Pancreatic Duct Width Research Articles

Potential factors affecting success rate and long term outcome in single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients with pancreaticojejunal anastomotic stenosis: a retrospective study

Pancreaticojejunal anastomotic stenosis (PJS) after pancreaticoduodenectomy (PD) is difficult to treat. Single-balloon enteroscope-assisted endoscopic retrograde pancreatography (SBE-assisted ERP) is a safe way to treat PJS with the strength of minimally invasion and repeatability, but since its technical difficulty and few patient number, data on long-term outcomes remain limited. The optimal treatment is still unknown. We aim to study the safety, effectiveness, and long-term outcome of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERP in patients with PJS in this study. The clinical information of patients undergoing SBE-assisted therapeutic ERP from March 2016 to March 2021 were retrospectively analyzed. All patients were diagnosed as PJS and without any contraindication for therapeutic endoscopy. Treatment details, postoperative complications, factors influencing technical success rate were evaluated. Long-term outcomes results were obtained by clinical or telephone follow-up. Sixteen patients with median age of 51 years were included in this study, surgical reconstruction methods including PD with Whipple reconstruction, PD with Child reconstruction, pylorus-preserving pancreaticoduodenectomy (PpPD) with Whipple reconstruction. Eight patients were successfully treated. No serious complications happened. Risk factors for the failure of pancreaticojejunal anastomotic site identification include the digestive tract reconstruction sequence, pancreaticojejunostomy method, pancreatic duct tube implantation, pancreatic duct width before surgery, and pancreatic fistula during perioperative period. The median follow-up time was 77.2 months, the mean indwelling time of the stent was 62.3 months [interquartile range (IQR), 6.8-153.7 months]. Two of eight patients developed recurrent PJS. The variation in body mass index (BMI) was +2.46 in the non-recurrence group compared to -1.09 in the recurrence group and -2.12 in the endoscopic retrograde cholangiopancreatography (ERCP) treatment failure group. ERP intervention should be carried out early once PJS occurs in order to increase success rate. BMI is a crucial indicator which can reflex PJS rehabilitation degree during follow-up. In order to reduce PJS recurrence rate, a wider pancreatic stent and a longer stent indwelling time are recommended.

A Systematic Comparative Study on the Diagnostic Value of Transabdominal Ultrasound in Patients with Pancreatic Cystic Lesions.

Pancreatic cystic lesions are a frequent incidental finding in abdominal imaging. Despite its usually benign background, a small fraction exhibiting features suspicious for cancerous development demands continuous follow-up or surgical removal. Current guidelines advocate magnetic resonance imaging and endoscopic ultrasound to evaluate the risk of malignancy, whereas transabdominal ultrasound is perceived as subordinate imaging. The objective of this study was to analyze cyst detection rates of latest-generation ultrasound machines compared to magnetic resonance imaging, computed tomography, and endosonographic ultrasound and to determine inter-rater reliability. The results showed that large cysts facilitate their visualization by transabdominal ultrasound while detection rates are independent of the anatomical part of the pancreas in which they were sited. Changes in the pancreatic duct width, a connection to the pancreatic duct system, and the architectural characteristics of cysts are poorly recognized by transabdominal ultrasound compared to magnetic resonance imaging and endoscopic ultrasound. Computed tomography imaging is preferred over transabdominal ultrasound to detect calcifications and regional lymphadenopathy. Even if conducted by experienced investigators, transabdominal ultrasound examinations fail to agree with magnetic resonance imaging scans regarding cyst detection rates (κ = 0.093).

Pankreatikoduodenektomili hastalarda albümin/globulin oranının postoperatif pankreas fistülünü öngörmedeki rolü

Background: The albumin/globulin ratio (AGR) is one of several indicators of inflammation and immunity. This ratio has a prognostic significance in many malignant diseases. Previous studies have demonstrated a relationship between inflammatory mediators and post-operative pancreatic fistula (POPF). This study aimed to evaluate the relationship of AGR, a relatively new indicator, with post-operative pancreatic fistula (POPF).
 Methods: Pancreaticoduodenectomy (PD) patients between 2017 and 2020 were retrospectively analyzed and divided into two groups: (1) with and (2) without clinically relevant POPF (CR-POPF). The two groups were compared in terms of pre-operative–post-operative AGR and clinicodemographic characteristics. AGR was calculated as albumin/total protein–albumin, and the cutoff point for AGR was determined according to Youden’s index.
 Results: CR-POPF developed in 21% of 121 patients who underwent PD. No differences between the groups in terms of age, gender, comorbid disease status, pancreatic duct width, and anastomosis technique were found. Pre- and post-operative day-3 (POD3) albumin levels and AGR were found to be significantly lower in the CR-POPF group. Multivariate analysis showed that AGR and pancreatic tissue stiffness are independent risk factors for POPF development.
 Conclusion: Low AGR is an independent risk factor for the development of CR-POPF. To reduce the incidence of POPF, this ratio should be maintained at an optimal level. The use of AGR as a useful tool for predicting POPF in pancreaticoduodenectomy patients is suggested.

The effect of duct width and pancreatic gland structure on pancreatic fistula rates in patients who underwent pancreaticoduodenectomy for pancreatic cancer

Introduction: One of the most important causes of morbidity in pancreaticoduodenectomy (PD) surgery is pancreatic anastomosis leakage. There is a possibility of pancreatic fistula even in the most experienced hands. After PD, pancreatic fistula occurs between 10% and 20% in various series. This study aims to evaluate the effects of pancreatic duct size and pancreatic tissue on the development of pancreatic fistula after PD is performed in our center. Material and Method: Pancreatic duct size was categorized as small <3 mm and large >3 mm. Pancreatic gland tissue was categorized as a soft, medium, and hard. These variables were calculated preoperatively with the help of computed tomography (CT), ultrasonography(USG), and Endoscopic ultrasound (EUS), and postoperative pathology results. It was accepted that the 24-hour flow rate of the drain behind the pancreatic anastomosis was more than 50 ml during 3 days after PD and/or the amylase concentration of the drain content measured at 3 different times was 3 times higher than the serum amylase concentration. Results: A total of 90 patients were included in the study, anastomotic leakage was not observed in 63 (70%) of 90 patients, and leakage was observed in 27 (30%) patients. The mean age was 71.22±10.78 years (p=0.615). There was no statistically significant difference between the ductus diameters between the two groups (p=0.240). There was no statistical difference between the groups formed according to pancreatic duct width. (p=0.059). It was observed that 60.3% of the patients in the non-leakage group had a hard appearance, and this rate was statistically significantly reduced to 29.6% in the patients with leakage (p=0.008). Conclusion: In summary, our study showed that pancreatic fistula after PD is associated with soft pancreatic parenchyma. The surgeon should consider this risk factor when performing a PD and be more careful to reduce the rate of pancreatic fistula.

P-P40 Can trainees safely perform pancreatoduodenectomy? A systematic review, meta-analysis and risk-adjusted analysis of post-operative pancreatic fistula

Abstract Background The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining operative experience. Objective to compare the POPF rate following PD by trainees or established surgeons. Methods A systematic review of the literature was performed using PRISMA guidelines, with differences in POPF rates after PD between trainee-led vs. consultant/attending surgeons pooled using meta-analysis. Variation in rates of POPF was further explored using risk-adjusted outcomes using published risk scores and CUSUM analysis in a retrospective cohort. Results Across 14 cohorts included in the meta-analysis, trainees tended towards a lower, but non significant rate of All-POPF (odds ratio [OR]: 0.77, p = 0.45) and clinically relevant (CR)-POPF (OR: 0.69, p = 0.37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3mm (OR: 0.45, p = 0.05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted All-POPF (median: 20 vs. 26%, p < 0.001) and CR-POPF (7 vs. 9%, p = 0.020) rates than consultant/attending surgeons, based on pre-operative risk scores. After adjusting for this on multivariable analysis, the risks of All-POPF (OR: 1.18, p = 0.604) and CR-POPF (OR: 0.85, p = 0.693) remained similar after PD by trainee or consultant/attending surgeons. Conclusions PD, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.

Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy.

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) continues to be a major contributor to morbidity after pancreaticoduodenectomy (PD), but it remains unclear what risk factors can precisely predict the development of CR-POPF after laparoscopic pancreatoduodenectomy (LPD). We thus aimed to identify the risk factors for predicting CR-POPF after LPD.MethodsA total of 388 consecutive patients who underwent LPD at our institution between July 2014 and December 2018 were identified. All data, including pre-, intra-, and postoperative risk factors associated with CR-POPF defined by the International Study Group of Pancreatic Fistula, were collected retrospectively. To evaluate the predictive performance of the risk factor models, areas under the receiver operating characteristic curve (ROC) were determined.ResultsCR-POPF was observed in 31 patients (8.0%) with significant association observed with body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), intra-abdominal fat thickness, main pancreatic duct width, soft pancreatic texture, operative time, underlying pathology, and albumin (Alb) on postoperative days (POD) 1­–3. Multivariate analyses revealed that VFA >82 cm2 [odds ratio (OR) =11.088; P=0.029], main pancreatic duct width <3 mm (OR =7.701; P=0.001), soft pancreatic texture (OR =12.543; P=0.022), and operative time >320 min (OR =6.061; P<0.001) were independent risk factors for CR-POPF after LPD. Areas under the ROC curve (AUC) analysis revealed the pancreatic texture was the strongest single predictor (AUC =0.854) of CR-POPF, and pancreatic texture + pancreatic duct width was the best two-predictor model (AUC =0.904). Meanwhile, our findings indicated an association between the TFA >221 cm2 (OR =8.637; P=0.001) and VFA >82 cm2 (OR =7.009; P<0.001) with soft pancreatic texture.ConclusionsSoft pancreatic texture, VFA >82 cm2, main pancreatic duct width <3 mm, and operative time >320 min were independent predictive risk factors of CR-POPF for LPD.

Potential Utility of Intraoperative Fluid Amylase Measurement during Pancreaticoduodenectomy

Introduction: Postoperative pancreatic fistula (POPF) is an important cause of morbidity after pancreaticoduodenectomy (PD), and may be predicted by preoperative and postoperative factors, including BMI, pancreatic duct width and first postoperative day drain fluid amylase (DFA1). We hypothesised that raised intraoperative amylase concentrations (IOAC) in intra-abdominal fluid taken adjacent to the pancreatic anastomosis may correlate with DFA1 and/or POPF. Methods: Intra-abdominal fluid samples were taken from adjacent to the pancreatic anastomosis immediately prior to abdominal closure and sent for fluid amylase analysis (IOAC) in patients undergoing PD. The relationship between IOAC and DFA1/POPF were evaluated using Pearson correlation. A cut-off value for IOAC to exclude POPF was determined by ROC analysis. Results: Data was prospectively collected for 52 patients who underwent PD between February-November 2020. All patients underwent an end-side pancreaticojejunostomy anastomosis. There was significant correlation between IOAC and DFA1 (R2 = 0.713; P<0.01). Using a cut-off value of IOAC = 260 U/L, IOAC<260 excluded a POPF with a negative predictive value of 97% (P= 0.001). 7/18 (39%) patients with IOAC≥260 developed POPF compared to only 1/34 (3%) patients with IOAC<260 (P = 0.001). Conclusion: Intraoperative detection of amylase-rich fluid adjacent to a completed pancreatic anastomosis is an early predictor of postoperative pancreatic fistula. Low risk patients with a low IOAC may be suitable for a ‘no drain’ strategy, whilst patients with a high IOAC may benefit from intraoperative mitigation strategies to reduce the incidence and/or severity of a postoperative pancreatic fistula.FP14.03ComplicationsSevere complications (CD grade>3a)5/529.6%Clavien Dindo GradesNo complications:15/5228.84%Biochemical pancreatic leak5/529.6%Grade 110/5219.2%CR-POPF (all grade C)3/525.8%Grade222/5242.30%PPH (all grade C)3/525.8%Grade 3a3/525.76%DGE (4 grade A, 1 grade B)5/529.6%Grade 3b1/521.92%In-hospital mortality1/521.9%Grade 40/5290-day mortalityCOVID-19Early cancer recurrence2/52113.8%1.9%1.9%Grade 51/521.92%ROC Curve AnalysisROCCut offSensitivitySpecificityPPVNPVAUROCCIP valueIOAC Vs DFA1>350236U/L82.4%82.9%70%90%0.9210.848 -0.9940.00IOAC Vs POPF260U/L87.5%75%38.88%97%0.9050.794 -1.0000.00 Open table in a new tab

Pancreaticoduodenectomy performed by surgeons in training and the risk of post-operative fistula: a systematic review and meta-analysis

Introduction: The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining vital experience. This meta-analysis sought to establish the POPF rate following PD by trainees or established surgeons. Methods: A systematic review of the literature was performed using PRISMA guidelines and meta-analysis compared complication rates using RevMan software. Results: 3 of 53 studies were included for meta-analysis, all defining POPF using ISGPS 2005 criteria. Some 309 PD (16%) were performed by trainees. The rate of POPF after surgery performed by those who had completed training was not different when surgery was performed by trainees (19.6 vs 23.0%; OR: 0.65; 95%CI 0.36-1.18; p=0.07) or mortality (OR: 1.08; 95%CI 0.30-3.97; p=0.60). Neither soft pancreatic texture (OR: 0.62; 95%CI: 0.19-1.99; p=0.042) nor pancreatic duct width significantly differed between the two groups. Gastrointestinal bleeding, blood loss and operative time were greater when operations were performed by trainees but there was no difference in delayed gastric emptying, intra-abdominal collection or mortality. Conclusions: PD, when performed by trainees, is associated with acceptable outcomes. Evidence of heterogeneity in key variables indicates a need for further studies and it is unclear whether outcomes are similar when trainees perform surgery among patients stratified as low or high risk for POPF using established risk scores. The use of risk adjusted CUSUM as reported recently could be a useful tool to assess trainees performance.

Predicting post-operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review.

Post-operative pancreatic fistulae (POPF) remain a major contributor to morbidity and mortality following pancreatic resection. Evidence for preoperative prediction of POPF based on cross-sectional imaging has not been systemically reviewed. This review aimed to determine whether preoperative imaging modalities can accurately predict the development of POPF. A systematic review of major reference databases was undertaken, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to May 2018. There were 18 studies (2150 patients), seven used magnetic resonance imaging (MRI), five used computed tomography (CT) scans, four used transabdominal ultrasonography and one study each used MRI and CT and endoscopic ultrasonography elastography. All were retrospective, single-centre studies. Intensity of the pancreas signal relative to the spleen, liver or muscle was commonly used. Other studies compared signal intensity between unenhanced and post-contrast-enhanced pancreas, apparent diffusion coefficient values comparing normal parenchyma to fibrosis, perfusion fraction (f) of intravoxel incoherent motion diffusion-weighted imaging, or utilized a muscle-normalized signal intensity curve with signal intensity ratio or directly assessed pancreatic volume and duct width. Shear wave velocity measurement on transabdominal ultrasonography may reflect pancreas tissue fibrosis or stiffness and predict POPF. Most parameters used to predict the development of POPF were based on identifying imaging features of a fatty or fibrotic pancreas and main pancreatic duct diameter. A number of different and highly promising parameters have been used for preoperative prediction of POPF using ultrasound, MRI, CT or both. Large multicentre prospective studies are needed to determine which parameters most accurately predict POPF, using standardized definitions and methodology.

Feasibility analysis of predicting the risk of pancreatic fistula after pancreatoduodenectomy by preoperative CT

Objective: To study the preoperative computed tomography (CT) data of patients with pancreaticoduodenectomy (PD) and to explore the effective of predicting the risk of postoperative pancreatic fistula (POPF). Methods: CT images of patients with PD were analyzed retrospectively from June 2010 to January 2017 in Zhengzhou University of People's Hospital. The pancreas index, pancreatic duct width, pancreas CT value, pancreas-spleen CT value, and pancreas thickness were collected. The relationship between the indicators and the POPF was determined, and the receiver operation characteristic (ROC) curve was calculated and the area under the curve (AUC) was evaluated. The maximum predictive performance of the critical value was determined by using the different cut-off values to calculate the Youden index and other indicators. Results: A total of 154 patients with PD were involved in the study and 27 (17.5%) had POPF. Seven indicators were significantly associated with POPF. The pancreas index had the largest AUC (AUC: 0.865, P<0.001) and pancreatic duct width (AUC: 0.834, P<0.001) also had a higher predictive value. The pancreatic duct (P<0.001) was significantly associated with POPF. Pancreas thickness, pancreas and spleen CT ratio, abdominal wall fat thickness, pancreas CT value, pancreatic abdominal aorta CT ratio and POPF were also related. Using 0.15 as the cut-off value, the sensitivity, specificity, Jordan index, and accuracy of pancreatic index were 83%, 86%, 0.69, and 0.88 respectively, with the highest performance prediction. Abdominal circumference, spleen CT value and other six indicators had no correlation with POPF. Conclusion: Analysis of preoperative CT indicators of patients can predict the risk of POPF in patients after PD. The pancreas index has the greatest predictive efficacy, while pancreatic duct width, pancreatic spleen density ratio and other indicators also associated with POPF.

Pancreas exocrine replacement therapy is associated with increased survival following pancreatoduodenectomy for periampullary malignancy

BackgroundAlthough many patients undergoing pancreatoduodenectomy (PD) for cancer have pancreatic exocrine insufficiency, pancreatic enzyme replacement therapy (PERT) is not routinely used, and effects upon post-operative survival are unclear. MethodsThis review of patients undergoing PD for periampullary malignancy sought to test for an association between PERT and overall survival, with post-hoc subgroup analysis performed after stratifying patients by the year of surgery, pancreatic duct width and tumour type. ResultsSome 202/469 (43.1%) patients received PERT. After accounting for pathological variables and chemotherapy, PERT use was found to be independently associated with improved survival on multivariable analysis [HR 0.72 (95% CI: 0.52–0.99), p = 0.044] and on propensity matched analysis (p = 0.009). The effect of PERT upon improved survival was predominantly observed amongst patients with a dilated pancreatic duct (≥3 mm). DiscussionPERT use was independently associated with improved survival following PD for cancer. The validity of this observation is supported by an effect largely confined to those patients with a dilated pancreatic duct. The nutritional status of patients undergoing PD for cancer needs further investigation and the effects of PERT require verification in further clinical studies.

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma.

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma is investigated.The medical records of 45 patients who had undergone radical resection for pancreatic adenocarcinoma from March 2010 to September 2013 were reviewed retrospectively. There were 34 patients in the pancreaticoduodenectomy (PD) group and 10 patients in the distal pancreatectomy (DP) group. One patient received total pancreatectomy. The endocrine function was measured using the glucose tolerance index (GTI), which was derived by dividing daily maximum serum glucose fluctuation by daily minimum glucose. Remnant pancreas volume (RPV) was estimated by considering pancreas body and tail as a column, and head as an ellipsoid, respectively. The pancreatic atrophic index (PAI) was defined as the ratio of pancreatic duct width to total pancreas width. Representative indices of each patient were compared before and after resection up to 2 years postoperatively.The area under receiver operating characteristic curve of GTI for diagnosing DM was 0.823 (95% confidence interval, 0.699–0.948, P < .001). Overall, GTI increased on postoperative day 1 (POD#1, mean ± standard deviation, 1.79 ± 1.40 vs preoperative, 1.02 ± 1.41; P = .001), and then decreased by day 7 (0.89 ± 1.16 vs POD#1, P < .001). In the PD group, the GTI on POD#14 became lower than preoperative (0.51 ± 0.38 vs 0.96 ± 1.37; P = .03). PAI in the PD group was significantly lower at 1 month postoperatively (0.22 ± 0.12 vs preoperative, 0.38 ± 0.18; P < .001). In the PD group, RPV was significantly lower at 1 month postoperatively (25.3 ± 18.3 cm3 vs preoperative, 32.4 ± 20.1 cm3; P = .02), due to the resolution of pancreatic duct dilatation. RPV of the DP group showed no significant change. GTI was negatively related to RPV preoperatively (r = –0.317, P = .04), but this correlation disappeared postoperatively (r = –0.044, P = .62).Pancreatic endocrine functional deterioration in pancreatic adenocarcinoma patients may in part be due to pancreatic duct obstruction and dilatation caused by the tumor. After resection, this proportion of endocrine insufficiency is corrected.

A comparative study of risk factors for pancreatic fistula after pancreatoduodenectomy or distal pancreatectomy

BackgroundEvidence associates various biometric and histological variables such as steatosis and absence of fibrosis as risk factors for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Following distal pancreatectomy (DP), the association between these factors and POPF is less clear. This study of patients, drawn from the same background population, undergoing PD or DP at a single centre is a comparative study of the risk factors for POPF after these two operations. MethodsAssociations between POPF and patient characteristics, pre-operative blood tests, data from pre-operative computed tomography (CT) imaging, assessment of histological steatosis and fibrosis were explored. Results26/107 (24%) and 26/90 (29%) patients developed POPF after PD and DP respectively. Absence of fibrosis was associated with POPF (p < 0.001) after PD and its presence correlated with pancreatic duct width (p < 0.001). Steatosis was not associated with POPF (p = 0.910). Multivariable analysis showed pancreatic duct width (p = 0.016) and fibrosis (p = 0.025) to be independent predictors of POPF after PD. The only variable associated with POPF after DP was underlying pathology (p = 0.005). ConclusionPancreatic duct width is the most important variable related to POPF after PD and is correlated with fibrosis. Steatosis was not related to POPF. In contrast, after DP POPF appears to be related to the underlying disease.

Specific Radiological Imaging Findings in Patients With Hereditary Pancreatitis During a Long Follow-up of Disease.

Hereditary pancreatitis (HP) is characterized by recurrent episodes of inflammation of the pancreas. Radiological imaging is used to diagnose HP and to monitor complications. The aim of this study was to describe specific imaging findings in HP. We retrospectively collected data of HP patients with serial imaging and reviewed all radiological imaging studies (transabdominal ultrasonography, computed tomography, and magnetic resonance imaging). We included 15 HP patients, with a mean age of 32.5 years (range, 9-61 years) and mean disease duration of 24.1 years (range, 6-42 years). In total, 152 imaging studies were reviewed. Seventy-three percent of patients had a dilated main pancreatic duct (MPD) (width 3.5-18 mm). The MPD varied in size during disease course, with temporary reduction in diameter after drainage procedures. A severe dilated MPD (>10 mm) often coincided with presence of intraductal calcifications (size, 1-12 mm). In 73% of patients, pancreatic parenchyma atrophy occurred, which did not correlate with presence of exocrine or endocrine insufficiency. In HP, the MPD diameter increases with time, mostly without dilated side branches, and is often accompanied by large intraductal calcifications. The size of the MPD is independent of disease state. Atrophy of pancreatic parenchyma is not correlated with exocrine or endocrine insufficiency.

Optimal duration of prophylactic antibiotics administration in pancreaticoduodenectomy

To review all reported methods of preoperative computed tomography (CT) in one patient cohort and to identify which were the strongest to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy.Consecutive patients undergoing pancreatoduodenectomy were included if they had unenhanced CT images for review. Eighteen variables and two scores were tested. Receiver operator characteristics (ROC) were explored.POPF affected 26 of 107 patients (24.3%). Nine variables were significantly related to POPF with pancreatic duct width having the largest area under the ROC curve (AUROC; 0.808, p<0.001). An obese body habitus was associated with POPF with six of nine related variables using data from CT images associated with POPF; of these intra-abdominal wall thickness yielded the largest AUROC (0.713, p=0.001). This corresponded to the finding that body mass index (BMI) was related to POPF (AUROC 0.705, p=0.002). The largest AUROC of all was associated with one of the predictive scores (0.828, p<0.001). Substituting BMI for intra-abdominal wall thickness in this score yielded a non-significant increase to predict POPF (AUROC 0.840, p=0.676). None of the assessments of organ density (in Hounsfield Units) were associated with POPF.Data from preoperative CT imaging provides valuable information regarding a patient's risk of POPF. Obesity as assessed by CT images strongly relates to POPF, but the largest single risk factor for POPF is a narrow pancreatic duct.

Comparison of preoperative CT-based imaging parameters to predict postoperative pancreatic fistula

To review all reported methods of preoperative computed tomography (CT) in one patient cohort and to identify which were the strongest to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. Consecutive patients undergoing pancreatoduodenectomy were included if they had unenhanced CT images for review. Eighteen variables and two scores were tested. Receiver operator characteristics (ROC) were explored. POPF affected 26 of 107 patients (24.3%). Nine variables were significantly related to POPF with pancreatic duct width having the largest area under the ROC curve (AUROC; 0.808, p<0.001). An obese body habitus was associated with POPF with six of nine related variables using data from CT images associated with POPF; of these intra-abdominal wall thickness yielded the largest AUROC (0.713, p=0.001). This corresponded to the finding that body mass index (BMI) was related to POPF (AUROC 0.705, p=0.002). The largest AUROC of all was associated with one of the predictive scores (0.828, p<0.001). Substituting BMI for intra-abdominal wall thickness in this score yielded a non-significant increase to predict POPF (AUROC 0.840, p=0.676). None of the assessments of organ density (in Hounsfield Units) were associated with POPF. Data from preoperative CT imaging provides valuable information regarding a patient's risk of POPF. Obesity as assessed by CT images strongly relates to POPF, but the largest single risk factor for POPF is a narrow pancreatic duct.

Risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy and its predictive score

To develop and test a scoring system to predict the risks of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy(PD). Clinic data and postoperative complications of the 445 consecutive patients who underwent a PD procedure between January 2008 and April 2015 in Peking University First Hospital were retrospectively collected and analyzed.The patients were randomly selected to modelling and validation sets at a ratio of 3∶1, respectively.The patient data were subjected to univariate and multivariate analysis in the modelling set of patients.A score predictive of POPF was designed and tested in the validation set. POPF occurred in 88 of 334 patients(26.4%) in the modelling set.The multivariate analysis showed that body mass index (BMI, P<0.01) and pancreatic duct width(P=0.001) are associated with POPF independently.A risk score to predict POPF was constructed based on these factors and successfully tested.The area under the receiver operating characteristic curve were 0.829(95% CI: 0.777-0.881) on the modelling set and 0.885(95% CI: 0.825-0.945) on the validation set, respectively. BMI and pancreatic duct width were associated with POPF after PD. The preoperative assessment of a patient's risk for POPF is feasible.The present risk score is a valid tool to predict POPF in patients undergoing PD, to make the selection on anastomosis types, and to take precautions against POPF.

Scoring System to Predict Pancreatic Fistula After Pancreaticoduodenectomy: A UK Multicenter Study.

To validate a preoperative predictive score of postoperative pancreatic fistula (POPF). Other risk factors for POPF were sought in an attempt to improve the score. POPF is the major contributor to morbidity after pancreaticoduodenectomy (PD). A preoperative score [using body mass index (BMI) and pancreatic duct width] to predict POPF was tested upon a multicenter patient cohort to assess its performance. Patients undergoing PD at 8 UK centers were identified. The association between the score and other pre-, intra-, and postoperative variables with POPF was assessed. A total of 630 patients underwent PD with 141 occurrences of POPF (22.4%). BMI, perirenal fat thickness, pancreatic duct width on computed tomography and at operation, bilirubin, pancreatojejunostomy technique, underlying pathology, T stage, N stage, R status, and gland firmness were all significantly associated with POPF. The score predicted POPF (P < 0.001) with a higher predictive score associated with increasing severity of POPF (P < 0.001). Stepwise multivariate analysis of pre-, intra-, and postoperative variables demonstrated that only the score was consistently associated with POPF. A table correlating the risk score to actual risk of POPF was created. The predictive score performed well and could not be improved. This provides opportunities for individualizing patient consent and selection, and treatment and research applications.

A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy

BackgroundVarious factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF. MethodsA post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2:1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set. ResultsPostoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768–0.897; P < 0.001) and successfully tested upon the validation set. ConclusionsPreoperative assessment of a patient's risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD.

Risk assessment of elder patients who undergo pancreatico-duodenectomy using abdominal arterial calcification score

To review all reported methods of preoperative computed tomography (CT) in one patient cohort and to identify which were the strongest to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy.Consecutive patients undergoing pancreatoduodenectomy were included if they had unenhanced CT images for review. Eighteen variables and two scores were tested. Receiver operator characteristics (ROC) were explored.POPF affected 26 of 107 patients (24.3%). Nine variables were significantly related to POPF with pancreatic duct width having the largest area under the ROC curve (AUROC; 0.808, p<0.001). An obese body habitus was associated with POPF with six of nine related variables using data from CT images associated with POPF; of these intra-abdominal wall thickness yielded the largest AUROC (0.713, p=0.001). This corresponded to the finding that body mass index (BMI) was related to POPF (AUROC 0.705, p=0.002). The largest AUROC of all was associated with one of the predictive scores (0.828, p<0.001). Substituting BMI for intra-abdominal wall thickness in this score yielded a non-significant increase to predict POPF (AUROC 0.840, p=0.676). None of the assessments of organ density (in Hounsfield Units) were associated with POPF.Data from preoperative CT imaging provides valuable information regarding a patient's risk of POPF. Obesity as assessed by CT images strongly relates to POPF, but the largest single risk factor for POPF is a narrow pancreatic duct.