Skip to main content
SpringerLink
Log in

Abdominal CT predictors of fibrosis in patients with chronic pancreatitis undergoing surgery

  • Gastrointestinal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objective

To determine which abdominal CT findings predict severe fibrosis and post-operative pain relief in chronic pancreatitis (CP).

Methods

Pre-operative abdominal CTs of 66 patients (mean age 52 ± 12 years, 53 % males) with painful CP who underwent the Whipple procedure (n = 32), Frey procedure (n = 32) or pancreatic head biopsy (n = 2), between 1/2003-3/2014, were evaluated. CT was evaluated for parenchymal calcifications, intraductal calculi, main pancreatic duct dilation (>5 mm), main pancreatic duct stricture, and abnormal side branch(es). The surgical histopathology was graded for fibrosis. CT findings were evaluated as predictors of severe fibrosis and post-operative pain relief using regression and area under receiver operating curve (AUC) analysis.

Results

Thirty-eight (58 %) patients had severe fibrosis. Parenchymal calcification(s) were an independent predictor of severe fibrosis (p = 0.03), and post-operative pain relief over a mean follow-up of 1-year (p = 0.04). Presence of >10 parenchymal calcifications had higher predictive accuracy for severe fibrosis than 1-10 parenchymal calcification(s) (AUC 0.88 vs. 0.59, p = 0.003). The predictive accuracy of >10 versus 1-10 parenchymal calcifications increased after adjusting for all other CT findings (AUC 0.89 vs. 0.63, p = 0.01).

Conclusion

Parenchymal calcification(s) independently predict severe fibrosis and are significantly associated with post-operative pain relief in CP. The presence of >10 parenchymal calcifications is a better predictor of severe fibrosis than 1-10 parenchymal calcification(s).

Key Points

• Parenchymal calcifications in chronic pancreatitis independently predict post-operative pain relief

• Intraductal calculi and MPD dilation are not associated with post-operative pain relief

• Better patient selection for pancreatic resection surgery in painful chronic pancreatitis

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

Access this article

Log in via an institution

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

Abbreviations

AUC:

Area Under receiver operating Curve

CECT:

Contrast Enhanced Computed Tomography

CI:

Confidence Interval

CP:

Chronic Pancreatitis

CT:

Computed Tomography

ERCP:

Endoscopic Retrograde Cholangio Pancreatography

H&E:

Haematoxylin and Eosin

MPD:

Main Pancreatic Duct

OR:

Odds Ratio

PACS:

Picture Archiving and Communication System

SD:

Standard Deviation

References

  1. Klöppel G, Detlefsen S, Feyerabend B (2004) Fibrosis of the pancreas: the initial tissue damage and the resulting pattern. Virchows Arch 445:1–8

    Article  PubMed  Google Scholar 

  2. Mueller PR, Miketic LM, Simeone JF et al (1988) Severe acute pancreatitis after percutaneous biopsy of the pancreas. AJR Am J Roentgenol 151:493–494

    Article  CAS  PubMed  Google Scholar 

  3. Thoeni RF, Blankenberg F (1993) Pancreatic imaging. Computed tomography and magnetic resonance imaging. Radiol Clin N Am 31:1085–1113

    CAS  PubMed  Google Scholar 

  4. Luetmer PH, Stephens DH, Ward EM (1989) Chronic pancreatitis: reassessment with current CT. Radiology 171:353–357

    Article  CAS  PubMed  Google Scholar 

  5. Hashimoto Y, Sclabas GM, Takahashi N et al (2011) Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. J Gastrointest Surg 15:2193–2204

    Article  PubMed  Google Scholar 

  6. Ammann RW, Largiadèr F, Akovbiantz A (1979) Pain relief by surgery in chronic pancreatitis? Relationship between pain relief, pancreatic dysfunction, and alcohol withdrawal. Scand J Gastroenterol 14:209–215

    Article  CAS  PubMed  Google Scholar 

  7. Ammann RW, Akovbiantz A, Largiader F, Schueler G (1984) Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 86:820–828

    CAS  PubMed  Google Scholar 

  8. Keck T, Adam U, Makowiec F et al (2012) Short- and long-term results of duodenum preservation versus resection for the management of chronic pancreatitis: a prospective, randomized study. Surgery 152:S95–S102

    Article  PubMed  Google Scholar 

  9. Traverso LW, Tompkins RK, Urrea PT, Longmire WP (1979) Surgical treatment of chronic pancreatitis. Twenty-two years’ experience. Ann Surg 190:312–319

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  10. Frey CF, Amikura K (1994) Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg 220:492–504, discussion -7

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  11. Jensen AR, Matzen P, Malchow-Møller A, Christoffersen I (1984) Pattern of pain, duct morphology, and pancreatic function in chronic pancreatitis. A comparative study. Scand J Gastroenterol 19:334–338

    CAS  PubMed  Google Scholar 

  12. Lankisch PG, Löhr-Happe A, Otto J, Creutzfeldt W (1993) Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion 54:148–155

    Article  CAS  PubMed  Google Scholar 

  13. Nealon WH, Thompson JC (1993) Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure. Ann Surg 217:458–466, discussion 66-8

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Amudhan A, Balachandar TG, Kannan DG et al (2008) Factors affecting outcome after Frey procedure for chronic pancreatitis. HPB (Oxford) 10:477–482

    Article  Google Scholar 

  15. Keus E, van Laarhoven CJ, Eddes EH, Masclee AA, Schipper ME, Gooszen HG (2003) Size of the pancreatic head as a prognostic factor for the outcome of Beger’s procedure for painful chronic pancreatitis. Br J Surg 90:320–324

    Article  CAS  PubMed  Google Scholar 

  16. Campisi A, Brancatelli G, Vullierme MP et al (2009) Are pancreatic calcifications specific for the diagnosis of chronic pancreatitis? A multidetector-row CT analysis. Clin Radiol 64:903–911

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  18. Cooper MA, Makary MA, Ng J et al (2013) Extent of pancreatic fibrosis as a determinant of symptom resolution after the Frey procedure: a clinico-pathologic analysis. J Gastrointest Surg 17:682–687

    Article  PubMed  Google Scholar 

  19. Whipple AO (1946) Radical surgery for certain cases of pancreatic fibrosis associated with calcareous deposits. Ann Surg 124:991–1008

    Article  PubMed Central  Google Scholar 

  20. Bachmann K, Tomkoetter L, Kutup A et al (2013) Is the Whipple procedure harmful for long-term outcome in treatment of chronic pancreatitis? 15-years follow-up comparing the outcome after pylorus-preserving pancreatoduodenectomy and Frey procedure in chronic pancreatitis. Ann Surg 258:815–820, discussion 20-1

    Article  PubMed  Google Scholar 

  21. Kamisawa T, Funata N, Hayashi Y et al (2003) Close relationship between autoimmune pancreatitis and multifocal fibrosclerosis. Gut 52:683–687

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  22. Hadidi A (1983) Pancreatic duct diameter: sonographic measurement in normal subjects. J Clin Ultrasound 11:17–22

    Article  CAS  PubMed  Google Scholar 

  23. Sarner M, Cotton PB (1984) Classification of pancreatitis. Gut 25:756–759

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  24. Klöppel G, Maillet B (1991) Pseudocysts in chronic pancreatitis: a morphological analysis of 57 resection specimens and 9 autopsy pancreata. Pancreas 6:266–274

    Article  PubMed  Google Scholar 

  25. Detlefsen S, Sipos B, Feyerabend B, Klöppel G (2005) Pancreatic fibrosis associated with age and ductal papillary hyperplasia. Virchows Arch 447:800–805

    Article  PubMed  Google Scholar 

  26. DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845

    Article  CAS  PubMed  Google Scholar 

  27. Owens JL, Howard JM (1958) Pancreatic calcification: a late sequel in the natural history of chronic alcoholism and alcoholic pancreatitis. Ann Surg 147:326–338

    Article  PubMed Central  PubMed  Google Scholar 

  28. Hastier P, Buckley MJ, Dumas R et al (1998) A study of the effect of age on pancreatic duct morphology. Gastrointest Endosc 48:53–57

    Article  CAS  PubMed  Google Scholar 

  29. Petrone MC, Arcidiacono PG, Perri F, Carrara S, Boemo C, Testoni PA (2010) Chronic pancreatitis-like changes detected by endoscopic ultrasound in subjects without signs of pancreatic disease: do these indicate age-related changes, effects of xenobiotics, or early chronic pancreatitis? Pancreatology 10:597–602

    Article  PubMed  Google Scholar 

  30. Glaser J, Högemann B, Krummenerl T et al (1987) Sonographic imaging of the pancreatic duct. New diagnostic possibilities using secretin stimulation. Dig Dis Sci 32:1075–1081

    Article  CAS  PubMed  Google Scholar 

  31. Smits ME, Badiga SM, Rauws EA, Tytgat GN, Huibregtse K (1995) Long-term results of pancreatic stents in chronic pancreatitis. Gastrointest Endosc 42:461–467

    Article  CAS  PubMed  Google Scholar 

  32. Sarles H, Sarles JC, Camatte R et al (1965) Observations on 205 confirmed cases of acute pancreatitis, recurring pancreatitis, and chronic pancreatitis. Gut 6:545–559

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Shimizu M, Hayashi T, Saitoh Y, Ohta K, Itoh H (1990) Postmortem autolysis in the pancreas: multivariate statistical study. The influence of clinicopathological conditions. Pancreas 5:91–94

    Article  CAS  PubMed  Google Scholar 

  34. Whitcomb DC (2013) Genetic risk factors for pancreatic disorders. Gastroenterology 144:1292–1302

    Article  PubMed Central  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The scientific guarantor of this publication is Atif Zaheer. The authors of this manuscript declare relationships with the following companies: Vikesh K. Singh is a consultant for Abbvie, Santarus, Boston Scientific, Enteromedics, and Novo Nordisk. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. This study has received funding by the Pancreatitis Research Fund at the Johns Hopkins Medical Institutions (VKS). One of the authors has significant statistical expertise. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was not required for this study because it is an anonymous retrospective chart review. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, diagnostic or prognostic study, performed at one institution.

Author information

Authors and Affiliations

  1. The Russel H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Sumera Ali, Siva P. Raman, Elliot K. Fishman & Atif Zaheer

  2. Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Amitasha Sinha, Vikesh K. Singh & Elham Afghani

  3. Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Michael Cruise & Karen Matsukuma

  4. Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Martin A. Makary

  5. Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Vikesh K. Singh, Martin A. Makary & Atif Zaheer

  6. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA

    Dana K. Andersen

  7. Johns Hopkins Medical Institutions, 601 North Caroline Street, JHOC 3235 A, Baltimore, MD, 21287, USA

    Atif Zaheer

Authors
  1. Amitasha Sinha
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vikesh K. Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Cruise
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Elham Afghani
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karen Matsukuma
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sumera Ali
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dana K. Andersen
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Martin A. Makary
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Siva P. Raman
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Elliot K. Fishman
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Atif Zaheer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Atif Zaheer.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sinha, A., Singh, V.K., Cruise, M. et al. Abdominal CT predictors of fibrosis in patients with chronic pancreatitis undergoing surgery. Eur Radiol 25, 1339–1346 (2015). https://doi.org/10.1007/s00330-014-3526-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-014-3526-x

Keywords

Search

Navigation