Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.
Highlights
Relevant postoperative pancreatic fistula (CR-Postoperative pancreatic fistula (POPF)) is a common severe surgical complication after pancreatic surgery
The presented data demonstrate that risk factors for the development of Clinically relevant postoperative pancreatic fistula (CR-POPF), such as small pancreatic duct diameter and soft pancreatic texture, can be determined before surgery based on preoperative contrast-enhanced computed tomography (CT) imaging
Four CT-derived parameters individually markedly correlated with the risk of CR-POPF development in our cohort: normal pancreatic morphology, small pancreatic duct diameter, radiologically assessed high-risk pathology and high estimated pancreatic remnant volume (PRV)
Summary
Relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Because of otherwise unmanageable complications of pancreatic surgery, mostly POPF and post-pancreatectomy hemorrhage, rescue completion (total) pancreatectomy can be necessary as a last-resort therapeutic option in cases, in which pancreas-preserving treatment options are technically unfeasible This procedure is characterized by exceptionally high morbidity and in-hospital mortality of over 40%6,7. In a clinical setting preoperative risk stratification is required to facilitate consideration of the risk of POPF development already during the planning phase of pancreatic surgery This would allow for critical reassessment of alternative surgical and conservative treatment approaches in patients with a preoperative high-risk constellation. Preoperative CT could serve as the basis of a preoperative image-guided FRS
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