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Madankan A, Jaliliyan A, Khalili P, Eghdami S, Mosavari H, Ahmadi SAY, Izadi A, Hosseininasab A, Eghbali F. Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis. ANZ J Surg 2024; 94:1030-1038. [PMID: 38837835 DOI: 10.1111/ans.19033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/23/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
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.
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Affiliation(s)
- Ahmad Madankan
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Jaliliyan
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Pantea Khalili
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shayan Eghdami
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hesam Mosavari
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyyed Amir Yasin Ahmadi
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amirreza Izadi
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseininasab
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Foolad Eghbali
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Addeo P, de Marini P, Averous G, Trog A, de Mathelin P, Gussago S, Fiore L, Geyer L, Noblet V, Bachellier P. Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score. HPB (Oxford) 2024; 26:717-725. [PMID: 38378305 DOI: 10.1016/j.hpb.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 10/27/2023] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications. METHODS A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents. RESULTS Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01). CONCLUSION A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France.
| | - Pierre de Marini
- Department of Radiology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Arnaud Trog
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France
| | - Pierre de Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Stefano Gussago
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Laura Fiore
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Lucas Geyer
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Vincent Noblet
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Sok C, Sandhu S, Shah H, Ajay PS, Russell MC, Cardona K, Maegawa F, Maithel SK, Sarmiento J, Goyal S, Kooby DA, Shah MM. Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg Oncol 2024; 31:1898-1905. [PMID: 37968411 PMCID: PMC10922305 DOI: 10.1245/s10434-023-14564-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF). METHODS Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C). RESULTS A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008). CONCLUSIONS Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.
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Affiliation(s)
- Caitlin Sok
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Sameer Sandhu
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hardik Shah
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Pranay S Ajay
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Felipe Maegawa
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Juan Sarmiento
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA.
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Kim SH, Kim SS, Hwang HK, Kang CM, Choi JY, Kim KS, Kim HI. Preoperative Fistula Risk Prediction Using Computed Tomography Image Before Pancreatoduodenectomy. Ann Surg Oncol 2023; 30:7731-7737. [PMID: 37490165 DOI: 10.1245/s10434-023-13969-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Although many formulas for predicting postoperative pancreatic fistula (POPF) have been introduced, POPF is generally predicted during pancreatic surgery due to pancreatic texture. This study was designed to verify the correlation between Hounsfield units (HU) and pancreatic texture and to suggest a fistula risk score (FRS) that can be used before surgery. METHODS Data from 545 patients who underwent pancreatoduodenectomy for malignant disease between January 2008 and December 2019 were retrospectively reviewed. The HU level of the pancreas was measured, and odds ratio (OR) of the HU for POPF was analyzed. Additionally, the assessed HU was compared with the pancreatic texture (soft vs. hard) and calculated cutoff level. Finally, the preoperatively chosen pancreatic texture according to HU level was applied to the FRS formula (preoperative-FRS: p-FRS), and the results were compared with a previously reported FRS formula (updated alternative-FRS: ua-FRS). RESULTS The Hounsfield unit levels were correlated with clinically relevant POPF (CR-POPF) (odds ratio [OR]: 1.04 (1.01-1.07), p = 0.015). In the receiver operating characteristic curve, the HU showed significant prediction potential for pancreatic texture (area under the curve [AUC]: 0.744, p < 0.001). The p-FRS also showed acceptable results in predicting CR-POPF (AUC = 0.702, p < 0.001). There was no statistically significant difference in the DeLong's test compared with the ua-FRS (p = 0.314). In the Hosmer-Lemeshow test, observed probabilities were correlated with predicted probabilities (p = 0.596). CONCLUSIONS The HU level on preoperative computed tomography (CT) is a predictive factor for POPF and could represent for pancreatic texture.
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Affiliation(s)
- Sung Hyun Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Seob Kim
- Department of Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Kyoung Hwang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Young Choi
- Department of Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Gastrointestinal Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis. Langenbecks Arch Surg 2022; 407:2801-2810. [PMID: 35752718 DOI: 10.1007/s00423-022-02599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.
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Xu SB, Jia CK, Liu L, Zhu HZ. The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data. ANZ J Surg 2022; 92:1097-1104. [PMID: 35388582 DOI: 10.1111/ans.17673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck. METHODS The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film. RESULTS Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF. CONCLUSION Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.
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Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chang-Ku Jia
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Ling Liu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Han-Zhang Zhu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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Abstract
Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.
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