Diagnostic criteria for a “soft” pancreas and their influence on the occurrence of pancreatic fistula after pancreatoduodenal

Purpose. Identification of the possibilities of contrast enhancement computed tomography in evaluated the number of the acinar structures in the pancreatic parenchyma at the preoperative stage to predict the development pancreatic fistula.

Material and methods. In 2016–2019, 196 pancreatoduodenectomy were performed. 86 patients were retrospectively selected. Patients were divided into 2 groups: group 1 included 16 observations with the development of clinically significant pancreatic fistula, in 2 – 70 cases without complications. According to preoperative contrast enhancement computed tomography, structure of the pancreas, pancreatic parenchyma thickness, pancreatic duct diameter, the density of the pancreas in the native phase, relative parenchyma enhancement ratio, washout coefficient, pancreas stump volume were evaluated. According histological, the number of acinar and fat cells in the section of the removed pancreas was evaluated.

Results. “Soft” structure of the pancreas (r = 0.374, p = 0.000), pancreatic parenchyma thickness (r = 0.549, p = 0.000), the density of the pancreas in the native phase of the scan (r = 0.568, p = 0.000), the values relative parenchyma enhancement ratio (r = 0.63, p = 0.000), pancreas stump volume (r = 0.508, p = 0.000) positively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic duct diameter (r = −0.339, p = 0.001) negatively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic fistula risk is 3.09 times higher with the number of acini more than 72.5%, sensitivity 75%, specificity 75.71%. Pancreatic fistula risk is 1.8 times higher with the density of the pancreas in the native phase over 35.5 HU sensitivity 62%, specificity 65%. Pancreatic fistula risk is 2.76 times higher with values parenchyma accumulation coefficient more than 1, sensitivity 75%, specificity 73%.

Conclusions. Contrast enhancement computed tomography allows evaluating acinar index in the preoperative period to pick out the high-risk patient group to development of pancreatic fistula.

1. Buchler M.W., Friess H., Wagner M., Kulli C.., Wagener V., Z`graggen K. Pancreatic fistula after pancreatic head resection. Br. J. Surg. 2000; 87 (7): 883–889. https://doi.org/10.1046/j.1365-2168.2000.01465.x

2. Diener M.K., Knaebel H.P., Heukaufer C., Antes G., Büchler M.W., Seiler C.M. A systematic review and metaanalysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann. Surg. 2007; 245 (2): 187–200. https://doi.org/10.1097/01.sla.0000242711.74502.a9

3. Ahtanin E.A., Kriger A.G. Causes and prevention of pancreatic fistulas after pancreas resection. Pirogov Russian Journal of Surgery = Khirurgiya. Zhurnal imeni N.I. Pirogova. 2014; 5: 79–83. (In Russian)

4. Raty S., Sand J., Lantto E., Nordback I. Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy. J.Gastro intest. Surg. 2006; 10 (8): 1131–1139. https://doi.org/10.1016/j.gassur.2006.05.012

5. Iacono C., Verlato G., Ruzzenente A., Campagnaro T., Bacchelli C., Valdegamberi A., Bortolasi L., Guglielmi A. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br. J. Surg. 2013; 100 (7): 873–885. https://doi.org/10.1002/bjs.9136

6. Berger A.C., Howard T.J., Kennedy E.P., Sauter P.K., BowerCherry M., Dutkevitch S., Hyslop T., Schmidt M., Rosato E.L., Lavu H., Nakeeb A., Pitt H.A., Lillemoe K.D.,Yeo C.J. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J. Am. Coll. Surg. 2009; 208 (5): 738–747. discussion 747–749. https://doi.org/10.1016/j.jamcollsurg.2008.12.031.

7. Bassi C., Marchegiani G., Dervenis C., Sarr M., Hilal M.A., Adham M., Allen P., Andersson R., Asbun H.J., Besselink M.G., Conlon K., Chiaro M.D., Falconi M., Fernandez-Cruz L., Castillo C.F., Fingerhu Abe., Friess H., Gouma D., Buchler M. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017; 161 (3): 584–591. https://doi.org/10.1016/j.surg.2016.11.014

8. Callery M.P., Pratt W.B., Kent T.S., Chaikof E.L., Vollmer C.M. Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. Am. Coll. Surg. 2013; 216 (1): 1–14. https://doi.org/10.1016/j.jamcollsurg.2012.09.002.

9. Stepan E.V., Ermolov A.S., Rogal' M.L., Teterin Y.S. External pancreatic fistulas management. Pirogov Russian Journal of Surgery = Khirurgiya. Zhurnalimeni N.I. Pirogova. 2017; 3: 42–49. https://doi.org/10.17116/hirurgia2017342-49 (In Russian)

10. Lin J.W., Cameron J.L., Yeo C.J., Riall T.S., Lillemoe K.D. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J. Gastrointest. Surg. 2004; 8 (8): 951–959. https://doi.org/10.1016/j.gassur.2004.09.044

11. Pratt W.B., Callery M.P., Vollmer C.M.Jr. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J. Surg. 2008; 32 (3): 419–428. https://doi.org/10.1007/s00268-007-9388-5

12. Wellner U.F., Kayser G., Lapshyn H., Sick O., Makowiec F., Höppner J., Hopt U.T., Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts post operative pancreatic fistula preoperatively. HPB (Oxford). 2010; 12 (10): 696–702. https://doi.org/10.1111/j.1477-2574.2010.00239.x

13. Kawai M., Kondo S., Yamaue H., Wada K., Sano K., Motoi F., Unno M., Satoi S., Kwon A.H., Hatori T., Yamamoto M., Matsumoto J., Murakami Y., Dоi R., Ito M., Miyakawa S., Shinchi H., Natsugoe S., Nakagawara H., Ohta T., Takada T. Predictive risk factors for clinically-relevant pancreatic fistula analyzed in 1,239 patients with pancreaticoduodenectomy: multicenter data collection as a project study of pancreatic surgery by the Japanese Society of Hepato- Biliary-Pancreatic Surgery. J. Hepatobiliary Pancreat. Sci. 2011; 18 (4): 601–608. https://doi.org/10.1007/s00534-011-0373-x

14. Ansorge C., Strömmer L., Andrén-Sandberg Å., Lundell L., Herrington M.K., Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br. J. Surg. 2012; 99 (8): 1076–1082. https://doi.org/10.1002/bjs.8784

15. El Nakeeb A., Salah T., Sultan A., El Hemaly M., Askr W., Ezzat H., Hamdy E., Atef E., El Hanafy E., El-Geidie A., Abdel Wahab M., Abdallah T. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J. Surg. 2013; 37 (6): 1405–1418. https://doi.org/10.1007/s00268-013-1998

16. Mathur A., Pitt H.A., Marine M., Saxena R., Schmidt C.M., Howard T.J., Nakeeb A., Zyromski N., Lillemoe K.D. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann. Surg. 2007; 246 (6): 1058–1064. https://doi.org/10.1097/SLA.0b013e31814a6906

17. Rosso E., Casnedi S., Pessaux P., Oussoultzoglou E., Panaro F., Mahfud M., Jaeck D., Bachellier P. The role of “fatty pancreas” and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J. Gastrointest. Surg. 2009; 13 (10): 1845–1851. https://doi.org/10.1007/s11605-009-0974-8

18. Laaninen M., Bläuer M., Vasama K., Jin H., Räty S., Sand J., Nordback I., Laukkarinen J. The risk for immediate postoperative complications after pancreaticoduodenectomy is increased by high frequency of acinar cells and decreased by prevalent fibrosis of the cut edge of pancreas. Pancreas. 2012; 41 (6): 957–961. https://doi.org/10.1097/MPA.0b013e3182480b81

19. Umezaki N., Hashimoto D., Nakagawa S., Kitano Y., Yamamura K., Chikamoto A., Matsumura F., Baba H. Number of acinar cells at the pancreatic stump predicts pancreatic fistula after pancreaticoduodenectomy. Surg. Today. 2018; 48 (8): 790–795. https://doi.org/10.1007/s00595-018-1656-5

20. Sugimoto M., Takahashi S., Kojima M., Kobayashi T., Gotohda N., Konishi M. In patients with a soft pancreas, a thick parenchyma, a small duct, and fatty infiltration are significant risks for pancreatic fistula after pancreaticoduodenectomy. J. Gastrointest. Surg. 2017; 21 (5): 846–854. https://doi.org/10.1007/s11605-017-3356-7

21. Nahm C.B., Lui I., Naidoo C.S., Roseverne L., Alzaabi S., Maher R., Mann G., Blome S., GillA. J., Samra J.S., Mittal A. Density and enhancement of the pancreatic tail on computer tomography predicts acinar score and pancreatic fistula after pancreatoduodenectomy. HPB. 2019; 21(5): 604–611. https://doi.org/10.1016/j.hpb.2018.09.014

22. Hashimoto Y., Sclabas G.M., Takahashi N., Kirihara Y., Smyrk T.C., Huebner M., Farnell M.B. Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. J. Gastrointest. Surg. 2011; 15 (12): 2193–2204. https://doi.org/10.1007/s11605-011-1687-3

23. Kim T., Murakami T., Takamura M., Hori M., Takahashi S., Nakamori S., Sakon M., Tanji Y., Wakasa K., Nakamura H. Pancreatic mass due to chronic pancreatitis: correlation of CT and MR imaging features with pathologic findings. AJR. Am. J. Roentgenol. 2001; 177 (2): 367–371. https://doi.org/10.2214/ajr.177.2.1770367

24. Kang J.H., Park J.S., Yu J.S., Chung J.J., Kim J.H., Cho E.S., Yoon D.S. Prediction of pancreatic fistula after pancreatoduodenectomy by preoperative dynamic CT and fecal elastase-1 levels. PloS One. 2017; 12 (5): e0177052. https://doi.org/10.1371/journal.pone.0177052

25. Bockman D.E. Microvasculature of the pancreas. Relation topancreatitis. Int. J. Pancreatol. 1992; 12 (1): 11–21. https://doi.org/10.1007/BF02927066

26. Delrue L., Blanckaert P., Mertens D., Van Meerbeeck S., Ceelen W., Duyck P. Tissue perfusion in pathologies of the pancreas: assessment using 128-slice computed tomography. Abdom. Imag. 2012; 37 (4): 595–601. https://doi.org/10.1007/s00261-011-9783-0

27.