A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively

Appropriate linear stapler selection for avoiding postoperative pancreatic fistula after distal pancreatectomy: A retrospective cohort study

BACKGROUND

Despite the progress in surgical techniques and perioperative managements, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Recently, pancreatic dissection using a linear stapler has been widely performed; however, risk factors influencing the occurrence of POPF after DP using a liner stapler is not fully understood. The purpose of this paper was to evaluate whether the relations between staple height and pancreatic thickness or main pancreatic duct (MPD) diameter influenced the incidence of POPF.

METHODS

Patients who underwent DP without other organ resections between 2015 and 2022 were retrospectively reviewed. Compression Index (CI) was defined as staple height/pancreatic thickness, and Suturing Index (SI) was defined as staple height/ MPD diameter.

RESULTS

In 51 patients undergoing DP, 16 patients (31.4%) developed POPF. ROC analyses revealed that lower CI and higher SI significantly increased the incidence of POPF, and the cutoff values were 0.186 and 0.821, respectively. Univariate and multivariate analyses revealed that CI ≤ 0.186 and SI ≥ 0.821 were independent risk factors for POPF after DP. Moreover, the incidence of POPF in patients fulfilling both CI > 0.186 and SI < 0.821 was 5.9%, which was extremely lower than in those without fulfilling the criteria (44.1%), suggesting that this new criteria in combination with CI and SI was an excellent predictor of POPF.

CONCLUSIONS

It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.

A single-center prospective analysis of the impact of glucose metabolism on pancreatic fistula onset after pancreaticoduodenectomy for periampullary tumors

BACKGROUND

Glucose impairment notably affects the postoperative course of gastrointestinal surgeries. However, evidence on its impact on clinically relevant pancreatic fistulas(CR-POPFs) after pancreaticoduodenectomy(PD) is lacking. This study evaluates if and how preoperative glucose metabolism affects the development of CR-POPF after PD.

METHODS

One hundred and ten consecutive PDs were included. Patients underwent preoperative metabolic profiling using the Oral Glucose Tolerance Test(OGTT) and the hyperinsulinemic euglycemic clamp procedure. Accordingly, patients were categorized as normal glucose tolerant (NGT), impaired glucose tolerant (IGT), diabetic (DM), and longstanding-DM. Receiver operating characteristics(ROC) analyses were performed to determine the values of metabolic features in prediction of CR-POPF.

RESULTS

The CR-POPF rate was 36.3 ​%(40 patients). NGT patients had a higher CR-POPF rate (51.7 ​%) compared to IGT(45.2 ​%), DM (15.8 ​%), and longstanding-DM (25.8 ​%) (p ​= ​0.03). CR-POPF patients had lower median fasting glucose levels (p ​= ​0.01) and higher c-peptide values at all OGTT time points (p ​< ​0.05). Fasting glucose and c-peptide levels had high diagnostic accuracy for CR-POPF (AUC>0.8) and were independent risk factors for CR-POPF (OR: 24.7[95%CI: 3.7-165.3] for fasting glucose; OR: 19.9[95%CI: 3.2-125.3] for c-peptide).

CONCLUSION

Normoglycemia and normal beta cell function may be risk factors for CR-POPF after PD. Fasting glucose and c-peptide levels effectively predicted CR-POPF development following PD.

CLINICALTRIALS GOV IDENTIFIER

NCT02175459.

Mahamana Technique of Pancreaticogastrostomy: A Safe and Reliable Technique for a Difficult Pancreatic Stump

Pancreatoduodenectomy is a complex surgical procedure involving three anastomoses. Anastomosis of the pancreatic stump with the gastrointestinal tract is associated with most complications described in the postoperative period. So, there have been multiple attempts to discover safe and sound steps for this particular anastomosis. Pancreaticogastrostomy involves anastomosis between the remaining pancreas and stomach. Since it was first performed, its surgical steps have been modified multiple times, but there is no gold standard method to perform it. In this paper, we describe the surgical steps of pancreaticogastrostomy in difficult pancreatic stumps in eight patients using two transpancreatic sutures, one purse string suture, and the incorporation of transpancreatic sutures in the third layer of the gastrojejunostomy anastomosis. Postoperative outcomes of this series have provided encouraging short-term results.

Updates in the management of postoperative pancreatic fistula

Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence- based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.

Optimizing prediction models for pancreatic fistula after pancreatectomy: Current status and future perspectives

Postoperative pancreatic fistula (POPF) is a frequent complication after pancreatectomy, leading to increased morbidity and mortality. Optimizing prediction models for POPF has emerged as a critical focus in surgical research. Although over sixty models following pancreaticoduodenectomy, predominantly reliant on a variety of clinical, surgical, and radiological parameters, have been documented, their predictive accuracy remains suboptimal in external validation and across diverse populations. As models after distal pancreatectomy continue to be progressively reported, their external validation is eagerly anticipated. Conversely, POPF prediction after central pancreatectomy is in its nascent stage, warranting urgent need for further development and validation. The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance. Moreover, there is potential for the development of personalized prediction models based on patient- or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF. In the future, prospective multicenter studies and the integration of novel imaging technologies, such as artificial intelligence-based radiomics, may further refine predictive models. Addressing these issues is anticipated to revolutionize risk stratification, clinical decision-making, and postoperative management in patients undergoing pancreatectomy.

Acinar content at pancreatic resection margin is significantly associated with clinically relevant pancreatic fistula after partial pancreatoduodenectomy

BACKGROUND

This study aimed to evaluate the clinical significance of acinar content at the pancreatic resection margin after partial pancreatoduodenectomy (PD).

METHODS

A total of 228 consecutive patients undergoing PD were included for analysis. Resection margins were assessed for acinar, fibrosis, and fat contents by 2 pathologists blinded to the patients' clinical data. Univariate and multivariable analyses of possible predictors for clinically relevant postoperative pancreatic fistula (cr-POPF) were performed.

RESULTS

The median acinar, fibrosis, and fat contents were 70% (IQR, 25%-82%), 13% (IQR, 5%-40%), and 15% (IQR, 9.25%-25%), respectively. The rates of cr-POPF were significantly higher in patients with an acinar content of >70% than in patients with an acinar content of ≤70% (26.4% vs 5.5%, respectively; P < .001). In addition, the rates of postoperative hyperamylasemia (POH) were significantly higher in patients with an acinar content of ≥70% than in patients with an acinar content of ≤70% (55.2% vs 13.8%, respectively; P < .001). The median fat content did not differ between patients with and without cr-POPF (13.0% [IQR, 7.5%-20.0%] vs 15.0% [IQR, 10.0%-30.0%], respectively; P = .06). An acinar content of >70% at the pancreatic resection margin (odds ratio [OR], 4.85; 95% CI, 1.61-14.58; P = .005) and a soft pancreatic texture (OR, 2.82; 95% CI, 1.02-7.76; P = .046) were independent predictive factors of cr-POPF in the multivariable analysis.

CONCLUSION

An acinar content of ≥70% at the pancreatic resection margin was a significant predictive factor for cr-POPF after PD and was also significantly associated with POH, a precursor of cr-POPF after PD in many cases. Fatty infiltration of the pancreatic resection margin was not associated with cr-POPF.

Preoperative ultrasound radiomics for predicting clinically relevant postoperative pancreatic fistula after pancreatectomy

OBJECTIVES

To evaluate the efficacy of the radiomics model based on preoperative B-mode ultrasound (BMUS) and shear wave elastography (SWE) for predicting the occurrence of clinically relevant-postoperative pancreatic fistula (CR-POPF).

METHODS

Patients who were scheduled to undergo pancreatectomy were prospectively enrolled and received ultrasound assessment within one week before surgery. The risk factors of POPF (grades B and grades C) were analyzed. Preoperative BMUS images, SWE values of pancreatic lesions and surrounding parenchyma were used to build preoperative prediction radiomics models. Radiomic signatures were extracted and constructed using a minimal Redundancy Maximal Relevance (mRMR) algorithm and an L1 penalized logistic regression. A combined model was built using multivariate regression which incorporated radiomics signatures and clinical data.

RESULTS

From January 2020 to November 2021, a total of 147 patients (85 distal pancreatectomies and 62 pancreaticoduodenectomies) were enrolled. During the three-week follow-up after pancreatectomy, the incidence rates of grade B/C POPF were 28.6% (42/147). Radiomic signatures constructed from BMUS of pancreas parenchymal regions (panRS) achieved an area under the receiver operating characteristic curve (AUC) of 0.75, accuracy of 68.7%, sensitivity of 85.7 %, and specificity of 61.9 % in preoperative noninvasive prediction of CR-POPF. The AUC of the radiomics model increased to 0.81 when panRS was used for the prediction of CR-POPF after pancreaticoduodenectomy.

CONCLUSIONS

Radiomics model based on ultrasound images was potentially useful for predicting CR-POPF. Patients with high-risk factors should be closely monitored when postoperation.

Prediction of pancreatic fibrosis by dual-energy CT-derived extracellular volume fraction: Comparison with MRI

OBJECTIVES

To investigate the correlation between dual-energy CT (DECT) and MRI measurements of the extracellular volume fraction (ECV) and to assess the accuracy of both methods in predicting pancreatic fibrosis (PF).

METHODS

We retrospectively analyzed 43 patients who underwent pancreatectomy and preoperative pancreatic DECT and MRI between November 2018 and May 2022. The ECV was calculated using the T1 relaxation time (for MR-ECV) or absolute enhancement (for DECT-ECV) at equilibrium phase (180 s after contrast injection in our study). Pearson coefficient and Bland-Altman analysis were used to compare the correlation between the two ECVs, Spearman correlations were used to investigate the association between imaging parameters and PF, Receiver operating characteristic (ROC) curves were used to assess the diagnostic performance of the ECVs for advanced fibrosis (F2-F3), and multivariate logistic regression analysis was used to examine the relationship between PF and imaging parameters.

RESULTS

There was a strong correlation between DECT- and MR-derived ECVs (r = 0.948; p < 0.001). The two ECVs were positively correlated with PF (DECT: r = 0.647, p < 0.001; MR: r = 0.614, p < 0.001), and the mean values were 0.34 ± 0.08 (range: 0.22-0.62) and 0.35 ± 0.09 (range: 0.24-0.66), respectively. The area under the operating characteristic curve (AUC) for subjects with advanced fibrosis diagnosed by ECV was 0.86 for DECT-ECV and 0.87 for MR-ECV. Multivariate logistic regression analysis showed that the DECT-ECV was an independent predictor of PF.

CONCLUSIONS

The ECV could be an effective predictor of histological fibrosis, and DECT is equivalent to MRI for characterizing pancreatic ECV changes.

External validation of scores predicting postoperative fistula after pancreatogastrostomy for pancreatoduodenectomy reconstruction. A single center experience

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction.

METHOD

This single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG.

RESULTS

CR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m2) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41-21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14-12.8) were the only independent prognostic factors on multivariate analysis.

CONCLUSIONS

Our study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

A Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis analysis to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy: A systematic review

BACKGROUND

Postoperative pancreatic fistula is a frequent and potentially lethal complication after pancreatoduodenectomy. Several models have been developed to predict postoperative pancreatic fistula risk. This study was performed to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist that provides guidelines on reporting prediction models to enhance transparency and to help in the decision-making regarding the implementation of the appropriate risk models into clinical practice.

METHODS

Studies that described prediction models to predict postoperative pancreatic fistula after pancreatoduodenectomy were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The TRIPOD checklist was used to evaluate the adherence rate. The area under the curve and other performance measures were extracted if reported. A quadrant matrix chart is created to plot the area under the curve against TRIPOD adherence rate to find models with a combination of above-average TRIPOD adherence and area under the curve.

RESULTS

In total, 52 predictive models were included (23 development, 15 external validation, 4 incremental value, and 10 development and external validation). No risk model achieved 100% adherence to the TRIPOD. The mean adherence rate was 65%. Most authors failed to report on missing data and actions to blind assessment of predictors. Thirteen models had an above-average performance for TRIPOD checklist adherence and area under the curve.

CONCLUSION

Although the average TRIPOD adherence rate for postoperative pancreatic fistula models after pancreatoduodenectomy was 65%, higher compared to other published models, it does not meet TRIPOD standards for transparency. This study identified 13 models that performed above average in TRIPOD adherence and area under the curve, which could be the appropriate models to be used in clinical practice.

Fistula Risk Score for Auditing Pancreatoduodenectomy: The Auditing-FRS

OBJECTIVE

To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals.

BACKGROUND

For proper comparisons of outcomes in surgical audits, case-mix variation should be accounted for.

METHODS

This study included consecutive patients after pancreatoduodenectomy from the mandatory nationwide Dutch Pancreatic Cancer Audit. Derivation of the score was performed with the data from 2014 to 2018 and validation with 2019 to 2020 data. The primary endpoint of the study was POPF (grade B or C). Multivariable logistic regression analysis was performed for case-mix adjustment of known risk factors.

RESULTS

In the derivation cohort, 3271 patients were included, of whom 479 (14.6%) developed POPF. Male sex [odds ratio (OR)=1.34; 95% confidence interval (CI): 1.09-1.66], higher body mass index (OR=1.07; 95% CI: 1.05-1.10), a final diagnosis other than pancreatic ductal adenocarcinoma/pancreatitis (OR=2.41; 95% CI: 1.90-3.06), and a smaller duct diameter (OR=1.43/mm decrease; 95% CI: 1.32-1.55) were independently associated with POPF. Diabetes mellitus (OR=0.73; 95% CI: 0.55-0.98) was independently associated with a decreased risk of POPF. Model discrimination was good with a C -statistic of 0.73 in the derivation cohort and 0.75 in the validation cohort (n=913). Hospitals differed in particular in the proportion of pancreatic ductal adenocarcinoma/pancreatitis patients, ranging from 36.0% to 58.1%. The observed POPF risk per center ranged from 2.9% to 25.4%. The expected POPF rate based on the 5 risk factors ranged from 11.6% to 18.0% among hospitals.

CONCLUSIONS

The auditing fistula risk score was successful in case-mix adjustment and enables fair comparisons of POPF rates among hospitals.

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.

Incidence of Postoperative Complications Following Pancreatectomy for Pancreatic Cystic Lesions or Pancreatic Cancer

BACKGROUND

In contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC.

METHODS

A prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups.

RESULTS

A total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed.

CONCLUSIONS

POPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation.

Establishment and external validation of neutrophil-to-lymphocyte ratio in excluding postoperative pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Factors excluding postoperative pancreatic fistula (POPF), facilitating early drain removal and hospital discharge represent a novel approach in patients undergoing enhanced recovery after pancreatic surgery. This study aimed to establish the relevance of neutrophil-to-lymphocyte ratio (NLR) in excluding POPF after pancreatoduodenectomy (PD).

METHODS

A prospectively maintained database of patients who underwent PD at two high-volume centres was used. Patients were divided into three cohorts (training, internal, and external validation). The primary endpoints of this study were accuracy, optimal timing, and cutoff values of NLR for excluding POPF after PD.

RESULTS

From 2012 to 2020, in a 2:1 ratio, 451 consecutive patients were randomly sampled as training (n = 301) and validation (n = 150) cohorts. Additionally, the external validation cohort included 197 patients between 2018 and 2020. POPF was diagnosed in 135 (20.8 per cent) patients. The 90-day mortality rate was 4.1 per cent. NLR less than 8.5 on postoperative day 3 (OR, 95 per cent c.i.) was significantly associated with the absence of POPF in the training (2.41, 1.19 to 4.88; P = 0.015), internal validation (5.59, 2.02 to 15.43; P = 0.001), and external validation (5.13, 1.67 to 15.76; P = 0.004) cohorts when adjusted for relevant clinical factors. Postoperative outcomes significantly differed using this threshold.

CONCLUSION

NLR less than 8.5 on postoperative day 3 may be a simple, independent, cost-effective, and easy-to-use criterion for excluding POPF.

Morbidity and survival after laparoscopic versus open pancreatoduodenectomy: propensity score matched comparison

PURPOSE

Technical challenges and a perceived higher risk of complications hinder a wide adoption of minimally invasive pancreatoduodenectomy. We aim to further define the place of minimally invasive pancreatoduodenectomy by comparison with the traditional open approach.

METHODS

A comparison of the surgical outcomes and survival after laparoscopic (LPD) versus open pancreatoduodenectomy (OPD) was retrospectively performed from a prospectively kept database. To reduce the effect of bias and confounding, baseline characteristics of both groups were matched using propensity score matching (NCT05110573; Nov 8, 2021; retrospectively registered).

RESULTS

From a total of 67 LPD and 105 OPD patients, propensity score matching resulted in two balanced groups of 38 patients. In both groups, 87% of surgeries were performed for cancer. In the LPD group, conversion rate was 22.4%. Mean operative time was significantly longer after LPD versus OPD (320.1 ± 53.8 vs. 277.7 ± 63.8 min; p = .008). Hospital stay was significantly shorter after LPD versus OPD (median 13.5 vs. 17.0 days; p = .039). No significant differences were observed in blood loss, total complication rate (73.7% vs. 86.8%; p = .249), major complication rate (26.5% vs. 10.5%; p = .137), postoperative pancreatic fistula rate (13.2% vs. 7.9%; p = .711), 90-day mortality rate (5.3% vs. 0%; p = .493), R0 resection rate (85.4% vs. 85.8%), or number of lymph nodes (median 10.0 vs. 8.5; p = .273). In cancer patients, no significant differences were observed in overall survival (median 27.1 vs. 23.9 months; p = .693), disease-free survival, or recurrence rate.

CONCLUSION

LPD provided acceptable short-term and oncological outcomes. Compared to OPD, we noted a higher major complication rate, without compromising surgical safety or oncological outcomes.

A Preliminary Pathological Evaluation of Extracellular Volume Fraction with Contrast-enhanced Computed Tomography as a Novel Quantitative Parameter of Pancreatic Fibrosis

Objective The extracellular volume (ECV) calculated based on contrast-enhanced computed tomography (CT) has been reported as a novel imaging parameter reflecting the morphological change of fibrosis in several parenchymal organs. Our retrospective study assessed the validity of the ECV fraction for diagnosing pancreatic fibrosis and the appropriate imaging condition as the "equilibrium phase". Methods In 27 patients undergoing multiphasic CT and subsequent pancreaticoduodenectomy, we investigated pathological fibrotic changes related to the ECV fraction and conducted analyses using the value obtained by subtracting the equilibrium CT value of the portal vein from that of the abdominal aorta (Ao-PV_equilibrium) to estimate eligibility of the equilibrium phase. Results In all patients, the ECV fraction showed a weak positive correlation with the collagenous compartment ratio (r=0.388, p=0.045). All patients were divided into two groups - the high-Ao-PV_equilibrium group and low-Ao-PV_equilibrium group - based on the median value. No significant correlation was found in the high-Ao-PV_equilibrium group, whereas a significant correlation was observed in the low-Ao-PV_equilibrium group (r=0.566, p=0.035). Conclusion The ECV fraction is a possible predictive factor for histopathological pancreatic fibrosis. In its clinical application, the eligibility of the "equilibrium phase" may affect the diagnostic capability. It will be necessary to verify the imaging conditions in order to improve the accuracy of the diagnosis.

Iterative Changes in Risk-Stratified Pancreatectomy Clinical Pathways and Accelerated Discharge After Pancreaticoduodenectomy

BACKGROUND

Previous implementation of risk-stratified pancreatectomy clinical pathways (RSPCPs) decreased length of stay (LOS) following pancreaticoduodenectomy (PD). This study's primary aim was to measure the association of iterative RSPCP revisions with accelerated discharge and early postoperative outcomes.

METHODS

This is a retrospective cohort study of a prospectively maintained surgical database (10/2016-9/2020). In February 2019, revised RSPCPs were implemented with earlier nasogastric tube (NGT) removal (postoperative day [POD] 1 for low risk; POD 2 for high risk) and updated drain fluid amylase cutoffs for POD 1/POD 3 removal. Perioperative outcomes between original and revised pathways were compared. Predictors of accelerated discharge (defined as ≤ POD 5 for low risk; ≤ POD 6 for high risk) were identified.

RESULTS

There were 233 (36% high risk) patients in original and 131 (32% high risk) in revised RSPCPs. After revision, the rate of POD 1 NGT removal was higher while POD ≤ 3 drain removal was similar. Median LOS decreased for low risk (5 vs. 6 days, p = 0.011) and high risk (6 vs. 9 days, p = 0.005) with no increase in delayed gastric emptying, postoperative pancreatic fistula, or readmissions. With POD 1 NGT removal, diet tolerance was earlier without increased NGT reinsertions. In low-risk patients, younger age, POD 1 NGT removal, and POD ≤ 3 drain removal were independent predictors of accelerated discharge. In high-risk patients, POD 1 NGT removal and POD ≤ 3 drain removal were independent predictors of accelerated discharge.

CONCLUSIONS

Following iterative revisions in RSPCPs, LOS after PD decreased further without increasing readmissions, and NGTs were removed earlier without increased reinsertions. Early NGT and drain removal are modifiable practices within RSPCPs that are associated with accelerated discharge.

Dual-Energy CT Iodine Concentration to Evaluate Postoperative Pancreatic Fistula after Pancreatoduodenectomy

Background Pancreatic fibrosis and fatty infiltration are associated with postoperative pancreatic fistula (POPF), but accurate preoperative assessment remains a challenge. Iodine concentration (IC) and fat fraction derived from dual-energy CT (DECT) may reflect the amount of fibrosis and steatosis, potentially enabling the preoperative prediction of POPF. Purpose To identify multiphasic DECT-derived IC and fat fraction that improve the prediction of POPF risks compared with contrast-enhanced CT attenuation values and to evaluate the underlying histopathologic changes. Materials and Methods This retrospective study included patients who underwent pancreatoduodenectomy and DECT (including pancreatic parenchymal, portal venous, and delayed phase scanning) between January 2020 and December 2020. The relationships of the quantitative DECT-derived IC and fat fraction, along with CT attenuation values from enhanced images with POPF risk, were analyzed with logistic regression analysis. The predictive performance of the IC was compared with that of the CT values. The histopathologic underpinnings of IC were evaluated with multivariable linear regression analysis. Results A total of 107 patients (median age, 65 years; interquartile range, 57-70 years; 56 men) were included. Of these, 23 (21%) had POPF. The pancreatic parenchymal-to-portal venous phase IC ratio (adjusted odds ratio [OR], 13; 95% CI: 2, 162; P < .001) was an independent predictor of POPF occurrence. The accuracy of the pancreatic parenchymal-to-portal venous phase IC ratio in predicting POPF was higher than that of the CT value ratio in the same phases (78% vs 65%, P < .001). The pancreatic parenchymal-to-portal venous phase IC ratio was independently associated with pancreatic fibrosis (β = -1.04; 95% CI: -0.44, -1.64; P = .001). Conclusion A higher pancreatic parenchymal-to-portal venous phase IC ratio was associated with less histologic fibrosis and greater risk of POPF. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Yoon in this issue.

External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores.

METHODS

Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models.

RESULTS

Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.

CONCLUSION

Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.

Association between pancreatic fibrosis and development of pancreoprivic diabetes after pancreaticoduodenectomy

This study investigated the correlation between pancreatic fibrosis (PF) and development of pancreoprivic diabetes after pancreaticoduodenectomy (PD). Ninety-five patients who underwent PD at Gangnam Severance Hospital between 2014 and 2017 were enrolled. PF grade was evaluated with alpha-smooth muscle actin (SMA) and Masson’s trichrome (TRC) staining. New-onset pancreoprivic diabetes and recurrence of disease were evaluated using fasting blood glucose measurement and radiography taken at 3-month intervals. Sixty-one patients did not have preoperative diabetes, however, 40 (65.6%) patients developed pancreoprivic diabetes after PD. High-grade PF was more common in the diabetes group than in the normal group (SMA, 42.5% vs. 28.6%, P = 0.747; TRC, 47.5% vs. 28.6%, P = 0.361). The 1-year cumulative incidence of hyperglycemia/pancreoprivic diabetes was higher with high-grade PF than low-grade PF (SMA, 94.4% vs. 73.0%, P = 0.027; TRC, 89.3% vs. 75.0%, P = 0.074). The SMA-TRC combined high-grade group had a higher proportion of primary pancreatic disease than the combined low-grade group (90.0% vs. 37.5%, P = 0.001). The 5-year disease-free survival of patients with pancreatic cancer was worse with high-grade PF than low-grade PF (SMA, 24.5% vs. 66.3%, P = 0.026; TRC, 23.6% vs. 58.4%, P = 0.047). In conclusion, patients with severe PF are more likely to develop pancreoprivic diabetes after PD and have worse disease-free survival.

Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study

PURPOSE

The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ).

METHODS

From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF.

RESULTS

The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence.

CONCLUSIONS

For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.

A machine learning risk model based on preoperative computed tomography scan to predict postoperative outcomes after pancreatoduodenectomy

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a life-threatening complication following pancreaticoduodenectomy (PD). Individualized preoperative risk assessment could improve clinical management and prevent or mitigate adverse outcomes. The aim of this study is to develop a machine learning risk model to predict occurrence of CR-POPF after PD from preoperative computed tomography (CT) scans. A total of 100 preoperative high-quality CT scans of consecutive patients who underwent pancreaticoduodenectomy in our institution between 2011 and 2019 were analyzed. Radiomic and morphological features extracted from CT scans related to pancreatic anatomy and patient characteristics were included as variables. These data were then assessed by a machine learning classifier to assess the risk of developing CR-POPF. Among the 100 patients evaluated, 20 had CR-POPF. The predictive model based on logistic regression demonstrated specificity of 0.824 (0.133) and sensitivity of 0.571 (0.337), with an AUC of 0.807 (0.155), PPV of 0.468 (0.310) and NPV of 0.890 (0.084). The performance of the model minimally decreased utilizing a random forest approach, with specificity of 0.914 (0.106), sensitivity of 0.424 (0.346), AUC of 0.749 (0.209), PPV of 0.502 (0.414) and NPV of 0.869 (0.076). Interestingly, using the same data, the model was also able to predict postoperative overall complications and a postoperative length of stay over the median with AUCs of 0.690 (0.209) and 0.709 (0.160), respectively. These findings suggest that preoperative CT scans evaluated by machine learning may provide a novel set of information to help clinicians choose a tailored therapeutic pathway in patients candidated to pancreatoduodenectomy.

Clinical validation of the risk scoring systems of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy in Chinese cohorts: A single-center retrospective study

BACKGROUND

Although several prediction models for the occurrence of clinically relevant postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy exist, most were established using Western cohorts. The utility of these models using a Chinese cohort has not been validated widely. The aim of the study was to validate the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score for patients undergoing laparoscopic pancreatoduodenectomy in a large-scale Chinese cohort externally.

METHODS

Three clinically relevant postoperative pancreatic fistula risk models were selected for external validation with our database. Primary outcome was grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula). Performance was measured based on sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, and area under the curve. The original Fistula Risk Score was also compared with the alternative Fistula Risk Score and the updated alternative Fistula Risk Score.

RESULTS

Of the 400 patients who underwent laparoscopic pancreatoduodenectomy, 60 (15.00%) developed clinically relevant postoperative pancreatic fistula. For the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score, the sensitivity was 65.00%, 90.00%, and 90.00%; the specificity was 43.53%, 44.12%, and 37.65%; the positive predictive value was 16.88%, 22.13%, and 20.30%; the negative predictive value was 87.57%, 96.15%, and 95.52%; positive likelihood ratio was 1.151, 1.611, and 1.443; negative likelihood ratio was 0.804, 0.227, and 0.266, respectively. The area under the curve values were 0.608 (95% confidence interval 0.573-0.649), 0.733 (95% confidence interval 0.692-0.797), and 0.720 (95% confidence interval 0.688-0.763) on the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score (P < .05).

CONCLUSION

The alternative Fistula Risk Score and the updated alternative Fistula Risk Score had similarly good predictive utility. The original Fistula Risk Score performed less well. We recommended to use the alternative Fistula Risk Score and the updated alternative Fistula Risk Score to predict occurrence of clinically relevant postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy when applied to a Chinese cohort.

Predicting postoperative pancreatic fistula in pancreatic head resections: which score fits all?

Purpose

Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery.

Methods

A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested.

Results

Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis.

Conclusion

Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.

Preoperative risk stratification of postoperative pancreatic fistula: A risk-tree predictive model for pancreatoduodenectomy

BACKGROUND

Existing postoperative pancreatic fistula risk scores rely on intraoperative parameters, which limits their value in the preoperative setting. A preoperative predictive model to stratify the risk of developing postoperative pancreatic fistula before pancreatoduodenectomy was built and externally validated.

METHODS

A regression risk-tree model for preoperative postoperative pancreatic fistula risk stratification was developed in the Verona University Hospital training cohort using preoperative variables and then tested prospectively in a validation cohort of patients who underwent pancreatoduodenectomy at San Raffaele Hospital of Milan.

RESULTS

In the study period 566 (training cohort) and 456 (validation cohort) patients underwent pancreatoduodenectomy. In the multivariable analysis body mass index, radiographic main pancreatic duct diameter and American Society of Anesthesiologists score ≥3 were independently associated with postoperative pancreatic fistula. The regression tree analysis allocated patients into 3 preoperative risk groups with an 8%, 21%, and 32% risk of postoperative pancreatic fistula (all P < .01) based on main pancreatic duct diameter (≥ or <5 mm) and body mass index (≥ or <25). The 3 groups were labeled low, intermediate, and high risk and consisted of 206 (37%), 188 (33%), and 172 (30%) patients, respectively. The risk-tree was applied to validation cohort, successfully reproducing 3 risk groups with significantly different postoperative pancreatic fistula risks (all P < .01).

CONCLUSION

In candidates for pancreatoduodenectomy, the risk of postoperative pancreatic fistula can be quickly and accurately determined in the preoperative setting based on the body mass index and main pancreatic duct diameter at radiology. Preoperative risk stratification could potentially guide clinical decision-making, improve patient counseling and allow the establishment of personalized preoperative protocols.

[Scoring systems to predict pancreatic fistula after Whipple procedure]

Specific complications is an «Achilles heel» of pancreaticoduodenectomy. Postoperative pancreatic fistula (POPF) is the most common specific complication. POPF prediction is an actual problem in pancreatic surgery. Analysis of statistically significant scoring systems to predict POPF is a modern trend in perioperative planning. Several prognostic scales (FRS, a-FRS, ua-FRS, Modified Fistula Risk Score) are recommended for clinical practice.

Comprehensive Diagnostic Nomogram for Predicting Clinically Relevant Postoperative Pancreatic Fistula After Pancreatoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a severe and challenging complication of pancreaticoduodenectomy (PD). This study aimed to establish a novel postoperative nomogram-based diagnostic model for the early detection of CR-POPF in patients subjected to PD.

METHODS

Consecutive patients who underwent PD in Zhongshan Hospital, Fudan University from December 2018 to October 2020 were retrospectively enrolled. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for CR-POPF. Then, a novel predictive nomogram was established accordingly.

RESULTS

Among the consecutive 176 patients who underwent PD, 37 (21.1%) patients developed CR-POPF. Through univariate and multivariate analyses, the drain amylase (P = 0.002), serum creatinine (P = 0.009), and serum C reactive protein (P = 0.045) at postoperative day 1 (POD1) as well as the neutrophil count (P = 0.025) and temperature (P = 0.025) at POD3 were identified as independent risk factors for CR-POPF. Based on this, a novel predictive nomogram containing these factors was constructed to predict the probability of CR-POPF after PD. The formulated nomogram showed better performance to detect CR-POPF after PD with a sensitivity of 0.784, specificity of 0.770, positive predictive value of 0.475, and negative predictive value of 0.930 when compared to other predictors. In addition, the predictive value of the nomogram was assessed by a concordance index of 0.814 (95% CI, 0.736-0.892), which was significantly higher than indicators alone. This was further validated and depicted by decision curve analysis and clinical impact curve.

CONCLUSION

This study established a diagnostic nomogram of postoperative objective parameters that can predict the development of CR-POPF after PD with a good discriminative ability and predictive accuracy.

Proposal of a Preoperative CT-Based Score to Predict the Risk of Clinically Relevant Pancreatic Fistula after Cephalic Pancreatoduodenectomy

Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases; the unenhanced density of the liver; the caliber of the main pancreatic duct (MPD); the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters; the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm³ vs. 34.87 ± 12.35 cm³, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694-0.941) and 0.774 (95% CI 0.599-0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Surgeon vs Pathologist for Prediction of Pancreatic Fistula: Results from the Randomized Multicenter RECOPANC Study

BACKGROUND

Surgically assessed pancreatic texture has been identified as the strongest predictor of postoperative pancreatic fistula. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathologic parameters collected over the course of the Pancreatogastrostomy vs Pancreatojejunostomy for RECOnstruction (RECOPANC) study.

STUDY DESIGN

The RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. There were 261 hematoxylin and eosin-stained slides allocated for histopathologic analyses. Pancreatic fibrosis was scored from 0 to III (no fibrosis up to severe fibrosis) by 2 blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis.

RESULTS

The fibrosis grade and pancreatic texture were scored in all 261 patients. In POPF B/C (postoperative pancreatic fistula grade B or C) patients, 71% had a soft pancreas, and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II, and 7% with score III, respectively. Fibrosis grading showed substantial inter-rater reliability (kappa = 0.74) and correlated positively with hard pancreatic texture (p < 0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture, and fibrosis grade. However, the addition of pancreatic texture only led to an incremental improvement (AUC 0.794 vs 0.819).

CONCLUSIONS

Histologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.

Evaluation of Pancreatic Fibrosis Grading by Multi Parametric Quantitative Magnetic Resonance Imaging

BACKGROUND

Early detection and grading of pancreatic fibrosis (PF) are important and challenging clinical goals.

PURPOSE

To determine main pancreatic duct (MPD) diameter, pancreatic thickness, and grades of PF via magnetic resonance elastography (MRE), T1 mapping, and intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI), assessing respective diagnostic performances.

STUDY TYPE

Prospective.

SUBJECTS

Histopathologic and imaging records (MRE, T1 mapping, and IVIM-DWI) generated by 144 patients between December 2018 and May 2020 were collected for analysis. Grades of PF were distributed as follows: F0, 82; F1, 22; F2, 22; and F3, 18.

FIELD STRENGTH/SEQUENCE

3 T pancreatic MRI, encompassing MRE, T1 mapping, and IVIM-DWI.

ASSESSMENT

In all patients, T1 relaxation times, pancreatic stiffness values, IVIM-DWI parameters, MPD diameter, and pancreatic thickness were measured.

STATISTICAL TESTS

Receiver operating characteristic (ROC) analysis served to assess imaging parameters useful in diagnosing PF. To identify relations between specific parameters and grades of PF, logistic regression analysis was invoked.

RESULTS

Both pancreatic stiffness (r = 0.754; P < 0.001) and T1 relaxation time (r = 0.433; P < 0.001) correlated significantly with PF (%). To determine PF grades ≥F1, a combined model (area under the curve [AUC] = 0.906) performed significantly better than pancreatic stiffness (AUC = 0.855; P < 0.001) or T1 relaxation time (AUC = 0.754; P < 0.001) alone. For PF grades ≥F2 or grade F3, both the combined model (≥F2: AUC = 0.910; F3: AUC = 0.939) and pancreatic stiffness (≥F2: AUC = 0.906; F3: AUC = 0.929) outperformed T1 relaxation time (≥F2: AUC = 0.768 [P = 0.005 and P = 0.004, respectively]; F3: AUC = 0.816 [both P < 0.005]). All IVIM-DWI parameters generated AUC values <0.700.

DATA CONCLUSION

A combination of MRE and T1 mapping seems promising in diagnosing various grades of PF, particularly at an early stage.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 2.

A Novel Pancreatic Fistula Risk Score Including Preoperative Radiation Therapy in Pancreatic Cancer Patients

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most serious complication following pancreaticoduodenectomy (PD). Identifying patients at high or low risk of developing POPF is important in perioperative management. This study aimed to determine a predictive risk score for POPF following PD, and compare it to preexisting scores.

METHODS

All patients who underwent open PD from 2012 to 2017 in two high-volume centers were included. The training dataset was used for the development of the POPF predictive risk score (using the 2016 ISGPS definition), while the testing dataset was used for external validation. The proposed score was compared to the fistula risk score (FRS), the NSQIP-modified FRS (mFRS), and the alternative FRS (aFRS).

RESULTS

Overall, 448 and 213 patients were included in the training and testing datasets, respectively. A probabilistic predictive risk score was developed using four independent POPF risk factors (increasing age, no preoperative radiation therapy, soft pancreatic stump, and decreasing main pancreatic duct diameter). The discriminative capacities of the new score, FRS, mFRS, and aFRS were similar (AUC ranging from 0.73 to 0.79 in the training cohort and from 0.73 to 0.76 in the testing cohort). However, the new score identified more specifically patients at low risk of POPF compared with other scores, in both cohorts, with a 6% false-negative rate.

CONCLUSIONS

Preoperative radiation therapy is an independent protective factor of POPF following PD. It should be included in the risk score of POPF to identify more precisely patients at low risk for this complication.

The Impact of Patient Age ≥80 Years on Postoperative Outcomes and Treatment Costs Following Pancreatic Surgery

As life expectancy is increasing, elderly patients are evaluated more frequently for resection of benign or malignant pancreatic lesions. However, the impact of age on postoperative morbidity, mortality, and treatment costs in octogenarian patients (≥80 years) undergoing major pancreatic surgery needs further investigation. The clinicopathological data of patients who underwent pancreatic surgery between January 2015 and March 2019 in a major hepatopancreatobiliary center in Switzerland were assessed. Postoperative outcomes and hospital costs of octogenarians and younger patients were compared in univariate and multivariate regression analysis. During the study period, 346 patients underwent pancreatic resection. Pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, and other procedures were performed in 54%, 20%, 13%, and 13% of patients, respectively. The major postoperative morbidity rate and postoperative mortality rate were 25% and 3.5%, respectively. A total of 39 patients (11%) were ≥80 years old, and 307 patients were <80 years old. The majority of octogenarians suffered from ductal adenocarcinoma, whereas among younger patients, other indications for a pancreatic resection were predominant (ductal adenocarcinoma 64% vs. 41%, p = 0.006). Age ≥80 was associated with more frequent postoperative medical (pulmonary, cardiovascular) and surgical (high-grade pancreatic fistula, postoperative hemorrhage) complications. Postoperative mortality was significantly higher in octogenarians (15.4% vs. 2%, p < 0.0001). This finding may be explained by the higher rate of type C pancreatic fistula (13% vs. 5%), resulting more frequently in postoperative hemorrhage (18% vs. 5%, p = 0.002) among patients ≥80 years old. In the multivariate logistic regression analysis, patient age ≥80 years predicted postoperative mortality independently of the tumor entity and surgical technique (p = 0.013, OR 6.71, 95% CI [1.5–30.3]). Increased major postoperative morbidity was responsible for lower cost recovery in octogenarians (94% vs. 102%, p = 0.046). In conclusion, patient age ≥80 years is associated with increased postoperative medical and surgical morbidity after major pancreatic surgery leading to lower cost recovery and a lower chance for successful resuscitation in patients requiring revisional surgery for postoperative hemorrhage and/or pancreatic fistula. In octogenarian patients suffering from pancreatic tumors, careful selection, and thorough prehabilitation is crucial to achieve the best postoperative and long-term oncologic outcomes.

[Evidence in minimally invasive surgery of the pancreas]

Minimally invasive pancreatic surgery lags behind the development of other fields of application of minimally invasive surgery. After a very slow development over the last two decades minimally invasive pancreatic surgery has currently gained wider acceptance especially in centers. This is due if nothing else, to the increasing availability of robotic assistance systems, which provide maneuverable instruments as well as a 3‑dimensional and enlarged view. Meanwhile, the technical feasibility for even complex pancreatic resections has been shown. This gives rise to the question whether laparoscopic or robotic techniques can generate equal or better results (evidence) with respect to perioperative morbidity, survival after oncological resection and the quality of life. As with all innovative techniques, which are implemented in surgery, the transferability to a wider audience, teaching methods and cost-effectiveness have to be evaluated. This article presents the current scientific evidence for laparoscopic and robotic pancreatic head and left-sided pancreatic surgery.

Pancreatic fistulas following distal pancreatectomy are unrelated to the texture quality of the pancreas

PURPOSE

The relevance of pancreatic texture for pancreatic fistula (POPF) formation after distal pancreatectomy (DP) remains ill defined. Recent POPF definition adjustments and common subjective pancreatic texture assessment are further drawbacks in the investigation of pancreatic texture as a factor for POPF development after DP.

METHODS

The predictive value of pancreatic texture by histologic assessment was investigated for POPF formation after DP, respecting the updated 2016 fistula definition. Histologic evaluation at the resection margin included amount of steatosis, degree of fibrosis, and pancreatic duct size.

RESULTS

A total of 102 patients who underwent DP were included. Thirty-six patients developed POPF. There was no difference in histologic variables in patients with and without POPF. In the univariate analysis, none of the three histologic features showed significant correlation with POPF formation. The ROC (receiver operating characteristic) curve demonstrated poor utility for the grade of steatosis 0.481 ± 0.058 (p = 0.75) and grade of fibrosis 0.466 ± 0.058 (p = 0.57) as predictive factors for POPF formation.

CONCLUSION

Results indicate that pancreatic texture does not predict POPF formation following DP. This is particularly relevant in the context of the increasing use of robotic and laparoscopic approaches for DPs with limited clinical pancreatic texture assessment by palpation.

Intraoperative amylase level of pancreatic juice as a simple predictor of pancreatic fistula after pancreaticoduodenectomy

INTRODUCTION

A soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD.

METHOD

This study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF.

RESULTS

Twenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p < 0.01), soft pancreatic remnant (p < 0.01), high intraoperative blood loss (p < 0.01), high intraoperative amylase level of pancreatic juice (p < 0.01), and low pancreatic fibrosis (p < 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p < 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 10⁵ IU/L (area under the curve = 0.726, sensitivity = 95.7%, and specificity = 50.0%) CONCLUSIONS: The intraoperative amylase level of pancreatic juice is a reliable objective predictor for POPF after PD.

Role of ultrasound shear wave elastography in preoperative prediction of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Majority of predictors of postoperative pancreatic fistula (POPF) use intraoperative variables. We aimed to study the role of preoperative ultrasound shear wave elastography (USWE) to predict POPF.

METHODS

The consecutive patients who underwent pancreaticoduodenectomy (PD) between January 2019 to March 2020 were prospectively enrolled. All patients underwent USWE assessment at the pancreatic neck level. Intraoperative variables including pancreatic texture, pancreatic duct diameter, blood loss and histological grading of fibrosis were also recorded. Associations between USWE and intraoperative variables and histological grading with the development of POPF were analyzed.

RESULTS

Of the 62 patients assessed, 50 patients (mean age: 53 ± 14 years; 31 males) were included. POPF and clinically relevant POPF (CRPOPF) were observed in 22 (44%) and 7 (14%) patients respectively. Soft pancreas was an independent predictor of CRPOPF (p = 0.04). The mean USWE valve was significantly lower in patients with CRPOPF as compared to no CRPOPF (9.7 Kpa vs. 12.8Kpa, p = 0.016). At receiver operating characteristic curve analysis, USWE value of 12.65Kpa yielded sensitivity and specificity of 100% and 47%, respectively, for prediction of CRPOPF. USWE showed significant correlation with intraoperative pancreatic texture (Spearman's rank correlation coefficient (ρ) = 0.565, p = 0.001).

CONCLUSION

USWE helps in preoperative prediction of CRPOPF. This may further help to customize management strategy in high risk patients.

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.

Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy

BACKGROUND

Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF.

METHODS

A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included.

RESULTS

Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI_95% ) 23-30) and 19% (CI_95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF.

CONCLUSION

In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.

Utilization of chemoradiation therapy provides strongest protective effect for avoidance of postoperative pancreatic fistula following pancreaticoduodenectomy: A NSQIP analysis

BACKGROUND

The utilization of neoadjuvant therapy (NAT) before performing pancreaticoduodenectomy for malignancy has been well established as a protective factor for the prevention of postoperative pancreatic fistula (POPF). However, there is a paucity of published data evaluating the specific NAT regimen that is the most protective against POPF development. We evaluated the differences between neoadjuvant chemotherapy (CT) and chemoradiation therapy (CRT) with regard to the effect on POPF rates.

METHODS

The main and targeted pancreatectomy American College of Surgeons National Surgical Quality Improvement Program registries for 2014-2016 were retrospectively reviewed. A total of 10,665 pancreaticoduodenectomy cases were present. The primary outcome was POPF development. The factors that have previously been shown to be associated with or suspected to be associated with POPF were evaluated. The factors included NAT, sex, age, body mass index (BMI), diabetes, smoking, steroid therapy, preoperative weight loss, preoperative albumin level, perioperative blood transfusions, wound classification, American Society of Anesthesiologists classification, duct size (<3 mm, 3-6 mm, and >6 mm), gland texture (soft, intermediate, and hard), and anastomotic technique. The factors identified to be statistically significant were then used for propensity score matching to compare POPF development between the cases utilizing CT versus CRT.

RESULTS

A total of 10,117 cases met the inclusion criteria. The development of POPF was significantly associated, on multivariate analysis, with a lack of NAT, male sex, higher BMI, nondiabetic status, nonsmoker status, decreased weight loss, preoperative albumin level, decreased duct size, and soft gland texture. NAT, duct size, and gland texture had the strongest associations with the development of POPF (p < .0001). The overall 1765 cases (17.45%) received NAT and the POPF rate for cases with NAT was 10.20% versus 20.10% for cases without NAT (p < .0001). A total of 1031 cases underwent CT and 734 cases underwent CRT, respectively. A total of 708 paired cases were selected for analysis based on propensity score matching. The POPF rates were 11.20% versus 3.50% for CT and CRT, respectively (p < .0001). There was no difference in the frequencies of specific POPF grades. The decreased POPF rate with CRT correlated with firmer gland texture rates.

CONCLUSIONS

To our knowledge, this is the largest analysis of specific NAT regimens with regard to the development of POPF following pancreaticoduodenectomy. CRT provided the strongest protective effect. That protective effect is most likely due to increased fibrosis in the pancreatic parenchyma from radiation therapy. These findings provide additional support to consider CRT over CT alone in the treatment of pancreatic cancer when NAT will be utilized.

Development and Validation of a New Nomogram for Predicting Clinically Relevant Postoperative Pancreatic Fistula After Pancreatoduodenectomy

BACKGROUND

There lacks an ideal model for accurately predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). This study aimed at developing a nomogram with high accuracy in predicting CR-POPF after PD.

METHODS

A total of 1182 patients undergoing PD in the First Affiliated Hospital of Sun Yat-sen University (FAHSYSU, n = 762) and Fudan University Shanghai Cancer Center (FUSCC, n = 420) between January 2010 and May 2018 were enrolled. The patients from FAHSYSU were assigned as testing cohort, and those from FUSCC were used as external validation cohort. Univariate and multivariate logistic regression analyses were performed to determine the predictive factors for CR-POPF. Nomogram was developed on the basis of significant predictors. The performance of nomogram was evaluated by area under receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis.

RESULTS

In testing cohort, 87 out of 762 patients developed CR-POPF. Three predictors were significantly associated with CR-POPF, including body mass index ≥24.0 kg/m², pancreatic duct diameter <3 mm, and drainage fluid amylase on postoperative day 1 ≥2484 units/L (all p ≤ 0.001). Prediction of nomogram was accurate with AUC of 0.934 (95% confidence interval [CI]: 0.914-0.950) in testing cohort and 0.744 (95% CI: 0.699-0.785) in external validation cohort. The predictive accuracy of nomogram was better than that of previously proposed fistula risk scores both in testing and external validation cohort (all p < 0.05).

CONCLUSIONS

The novel nomogram based on three easily available parameters could accurately predict CR-POPF after PD. It would have high clinical value due to its accuracy and convenience.

Frailty is a useful predictive marker of postoperative complications after pancreaticoduodenectomy

Background

Frailty results in a high risk for disability, hospitalization, and mortality. This study aimed to investigate perioperative details of frail patients who underwent pancreatectomy and whether frailty can be a predictive factor of postoperative complications, especially of clinically relevant postoperative pancreatic fistula (CR-POPF).

Methods

This retrospective study included patients who underwent pancreatectomy in our hospital between August 2016 and March 2019. The patients were divided into frail and pre-/non-frail groups. The diagnostic criteria were based on the Japanese version of the Cardiovascular Health Study.

Results

Of 93 patients, 11 (11.8%) and 82 (88.2%) were frail and pre-/non-frail patients, with median ages of 82 and 72 years, respectively (p = 0.041). Postoperative complications (Clavien-Dindo ≧ IIIa) were found in 8 and 32 patients (p = 0.034), CR-POPF in 3 and 13 patients (p = 0.346), and postoperative hospital stays were 21 and 17 days (p = 0.041), respectively. On multivariate analysis, frailty was an independent predictive factor (odds ratio [OR] 5.604, 95.0% confidence interval [CI] 1.002-30.734; p = 0.047) of postoperative complications (Clavien-Dindo ≧ IIIa) after pancreaticoduodenectomy. On multivariate analysis, a soft pancreas (OR 5.696, 95.0% CI 1.142-28.149; p = 0.034) was an independent and significant predictive factor of CR-POPF after pancreaticoduodenectomy.

Conclusions

Frailty may be a useful predictive factor of postoperative complications in patients undergoing pancreaticoduodenectomy.

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.