Skip to main content
Log in

Schematic Pancreatic Configuration: A Risk Assessment for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

Methods

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4 %), grade B in 84 (26.4 %), and grade C in 6 (1.9 %).

Conclusions

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 2010;145:634–640.

    Article  PubMed  Google Scholar 

  2. Reid-Lombardo KM, Farnell MB, Crippa S, Barnett M, Maupin G, Bassi C, Traverso LW, Pancreatic Anastomotic Leak Study Group. Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1,507 patients: a report from the Pancreatic Anastomotic Leak Study Group. J Gastrointest Surg 2007;11:1451–1458.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. Yamamoto Y, Sakamoto Y, Nara S, Esaki M, Shimada K, Kosuge T. A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg 2011;35:2747–2755.

    Article  PubMed  Google Scholar 

  5. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216:1–14.

    Article  PubMed  Google Scholar 

  6. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M; International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13.

    Google Scholar 

  7. Rosso E, Casnedi S, Pessaux P, Oussoultzoglou E, Panaro F, Mahfud M, Jaeck D, Bachellier P. The role of "fatty pancreas" and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg 2009;13:1845–1851.

    Article  PubMed  Google Scholar 

  8. Ansorge C, Strömmer L, Andrén-Sandberg Å, Lundell L, Herrington MK, Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br J Surg 2012;99:1076–1082.

    Article  PubMed  CAS  Google Scholar 

  9. Pecorelli N, Balzano G, Capretti G, Zerbi A, Di Carlo V, Braga M. Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg 2012;16:518–523.

    Article  PubMed  Google Scholar 

  10. Hashimoto Y, Traverso LW. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a web-based calculator to improve homogeneity of definition. Surgery 2010;147:503–515.

    Article  PubMed  Google Scholar 

  11. Frozanpor F, Loizou L, Ansorge C, Segersvärd R, Lundell L, Albiin N. Preoperative pancreas CT/MRI characteristics predict fistula rate after pancreaticoduodenectomy. World J Surg 2012;36:1858–1865.

    Article  PubMed  CAS  Google Scholar 

  12. Hashimoto Y, Sclabas GM, Takahashi N, Kirihara Y, Smyrk TC, Huebner M, Farnell MB. Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. J Gastrointest Surg 2011;15:2193–2204.

    Article  PubMed  Google Scholar 

  13. Hwang HK, Park JS, Park CI, Kim JK, Yoon DS. The impact of body mass index on pancreatic fistula after pancreaticoduodenectomy in Asian patients on the basis of Asia-Pacific perspective of body mass index. JOP 2011;12:586–592.

    PubMed  Google Scholar 

  14. Callery MP, Pratt WB, Vollmer CM Jr. Prevention and management of pancreatic fistula. J Gastrointest Surg 2009;13:163–173.

    Article  PubMed  Google Scholar 

  15. Lai EC, Lau SH, Lau WY. Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 2009;144:1074–1080.

    Article  PubMed  Google Scholar 

  16. Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 2012;99:524–531.

    Article  PubMed  CAS  Google Scholar 

  17. Okano K, Oshima M, Kakinoki K, Yamamoto N, Akamoto S, Yachida S, Hagiike M, Kamada H, Masaki T, Suzuki Y. Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler. Surg Today 2013;43:141–147.

    Article  PubMed  Google Scholar 

  18. Sugimoto M, Gotohda N, Kato Y, Takahashi S, Kinoshita T, Shibasaki H, Nomura S, Konishi M, Kaneko H. Risk factor analysis and prevention of postoperative pancreatic fistula after distal pancreatectomy with stapler use. J Hepatobiliary Pancreat Sci 2013; 20:538–544.

    Google Scholar 

  19. Kakita A, Takahashi T, Yoshida M, Furuta K. A simpler and more reliable technique of pancreatojejunal anastomosis. Surg Today 1996;26:532–535.

    Article  PubMed  CAS  Google Scholar 

  20. Molinari E, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G, Falconi M, Pederzoli P. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg 2007;246:281–287.

    Article  PubMed  Google Scholar 

  21. Tranchart H, Gaujoux S, Rebours V, Vullierme MP, Dokmak S, Levy P, Couvelard A, Belghiti J, Sauvanet A. Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy. Ann Surg 2012;256:139–145.

    Article  PubMed  Google Scholar 

  22. Lermite E, Pessaux P, Brehant O, Teyssedou C, Pelletier I, Etienne S, Arnaud JP. Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg 2007;204:588–596.

    Article  PubMed  Google Scholar 

  23. Noji T, Nakamura T, Ambo Y, Suzuki O, Nakamura F, Kishida A, Hirano S, Kondo S, Kashimura N. Clinically relevant pancreas-related infectious complication after pancreaticoenteral anastomosis could be predicted by the parameters obtained on postoperative day 3. Pancreas 2012;41:916–921.

    Article  PubMed  Google Scholar 

  24. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, Talamini G, Pederzoli P. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg 2010;252:207–214.

    Article  PubMed  Google Scholar 

  25. Tajima Y, Kuroki T, Tsutsumi R, Fukuda K, Kitasato A, Adachi T, Mishima T, Kanematsu T. Risk factors for pancreatic anastomotic leakage: the significance of preoperative dynamic magnetic resonance imaging of the pancreas as a predictor of leakage. J Am Coll Surg 2006;202:723–731.

    Article  PubMed  Google Scholar 

  26. Tajima Y, Matsuzaki S, Furui J, Isomoto I, Hayashi K, Kanematsu T. Use of the time-signal intensity curve from dynamic magnetic resonance imaging to evaluate remnant pancreatic fibrosis after pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy. Br J Surg 2004;91:595–600.

    Article  PubMed  CAS  Google Scholar 

  27. Ammann RW, Heitz PU, Klöppel G. Course of alcoholic chronic pancreatitis: a prospective clinicomorphological long-term study. Gastroenterology 1996;111:224–231.

    Article  PubMed  CAS  Google Scholar 

  28. Friess H, Malfertheiner P, Isenmann R, Kühne H, Beger HG, Büchler MW. The risk of pancreaticointestinal anastomosis can be predicted preoperatively. Pancreas 1996;13:202–208.

    PubMed  CAS  Google Scholar 

  29. Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, Nakeeb A, Zyromski NJ, Lillemoe KD. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg 2007;246:1058–1064.

    Article  PubMed  Google Scholar 

  30. Ahmad SA, Edwards MJ, Sutton JM, Grewal SS, Hanseman DJ, Maithel SK, Patel SH, Bentram DJ, Weber SM, Cho CS, Winslow ER, Scoggins CR, Martin RC, Kim HJ, Baker JJ, Merchant NB, Parikh AA, Kooby DA. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg 2012;256:529–537.

    Article  PubMed  Google Scholar 

  31. Gebauer F, Kloth K, Tachezy M, Vashist YK, Cataldegirmen G, Izbicki JR, Bockhorn M. Options and limitations in applying the fistula classification by the International Study Group for Pancreatic Fistula. Ann Surg 2012;256:130–138.

    Article  PubMed  Google Scholar 

  32. Shirakawa S, Matsumoto I, Toyama H, Shinzeki M, Ajiki T, Fukumoto T, Ku Y. Pancreatic volumetric assessment as a predictor of new-onset diabetes following distal pancreatectomy. J Gastrointest Surg. 2012;16:2212–2219.

    Article  PubMed  Google Scholar 

  33. Kirihara Y, Takahashi N, Hashimoto Y, Sclabas GM, Khan S, Moriya T, Sakagami J, Huebner M, Sarr MG, Farnell MB. Prediction of pancreatic anastomotic failure after pancreatoduodenectomy: the use of preoperative, quantitative computed tomography to measure remnant pancreatic volume and body composition. Ann Surg 2013;257:512–519.

    Article  PubMed  Google Scholar 

  34. Fernández-Cruz L, Belli A, Acosta M, Chavarria EJ, Adelsdorfer W, López-Boado MA, Ferrer J. Which is the best technique for pancreaticoenteric reconstruction after pancreaticoduodenectomy? A critical analysis. Surg Today 2011;41:761–766.

    Article  PubMed  Google Scholar 

  35. Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, Hyslop T, Schmidt CM, Rosato EL, Lavu H, Nakeeb A, Pitt HA, Lillemoe KD, Yeo CJ. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009;208:738–747.

    Article  PubMed  Google Scholar 

  36. Barakat O, Ozaki CF, Wood RP. Topically applied 2-octyl cyanoacrylate (Dermabond) for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg 2012;16:1499–1507.

    Article  PubMed  Google Scholar 

  37. Tani M, Kawai M, Hirono S, Hatori T, Imaizumi T, Nakao A, Egawa S, Asano T, Nagakawa T, Yamaue H. Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: nationwide survey of the Japanese Society of Pancreatic Surgery. Surgery 2012;151:183–191.

    Article  PubMed  Google Scholar 

  38. Koti RS, Gurusamy KS, Fusai G, Davidson BR. Meta-analysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: a Cochrane review. HPB (Oxford) 2010;12:155–165.

    Article  Google Scholar 

Download references

Conflict of interest

None

Sources of funding for research and/or publication

None

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Shinichiro Takahashi.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sugimoto, M., Takahashi, S., Gotohda, N. et al. Schematic Pancreatic Configuration: A Risk Assessment for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 17, 1744–1751 (2013). https://doi.org/10.1007/s11605-013-2320-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-013-2320-4

Keywords

Navigation