth and body mass index (AD/BMI ratio) could predict postoperative complications following LPD.

METHODS

We retrospectively analyzed 231 patients who underwent LPD and had a computed tomography scan between 2014 and 2018. Demographic, radiologic, and pathologic data were correlated to the occurrence of postoperative complications. Propensity score matching was performed to minimize selection biases associated with the comparison of retrospective data between the high and low AD/BMI ratio groups. Univariate and multivariate analyses were also performed to assess the risk factors for postoperative complications.

RESULTS

Of the 102 patients identified for propensity score matching analysis, 29 patients (28.4%) experienced postoperative complications. Patients with a high AD/BMI ratio had a higher prevalence of overall complications (45.1% vs. 11.8%, P < 0.001), postoperative pancreatic fistula (17.6% vs. 2.00%, P = 0.008), delayed gastric emptying (33.3% vs. 3.90%, P < 0.001), and intra-abdominal abscess (17.6% vs. 0, P = 0.002). In the multivariate analysis, an AD/BMI ratio greater than 2.7 (m³/[kg·10³]; OR = 6.16, 95% confidence interval [1.04-36.4], P = 0.045) was the only independent predictive factor of postoperative complications.

CONCLUSIONS

The preoperative AD/BMI ratio is a predictor of postoperative complications following LPD.