Prediction of pancreatic anastomotic failure after pancreatoduodenectomy: the use of preoperative, quantitative computed tomography to measure remnant pancreatic volume and body composition. Ann Surg. 2013;257:512-519. [PMID: 23241871 DOI: 10.1097/sla.0b013e31827827d0]

Baseline Body Composition and 3D-Extracellular Volume Fraction for Predicting Pancreatic Fistula after Distal Pancreatectomy in Pancreatic Body and/or Tail Adenocarcinoma

RATIONALE AND OBJECTIVES

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a threatening complication in body and/or tail pancreatic ductal adenocarcinoma (PDAC) receiving distal pancreatectomy (DP) and is difficult to predict preoperatively. We aimed to identify the role of baseline CT-based body composition analysis and extracellular volume (ECV) map in predicting the risk of CR-POPF preoperatively.

MATERIALS AND METHODS

A total of 329 resectable PDAC patients were enrolled and underwent multiphasic contrast-enhanced CT. Body composition indicators were calculated, and ECV maps were generated through multiphasic CT images. The differences in clinical variables and quantitative parameters between CR-POPF and non-CR-POPF patients were compared. Correlations between ECV fraction and pancreatic fibrosis stage were analyzed. Multivariate logistic regression was performed to screen the independent predictors and develop prediction models for CR-POPF. Receiver operating characteristic curve was utilized to evaluate the predictive performance.

RESULTS

Among 329 patients, 19.76% (65/329) developed CR-POPF. Albumin, pancreatic texture, and intraoperative blood loss were used to build the clinical model with an AUC of 0.764. ECV fraction and total muscle ratio (TMR) were chosen to build the radiological model with an AUC of 0.872. A combined nomogram integrated with albumin, ECV fraction, and TMR could significantly improve the discrimination ability to an AUC of 0.924 (Delong test, all p < 0.05). The ECV fraction showed high positive correlation with histological fibrosis grade (Spearman ρ = 0.81).

CONCLUSION

CT-based body composition analysis and ECV exhibited great potential for predicting CR-POPF in body and/or tail PDAC after DP. The combined nomogram could further improve the predictive performance.

The Degradation of Absorbable Surgical Threads in Body Fluids: Insights from Infrared Spectroscopy Studies

This study investigates the degradation of six different types of absorbable surgical threads commonly used in clinical practice, focusing on their response to exposure to physiological fluids. The threads were subjected to hydrolytic and enzymatic degradation in physiological saline, bile, and pancreatic juice. Our findings demonstrate that bile and pancreatic juice, particularly when contaminated with bacterial strains such as Escherichia coli, Klebsiella spp., and Enterococcus faecalis, significantly accelerate the degradation process. Using Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), and tensile strength testing, we observed distinct differences in the chemical structure and mechanical integrity of the sutures. Principal component analysis (PCA) of the FTIR spectra revealed that PDS threads exhibited the highest resistance to degradation, maintaining their mechanical properties for a longer duration compared with Monocryl and Vicryl. These results highlight the critical role of thread selection in gastrointestinal surgeries, where prolonged exposure to bile and pancreatic juice can compromise the suture integrity and lead to postoperative complications. The insights gained from this study will contribute to improving the selection and application of absorbable threads in clinical settings.

The ratio of skeletal muscle mass to body mass index combined with inflammatory immune markers to stratify survival of pancreatic cancer after pancreatoduodenectomy

BACKGROUND

We sought to combine skeletal muscle index and inflammatory immune markers to stratify long-term survival in patients with pancreatic cancer after pancreatoduodenectomy (PD).

METHODS

A total of 581 patients with pancreatic cancer underwent PD were included, and divided into the training and validation cohort. Image analysis of computed tomography scans was used to calculate the ratio of skeletal muscle (SM) area to body mass index (BMI). Naples prognostic score (NPS) was calculated from blood-test inflammatory immune markers. Propensity score matching (PSM) analysis was performed to minimize biases of clinicopathological characteristics. To estimate the overall survival (OS), a nomogram was developed using the training cohort. The predictive accuracy of nomogram was estimated by concordance index (C-index), calibration curve, and receiver operating characteristics (ROC) curve.

RESULTS

After PSM analysis, SM/BMI ratio, NPS, lymph node metastasis, TNM stage, surgical margin, tumor grade and adjuvant therapy were independent predictors of OS, which were all assembled into nomogram. The SM/BMI ratio was the best single-predictor for 3- and 5-year OS, with an AUC of 0.805 (95% CI: 0.755-0.855) and 0.812 (95% CI: 0.736-0.888), respectively. Harrell's c-index of the nomogram in the training cohort was 0.786 (95% CI: 0.770-0.802), and the area under ROC curve of 1-year, 3- and 5-year OS prediction were 0.869 (95%CI: 0.837-0.901), 0.846 (95%CI: 0.810-0.882) and 0.849 (95%CI: 0.801-0.896).

CONCLUSIONS

The nomogram based on SM/BMI ratio and NPS had excellent predictive performance, which should be incorporated to conventional risk scores to stratify survival of patients with PDAC after PD.

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.

High hand grip strength is a significant risk factor and a useful predictor of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most critical complications of pancreaticoduodenectomy (PD). Studies on predictive factors for POPF that can be identified preoperatively are limited. Recent reports have highlighted the association between the preoperative nutritional status, including sarcopenia, and postoperative complications. We examined preoperative risk factors for POPF after PD, focusing on nutritional indicators.

METHODS

A total of 153 consecutive patients who underwent PD at our institution were enrolled in this study. Preoperative nutritional parameters, including hand grip strength (HGS) and skeletal muscle mass as components of sarcopenia, were incorporated into the analysis. POPFs were categorized according to the International Study Group of Pancreatic Fistula (ISGPF) definition as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C).

RESULTS

Thirty-seven of the 153 patients (24.1%) fulfilled the ISGPF definition of CR-POPF postoperatively. In the univariate analysis, the incidence of CR-POPF was associated with male sex, non-pancreatic tumor diseases, a high body mass index, a high HGS and a high skeletal muscle mass index. In the multivariate analysis, non-pancreatic tumor diseases and an HGS ≥23.0 kg were selected as independent risk factors for CR-POPF (P <0.05).

CONCLUSIONS

A high HGS, a screening tool for sarcopenia, was a risk factor for CR-POPF. It can accurately serve as a useful predictor of POPF risk in patients undergoing PD. These results highlight the potential of sarcopenia to reduce the incidence of POPF and highlight the need to clarify the mechanism of POPF occurrence.

Effect of sarcopenia on survival in patients after pancreatic surgery: a systematic review and meta-analysis

Background

Numerous studies have reported sarcopenia to be associated with unfavorable outcomes in patients who have undergone pancreatectomy. Therefore, in this meta-analysis, we examined the relationship between sarcopenia and survival after pancreatic surgery.

Methods

PubMed, Embase, and Cochrane Library were searched for studies that examined the association between sarcopenia and survival after pancreatic surgery from the inception of the database until June 1, 2023. Hazard ratio (HR) for overall survival (OS) and/or progression-free survival (PFS) of sarcopenia and pancreatic surgery were extracted from the selected studies and random or fixed-effect models were used to summarize the data according to the heterogeneity. Publication bias was assessed using Egger's linear regression test and a funnel plot.

Results

Sixteen studies met the inclusion criteria. For 13 aggregated univariate and 16 multivariate estimates, sarcopenia was associated with decreased OS (univariate analysis: HR 1.69, 95% CI 1.48-1.93; multivariate analysis: HR 1.69; 95% CI 1.39-2.05, I2 = 77.4%). Furthermore, sarcopenia was significantly associated with poor PFS of pancreatic resection (Change to univariate analysis: HR 1.74, 95% CI 1.47-2.05; multivariate analysis: HR 1.54; 95% CI 1.23-1.93, I2 = 63%).

Conclusion

Sarcopenia may be a significant prognostic factor for a shortened survival following pancreatectomy since it is linked to an elevated risk of mortality. Further studies are required to understand how sarcopenia affects long-term results after pancreatic resection.Systematic review registrationRegistration ID: CRD42023438208 https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

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.

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data

Clinically relevant postoperative pancreatic fistula (CR-POPF) can significantly affect the treatment course and outcome in pancreatic cancer patients. Preoperative prediction of CR-POPF can aid the surgical decision-making process and lead to better perioperative management of patients. In this retrospective study of 108 pancreatic head resection patients, we present risk models for the prediction of CR-POPF that use combinations of preoperative computed tomography (CT)-based radiomic features, mesh-based volumes of annotated intra- and peripancreatic structures and preoperative clinical data. The risk signatures were evaluated and analysed in detail by visualising feature expression maps and by comparing significant features to the established CR-POPF risk measures. Out of the risk models that were developed in this study, the combined radiomic and clinical signature performed best with an average area under receiver operating characteristic curve (AUC) of 0.86 and a balanced accuracy score of 0.76 on validation data. The following pre-operative features showed significant correlation with outcome in this signature ([Formula: see text]) - texture and morphology of the healthy pancreatic segment, intensity volume histogram-based feature of the pancreatic duct segment, morphology of the combined segment, and BMI. The predictions of this pre-operative signature showed strong correlation (Spearman correlation co-efficient, [Formula: see text]) with the intraoperative updated alternative fistula risk score (ua-FRS), which is the clinical gold standard for intraoperative CR-POPF risk stratification. These results indicate that the proposed combined radiomic and clinical signature developed solely based on preoperatively available clinical and routine imaging data can perform on par with the current state-of-the-art intraoperative models for CR-POPF risk stratification.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Selective use of pancreatic duct occlusion during pancreaticoduodenectomy in patients with a small-size duct and atrophic parenchyma in the distal pancreas: A retrospective study

BACKGROUND

Despite the advancements in surgical techniques, postoperative pancreatic fistula (POPF) remains a potentially life-threatening complication of pancreaticoduodenectomy (PD). Pancreatic duct occlusion (PDO) without anastomosis has also been proposed to alleviate the clinical consequences of POPF in selected patients after PD.

OBJECTIVES

To assess the safety and effectiveness of PDO with mechanical closure after PD in patients with an atrophic pancreatic body-tail and a small pancreatic duct.

METHODS

We retrospectively identified two female and two male patients from April 2019 to October 2020 through preoperative computed tomography of the abdomen. Among them, three patients underwent PDO with mechanical closure after PD, and one underwent PDO after pylorus-preserving PD. In addition, patients' medical records and medium-and long-term follow-up data were analyzed.

RESULTS

Postoperative histological examination revealed a solid pseudopapillary tumor in two patients, pancreatic ductal adenocarcinoma in one patient, and chronic pancreatitis with pancreatic duct stones in one patient. However, none of the patients developed biochemical or clinically relevant POPF, with no postpancreatectomy hemorrhage, biliary leakage, delayed gastric emptying, intra-abdominal abscess, or chyle leakage. Among the four patients, three developed new-onset diabetes mellitus, and one had impaired glucose tolerance. Furthermore, three patients received pancreatic enzyme supplementation at a dose of 90,000 Ph. Eur. units/d, and one was prescribed a higher dose of 120,000 Ph. Eur. units/d.

CONCLUSIONS

PDO with mechanical closure is an alternative approach for patients with an atrophic pancreatic body-tail and a small pancreatic duct after PD. Therefore, further evidence should evaluate the potential benefits of selective PDO in these patients.

The Impact of CT-Assessed Liver Steatosis on Postoperative Complications After Pancreaticoduodenectomy for Cancer

INTRODUCTION

Liver steatosis (LS) has been increasingly described in preoperative imaging of patients undergoing pancreaticoduodenectomy (PD). The aim of this study was to assess the impact of preoperative LS on complications after PD and identify possible contributors to LS development in this specific cohort.

METHODS

Pancreatic head adenocarcinoma (PDAC) patients scheduled for PD, with preoperative CT-imaging available were included in the study. LS was defined as mean liver density lower than 45 Hounsfield units. Patients showing preoperative LS were matched for patient age, gender, BMI, ASA score, neoadjuvant treatment, and vascular and multivisceral resections, based on propensity scores in a 1:2 ratio to patients with no LS. The primary outcome was postoperative complication severity at 90 days as measured by the comprehensive complication index (CCI) RESULTS: Overall, 247 patients were included in the study. Forty-three (17%) patients presented with LS at preoperative CT-scan. After matching, the LS group included 37 patients, whereas the non-LS group had 74 patients. LS patients had a higher mean (SD) CCI, 29.7 (24.5) versus 19.5 (22.5), p = 0.035, and a longer length of hospital stay, median [IQR] 12 [8-26] versus 8 [7-13] days, p = 0.006 compared with non-LS patients. On multivariate analysis, variables independently associated with CCI were: LS (16% increase, p = 0.048), male sex (19% increase, p = 0.030), ASA score ≥ 3 (26% increase, p = 0.002), fistula risk score (FRS) (28% increase for each point of FRS, p = 0.001) and vascular resection (20% increase, p = 0.019).

CONCLUSION

Preliminary evidence suggests that preoperative LS assessed by CT-scan influences complication severity in patients undergoing PD for PDAC.

Quantification of Coronary Artery Atherosclerotic Burden and Muscle Mass: Exploratory Comparison of Two Freely Available Software Programs

Coronary artery calcification and sarcopenia may have a relevant prognostic impact in oncological and non-oncological patients. The use of freeware software is promising for quantitative evaluation of these parameters after whole-body positron emission tomography (PET)/computed tomography (CT) and might be useful for one-stop shop risk stratification without additional radiation ionizing burden and further charges to health care costs. In this study, we compared two semiautomatic freeware software tools (Horos Medical Image software and LIFEx) for the assessment of coronary artery calcium (CAC) score and muscle mass in 40 patients undergoing whole-body PET/CT. The muscle areas obtained by the two software programs were comparable, showing high correlation with Lin’s concordance coefficient (0.9997; 95% confidence intervals: 0.9995–0.9999) and very good agreement with Bland–Altman analysis (mean difference = 0.41 cm2, lower limit = −1.06 cm2, upper limit = 1.89) was also found. For CAC score, Lin’s concordance correlation coefficient was 0.9976 (95% confidence intervals: 0.9965–0.9984) and in a Bland–Altman analysis an increasing mean difference from 8 to 78 by the mean values (intercept = −0.050; slope = 0.054; p < 0.001) was observed, with a slight overestimation of Horos CAC score as compared to LIFEx, likely due to a different calculation method of the CAC score, with the ROI being equal for the two software programs. Our results demonstrated that off-line analysis performed with freeware software may allow a comprehensive evaluation of the oncological patient, making available the evaluation of parameters, such as muscle mass and calcium score, that may be relevant for the staging and prognostic stratification of these patients, beside standard data obtained by PET/CT imaging. For this purpose, the Horos and LIFEx software seem to be interchangeable.

Which Suture to Choose in Hepato-Pancreatic-Biliary Surgery? Assessment of the Influence of Pancreatic Juice and Bile on the Resistance of Suturing Materials—In Vitro Research

(1) Background: The choice of appropriate surgical suture during operation is of great significance. Currently, there are no objective studies regarding the resistance of commonly used sutures in biliary tract surgery. (2) Methods: This fact leads one to conduct research concerning the resistance of the sutures (Polydioxanone, Poliglecaprone, Poliglactin 910, and their analogues coated with antibacterial triclosan) in the environment of sterile and contaminated bile and pancreatic juice. Tensile strength was tested at days 0, 7, 14, 21, and 28 of research. The study was performed in in vitro conditions for 28 days. (3) Results: Pancreatic juice and bile has a significant influence on the tensile strength of each suture. (4) Conclusions: The study indicated that sutures made of polydioxanone had the best qualities during the entire experiment.

The impact of nutritional status on pancreatic cancer therapy

INTRODUCTION

Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive disease with poor outcomes. One of the reasons for the dismal prognosis resides in its impressive ability to alter the nutritional status of patients who develop malnutrition, cachexia, anorexia, and sarcopenia in most cases. The ideal way to measure such changes in PDAC patients, in order to readily identify them and avoid complications or discontinuations of treatment is a relatively unexplored area. In addition, most PDAC patients experience pancreatic exocrine insufficiency (PEI) that contributes to the complex puzzle of malnutrition and that can be treated with Pancreatic Enzyme Replacement Therapy (PERT).

AREAS COVERED

We review current knowledge on the impact of nutritional status on both surgical and medical treatments for PDAC, reporting available data on the causes of malnutrition, characteristics, and advantages of different tools to investigate nutritional status and possible strategies to improve patient outcomes.

EXPERT OPINION

All PDAC patients should receive a careful nutritional assessment at diagnosis, and this should be repeated alongside their treatment path. Screening tools and biochemical variables or scores are associated with prognosis, but bioimpedance vector analysis (BIVA) and radiological assessment of body composition seem more accurate in predicting clinical outcomes and postoperative complications.

Robotic distal pancreatectomy reduces pancreatic fistula in patients without visceral obesity as compared to open distal pancreatectomy: A propensity score matching retrospective cohort study

BACKGROUND

Several studies have suggested an association between visceral obesity and adverse perioperative outcomes in pancreatic surgery. However, no study has reported the impact of visceral obesity on robotic pancreatic surgery. This study aimed to assess the impact of preoperative visceral obesity on clinically relevant postoperative pancreatic fistula (CR-POPF) in pancreatic ductal adenocarcinoma (PDAC) patients following robotic distal pancreatectomy (RDP) or open distal pancreatectomy (ODP).

METHODS

A retrospective analysis was performed on all patients who consecutively underwent RDP or ODP for PDAC. The visceral adipose tissue was measured on preoperative computed tomography (CT) images at the L3 vertebra level. A 1:1 propensity score matching method was used in the visceral obesity group and the nonvisceral obesity group to minimize the bias between RDP and ODP.

RESULTS

Between December 2011 and December 2018, a total of 445 patients were included. Visceral obesity (n = 219) was found to be associated with higher estimated blood loss (p = 0.033), a higher CR-POPF rate (p = 0.001), delayed drain removal (p = 0.005) and a longer length of stay (p = 0.033). In multivariable analysis, visceral obesity was an independent risk factor for CR-POPF (OR: 1.69; 95% CI 1.07-2.67, p = 0.024). Among patients without visceral obesity, the incidence of CR-POPF was lower among RDP than among ODP patients (11.27% vs. 23.87%, p = 0.028), and the difference remained after propensity score matching (9.52% vs. 26.98%, p = 0.011). However, there was no significant difference in the CR-POPF rate between RDP and ODP for visceral obesity patients.

CONCLUSION

In nonvisceral obesity patients, RDP had better perioperative outcomes than ODP, with a significantly lower CR-POPF rate. However, in visceral obesity patients, RDP showed equivalent CR-POPF rate when compared to ODP.

Relation of computed tomography features of the pancreatic tissue and development of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic density and steatosis detected in pre-operative computed tomography (CT) may be a risk factor for PF development after pancreatoduodenectomy (PD). There is insufficient data available on the relationship between PF and atherosclerosis in pancreatic vasculature of pancreatitis. This study aims to investigate whether PF development in patients undergoing PD can be predicted by preoperative CT findings.

MATERIAL-METHOD

Pancreas and spleen densities were measured on non-contrast CT images and pancreatic index (PI) was calculated to detect pancreatic steatosis. Pancreatic density and Wirsung diameter (WD) were measured on portal venous phase. Pancreatic fistulae were identified as biochemical leak (BL), grade B and grade C using ISGPF classification. The findings were compared between the fistula and non-fistula groups and ISGPF subgroups.

RESULTS

Of 148 patients, PF was detected on 31 (20.9%). In PF group, mean pancreatic density and PI were significantly lower than non-PF group, while pancreatic steatosis was detected at a higher rate. The WD was significantly narrower in the PF group. No significant relationship was found between the development of PF and the findings of atherosclerosis in the CT and SMA or acute pancreatitis. There was no significant difference between the PF subgroups for pancreas density.

CONCLUSION

In preoperative CT examinations, measuring the pancreatic density, PI index and WD can be used as a noninvasive quantitative method to predict the possibility of postoperative PF development.

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.

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.

A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct

BACKGROUND

We investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

METHODS

We investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography.

RESULTS

One hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m²) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤-3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019-5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m² vs 19.6 kg/m²; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (-9.6 Hounsfield units vs -4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively.

CONCLUSION

Deep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

[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.

Computed tomography-adjusted fistula risk score for predicting clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy: Training and external validation of model upgrade

BACKGROUND

To develop a modified Fistula Risk Score (FRS) for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) based on both FRS and contrast-enhanced computed tomography (CE-CT).

METHODS

In this multicenter retrospective analysis, we focused on 990 consecutive patients with pancreatoduodenectomy performed at four institutions between 2009 and 2019. The enhanced CT-FRS model initially targeted 26 pre- and intraoperative factors, including CT descriptors, FRS elements and clinical factors, using LASSO-penalized multivariable logistic regression for predicting CR-POPF events in discovery (n = 718) and externally validated (n = 272) datasets. Probabilities generated were further correlated with histologic features of pancreatic stumps in 356 patients. C-indices were analyzed to compare the predictive potential between the original FRS and the CT-FRS.

FINDINGS

CR-POPF developed in 112 (15.6%) and 36 (13.2%) patients in discovery and validation datasets, respectively. The final CT-FRS construct, incorporating remnant pancreatic volume (RPV), stump area, fat and atrophy scores by CT, and main pancreatic duct size, offered significantly greater overall predictability than the original FRS in discovery (C-index: 0.825 vs 0.794; p = 0.04) and validation (0.807 vs 0.741; p = 0.05) cohorts. Importantly, it outperformed the FRS in patients at moderate risk levels (FRS: 3-6), showing remarkably improved C-indices (discovery: 0.729 vs 0.626 [p<0.001], validation: 0.722 vs 0.573 [p = 0.006]). CT-FRS probabilities increased in conjunction with less extensive pancreatic fibrosis (p<0.001), ample glandular acini (p<0.001), and advanced lipomatosis (p<0.001).

INTERPRETATION

The enhanced CT-FRS performed significantly better than the original FRS in predicting CR-POPF occurrences after PD, especially at moderate FRS levels.

Prediction of clinically relevant pancreatic fistula after pancreatic surgery using preoperative CT scan: A systematic review and meta-analysis

BACKGROUND

Body composition analysis has emerged as a practical tool for predicting outcomes following pancreatic surgery. However, the impact of body composition disorders on clinically relevant postoperative pancreatic fistula (CR-POPF) remains inconclusive. The aim of this study was to review and analyse whether radiographically assessed body composition is predictive of CR-POPF.

METHODS

PubMed, MEDLINE, Web of Science, and the Cochrane Library databases were searched up to January 2020 to identify relevant studies. CR-POPF was defined according to the definition and grading system proposed by the International Study Group on Pancreatic Surgery (ISGPS). Pooled odds ratios (OR) for CR-POPF were calculated to evaluate the predictive values of radiographically assessed body composition.

RESULTS

Fifteen studies published between 2008 and 2019 with a total of 3136 patients were included. There was a significant increase in the incidence of CR-POPF in patients with visceral obesity (OR 2.97, 95% CI 2.05-4.29, P < 0.00001) and sarcopenic obesity (OR 2.88, 95% CI 1.31-6.34, P = 0.009). Conversely, the impact of sarcopenia (OR 0.91, 95% CI 0.65-1.28, P = 0.59) and low muscle attenuation (MA) on CR-POPF did not reach statistical significance.

CONCLUSION

Preoperative visceral obesity and sarcopenic obesity are more effective at predicting CR-POPF than decreased muscle quantity and quality. This finding may lead to appropriate management and early intervention of patients at risk of CR-POPF.

Risk factors and preventive measures for postoperative pancreatic fistula after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD), which can lead to slow recovery, deterioration, and even reoperation and death. At present, the mortality rate after PD has decreased, but the incidence of POPF is still high. Therefore, exploring the risk factors and prevention strategies for pancreatic fistula has become a hot research topic in pancreatic surgery. This paper summarizes the nature, risk factors, and preventive measures for POPF.

Prediction of clinically relevant Pancreatico-enteric Anastomotic Fistulas after Pancreatoduodenectomy using deep learning of Preoperative Computed Tomography

Rationale: Clinically relevant postoperative pancreatic fistula (CR-POPF) is among the most formidable complications after pancreatoduodenectomy (PD), heightening morbidity/mortality rates. Fistula Risk Score (FRS) is a well-developed predictor, but it is an intraoperative predictor and quantifies >50% patients as intermediate risk. Therefore, an accurate and easy-to-use preoperative index is desired. Herein, we test the hypothesis that quantitative analysis of contrast-enhanced computed tomography (CE-CT) with deep learning could predict CR-POPFs.

Methods: A group of 513 patients underwent pancreatico-enteric anastomosis after PD at three institutions between 2006 and 2019 was retrospectively collected, and formed a training (70%) and a validation dataset (30%) randomly. A convolutional neural network was trained and generated a deep-learning score (DLS) to identify the patients with higher risk of CR-POPF preoperatively using CE-CT images, which was further externally tested in a prospective cohort collected from August 2018 to June 2019 at the fourth institution. The biological underpinnings of DLS were assessed using histomorphological data by multivariate linear regression analysis.

Results: CR-POPFs developed in 95 patients (16.3%) in total. Compared to FRS, the DLS offered significantly greater predictability in training (AUC:0.85 [95% CI, 0.80-0.90] vs. 0.78 [95% CI, 0.72-0.84]; P = 0.03), validation (0.81 [95% CI, 0.72-0.89] vs. 0.76 [95% CI, 0.66-0.84], P = 0.05) and test (0.89 [95% CI, 0.79-0.96] vs. 0.73 [95% CI, 0.61-0.83], P < 0.001) cohorts. Especially in the challenging patients of intermediate risk (FRS: 3-6), the DLS showed significantly higher accuracy (training: 79.9% vs. 61.5% [P = 0.005]; validation: 70.3% vs. 56.3% [P = 0.04]; test: 92.1% vs. 65.8% [P = 0.013]). Additionally, DLS was independently associated with pancreatic fibrosis (coefficients: -0.167), main pancreatic duct (coefficients: -0.445) and remnant volume (coefficients: 0.138) in multivariate linear regression analysis (r² = 0.512, P < 0.001). The user satisfaction score in the test cohort was 4 out of 5.

Conclusions: Preoperative CT based deep-learning model provides a promising novel method for predicting CR-POPF occurrences after PD, especially at intermediate FRS risk level. This has a potential to be integrated into radiologic reporting system or incorporated into surgical planning software to accommodate the preferences of surgeons to optimize preoperative strategies, intraoperative decision-making, and even postoperative care.

The 2019 ESPEN Arvid Wretlind lecture perioperative nutritional and metabolic care: Patient-tailored or organ-specific approach?

BACKGROUND & AIM

The perioperative severe changes in the nutritional and metabolic homeostasis are, by some means, proportional to the extent of tissue injury and magnitude of operative trauma. An adequate qualitative and quantitative replacement of nutritional substrates are of utmost importance to facilitate proper tissue healing and recovery and maintenance of organ function after surgery.

METHODS

The present manuscript has been planned to put the most recent research of the Milano-Bicocca University surgical working group in the context of a more personalized nutritional therapy and metabolic care for surgical patients. Particular prominence has been given to major pancreatic resections because these surgeries are among the most complex and challenging operations for the degree of parenchyma resection and tissue dissection, the consequent overall injury, and the fairly high rate of major complications resulting in a catabolic response.

RESULTS

Anthropometric parameters and particularly sarcopenia, visceral obesity - and their relative proportion -, are strongly associated with poor outcome after pancreatic surgery. Adequate perioperative nutritional therapy is of utmost importance in affecting morbidity. Long-term nutritional and metabolic sequelae, caused by exocrine pancreatic insufficiency, need to be promptly recognized and treated with an adequate enzyme supplementation.

CONCLUSIONS

There is strong evidence sustaining the necessity of proper perioperative metabolic and nutritional care into the management of patients undergoing major pancreatic surgery.

[Contrast-enhanced computed tomography in evaluation of pancreatic stump volume in pancreaticoduodenectomy]

OBJECTIVE

To analyze the role of contrast-enhanced computed tomography in evaluation of pancreatic stump volume for prediction of significant pancreatic fistula.

MATERIAL AND METHODS

A retrospective analysis enrolled 99 patients. Patients were divided into 2 groups depending on the course of postoperative period and development of clinically significant pancreatic fistula. The first group included 24 patients (25%) with clinically significant postoperative pancreatic fistula. The second group included 75 patients (75%) without postoperative complications. Pancreatic structure, pancreatic parenchyma thickness (mm), pancreatic duct diameter (mm) and volume of pancreatic stump (cm³) were preoperatively analyzed considering contrast-enhanced computed tomography data.

RESULTS

The risk of postoperative pancreatic fistula is 10 times higher in case of soft structure of the pancreas, 1,7 times higher in decrease of pancreatic duct diameter, 9,3 times higher in increased volume of residual pancreatic parenchyma, 8.6 times higher in increase of pancreatic parenchyma thickness.

CONCLUSION

Contrast-enhanced computed tomography is valuable for preoperative evaluation of the volume of residual pancreatic parenchyma and identification of patients with high risk of postoperative pancreatic fistula.

Impact of the preoperative body composition indexes on intraoperative blood loss in patients undergoing pancreatoduodenectomy

PURPOSES

This study sought to identify any significant predictors of blood loss during pancreatoduodenectomy (PD) among preoperative variables, including the body composition indexes.

METHODS

The preoperative data of patients undergoing PD were retrospectively reviewed. The objective variable was the percentage of blood loss during PD to the estimated circulating blood volume (proportional blood loss: PBL). The circulating blood volume was estimated using Nadler's formula. The total psoas area, average Hounsfield units of psoas area (psoas muscle density: PMD), and visceral to subcutaneous adipose tissue area ratio (VSR) were measured at the third vertebra using preoperative plain computed tomography images. A univariate analysis and multiple linear regression analysis for PBL were conducted using the preoperative variables.

RESULTS

A total of 415 patients were analyzed. The median PBL was 24.5%. The PMD (coefficient - 0.267; 95% CI - 0.518, - 0.015), VSR (coefficient 2.719; 95% CI 0.238, 5.201), serum albumin level (coefficient - 8.458; 95% CI - 13.02, - 3.898), neoadjuvant therapy (coefficient 9.605; 95% CI 1.722, 17.49), and prothrombin time-international normalized ratio (PT-INR, coefficient 38.63; 95% CI 10.94, 66.31) were independently associated with PBL.

CONCLUSIONS

The preoperative PMD, VSR, serum albumin level, neoadjuvant therapy, and PT-INR independently affected PBL. These factors could therefore be potential targets to reduce blood loss during PD.

Pancreatic Fat and Body Composition Measurements by Computed Tomography are Associated with Pancreatic Fistula After Pancreatectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the most threatening complication after pancreatectomy. This study aimed to directly assess pancreatic fatty infiltration with preoperative computed tomography (CT) imaging and to investigate whether a preoperative analysis of patient variables, including CT characteristics and clinical factors, can predict POPF.

METHODS

We enrolled 150 consecutive patients who underwent curative pancreatectomy. Radiographic factors, including pancreatic fat volume, were measured using preoperative CT imaging and the predictive factors were explored using univariate and multivariate analyses.

RESULTS

POPF developed in 30 patients (20.0%). The ratio of pancreatic fat (RPF) ≥ 4.83% was associated with a risk of POPF, high body mass index (BMI), and obese body habitus. Patients with POPF were significantly more likely to have high BMI (≥ 25 kg/m²), obese body habitus, and an RPF ≥ 4.83% than patients without POPF. In the multivariate analysis, visceral fat area/skeletal muscle index (VFA/SMI) ≥ 1.94 (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.43-12.9, p = 0.0095) was the sole independent predictive factor for POPF. For patients with a soft pancreas, VFA/SMI ≥ 1.94 (OR 5.67, 95% CI 2.05-15.7, p = 0.0008) was again the sole independent predictive factor for POPF.

CONCLUSION

Preoperative CT images can examine pancreatic fatty infiltration, and patients who had POPF were significantly associated with a high RPF. Among several parameters, VFA/SMI was the only independent predictive factor for clinically relevant POPF. Preoperative evaluation of these body composition variables and the pancreatic configuration could be useful for predicting POPF.

Preoperative fecal elastase-1 (FE-1) adds value in predicting post-operative pancreatic fistula: not all soft pancreas share the same risk - A prospective analysis on 105 patients

BACKGROUND

Scores predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) mainly use intraoperative predictors. The aim of this study is to investigate the role of pancreatic exocrine function expressed by fecal elastase (FE-1) as preoperative predictor of POPF.

METHODS

Patients scheduled for PD at the Department of General and Pancreatic Surgery, University of Verona Hospital, from April 2017 to July 2018 were prospectively enrolled. FE-1 was measured in a preoperative stool sample through an ELISA test.

RESULTS

The study population consisted of 105 patients. The POPF rate was 17.1%. Patients developing POPF showed high values of FE-1 (454 vs 155 mcg/g; p < 0.01), and FE-1 was an independent predictor of POPF (OR 1.008, CI 95% 1.003-1.014; p < 0.01), even considering only patients with a "soft" texture. A cut-off value of 260 mcg/g presented 100% sensitivity and 64.3% specificity (AUC 0.83) in predicting POPF. Approximately 30% of patients with a "soft" pancreatic texture presented with FE-1 < 260 mcg/g and did not develop POPF.

CONCLUSION

FE-1 is a promising tool to preoperatively assess the risk of POPF after PD. Further studies with larger populations are needed to potentially incorporate FE-1 into risk scores for PD with better stratification.

Significance of fistulography findings to the healing time of postoperative pancreatic fistula after pancreaticoduodenectomy

PURPOSE

Pancreatic fistula (PF) is a common and serious complications after pancreaticoduodenectomy (PD). However, few studies have discussed the time required for PF healing in patients with this complication. This study investigates the PF healing time (PF-HT) and its association with findings of postoperative fistulography performed via the drainage tubes.

METHODS

The subjects of this study were 35 patients with PF among a total of 144 patients who underwent PD for periampullary diseases in our hospital. PF-HT, which was defined as the duration from the first postoperative fistulography to removal of the drainage tubes, was assessed in the enrolled patients. Fistulography findings were classified into four types based on fluid collection and communication with the jejunal loop. We investigated the factors affecting the PF-HT, including the fistulography findings.

RESULTS

The average PF-HT was 22 ± 20 days. Multivariate analysis revealed that the fistulography type was the only independent factor that affected PF-HT significantly. The PF-HT was significantly shorter in patients without fluid collection than in those with fluid collection. Moreover, those patients with fluid collection and a communication had a significantly shorter PF-HT than those without a communication.

CONCLUSIONS

We found that fistulography findings were significantly associated with the PF-HT. This suggests that fistulography findings could help to predict the time needed for PF healing.

Body composition assessment and sarcopenia in patients with pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Numerous studies have suggested an association between sarcopenia in pancreatic cancer and adverse outcomes. This systematic review examines the evidence for the impact of sarcopenia on post-operative complications and survival METHODS: A systematic literature search was conducted to identify randomised and non-randomised studies of sarcopenia in pancreatic cancer. Meta-analyses of intra- and post-operative outcomes were performed (operating time, all complications, major complications, pancreatic fistulae, peri-operative mortality, overall survival).

RESULTS

Forty-two studies reported the assessment of body composition in 7619 patients. Methods used to assess body composition in patients with pancreatic cancers were computerized tomography (n = 34), bioelectrical impedance analysis (n = 7), and dual-energy-X-ray-absorptiometry (n = 1). Only 10 studies reported the impact of pre-operative sarcopenia upon post-operative outcomes. Sarcopenia was associated with increased peri-operative mortality (OR: 2.40, CI_95%:1.19-4.85, p < 0.01) and decreased overall survival by univariable (HR: 1.95, CI_95%:1.35-2.81, p < 0.001) and multivariable analysis (HR: 1.78, CI_95%:1.54-2.05). Sarcopenia was not significantly associated with all complications (OR: 0.96, CI_95%:0.78-1.19) or pancreatic fistula (OR: 0.95, CI_95%: 0.59-1.54).

CONCLUSIONS

Assessment of sarcopenia in pancreatic cancer provides prognostic value but, more importantly, may provide a basis for therapeutic intervention. However, variation in the methods of assessing and reporting sarcopenia in this patient group limits the assessment of post-operative outcomes currently.

Morphological changes of the pancreas after pancreaticoduodenectomy

The aim of this retrospective study was thus to evaluate postoperative morphological changes in the remnant pancreas after pancreaticoduodenectomy (PD) associated with postoperative pancreatic fistula (POPF). Fifty-one patients subjected to PD were enrolled in the study and allocated into 2 groups according to the presence (n = 16) or absence of POPF (n = 35). A morphological evaluation of the pancreas was conducted for up to a 20 months follow-up on CT scans and compared between groups. No significant differences were observed in morphology between the groups at the different preoperative and PO intervals, regardless of the clinical relevance of the POPF or POPF grade. However, in the overall patient analysis we observed a significant reduction of the entire pancreas over time. In fact, thickness decreased 0.4 mm/month, length 1.2 mm/month and volume 1.17 cm³/month over the PO. The impact of age, POPF, type of anastomosis, surgical technique and PO follow-up (time) was evaluated in a multivariate analysis using the general linear model, but only PO follow-up had a significant influence on the final model (p < 0.001). A significant reduction on pancreatic parenchyma (thickness, length and volume) occurs after PD with no significant differences between patients with or without POPF.

Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy-Stratification of Patient Risk

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). We sought to develop and validate a risk score system that utilized preoperative computed tomography (CT) measurements, laboratory values, and intraoperative pancreatic texture to estimate risk of developing POPF after PD.

METHODS

Patients who underwent PD between 2014 and 2017 were identified. Pre- and intraoperative risk factors associated with POPF were identified. Three separate risk models were developed and assessed using multivariable analyses and receiver operating curves.

RESULTS

Among the 150 patients who underwent a PD, mean age was 64 years and the majority of the patients were male (59.3%, n = 89). Overall, the incidence of BL/POPF following PD was 22%. On multivariable analysis, factors associated with POPF included preoperative total serum protein < 6 g/dL (OR 3.35, 95% CI 1.04-10.34, p = 0.04), radiologic pancreatic duct diameter (OR 0.72, 95% CI 0.53-0.97, p = 0.03), intraoperative pancreatic gland texture estimated by surgeon (OR 0.17, 95% CI 0.05-0.62, p = 0.006), as well as intraoperative pancreatic duct diameter measured by surgeon (OR 0.77, 95% CI 0.61-0.98, p = 0.030). Each risk factor was assigned a weighted score (CT pancreatic duct diameter < 5 mm: 8 points; soft pancreatic gland texture: 5 points; total serum protein < 6 g/dL: 3 points; CT visceral abdominal fat ≥ 230 cm2: 2 points). Patients scoring 4-5 were at low risk of POPF, while patients with a score of 6-18 had a high risk for POPF. The Harrell's c-index for the scoring system was 0.71 (standard error [SD] 0.094) for the training set and 0.67 (SD 0.034) for the test set (with n = 1000 bootstrapping resamples).

CONCLUSION

A simple risk score for POPF that utilized preoperative radiologic and clinical variables combined with specific intra-operative factors was able to stratify patients relative to POPF risk with good discriminatory ability.

Preoperative Evaluation of Pancreatic Fibrosis and Lipomatosis: Correlation of Magnetic Resonance Findings With Histology Using Magnetization Transfer Imaging and Multigradient Echo Magnetic Resonance Imaging

OBJECTIVES

The purpose of this study was to evaluate the diagnostic performance of magnetization transfer (MT) imaging and multigradient echo magnetic resonance imaging (MRI) to quantify pancreatic fibrosis and lipomatosis in patients before pancreatoduodenectomy for postoperative risk stratification with histopathology as the reference standard.

MATERIALS AND METHODS

Twenty-four patients (age, 68 ± 8 years, 16 males) prospectively underwent quantitative MT imaging using a 2-dimensional gradient echo sequence with and without MT prepulse and multigradient echo imaging on a 3 T MRI 1 day before pancreatoduodenectomy due to adenocarcinoma of the pancreatic head region (n = 20), neuroendocrine tumor (n = 3), or intraductal papillary mucinous neoplasm (n = 1). Magnetization transfer ratio (MTR) and proton density fat fraction (PDFF) were measured in pancreatic tail (PT) and at the resection margin (RM). Histopathologically, pancreatic fibrosis was graded as mild, moderate, or severe (F1-F3), lipomatosis was graded as 0% to 10%, 11% to 30%, and greater than 30% fat deposition (L1-L3). In addition, MTR and histopathologic fibrosis was assessed in pancreatic adenocarcinoma. Mann-Whitney U test and Spearman correlation were used.

RESULTS

Patients with advanced pancreatic fibrosis (F3) showed a significantly higher MTR compared with the F1 group at the RM and PT (38 ± 4 vs 32.3 ± 1.6, P = 0.018 and 39.7 ± 5.5 vs 31.2 ± 1.7, P = 0.001). Spearman correlation coefficient of MTR and fibrosis grade was r = 0.532 (P = 0.011) and 0.554 (P = 0.008), respectively. Pancreatic parenchyma with advanced fat deposition (L2-L3) showed significantly higher PDFF compared with lipomatosis grade L1 (RM: P = 0.002 and PT: P = 0.001). Proton density fat fraction of pancreatic parenchyma exhibited a moderate and significant correlation with histopathologic lipomatosis grade (RM: r = 0.668 and PT: r = 0.707, P < 0.001). Magnetization transfer ratio was significantly higher in pancreatic adenocarcinoma compared with pancreatic parenchyma (44 ± 5.5 vs 36.0 ± 4.4 and 37.4 ± 5.4, P = 0.004).

CONCLUSIONS

Multiparametric MRI of the pancreas including MTR and PDFF maps may provide quantitative and noninvasive information on pancreatic fibrosis and lipomatosis before surgery.

Remnant pancreatic volume as an indicator of poor prognosis in pancreatic cancer patients after resection

BACKGROUND

Remnant pancreatic volume (RPV) is a well-known marker for short-term outcomes in pancreatic cancer patients after resection. However, in terms of the long-term outcomes, the significance of the RPV value remains unclear. Here, we address whether the RPV value is a predictor of the long-term outcomes in pancreatic cancer patients after resection by comparing various cancer-, patient-, and surgery-related prognostic factors and systemic inflammatory response markers in a retrospective cohort.

METHODS

The RPV was measured on a three-dimensional (3D) image, revealing the actual pancreatic parenchymal remnant volume. Ninety-one patients who underwent pancreaticoduodenectomy were retrospectively enrolled. We divided the cohort into high- and low-RPV groups based on a cut-off value (>31.5 cm³, n = 66 and ≤31.5 cm³, n = 25, respectively). The median survival times (MSTs) were compared between the two groups. Using multivariate analysis, the RPV and other well-known prognostic factors were independently assessed.

RESULTS

The MSTs (days) were significantly different between the two groups (high, 823 vs. low, 482, p = 0.001). Multivariate analysis identified the RPV (≤31.5 cm³) (hazard ratio [HR], 2.015; p = 0.011), lymph node metastasis (HR, 8.415; p = 0.002), lack of adjuvant chemotherapy (HR, 5.352; p < 0.001), stage III/IV disease (HR, 2.352; p = 0.029), and pathological fibrosis (HR, 1.771; p = 0.031) as independent prognostic factors.

CONCLUSIONS

The present study suggests that the RPV value is also useful for predicting long-term outcomes in pancreatic cancer patients after resection.

Body composition changes after left gastric artery embolization in overweight and obese individuals

PURPOSE

To determine the effects of left gastric artery embolization (LGAE) on computed tomography (CT) body composition change.

MATERIALS AND METHODS

Sixteen overweight or obese patients who had abdominal CT scans before and after LGAE for gastric bleeding were retrospectively reviewed. Body composition analysis was performed with semiautomated imaging processing algorithms (MATLAB 13.0, Math Works, MA). Adipose tissue and lean skeletal muscle were measured using threshold attenuation values. Total body fat index (BFI), subcutaneous fat index (SFI), visceral fat index (VFI), intramuscular fat index (IMFI), and skeletal muscle index (SMI) were determined ([tissue area (cm)]²/[height (m)]²). Excess body weight (EBW) was determined based on the Lorentz formula for ideal body weight.

RESULTS

Mean follow-up was 1.5 ± 0.8 months. Following LGAE, patients experienced significantly decreased body weight (p = 0.003), BMI (p = 0.005), EBW (p = 0.003), BFI (p = 0.03), SFI (p = 0.03), and SMI (p < 0.001). Changes in VFI and IMFI did not significantly change (p = 0.13 and p = 0.83, respectively).

CONCLUSIONS

Patients who underwent LGAE had significant unintended weight loss as a result of decreased body fat and skeletal muscle. Body composition analysis can readily assess the extent of fat loss and identify muscle wasting.

Predicting post-operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review

BACKGROUND

Post-operative pancreatic fistulae (POPF) remain a major contributor to morbidity and mortality following pancreatic resection. Evidence for preoperative prediction of POPF based on cross-sectional imaging has not been systemically reviewed. This review aimed to determine whether preoperative imaging modalities can accurately predict the development of POPF.

METHODS

A systematic review of major reference databases was undertaken, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to May 2018.

RESULTS

There were 18 studies (2150 patients), seven used magnetic resonance imaging (MRI), five used computed tomography (CT) scans, four used transabdominal ultrasonography and one study each used MRI and CT and endoscopic ultrasonography elastography. All were retrospective, single-centre studies. Intensity of the pancreas signal relative to the spleen, liver or muscle was commonly used. Other studies compared signal intensity between unenhanced and post-contrast-enhanced pancreas, apparent diffusion coefficient values comparing normal parenchyma to fibrosis, perfusion fraction (f) of intravoxel incoherent motion diffusion-weighted imaging, or utilized a muscle-normalized signal intensity curve with signal intensity ratio or directly assessed pancreatic volume and duct width. Shear wave velocity measurement on transabdominal ultrasonography may reflect pancreas tissue fibrosis or stiffness and predict POPF. Most parameters used to predict the development of POPF were based on identifying imaging features of a fatty or fibrotic pancreas and main pancreatic duct diameter.

CONCLUSION

A number of different and highly promising parameters have been used for preoperative prediction of POPF using ultrasound, MRI, CT or both. Large multicentre prospective studies are needed to determine which parameters most accurately predict POPF, using standardized definitions and methodology.

Predictive value of sarcopenia and visceral obesity for postoperative pancreatic fistula after pancreaticoduodenectomy analyzed on clinically acquired CT and MRI

OBJECTIVE

To evaluate predictive values of sarcopenia and visceral obesity measured from preoperative CT/MRIs for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy in patients with periampullary malignancies.

METHODS

From the prospectively constructed surgical registry, we included adult patients treated with pancreaticoduodenectomy. Based on CT/MRIs, body morphometric analysis was performed to evaluate the visceral obesity and sarcopenia, based on the areas of visceral fat and skeletal muscle measured at the L3 vertebrae level. We retrieved various perioperative factors from registry. As outcomes of postoperative complications, we evaluated POPF and major complications based on the Clavien-Dindo classification. Multivariate logistic regression analyses were performed.

RESULTS

From a total of 284 patients (163 males, 121 females) who met the inclusion/exclusion criteria, POPF, major complications, and 60-day mortality occurred in 52 (18.3%), 34 (12.0%), and 6 (2.1%), respectively. Sarcopenia and visceral obesity were noted in 123 (75.5%) and 66 (40.5%) of men and 68 (56.2%) and 53 (43.8%) of women, respectively. Combination of sarcopenia and obesity (sarcopenic obesity) was noted in 31.9% (52/163) of men and in 26.4% (32/121) of women. In multivariate logistic regression analyses, sarcopenic obesity was the only independent predictor for POPF (OR 2.65, 95% CI 1.43-4.93), and the vascular resection during pancreaticoduodenectomy was the only independent predictor for severe complications (OR 3.75, 95% CI 1.61-8.70).

CONCLUSION

Sarcopenic obesity might be highly predictive for POPF. Body morphometric analysis in preoperative CT/MRI combined with assessment of perioperative clinical features may help to identify high-risk patients and determine perioperative management strategies.

KEY POINTS

• Sarcopenic obesity might be predictive for postoperative pancreatic fistula after pancreaticoduodenectomy. • The vascular resection during pancreaticoduodenectomy might be predictive of major complications. • Body morphometric analysis might be helpful for identifying high-risk patients.

Endoluminal radiofrequency ablation of the main pancreatic duct is a secure and effective method to produce pancreatic atrophy and to achieve stump closure

Radiofrequency energy has been used both experimentally and clinically to manage the pancreatic remnant after distal pancreatectomies. Our goal was to determine whether endoluminal radiofrequency (RF) ablation of the main pancreatic duct in large animals would be more efficient than glue occlusion as an exocrine pancreatic atrophy-inducing procedure. Thirty-four Landrace pigs were assigned to either the transpapilar (n = 16) or transection (n = 18) groups. The transection implied the pancreas neck was severed. In each of these groups the remaining distal pancreatic duct was occluded either by RF or by glue. In the transpapilar group complete atrophy was observed in all the RF cases, while atrophy was incomplete in all the members of the glue subgroup. The failure rate of the main pancreatic duct (usually expressed by a pseudocyst) in the transection groups was dramatically higher in the glue subgroup than the RF subgroups (9 out of 9 and 1 out of 9, respectively) and postoperative mortality occurred only in the glue subgroup (3 out of 9). These results show the superiority of endoluminal RF ablation over glue for main pancreatic duct occlusion, as seen by the degree of atrophy and fewer postoperative pancreatic fistulas.

Malnutrition, frailty, and sarcopenia in pancreatic cancer patients: assessments and interventions for the pancreatic surgeon

The objective of this article is to review the available literature examining the impact of malnutrition, frailty, and sarcopenia on surgical morbidity among pancreatic cancer patients. We examine definitions used to diagnose and quantify these conditions and review the differences between them with regards to preoperative assessment and postoperative outcomes. The most relevant scoring systems are summarized. Lastly, we summarize current knowledge regarding effectiveness of specific interventions aimed at malnutrition, frailty, and sarcopenia for patients undergoing pancreatic cancer surgery.

Factors affecting healing time of postoperative pancreatic fistula in patients undergoing pancreaticoduodenectomy

Clinically-relevant postoperative pancreatic fistula (CR-POPF) is one of the most serious complications following pancreaticoduodenectomy. While many investigators have studied risk factors for the development of CR-POPF, few studies have focused on time needed for CR-POPF healing in patients who develop this complication. The present study enrolled 38 cases in whom CR-POPF developed following pancreaticoduodenectomy (24.1%) out of 158 cases receiving treatment with pancreaticoduodenectomy between 2009 and 2017 for periampullary diseases. CR-POPF healing time, was defined as the length of time from the day of pancreaticoduodenectomy to the day when intraabdominal drainage tubes used for CR-POPF treatment were removed, were assessed and factors affecting the healing time were investigated. The mean CR-POPF healing time was 40.2±21.7 days (median; 35 days, range; 10-110 days). Univariate analysis demonstrated a significant relationship between CP-POPE healing time and sex, intraoperative blood loss, and type of pancreaticojejunostomy procedure. Multivariate Cox regression analysis using these factors revealed that intraoperative blood loss and type of pancreaticojejunostomy procedure were significant independent factors for the length of CR-POPF healing time. CR-POPF healing time following pancreaticoduodenectomy was 40.2±21.7 days on average (median, 35 days; range 10-110 days). Intraoperative blood loss and type of pancreaticojejunostomy procedure were identified as significant independent factors associated with the healing time. These results will help with earlier recovery from CR-POPF.

Association of fatty pancreas with pancreatic endocrine and exocrine function

Aim

The purpose of this study was to clarify whether fatty pancreas might lead to impaired pancreatic endocrine or exocrine function.

Material and methods

The study involved 109 participants who had undergone the glucagon stimulation test and N-benzoyl-L-tyros-p-amino benzoic acid (BT-PABA) test to assess pancreatic function as well as unenhanced abdominal computed tomography (CT). Pancreatic endocrine impairment was defined as ΔC peptide immunoreactivity less than 2 [mmol/L] in the glucagon stimulation test, and pancreatic exocrine impairment was defined as a urinary PABA excretion rate less than 70% on the BT-PABA test. We defined as the mean CT value of pancreas / CT value of spleen (P/S ratio) as a marker to assess fatty pancreas. We analyzed the association between fatty pancreas and pancreatic impairment using the logistic regression model. The odds ratio (OR) is shown per 0.1 unit.

Results

Pancreatic endocrine function was impaired in 33.0% of the participants, and 56.9% of those were regarded as having pancreatic exocrine impairment. The P/S ratio was significantly correlated with pancreatic endocrine impairment in univariate analysis (OR = 0.61, 95% confidence interval (CI) = 0.43–0.83, P = 0.0013) and multivariate analysis (OR = 0.38, 95% CI = 0.22–0.61, P < .0001) for all participants. Similar significant relationships were observed in both univariate (OR = 0.70, 95% CI = 0.49–0.99, P = 0.04) and multivariate (OR = 0.39, 95% CI = 0.21–0.66, P = 0.0002) analyses for the participants without diabetes (n = 93). The amount of pancreatic fat was not associated with exocrine impairment in univariate analysis (OR = 0.80, 95% CI = 0.59–1.06, P = 0.12).

Conclusion

Fatty pancreas was associated with pancreatic endocrine impairment but did not have a clear relationship with pancreatic exocrine impairment.

Three-Dimensional Remnant Pancreatic Volumetry Predicts Postoperative Pancreatic Fistula in Pancreatic Cancer Patients after Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a serious complication that can occur following pancreaticoduodenectomy (PD). Recent studies suggest that remnant pancreatic volume (RPV) values from preoperative multidetector computed tomography (MDCT) are highly predictive of POPF. We performed three-dimensional (3D) surgical simulation of PD including RPV measurements. The aim of this study was to determine whether 3D-measured RPV is predictive of POPF after PD.

Methods

We used the SYNAPSE VINCENT® medical imaging system (Fujifilm Medical Co., Ltd., Tokyo, Japan) to construct 3D images after integrating MDCT and magnetic resonance cholangiopancreatography images. RPV was measured using this 3D image, which simulated actual intraoperative pancreatic parenchymal remnant volume. Ninety-one patients who underwent PD were retrospectively enrolled. Using multivariate analysis, RPV and other well-known POPF risk factors were independently assessed.

Results

Multivariate analysis identified high RPV values (hazard ratio [HR] = 8.41, p = 0.01), pancreatic duct diameter < 3.0 mm (HR = 5.48, p < 0.01), no pathological fibrosis (HR = 3.41, p < 0.01), and body mass index > 25 kg/m² (HR = 1.53, p = 0.02) as independent risk factors for POPF.

Conclusion

The present study indicates that preoperative 3D-measured RPV is predictive of POPF after PD.

Impact of preoperative sarcopenia on postoperative outcomes following pancreatic resection: A systematic review and meta-analysis

BACKGROUND

Morphometric analysis of sarcopenia has garnered interest due to its putative role in predicting outcomes following surgery for a variety of pathologies, including resection for pancreatic disease. However, there are no standard recommendations on whether sarcopenia is a clinically relevant predictor of outcomes in this setting. The aim of this study was to review the prognostic impact of preoperatively diagnosed sarcopenia on postoperative outcomes following pancreatic resection.

METHODS

A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases until May 2018.

RESULTS

Thirteen studies, including 3608 patients, were included. There was a significant increase in the mean duration of post-operative hospital stay (mean difference of 0.73 days, CI: 0.06-1.40, P = 0.033), there was no difference in the postoperative outcomes, including: clinically relevant postoperative pancreatic fistula, delayed gastric emptying, post-operative bile leak, surgical site infection, significant morbidity and overall morbidity.

CONCLUSION

Preoperative sarcopenia is associated with prolonged hospital stay after pancreatic surgery. However, sarcopenia does not appear to be a significant negative predictive factor in postoperative morbidity although study heterogeneity and risk of bias limit the strength of these conclusions.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

BACKGROUND

The optimal nutritional therapy in the field of pancreatic surgery is still debated.

METHODS

An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group.

RESULTS

The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement.

CONCLUSION

The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.