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Zhu L, Sun Z, Dai M, Wu H, Wang X, Xu J, Xue H, Jin Z, Nickel MD, Guo J, Sack I. Tomoelastography and Pancreatic Extracellular Volume Fraction Derived From MRI for Predicting Clinically Relevant Postoperative Pancreatic Fistula. J Magn Reson Imaging 2024; 59:1074-1082. [PMID: 37209387 DOI: 10.1002/jmri.28788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Pancreatic stiffness and extracellular volume fraction (ECV) are potential imaging biomarkers for pancreatic fibrosis. Clinically relevant postoperative fistula (CR-POPF) is one of the most severe complications after pancreaticoduodenectomy. Which imaging biomarker performs better for predicting the risk of CR-POPF remains unknown. PURPOSE To evaluate the diagnostic performance of ECV and tomoelastography-derived pancreatic stiffness for predicting the risk of CR-POPF in patients undergoing pancreaticoduodenectomy. STUDY TYPE Prospective. POPULATION Eighty patients who underwent multiparametric pancreatic MRI before pancreaticoduodenectomy, among whom 16 developed CR-POPF and 64 did not. FIELD STRENGTH/SEQUENCE 3 T/tomoelastography and precontrast and postcontrast T1 mapping of the pancreas. ASSESSMENT Pancreatic stiffness was measured on the tomographic c-map, and pancreatic ECV was calculated from precontrast and postcontrast T1 maps. Pancreatic stiffness and ECV were compared with histological fibrosis grading (F0-F3). The optimal cutoff values for predicting CR-POPF were determined, and the correlation between CR-POPF and imaging parameters was evaluated. STATISTICAL TESTS The Spearman's rank correlation and multivariate linear regression analysis was conducted. The receiver operating characteristic curve analysis and logistic regression analysis was performed. A double-sided P < 0.05 indicated a statistically significant difference. RESULTS Pancreatic stiffness and ECV both showed a significantly positive correlation with histological pancreatic fibrosis (r = 0.73 and 0.56, respectively). Patients with advanced pancreatic fibrosis had significantly higher pancreatic stiffness and ECV compared to those with no/mild fibrosis. Pancreatic stiffness and ECV were also correlated with each other (r = 0.58). Lower pancreatic stiffness (<1.38 m/sec), lower ECV (<0.28), nondilated main pancreatic duct (<3 mm) and pathological diagnosis other than pancreatic ductal adenocarcinoma were associated with higher risk of CR-POPF at univariate analysis, and pancreatic stiffness was independently associated with CR-POPF at multivariate analysis (odds ratio: 18.59, 95% confidence interval: 4.45, 77.69). DATA CONCLUSION Pancreatic stiffness and ECV were associated with histological fibrosis grading, and pancreatic stiffness was an independent predictor for CR-POPF. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 5.
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Affiliation(s)
- Liang Zhu
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Zhaoyong Sun
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Xuan Wang
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Jia Xu
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | | | - Jing Guo
- Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ingolf Sack
- Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Ashraf Ganjouei A, Romero-Hernandez F, Wang JJ, Casey M, Frye W, Hoffman D, Hirose K, Nakakura E, Corvera C, Maker AV, Kirkwood KS, Alseidi A, Adam MA. A Machine Learning Approach to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy Using Only Preoperatively Known Data. Ann Surg Oncol 2023; 30:7738-7747. [PMID: 37550449 DOI: 10.1245/s10434-023-14041-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/14/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Clinically-relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) is a major postoperative complication and the primary determinant of surgical outcomes. However, the majority of current risk calculators utilize intraoperative and postoperative variables, limiting their utility in the preoperative setting. Therefore, we aimed to develop a user-friendly risk calculator to predict CR-POPF following PD using state-of-the-art machine learning (ML) algorithms and only preoperatively known variables. METHODS Adult patients undergoing elective PD for non-metastatic pancreatic cancer were identified from the ACS-NSQIP targeted pancreatectomy dataset (2014-2019). The primary endpoint was development of CR-POPF (grade B or C). Secondary endpoints included discharge to facility, 30-day mortality, and a composite of overall and significant complications. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated and a user-friendly risk calculator was then developed. RESULTS Of the 8666 patients who underwent elective PD, 13% (n = 1160) developed CR-POPF. XGBoost was the best performing model (AUC = 0.72), and the top five preoperative variables associated with CR-POPF were non-adenocarcinoma histology, lack of neoadjuvant chemotherapy, pancreatic duct size less than 3 mm, higher BMI, and higher preoperative serum creatinine. Model performance for 30-day mortality, discharge to a facility, and overall and significant complications ranged from AUC 0.62-0.78. CONCLUSIONS In this study, we developed and validated an ML model using only preoperatively known variables to predict CR-POPF following PD. The risk calculator can be used in the preoperative setting to inform clinical decision-making and patient counseling.
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Affiliation(s)
| | | | - Jaeyun Jane Wang
- Department of Surgery, University of California, San Francisco, USA
| | - Megan Casey
- School of Medicine, University of California, San Francisco, USA
| | - Willow Frye
- School of Medicine, University of California, San Francisco, USA
| | - Daniel Hoffman
- Department of Surgery, University of California, San Francisco, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA.
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Tian XF, Zhang L, Lou WH, Qiu YJ, Zuo D, Wang WP, Dong Y. Application of ultrasound shear wave elastography in pre-operative and quantitative prediction of clinically relevant post-operative pancreatic fistula after pancreatectomy: a prospective study for the investigation of risk evaluation model. Eur Radiol 2023; 33:7866-7876. [PMID: 37368114 DOI: 10.1007/s00330-023-09859-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES The aim of this study was to modify recognized clinically relevant post-operative pancreatic fistula (CR-POPF) risk evaluation models with quantitative ultrasound shear wave elastography (SWE) values and identified clinical parameters to improve the objectivity and reliability of the prediction. METHODS Two prospective, successive cohorts were initially designed for the establishment of CR-POPF risk evaluation model and the internal validation. Patients who scheduled to receive pancreatectomy were enrolled. Virtual touch tissue imaging and quantification (VTIQ)-SWE was used to quantify pancreatic stiffness. CR-POPF was diagnosed according to 2016 International Study Group of Pancreatic Fistula standard. Recognized peri-operative risk factors of CR-POPF were analyzed, and the independent variables selected from multivariate logistic regression were used to build the prediction model. RESULTS Finally, the CR-POPF risk evaluation model was built in a group of 143 patients (cohort 1). CR-POPF occurred in 52/143 (36%) patients. Constructed from SWE values and other identified clinical parameters, the model achieved an area under the receiver operating characteristic curve of 0.866, with sensitivity, specificity, and likelihood ratio of 71.2%, 80.2%, and 3.597 in predicting CR-POPF. Decision curve of modified model revealed a better clinical benefit compared to the previous clinical prediction models. The models were then examined via internal validation in a separate collection of 72 patients (cohort 2). CONCLUSIONS Risk evaluation model based on SWE and clinical parameters is a potential non-invasive way to pre-operatively, objectively predict CR-POPF after pancreatectomy. CLINICAL RELEVANCE STATEMENT Our modified model based on ultrasound shear wave elastography may provide an easy access in pre-operative and quantitative evaluating the risk of CR-POPF following pancreatectomy and improve the objectivity and reliability of the prediction compared to previous clinical models. KEY POINTS • Modified prediction model based on ultrasound shear wave elastography (SWE) provides an easy access for clinicians to pre-operatively, objectively evaluate the risk of clinically relevant post-operative pancreatic fistula (CR-POPF) following pancreatectomy. • Prospective study with validation showed that the modified model provides better diagnostic efficacy and clinical benefits compared to previous clinical models in predicting CR-POPF. • Peri-operative management of CR-POPF high-risk patients becomes more possible.
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Affiliation(s)
- Xiao-Fan Tian
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Lei Zhang
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Hui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Qiu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Dan Zuo
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China.
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Pancreatic Steatosis Is Associated with Both Metabolic Syndrome and Pancreatic Stiffness Detected by Ultrasound Elastography. Dig Dis Sci 2022; 67:293-304. [PMID: 33651254 DOI: 10.1007/s10620-021-06844-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/10/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION There is increasing evidence that pancreatic steatosis (PS) is associated with metabolic syndrome (MS). However, it is not known whether it is associated with PS grade and pancreatic stiffness, or not. We aimed to evaluate the relationship between PS and its grade detected by transabdominal ultrasound, and pancreatic stiffness determined by two-dimensional shearwave elastography (2D-SWE), whether it has clinical significance and its relationship with MS. METHODS Patients with and without PS were evaluated prospectively. RESULTS Patients with PS had higher odds ratio for MS (OR 5.49). Also, ultrasonographic grade of PS was associated with MS parameters and hepatosteatosis. Pancreatic SWE value was significantly higher in PS group and positively correlated with PS grade, liver fat, MS, number of MS criteria. DISCUSSION/CONCLUSION PS and its grade were associated with MS. In this first comprehensive PS-SWE study, we found that pancreas stiffness increased in the presence of PS, in correlation with PS grade and MS.
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A modified alternative fistula risk score (a-FRS) obtained from the computed tomography enhancement pattern of the pancreatic parenchyma predicts pancreatic fistula after pancreatoduodenectomy. HPB (Oxford) 2021; 23:1759-1766. [PMID: 33975799 DOI: 10.1016/j.hpb.2021.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alternative fistula risk score (a-FRS) is useful to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). METHODS Clinical data from 239 patients undergoing PD were collected. The CT value of the pancreatic parenchyma was measured in the nonenhanced (N), arterial (A), portal venous (P), and late (L) phases. The A/N, A/P, P/L and A/L ratios were calculated and their correlation with CR-POPF were analyzed. By replacing pancreatic texture with the best CT attenuation ratio, a modified a-FRS was developed. RESULTS Forty-seven patients developed CR-POPF. The A/P ratio (P < 0.001), P/L ratio (P = 0.002) and A/L ratio (P < 0.001) were significantly higher in the CR-POPF group. The A/L ratio performed best in predicting CR-POPF (AUC: 0.803) and the cut-off value is 1.36. A/L ratio >1.36 (P < 0.001), body mass index (P = 0.005) and duct diameter (P = 0.037) were independently associated with CR-POPF. By replacing soft texture with an A/L ratio >1.36, a modified a-FRS was developed and performed better than the a-FRS (AUC: 0.823 vs 0.748, P = 0.006) in predicting CR-POPF. CONCLUSIONS The modified a-FRS is an objective and preoperative model for predicting the occurrence of CR-POPF after PD.
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Sezgin O, Yaraş S, Özdoğan O. The course and prognostic value of increased pancreas stiffness detected by ultrasound elastography during acute pancreatitis. Pancreatology 2021; 21:1285-1290. [PMID: 34344610 DOI: 10.1016/j.pan.2021.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/03/2021] [Accepted: 07/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In this study, we determined the pancreatic stiffness (PS) changes in the course of acute pancreatitis (AP) by ultrasound elastography and evaluated its relation with prognosis. MATERIAL/METHODS Pancreatic shear wave velocity measurements (SWM) were evaluated at the time of admission to the hospital, following clinical improvement, and one-month after for AP patients and compared to healthy volunteers. Its relationship with clinical severity indexes was evaluated. RESULTS The pancreatic SWM value in the healthy group was 7.72 ± 2.50 kPa, and in AP group was 10.97 ± 2.26 kPa (p = 0.000). There was no difference between mild and severe pancreatitis. The mean SWM was 8.96 ± 1.53 kPa after disease remission, and 8.83 ± 1.24 kPa after 1-month. CONCLUSIONS PS increases significantly during AP and decreases with clinical improvement, but this was still higher than controls, and it kept its elevation after 1-month. We think that larger, long-term studies are needed to determine the clinicopathological significance of this.
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Affiliation(s)
- Orhan Sezgin
- Mersin University Faculty of Medicine Gastroenterology Department, Mersin, Turkey
| | - Serkan Yaraş
- Mersin University Faculty of Medicine Gastroenterology Department, Mersin, Turkey.
| | - Osman Özdoğan
- Mersin University Faculty of Medicine Gastroenterology Department, Mersin, Turkey
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Sushma N, Gupta P, Kumar H, Sharma V, Mandavdhare H, Kumar-M P, Nada R, Yadav TD, Singh H. Role of ultrasound shear wave elastography in preoperative prediction of pancreatic fistula after pancreaticoduodenectomy. Pancreatology 2020; 20:1764-1769. [PMID: 33139201 DOI: 10.1016/j.pan.2020.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/15/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Majority of predictors of postoperative pancreatic fistula (POPF) use intraoperative variables. We aimed to study the role of preoperative ultrasound shear wave elastography (USWE) to predict POPF. METHODS The consecutive patients who underwent pancreaticoduodenectomy (PD) between January 2019 to March 2020 were prospectively enrolled. All patients underwent USWE assessment at the pancreatic neck level. Intraoperative variables including pancreatic texture, pancreatic duct diameter, blood loss and histological grading of fibrosis were also recorded. Associations between USWE and intraoperative variables and histological grading with the development of POPF were analyzed. RESULTS Of the 62 patients assessed, 50 patients (mean age: 53 ± 14 years; 31 males) were included. POPF and clinically relevant POPF (CRPOPF) were observed in 22 (44%) and 7 (14%) patients respectively. Soft pancreas was an independent predictor of CRPOPF (p = 0.04). The mean USWE valve was significantly lower in patients with CRPOPF as compared to no CRPOPF (9.7 Kpa vs. 12.8Kpa, p = 0.016). At receiver operating characteristic curve analysis, USWE value of 12.65Kpa yielded sensitivity and specificity of 100% and 47%, respectively, for prediction of CRPOPF. USWE showed significant correlation with intraoperative pancreatic texture (Spearman's rank correlation coefficient (ρ) = 0.565, p = 0.001). CONCLUSION USWE helps in preoperative prediction of CRPOPF. This may further help to customize management strategy in high risk patients.
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Affiliation(s)
- Nakka Sushma
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Radiodiagnosis (GE Radiology), Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemanth Kumar
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Clinical Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Drozdov ES, Koshel AP, Rodionova OV, Dibina TV, Klokov SS. [Predictors of external pancreatic fistulae after pancreatic resection]. Khirurgiia (Mosk) 2020:107-114. [PMID: 33210516 DOI: 10.17116/hirurgia2020111107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.
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Affiliation(s)
- E S Drozdov
- Siberian State Medical University, Tomsk, Russia.,Tomsk Regional Oncology Hospital, Tomsk, Russia
| | - A P Koshel
- Siberian State Medical University, Tomsk, Russia.,Alperovich Tomsk City Clinical Hospital No. 3, Tomsk, Russia
| | | | | | - S S Klokov
- Siberian State Medical University, Tomsk, Russia.,Zherlov Medical Center, Seversk, Russia
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Pancreatic ultrasound elastography is not useful to predict the risk of pancreatic fistulas after pancreatic resection. Updates Surg 2020; 72:1081-1087. [PMID: 32248425 DOI: 10.1007/s13304-020-00748-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/18/2020] [Indexed: 12/17/2022]
Abstract
The clinical usefulness of pancreatic elastography (PE) in the assessment of the pancreatic texture before pancreatic resection still remains uncertain. The aims are: to evaluate the value of pancreatic stiffness in both healthy volunteers and patients affected by pancreatic tumor; to evaluate the ability of PE in predicting clinically relevant postoperative pancreatic fistula (CR-POPF). Pancreatic stiffness of healthy subjects was compared with those of pancreatic tumors measuring shear wave velocity (SWV). In the last group, the ability of preoperative SWV in predicting CR-POPF was evaluated using linear regression. Ninety subjects were consecutively enrolled. No difference was found in SWV in the two groups (1.33 ± 0.31 vs 1.26 ± 0.30, p = 0.337). Multivariate analyses showed that male gender was associated with a softer pancreas (OR 0.74, CI 0.55-0.98, p = 0.035). In the 45 patients suitable for a secondary endpoint, the presence of soft pancreas assessed by surgeon's palpation (OR 61.21; CI 2.14- > 1000; p = 0.016) and preoperative risk score (OR 1.72; CI 1.01-2.96; p = 0.049) was predictors of CR-POPF. SWV showed a trend in predicting CR-POPF. The pancreatic stiffness far to the pancreatic neoplasm is the same as healthy controls. SWV showed a trend in predicting CR-POPF but the clinical utility is limited.
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Marasco G, Ricci C, Buttitta F, Dajti E, Ravaioli F, Ingaldi C, Alberici L, Serra C, Festi D, Colecchia A, Casadei R. Is Ultrasound Elastography Useful in Predicting Clinically Relevant Pancreatic Fistula After Pancreatic Resection?: A Systematic Review and Meta-analysis. Pancreas 2020; 49:1342-1347. [PMID: 33122523 DOI: 10.1097/mpa.0000000000001685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Ultrasound (US) elastography has been proposed for the non-invasive prediction of clinically relevant pancreatic fistula (CR-POPF) in patients undergoing pancreatic resection. We aimed to perform a systematic review with meta-analysis to assess the diagnostic value of US elastography in predicting CR-POPF. METHODS MEDLINE via PubMed, Ovid Embase, Scopus, and Cochrane Library databases, and abstracts of international conference proceedings were searched up to April 20, 2020. Studies assessing the performance of abdominal US elastography in predicting CR-POPF in patients undergoing pancreatic resection were included. The quality of the studies was assessed using Quality Assessment of Diagnostic Accuracy Studies. RESULTS Five studies, including 247 patients who underwent partial pancreatic resection of whom 72 patients experiencing CR-POPF, were selected. All studies performed US elastography in different pancreatic sites. The pooled mean strain value was lower in pancreatic segments of patients experiencing CR-POPF than in those without, with a pooled weighted mean difference of -0.187 (95% confidence intervals, -0.303 to -0.071; P = 0.002). There was low heterogeneity between studies (I = 7.6%), and all studies were at "high risk" or "unclear risk" of bias. CONCLUSIONS This study provides evidence that US elastography values are statistically significantly lower in patients experiencing CR-POPF.
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Affiliation(s)
- Giovanni Marasco
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Claudio Ricci
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Francesco Buttitta
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Elton Dajti
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Federico Ravaioli
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Carlo Ingaldi
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Laura Alberici
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Carla Serra
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Organ Failure and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Riccardo Casadei
- From the Azienda Ospedaliero-Universitaria di Bologna, Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna
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Dietrich CF, Hocke M. Elastography of the Pancreas, Current View. Clin Endosc 2019; 52:533-540. [PMID: 31311914 PMCID: PMC6900297 DOI: 10.5946/ce.2018.156] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Ultrasound elastography (USE) of the pancreas allows pancreatic tissue stiffness assessment by virtual palpation. Two main types of USE are used. For the pancreas strain elastography applying by endoscopic ultrasound has been established for the characterisation of small solid pancreatic lesions (SPL). In larger SPL >30 mm the results are less convincing mainly due to the heterogenicity of the lesions but also by concomitant changes of the surrounding pancreatic parenchyma. The current role of shear wave elastography has to be determined. This article reviews the current use of elastography of the pancreas.
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Affiliation(s)
- Christoph F. Dietrich
- Ultrasound Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Internal Medicine, Caritas Hospital Bad Mergentheim, Bad Mergentheim, Germany
| | - Michael Hocke
- Department of Internal Medicine, HELIOS Klinikum Meiningen, Meiningen, Germany
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Ryu Y, Shin SH, Park DJ, Kim N, Heo JS, Choi DW, Han IW. Validation of original and alternative fistula risk scores in postoperative pancreatic fistula. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:354-359. [PMID: 31125494 PMCID: PMC6771591 DOI: 10.1002/jhbp.638] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background In 2013, the fistula risk score (FRS) was developed to assess the risk of clinically relevant postoperative pancreatic fistula (CR‐POPF). In 2017, the alternative FRS (a‐FRS) was proposed. The purpose of this study was to validate the original FRS (o‐FRS) and a‐FRS for CR‐POPF in pancreaticoduodenectomy (PD). Methods From January 2007 to December 2016, 1,771 patients underwent PD for periampullary cancers. POPF was defined and classified according to the 2016 International Study Group for Pancreatic Fistula. All data were reviewed retrospectively. Results Pathologic diagnosis other than ductal adenocarcinoma (P < 0.001), pancreas duct diameter (P < 0.001), and body mass index (P < 0.001) were independent risk factors for CR‐POPF. Pancreatic texture (P = 0.534) and estimated blood loss (P = 0.827) were not associated with CR‐POPF. The CR‐POPF incidence increased with increasing o‐FRS score (P < 0.001), and also increased statistically significantly with increasing a‐FRS in the higher risk group (P < 0.001). However, the correlations differed. The area under the curve was 0.629 for o‐FRS and 0.622 for a‐FRS. Conclusions Both o‐FRS and a‐FRS might reflect CR‐POPF incidence, but some risk factors had no or low statistical significance. Further research is needed to revise the FRS.
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Affiliation(s)
- Youngju Ryu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Dae Joon Park
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Naru Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Dong Wook Choi
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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Barreto SG, Dirkzwager I, Windsor JA, Pandanaboyana S. Predicting post-operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review. ANZ J Surg 2019; 89:659-665. [PMID: 30306712 DOI: 10.1111/ans.14891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/19/2018] [Accepted: 09/02/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Ilse Dirkzwager
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - John A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- HBP Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- HBP Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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Computed Tomography Enhancement Pattern of the Pancreatic Parenchyma Predicts Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. Pancreas 2019; 48:209-215. [PMID: 30589830 DOI: 10.1097/mpa.0000000000001229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to assess the relationship between the computed tomography (CT) pancreatic parenchyma attenuation value and clinically relevant postoperative pancreatic fistula (POPF). METHODS The medical records of 115 patients who underwent pancreaticoduodenectomy and preoperative dynamic CT were retrospectively reviewed. The CT attenuation values of the nonenhanced (N), arterial (A), portal venous (P), and late (L) phase in the pancreatic parenchyma were determined via CT, and the A/N, A/P, and P/L ratios were calculated. The CT attenuation values and value ratios were compared between the POPF and non-POPF groups. RESULTS Thirty-two patients (28%) were categorized in the POPF group. On univariate analysis, the A/P ratio (P < 0.001) and P/L ratio (P = 0.018) were significantly higher in the POPF group. On receiver operating characteristic curve analysis, the A/P and P/L ratio cutoff values for predicting POPF were 1.19 and 1.17, respectively. Of the preoperative evaluable factors, A/P ratio of 1.19 or greater (P < 0.001; odds ratio, 10.3) and P/L ratio of 1.17 or greater (P = 0.049; odds ratio, 3.23) were independent predictive factors for POPF, and the combination of the 2 ratios was useful in detecting POPF preoperatively. CONCLUSIONS The enhancement pattern of the pancreatic parenchyma is associated with the development of clinically relevant POPF.
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15
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Evaluation of Pancreatic Fibrosis With Acoustic Radiation Force Impulse Imaging and Automated Quantification of Pancreatic Tissue Components. Pancreas 2018; 47:1277-1282. [PMID: 30286012 DOI: 10.1097/mpa.0000000000001179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether computer-assisted digital analysis and acoustic radiation force impulse (ARFI) imaging were useful for assessing pancreatic fibrosis, and if ARFI imaging predicted postoperative pancreatic fistula (POPF). METHODS Seventy-eight patients scheduled to undergo pancreatic resection were enrolled. Shear wave velocity (SWV) at the pancreatic neck was measured preoperatively using ARFI imaging. Pancreatic tissue components on a whole slide image were quantified using an automatic image processing software. The relationship between SWV, fibrotic tissue content, and POPF incidence and clinical severity was analyzed. RESULTS The median collagen fiber, fatty tissue, and acinar cell contents were 11.6%, 8.5%, and 61.3%, respectively. Unlike fatty tissue, collagen fiber content and acinar cells were correlated with SWV (ρ = 0.440, P < 0.001 and ρ = -0.428, P < 0.001, respectively). Although collagen fiber content and SWV were associated with the overall incidence of POPF (P = 0.004 and 0.001, respectively), collagen fiber content and SWV had no statistical correlation with clinically relevant POPF (P = 0.268 and 0.052, respectively). CONCLUSIONS We objectively quantified the pancreatic tissue components using an automatic image processing software. Shear wave velocity was significantly related to collagen fiber content and suggests that ARFI imaging can be useful for evaluating pancreatic fibrosis.
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16
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Kirks RC, Cochran A, Barnes TE, Murphy K, Baker EH, Martinie JB, Iannitti DA, Vrochides D. Developing and validating a center-specific preoperative prediction calculator for risk of pancreaticoduodenectomy. Am J Surg 2018. [PMID: 29519551 DOI: 10.1016/j.amjsurg.2018.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Surgical Risk Calculator predicts postoperative risk based on preoperative variables. The ACS model was compared to an institution-specific risk calculator for pancreaticoduodenectomy (PD). METHODS Observed outcomes were compared with those predicted by the ACS and institutional models. Receiver operating characteristic (ROC) analysis evaluated the models' predictive ability. Institutional models were evaluated with retrospective and prospective internal validation. RESULTS Brier scores indicate equivalent aggregate predictive ability. ROC values for the institutional model (ROC: 0.675-0.881, P < 0.01) indicate superior individual event occurrence prediction (ACS ROC: 0.404-0.749, P < 0.01-0.860). Institutional models' accuracy was upheld in retrospective (ROC: 0.765-0.912) and prospective (ROC: 0.882-0.974) internal validation. CONCLUSIONS Identifying higher-risk patients allows for individualized care. While ACS and institutional models accurately predict average complication occurrence, the institutional models are superior at predicting individualized outcomes. Predictive metrics specific to PD center volume may more accurately predict outcomes.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - T Ellis Barnes
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith Murphy
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Tajima Y, Kawabata Y, Hirahara N. Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2018; 48:140-150. [PMID: 28421350 DOI: 10.1007/s00595-017-1529-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/31/2017] [Indexed: 12/13/2022]
Abstract
In performing pancreaticoduodenectomy (PD) or when conducting clinical trials involving PD procedure, a universal platform for predicting the risk of postoperative pancreatic fistula (POPF) is indispensable. In this article, the most significant imaging studies that focused on the objective preoperative assessment of pancreatic pathologies in association with the occurrence of POPF after PD were reviewed. Several recently developed imaging modalities can objectively predict the occurrence of POPF after PD by assessing the elasticity, fibrosis, and fatty infiltration of the pancreas. These valuable imaging modalities include: (1) acoustic radiation force impulse ultrasound (US) electrography which provides information about the elastic properties of the pancreas; (2) contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with/without contrast-enhancement which reflect the histological degree of pancreatic fibrosis; and (3) multi-detector row CT and/or MRI which reflects the microscopic fatty infiltration of the pancreas. The precise and objective preoperative risk assessment of POPF enables surgeons to customize appropriate management strategies for individual patients undergoing PD. This would be also beneficial for stratifying patients for enrolment in relevant studies that involve pancreatic head resection, as objective criteria could be set for the definitive evaluation of collected data related to surgical outcomes across different institutions and surgeons.
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Affiliation(s)
- Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enya, Izumo, Shimane, 693-8501, Japan.
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
| | - Noriyuki Hirahara
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
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18
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Rungsakulkij N, Mingphruedhi S, Tangtawee P, Krutsri C, Muangkaew P, Suragul W, Tannaphai P, Aeesoa S. Risk factors for pancreatic fistula following pancreaticoduodenectomy: A retrospective study in a Thai tertiary center. World J Gastrointest Surg 2017; 9:270-280. [PMID: 29359033 PMCID: PMC5752962 DOI: 10.4240/wjgs.v9.i12.270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/15/2017] [Accepted: 10/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the risk factors of postoperative pancreatic fistula following pancreaticoduodenectomy in a Thai tertiary care center.
METHODS We retrospectively analyzed 179 patients who underwent pancreaticoduodenectomy at our hospital from January 2001 to December 2016. Pancreatic fistula were classified into three categories according to a definition made by an International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.
RESULTS Pancreatic fistula were detected in 88/179 patients (49%) who underwent pancreaticoduodenectomy. Fifty-eight pancreatic fistula (65.9%) were grade A, 22 cases (25.0%) were grade B and eight cases (9.1%) were grade C. Clinically relevant pancreatic fistula were detected in 30/179 patients (16.7%). The 30-d mortality rate was 1.67% (3/179 patients). Multivariate logistic regression analysis revealed that soft pancreatic texture (odds ratio = 3.598, 95%CI: 1.77-7.32) was the most significant risk factor for pancreatic fistula. A preoperative serum bilirubin level of > 3 mg/dL was the most significant risk factor for clinically relevant pancreatic fistula according to univariate and multivariate analysis.
CONCLUSION Soft pancreatic tissue is the most significant risk factor for postoperative pancreatic fistula. A high preoperative serum bilirubin level (> 3 mg/dL) is the most significant risk factor for clinically relevant pancreatic fistula.
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Affiliation(s)
- Narongsak Rungsakulkij
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Somkit Mingphruedhi
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pongsatorn Tangtawee
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Chonlada Krutsri
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Paramin Muangkaew
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Wikran Suragul
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Suraida Aeesoa
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Kuwahara T, Hirooka Y, Kawashima H, Ohno E, Yokoyama Y, Fujii T, Nakamura S, Kodera Y, Nagino M, Goto H. Usefulness of endoscopic ultrasonography-elastography as a predictive tool for the occurrence of pancreatic fistula after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:649-656. [PMID: 29032609 DOI: 10.1002/jhbp.514] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) is a major complication following pancreatoduodenectomy (PD). Pancreatic texture is a risk factor for PF, but its evaluation depends on the subjective judgment. The aim of this study was to investigate whether preoperative endoscopic ultrasonography-elastography (EUS-EG), which objectively assesses tissue elasticity, predict the development of PF following PD. METHODS Fifty-nine patients who underwent EUS-EG before PD and had pancreas parenchyma histologically evaluated were included. Using histogram analysis, mean elasticity (ME), which represents tissue elasticity and is inversely correlated with pancreatic fibrosis, was calculated. RESULTS Among 59 patients, 19 developed PF (32.2%). The ME in patients with PF was significantly higher than that in patients without PF (85.4 vs. 55.6, P < 0.001). Area under the receiver operating characteristic curve for the accuracy of pancreatic texture and ME for predicting PF were 0.718 and 0.846, respectively. When a ME of 70.0 was used as a cut-off value for predicting PF, the sensitivity and specificity were 84.2% and 80.0%, respectively. In a multivariate logistic regression analysis, only a ME of >70.0 was an independent predictor of PF (odds ratio 10.02, P = 0.008). CONCLUSIONS Endoscopic ultrasonography-elastography may be an accurate and objective method for predicting PF following PD.
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Affiliation(s)
- Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeo Nakamura
- Department of Pathology and Molecular Diagnostics, Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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20
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Kiyochi H. Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy: Reply. World J Surg 2017; 39:2967-74. [PMID: 26732669 DOI: 10.1007/s00268-015-3211-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kawada N, Tanaka S. Elastography for the pancreas: Current status and future perspective. World J Gastroenterol 2016; 22:3712-3724. [PMID: 27076756 PMCID: PMC4814734 DOI: 10.3748/wjg.v22.i14.3712] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Elastography for the pancreas can be performed by either ultrasound or endoscopic ultrasound (EUS). There are two types of pancreatic elastographies based on different principles, which are strain elastography and shear wave elastography. The stiffness of tissue is estimated by measuring the grade of strain generated by external pressure in the former, whereas it is estimated by measuring propagation speed of shear wave, the transverse wave, generated by acoustic radiation impulse (ARFI) in the latter. Strain elastography is difficult to perform when the probe, the pancreas and the aorta are not located in line. Accordingly, a fine elastogram can be easily obtained in the pancreatic body but not in the pancreatic head and tail. In contrast, shear wave elastography can be easily performed in the entire pancreas because ARFI can be emitted to wherever desired. However, shear wave elastography cannot be performed by EUS to date. Recently, clinical guidelines for elastography specialized in the pancreas were published from Japanese Society of Medical Ultrasonics. The guidelines show us technical knacks of performing elastography for the pancreas.
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Harada N, Ishizawa T, Inoue Y, Aoki T, Sakamoto Y, Hasegawa K, Sugawara Y, Tanaka M, Fukayama M, Kokudo N. Acoustic radiation force impulse imaging of the pancreas for estimation of pathologic fibrosis and risk of postoperative pancreatic fistula. J Am Coll Surg 2014; 219:887-94.e5. [PMID: 25262282 DOI: 10.1016/j.jamcollsurg.2014.07.940] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/17/2014] [Accepted: 07/30/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND We sought to evaluate whether pancreatic elasticity, measured using acoustic radiation force impulse (ARFI) imaging, can determine the degree of pancreatic fibrosis and risk of pancreatic fistula (PF) in patients undergoing pancreatic resection. Although soft pancreatic texture is a reliable predictor of postoperative PF, noninvasive, quantitative methods of assessing pancreatic hardness have not been established. STUDY DESIGN Shear wave velocity (SWV) of the pancreas was preoperatively measured by ARFI imaging in 62 patients undergoing pancreatic resection. Correlations of SWV with pathologic degree of fibrosis in the resected pancreas, exocrine function of the remnant pancreas, and the incidence of postoperative PF were determined. RESULTS The SWV was positively correlated with the degree of pancreatic fibrosis (Spearman's rank correlation coefficient [ρ] = 0.660, p < 0.001) and inversely correlated with postoperative amylase concentrations and daily output of pancreatic juice. The incidence of postoperative PF was significantly higher in the 32 patients with soft (SWV < 1.54 m/s) than in the 30 with hard (SWV ≥ 1.54 m/s) pancreata (63% vs 17%, p < 0.001). Multivariate analysis showed that a soft pancreas (SWV < 1.54 m/s) was an independent predictor of postoperative PF (odds ratio 38.3; 95% CI 5.82 to 445; p = 0.001). CONCLUSIONS Pancreatic elasticity on preoperative ARFI imaging accurately reflected the pathologic degree of fibrosis and exocrine function of the pancreas, enabling surgeons to adopt appropriate surgical procedures according to the risk of postoperative PF in each patient undergoing pancreatic resection.
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Affiliation(s)
- Nobuhiro Harada
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taku Aoki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masashi Fukayama
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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