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©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?
Senthil Gnanasekaran, Satish Durgesh, Ramprakash Gurram, Raja Kalayarasan, Biju Pottakkat, M Rajeswari, Bheemanathi Hanuman Srinivas, A Ramesh, Jayaprakash Sahoo
Senthil Gnanasekaran, Satish Durgesh, Ramprakash Gurram, Raja Kalayarasan, Biju Pottakkat, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
M Rajeswari, Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Bheemanathi Hanuman Srinivas, Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
A Ramesh, Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Jayaprakash Sahoo, Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Author contributions: Gnanasekaran S and Kalayarasan R conceptualized the study; Durgesh S and Gurram R performed the research work; Rajeswari M performed the data analysis; Srinivas BH reviewed the histopathological slides for postoperative analysis; Ramesh A performed a preoperative radiological assessment of study participants; Durgesh S and Gurram R wrote the first draft of the manuscript; Gnanasekaran S, Kalayarasan R, Pottakkat B and Sahoo J gave intellectual input and critically revised the manuscript.
Institutional review board statement: The study was reviewed and approved by the institutional ethics committee (Human studies) of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India (JIP/IEC/2018/500 dated 25-01-2019). The study protocol can be fully accessed at
https://jipmer.edu.in/.
Informed consent statement: All study participants, or their legal guardian, provided written consent prior to study enrolment.
Conflict-of-interest statement: All authors of this manuscript have no financial relationships to disclose.
Data sharing statement: No additional data are available.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Raja Kalayarasan, DNB, MCh, MS, Additional Professor, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Room No. 5442, 4th Floor, Super Specialty Block, Puducherry-605006, India. kalayarasanraja@yahoo.com
Received: January 29, 2022
Peer-review started: January 29, 2022
First decision: April 10, 2022
Revised: April 26, 2022
Accepted: June 20, 2022
Article in press: June 20, 2022
Published online: June 28, 2022
ARTICLE HIGHLIGHTS
Research background
Postoperative pancreatic fistula is the critical cause of morbidity after pancreaticoduodenectomy. Identifying patients at risk of clinically relevant postoperative pancreatic fistula can potentially improve clinical outcomes after pancreaticoduodenectomy.
Research motivation
Most of the available models to predict postoperative pancreatic fistula can be used only in the postoperative setting.
Research objectives
To calculate the accuracy of the pancreatic neck pancreatic attenuation index (PAI) and pancreatic enhancement ratio (PER) in predicting clinically relevant postoperative pancreatic fistula and its correlation with histological pancreatic neck fat fraction and fibrosis scoring.
Research methods
Patients who underwent pancreaticoduodenectomy for benign and malignant pathology of the periampullary region or pancreatic head between February 2019 and February 2021 were included in the prospective observational study. The PAI was measured in the neck of the pancreas by marking regions of interest in the preoperative non-contrast computed tomography (CT), and the PER was measured during the contrast phase of the CT abdomen. Preoperative pancreatic neck CT indices were correlated with histopathological evaluation of Fibrosis score and the fat fraction of the pancreatic neck and clinically relevant postoperative pancreatic fistula.
Research results
The PAI had no significant association with the development of clinically relevant postoperative pancreatic fistula (CR-POPF). However, PER was significantly lower in patients developing CR-POPF (0.58 ± 0.20 vs 0.81 ± 0.44, P = 0.006). Also, PER cut-off of 0.673 predicts CR-POPF with 77.8% sensitivity and 55.8% specificity. The PER showed a moderately positive correlation with fibrosis (Strength 0.50, P < 0.001).
Research conclusions
PER showed good accuracy in predicting CR-POPF. Also, PER showed a good correlation with fibrosis scores and may be used as an objective preoperative surrogate for assessing pancreatic texture.
Research perspectives
Quantifying PER on preoperative computed tomography can improve the risk stratification and management of patients at high risk of clinically relevant postoperative pancreatic fistula. Failure to demonstrate an association of PAI with clinically relevant postoperative pancreatic fistula and postoperative fat fraction suggests that area-based assessment for the pancreatic fat fraction may be better than the region of interest-based estimation.
