Perfusion CT in predicting deep pancreatic necrosis and planning early interventions for severe acute pancreatitis

Aim. To explore the potential of perfusion CT for predicting deep pancreatic necrosis and duct injury as well as for determining treatment strategy.  

Materials and methods. The prospective study included 74 patients hospitalized within 1–2 days of acute pancreatitis. They were exposed to perfusion CT and examination of their arterial blood flow velocity. In 37 observations, a standard CT was also performed on day 3–9 to study the depth and configuration of the necrosis. The severity of acute pancreatitis was assessed according to standard integral scoring systems, organ failure and severity of peripancreatitis. The alfa-amylase activity in fluid collections was examined.  

Results. Necrosis was detected in 20 patients: deep necrosis – in 11 cases, shallow – in 9. 17 patients did not reveal necrosis. Necrosis configuration of type 1 was detected in 16 patients, type 2 – in 4. Deep necrosis was preceded by a significant decrease in the arterial blood flow velocity: 39–52 ml/min/100 ml. This rate was greater in patients with shallow necrosis and without necrosis: 72–100 and 95–117 ml/min/100 ml (p < 0.001). In cases of deep necrosis, advanced peripancreatitis was formed, organ failure was noted in 9 patients, 3 patients died. Internal pancreatic fistula was detected in 7 out of 9 patients with deep necrosis and in 1 out of 6 patients with shallow necrosis and type 1 configuration. In cases of necrosis type 2 configuration the pancreatic fistula was not noted. Minimally invasive interventions and transformation of the internal fistula into the external one were performed in 12 out of 20 patients: percutaneous drainage of fluid collections – in 9 observations, stenting of the pancreatic duct – in 3.  

Conclusion. Perfusion CT can be used to predict pancreatic necrosis on day 1–2 of the disease. A decrease in the arterial blood flow velocity in the range of 39–52 ml/min/100 ml is associated with the risk of parenchyma deep necrosis and duct injury. This parameter can be taken into account when determining indications for early minimally invasive interventions. 

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