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Reducing the risk of postoperative pancreatic fistula in radical gastrectomy: pre-assessment with computed tomography for the diagnosis of pancreatic steatosis

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Abstract

Purpose

To determine whether pancreatic steatosis (PS) is associated with the risk of postoperative pancreatic fistula (POPF) after radical gastrectomy, and if so, to investigate whether pre-assessment by diagnostic imaging can mitigate the risk.

Methods

The clinical records of 276 patients with cStage I gastric cancer who underwent laparoscopic gastrectomy with D1 + lymphadenectomy between 2012 and 2015 were reviewed. In the first phase up to July 2013 (n = 138), PS was classified from computed tomography (CT) findings into type S (superficial fat deposition) or type D (diffuse fatty replacement) and examined for association with POPF. In the second phase (n = 138), the preoperative CT assessment of PS was routinized. Separate samples from pancreatoduodenectomy consistent with each type were histologically examined.

Results

In the first phase, the incidence of POPF was significantly higher in group S, but not in group D, compared with normal pancreas (16.3% and 9.1% vs. 3.6%, respectively; P = 0.03). The drain amylase level was lowest in group D, reflecting exocrine insufficiency. Histologically, the loose connective-tissue space between the fat infiltrating the pancreas and the peripancreatic fat containing the lymph nodes was unclear in type D but conserved in type S. In the second phase, surgery was performed with more intention on accurately tracing the dissection plane and significantly lowered incidence of POPF in Group S (16.3% to 2.1%; P = 0.047).

Conclusion

Peripancreatic lymphadenectomy is more challenging and likely to cause POPF in patients with PS. However, the risk may be reduced using appropriate dissection techniques based on the CT pre-assessment findings.

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Data availability

The datasets generated during and/or analyzed during the current study are not publicly available due to the medical data including participants’ personal data.

Code availability

Not applicable.

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Acknowledgements

The authors thank Dr. Ken Motoori at the Department of Radiology, Tsudanuma General Hospital, for specialist evaluation of the CT classification used in this study; Caryn Jones at ThinkSCIENCE for professional editing and language revision; and all the young surgeons at Toranomon Hospital for their assistance in surgical specimen handling.

Funding

This work was supported in part by the Japan Society for the Promotion of Science (KAKENHI Grant Number 19H03735). The sponsor had no role in study design, data collection, data analysis, manuscript preparation, or publication decisions.

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Author notes

  1. Nao Kobayashi and Hisashi Shinohara contributed equally to this work.

Authors and Affiliations

  1. Department of Surgery, Tsudanuma General Hospital, Narashino, Japan

    Nao Kobayashi

  2. Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan

    Nao Kobayashi, Hisashi Shinohara, Shusuke Haruta, Harushi Udagawa & Masaki Ueno

  3. Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan

    Hisashi Shinohara

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  1. Nao Kobayashi
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  2. Hisashi Shinohara
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  4. Harushi Udagawa
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  5. Masaki Ueno
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Contributions

Study conception and design: Kobayashi N and Shinohara H; acquisition of data: Kobayashi N and Haruta S; analysis and interpretation of data: Kobayashi N and Shinohara H; drafting of manuscript: Shinohara H; critical revision of manuscript: Udagawa H and Ueno M.

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Correspondence to Hisashi Shinohara.

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Kobayashi, N., Shinohara, H., Haruta, S. et al. Reducing the risk of postoperative pancreatic fistula in radical gastrectomy: pre-assessment with computed tomography for the diagnosis of pancreatic steatosis. Langenbecks Arch Surg 407, 587–596 (2022). https://doi.org/10.1007/s00423-021-02337-z

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