Abstract
Introduction
Delayed or decreased computed tomography (CT) enhancement characteristics in pancreatic fibrosis have been described.
Methods
A review of 157 consecutive patients with preoperative dual-phase CT between 2004 and 2009 was performed. Pancreatic CT attenuation upstream from the tumor was measured in the pancreatic and hepatic imaging phases. The ratio of the mean CT attenuation value [hepatic to pancreatic phase; late/early (L/E) ratio] and histological grade of pancreatic fibrosis was correlated with the development of a clinically relevant pancreatic anastomotic failure (PAF) and other clinical parameters.
Results
A clinically relevant PAF was observed in 21 patients (13.4%) with morbidity and mortality of 39.5% and 0%, respectively. The PAF group showed maximum enhancement in the pancreatic and washout in the hepatic CT phase, while the no PAF group showed a delayed enhancement pattern. Degree of pancreatic fibrosis and L/E ratio were significantly lower for the PAF group than the no PAF group (0.86 ± 0.14 vs. 1.09 ± 0.24; P < 0.0001 and 21.0 ± 17.9 vs. 40.4 ± 29.8; P < 0.0001); fewer PAF patients showed an atrophic histological pattern (14% vs. 39%; P = 0.046). The L/E ratio was positively correlated with pancreatic fibrosis. Pancreatic fibrosis and L/E ratio increased with larger duct size (P < 0.001), the presence of diabetes (P < 0.05), and the surgeon’s assessment of pancreas firmness (P < 0.001). In multivariate analyses, L/E ratio and body mass index were significant predictors for the development of a clinically relevant PAF; a 0.1-U increase of L/E ratio decreased the odds of a PAF by 54%.
Conclusion
Pancreatic CT enhancement pattern can accurately assess pancreatic fibrosis and is a powerful tool to predict the risk of developing a clinically relevant PAF following PD.
Similar content being viewed by others
References
Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993; 217:430–435; discussion 435–438.
Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery 2005; 138:618–628; discussion 628–630.
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.
Lillemoe KD, Cameron JL, Kim MP, Campbell KA, Sauter PK, Coleman JA, Yeo CJ. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004; 8:766–772; discussion 772–764.
Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997; 226:632–641.
Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995; 221:635–645; discussion 645–638.
Murakami Y, Uemura K, Hayashidani Y, Sudo T, Hashimoto Y, Nakagawa N, Ohge H, Sueda T. No mortality after 150 consecutive pancreatoduodenectomies with duct-to-mucosa pancreaticogastrostomy. J Surg Oncol 2008; 97:205–209.
Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C. Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg 2009; 249:97–104.
Poon RT, Fan ST, Lo CM, Ng KK, Yuen WK, Yeung C, Wong J. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 2007; 246:425–433; discussion 433–425.
Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM, Jr. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007; 245:443–451.
Roder JD, Stein HJ, Bottcher KA, Busch R, Heidecke CD, Siewert JR. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study. Ann Surg 1999; 229:41–48.
Sarr MG. The potent somatostatin analogue vapreotide does not decrease pancreas-specific complications after elective pancreatectomy: a prospective, multicenter, double-blinded, randomized, placebo-controlled trial. J Am Coll Surg 2003; 196:556–564; discussion 564–555; author reply 565.
Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995; 222:580–588; discussion 588–592.
Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004; 8:951–959.
Hashimoto Y, Traverso LW. Pancreatic anastomotic failure rate after pancreaticoduodenectomy decreases with microsurgery. J Am Coll Surg 2010; 211:510–521.
Nakamura H, Murakami Y, Uemura K, Hayashidani Y, Sudo T, Ohge H, Sueda T. Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy. J Gastrointest Surg 2009; 13:1321–1327.
Yeo CJ, Cameron JL, Lillemoe KD, Sauter PK, Coleman J, Sohn TA, Campbell KA, Choti MA. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000; 232:419–429.
Dinter DJ, Aramin N, Weiss C, Singer C, Weisser G, Schoenberg SO, Post S, Niedergethmann M. Prediction of anastomotic leakage after pancreatic head resections by dynamic magnetic resonance imaging (dMRI). J Gastrointest Surg 2009; 13:735–744.
Kim T, Murakami T, Takamura M, Hori M, Takahashi S, Nakamori S, Sakon M, Tanji Y, Wakasa K, Nakamura H. Pancreatic mass due to chronic pancreatitis: correlation of CT and MR imaging features with pathologic findings. AJR Am J Roentgenol 2001; 177:367–371.
Lee SE, Jang JY, Lim CS, Kang MJ, Kim SH, Kim MA, Kim SW. Measurement of pancreatic fat by magnetic resonance imaging: predicting the occurrence of pancreatic fistula after pancreatoduodenectomy. Ann Surg 2010; 251:932–936.
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.
Takahashi N, Fletcher JG, Hough DM, Fidler JL, Kawashima A, Mandrekar JN, Chari ST. Autoimmune pancreatitis: differentiation from pancreatic carcinoma and normal pancreas on the basis of enhancement characteristics at dual-phase CT. AJR Am J Roentgenol 2009; 193:479–484.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8–13.
Harrell F. Regression modeling strategies. New York: Springer, 2001.
R: A Language and Environment for Statistical Computing. Version 2.10.1. Available from: R Foundation for Statistical Computing, Vienna, Austria. Available at: http://www.R-project.org.
Friess H, Malfertheiner P, Isenmann R, Kuhne H, Beger HG, Buchler MW. The risk of pancreaticointestinal anastomosis can be predicted preoperatively. Pancreas 1996; 13:202–208.
Hamanaka Y, Nishihara K, Hamasaki T, Kawabata A, Yamamoto S, Tsurumi M, Ueno T, Suzuki T. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery 1996; 119:281–287.
Romero-Gomez M, Gomez-Gonzalez E, Madrazo A, Vera-Valencia M, Rodrigo L, Perez-Alvarez R, Perez-Lopez R, Castellano-Megias VM, Nevado-Santos M, Alcon JC, Sola R, Perez-Moreno JM, Navarro JM, Andrade RJ, Salmeron J, Fernandez-Lopez M, Aznar R, Diago M. Optical analysis of computed tomography images of the liver predicts fibrosis stage and distribution in chronic hepatitis C. Hepatology 2008; 47:810–816.
Ronot M, Asselah T, Paradis V, Michoux N, Dorvillius M, Baron G, Marcellin P, Van Beers BE, Vilgrain V. Liver fibrosis in chronic hepatitis C virus infection: differentiating minimal from intermediate fibrosis with perfusion CT. Radiology 2010; 256:135–142.
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.
Buchler M, Friess H, Klempa I, Hermanek P, Sulkowski U, Becker H, Schafmayer A, Baca I, Lorenz D, Meister R, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992; 163:125–130; discussion 130–121.
Traverso LW, Kozarek RA. Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis. Ann Surg 1997; 226:429–435; discussion 435–428.
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226:248–257; discussion 257–260.
Author information
Authors and Affiliations
Corresponding author
Additional information
Yasushi Hashimoto and Guido M. Sclabas contributed equally as first author.
Rights and permissions
About this article
Cite this article
Hashimoto, Y., Sclabas, G.M., Takahashi, N. et al. Dual-Phase Computed Tomography for Assessment of Pancreatic Fibrosis and Anastomotic Failure Risk Following Pancreatoduodenectomy. J Gastrointest Surg 15, 2193–2204 (2011). https://doi.org/10.1007/s11605-011-1687-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-011-1687-3