Preoperative CT enhancement pattern in the pancreatic isthmus may predict clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy

Abstract

Introduction: Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most remarkable complication after pancreatoduodenectomy (PD), and it is still associated with in-hospital mortality. Hence, preoperative prediction would be of utmost importance for prevention. Our aim is to analyze whether preoperative computed tomography (CT) might be a reliable tool for predicting CR-POPF. Methods: We retrospectively reviewed the acinar cell density at the resection margin of surgical specimens by scoring the proportion of pancreatic acini in HE-stained slides, and the preoperative CT enhancement pattern (Hounsfield units in arterial and portal phases) with manually delineated regions of interest (ROI) along the pancreas (head, isthmus, body and tail) in patients who underwent PD with pancreaticojejunostomy (PJ) in our center, and we analyzed their association with CR-POPF, collected from our prospectively maintained database. ROC analysis and logistic regression model were performed. Results: From 2015 – 2019, 69 patients had a PD with PJ in our center. After excluding patients without both arterial and portal phases, a total of 22 patients were included. Acinar cell density at the resection margin was associated with CR-POPF (p < 0.001). The CT ratio between arterial and portal phases in the pancreatic isthmus was strongly associated with CR-POPF (AUROC 0.940, p = 0.001). A cut-off value of > 0.957 would predict POPF with 100% sensitivity and 76.9% specificity, and of > 0.977 with 97.7% and 84.6% of sensitivity and specificity respectively. Conclusion: Preoperative arterial/portal ratio CT enhancement of the pancreatic isthmus correlates with acinar cell density at the resection margin and can potentially predict the development of CR-POPF after PD with high accuracy. A larger prospective study would be advisable to confirm these findings.Tabled 1Patients n = 22CR-POPF – (x¯), (n = 13)CR-POPF + (x¯), (n = 9)Sig. (p value)Acinar%42.1372.620.001Collagen%26.386.900.001Fat%27.2320.480.089Pancreatic isthmus arterial/portal HU ratio0.891.190.001CR-POPF: clinically relevant postoperative pancreatic fistula; Sig.: significance; HU: Hounsfield Units Open table in a new tab CR-POPF: clinically relevant postoperative pancreatic fistula; Sig.: significance; HU: Hounsfield Units