European Radiology

, Volume 29, Issue 5, pp 2399–2407 | Cite as

Multidetector CT findings differ between surgical grades of pancreatic fistula after pancreaticoduodenectomy

  • Hyo-jae Lee
  • Jin Woong KimEmail author
  • Young Hoe Hur
  • Byung Kook Lee
  • Sung Bum Cho
  • Eu Chang Hwang
  • Seung Jin Lee
  • Eun Ju Yoon
  • Hyun Ju Seon



To define and correlate multidetector CT (MDCT) findings of pancreatic fistula after pancreaticoduodenectomy with surgical grading based on the 2016 Revised International Study Group of Pancreatic Fistula (ISGPF) classification.


Between May 2011 and December 2016, 235 patients with periampullary tumor underwent pancreaticoduodenectomy and postoperative MDCT. Patients were classified into three groups (clinically no pancreatic fistula (cNo-PF), grade B, and grade C) according to the ISGPF classification. MDCT images were retrospectively evaluated by two radiologists in consensus for the presence of pancreaticojejunostomy (PJ) dehiscence, PJ dehiscence diameter, PJ defect, acute necrotic collection (ANC), peripancreatic fluid collection, and imaging findings of complications. Categorical MDCT findings were compared among the three groups using Pearson’s chi-square test, and PJ dehiscence diameter was compared using the Kruskal–Wallis test.


There was no significant difference in patient demographics among the groups (cNo-PF = 133, grade B = 68, and grade C = 34), but the MDCT findings were significantly different regarding the presence of PJ dehiscence (p < 0.001), PJ defect (p < 0.001), ANC (p = 0.002), and imaging findings of total complications (p < 0.001). The diameters of PJ dehiscence were significantly different among the groups (cNo-PF [0.42 ± 1.54 mm], grade B [1.47 ± 2.33 mm], and grade C [5.38 ± 6.45 mm]) (p < 0.001).


With respect to the presence of PF, postoperative MDCT findings may differ between surgical grading based on the ISGPF classification.

Key Points

Regarding the presence of pancreatic fistula, the postoperative multidetector CT findings correlate well with surgical grading based on the International Study Group of Pancreatic Fistula classification.

• Multidetector CT may provide reliable information to suggest pancreatic fistula after pancreaticoduodenectomy.


Pancreaticoduodenectomy Pancreatic fistula Pancreaticojejunostomy Postoperative complications 



Acute necrotic collection


Area under the receiver operating characteristic curve


Confidence interval


Clinically no pancreatic fistula


2016 Revised International Study Group of Pancreatic Fistula


Multidetector CT


Pancreatic fistula

PJ defect

Pancreaticojejunostomy defect

PJ dehiscence

Pancreaticojejunostomy dehiscence


Postoperative pancreatitis


Postoperative pancreatic fistula


Pylorus-preserving pancreaticoduodenectomy



This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korea government (MEST) (No. 2017R1D1A3B04033613).

Compliance with ethical standards


The scientific guarantor of this publication is Jin Woong Kim.

Conflict of interest

Jin Woong Kim, MD, PhD, has received research grants from the National Research Foundation of Korea (NRF) (No. 2017R1D1A3B04033613). Hyo-jae Lee, Young Hoe Hur, Byung Kook Lee, Sung Bum Cho, Eu Chang Hwang, Seung Jin Lee, Eun Ju Yoon, and Hyun Ju Seon declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Byung Kook Lee and Eu Chang Hwang kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained (No.: CNUHH-2017-140).


• retrospective

• diagnostic or prognostic study

• performed at one institution


  1. 1.
    Kawai M, Yamaue H (2010) Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: a new era of pancreatic surgery. Surg Today 40:1011–1017CrossRefGoogle Scholar
  2. 2.
    Raman SP, Horton KM, Cameron JL, Fishman EK (2013) CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol 201:2–13CrossRefGoogle Scholar
  3. 3.
    Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM Jr (2007) Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 245:443–451CrossRefGoogle Scholar
  4. 4.
    Machado NO (2012) Pancreatic fistula after pancreatectomy: definitions, risk factors, preventive measures, and management-review. Int J Surg Oncol 2012:602478Google Scholar
  5. 5.
    Lai ECH, Lau SHY, Lau WY (2009) Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 144:1074–1080CrossRefGoogle Scholar
  6. 6.
    Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13CrossRefGoogle Scholar
  7. 7.
    Bassi C, Marchegiani G, Dervenis C et al (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591CrossRefGoogle Scholar
  8. 8.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr (2013) A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 216:1–14CrossRefGoogle Scholar
  9. 9.
    Strasberg SM, Drebin JA, Mokadam NA et al (2002) Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure. J Am Coll Surg 194:746–758 discussion 759–760CrossRefGoogle Scholar
  10. 10.
    Bai X, Zhang Q, Gao S et al (2016) Duct-to-mucosa vs invagination for pancreaticojejunostomy after pancreaticoduodenectomy: a prospective, randomized controlled trial from a single surgeon. J Am Coll Surg 222:10–18CrossRefGoogle Scholar
  11. 11.
    Gervais DA, Fernandez-del Castillo C, O'Neill MJ, Hahn PF, Mueller PR (2001) Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics 21:673–690CrossRefGoogle Scholar
  12. 12.
    Banks PA, Bollen TL, Dervenis C et al (2013) Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 62:102–111CrossRefGoogle Scholar
  13. 13.
    Malleo G, Crippa S, Butturini G et al (2010) Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford) 12:610–618CrossRefGoogle Scholar
  14. 14.
    Ho CK, Kleeff J, Friess H, Büchler MW (2005) Complications of pancreatic surgery. HPB (Oxford) 7:99–108CrossRefGoogle Scholar
  15. 15.
    Coombs RJ, Zeiss J, Howard JM, Thomford NR, Merrick HW (1990) CT of the abdomen after the Whipple procedure: value in depicting postoperative anatomy, surgical complications, and tumor recurrence. AJR Am J Roentgenol 154:1011–1014Google Scholar
  16. 16.
    Mortelé KJ, Lemmerling M, de Hemptinne B, De Vos M, De Bock G, Kunnen M (2000) Postoperative findings following the Whipple procedure: determination of prevalence and morphologic abdominal CT features. Eur Radiol 10:123–128CrossRefGoogle Scholar
  17. 17.
    Lepanto L, Gianfelice D, Déry R, Dagenais M, Lapointe R, Roy A (1994) Postoperative changes, complications, and recurrent disease after Whipple’s operation: CT features. AJR Am J Roentgenol 163:841–846CrossRefGoogle Scholar
  18. 18.
    Thoeni RF (2012) The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 262:751–764CrossRefGoogle Scholar
  19. 19.
    Hashimoto M, Koga M, Ishiyama K et al (2007) CT features of pancreatic fistula after pancreaticoduodenectomy. AJR Am J Roentgenol 188:W323–W327CrossRefGoogle Scholar
  20. 20.
    Park SH, Goo JM, Jo CH (2004) Receiver operating characteristic (ROC) curve: practical review for radiologists. Korean J Radiol 5:11–18CrossRefGoogle Scholar
  21. 21.
    Schulick RD (2008) Complications after pancreaticoduodenectomy: intraabdominal abscess. J Hepatobiliary Pancreat Surg 15:252–256CrossRefGoogle Scholar
  22. 22.
    Halloran CM, Ghaneh P, Bosonnet L, Hartley MN, Sutton R, Neoptolemos JP (2002) Complications of pancreatic cancer resection. Dig Surg 19:138–146CrossRefGoogle Scholar
  23. 23.
    Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM (2002) Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 137:55–59CrossRefGoogle Scholar
  24. 24.
    Puppala S, Patel J, McPherson S, Nicholson A, Kessel D (2011) Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol 196:192–197CrossRefGoogle Scholar
  25. 25.
    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH (1990) Acute pancreatitis: value of CT in establishing prognosis. Radiology 174:331–336CrossRefGoogle Scholar
  26. 26.
    McMillan MT, Soi S, Asbun HJ et al (2016) Risk-adjusted outcomes of clinically relevant pancreatic fistula following pancreatoduodenectomy: a model for performance evaluation. Ann Surg 264:344–352CrossRefGoogle Scholar
  27. 27.
    Tran KT, Smeenk HG, van Eijck CH et al (2004) Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 240:738CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of RadiologyChonnam National University Hwasun Hospital and Chonnam National University Medical SchoolGwangjuRepublic of Korea
  2. 2.Department of RadiologyChosun University Hospital and Chosun University College of MedicineGwangjuRepublic of Korea
  3. 3.Department of Hepato-Pancreato-Biliary SurgeryChonnam National University Hwasun Hospital and Chonnam National University Medical SchoolGwangjuRepublic of Korea
  4. 4.Department of Emergency MedicineChonnam National University Hwasun Hospital and Chonnam National University Medical SchoolGwangjuRepublic of Korea
  5. 5.Department of Internal MedicineChonnam National University Hwasun Hospital and Chonnam National University Medical SchoolGwangjuRepublic of Korea
  6. 6.Department of UrologyChonnam National University Hwasun Hospital and Chonnam National University Medical SchoolGwangjuRepublic of Korea

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