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Miranda J, Key Wakate Teruya A, Leão Filho H, Lahan-Martins D, Tamura Sttefano Guimarães C, de Paula Reis Guimarães V, Ide Yamauchi F, Blasbalg R, Velloni FG. Diffuse and focal liver fat: advanced imaging techniques and diagnostic insights. Abdom Radiol (NY) 2024; 49:4437-4462. [PMID: 38896247 DOI: 10.1007/s00261-024-04407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024]
Abstract
The fatty liver disease represents a complex, multifaceted challenge, requiring a multidisciplinary approach for effective management and research. This article uses conventional and advanced imaging techniques to explore the etiology, imaging patterns, and quantification methods of hepatic steatosis. Particular emphasis is placed on the challenges and advancements in the imaging diagnostics of fatty liver disease. Techniques such as ultrasound, CT, MRI, and elastography are indispensable for providing deep insights into the liver's fat content. These modalities not only distinguish between diffuse and focal steatosis but also help identify accompanying conditions, such as inflammation and fibrosis, which are critical for accurate diagnosis and management.
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Affiliation(s)
- Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
- Department of Radiology, University of São Paulo, R. Dr. Ovídio Pires de Campos, 75-Cerqueira César, São Paulo, SP, 05403-010, Brazil.
| | - Alexandre Key Wakate Teruya
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Hilton Leão Filho
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Daniel Lahan-Martins
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
- Departament of Radiology-FCM, State University of Campinas (UNICAMP), R. Tessália Vieira de Camargo, 126 Cidade Universitária, Campinas, SP, 13083-887, Brazil
| | - Cássia Tamura Sttefano Guimarães
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Vivianne de Paula Reis Guimarães
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Fernando Ide Yamauchi
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Roberto Blasbalg
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
| | - Fernanda Garozzo Velloni
- Department of Radiology, Diagnósticos da América SA (DASA), Av Juruá 434, Alphaville Industrial, Barueri, São Paulo, SP, 06455-010, Brazil
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Cardoso D, Miranda J, de Arimateia Batista Araujo-Filho J, Soares LE, Chagas L, Seidel K, Fonseca GM, Hamdan D, Kalaycioglu B, Chhabra S, Yildirim O, Chakraborty J, Horvat N. Cross-sectional imaging of pancreatic leak: a pictorial review. Abdom Radiol (NY) 2024; 49:4507-4520. [PMID: 38900317 DOI: 10.1007/s00261-024-04401-w] [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: 04/02/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024]
Abstract
Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the abdominal cavity. While often associated with pancreatic surgical procedures, trauma and necrotizing pancreatitis are also common culprits. Cross-sectional imaging, particularly computed tomography, plays a crucial role in assessing postoperative conditions and identifying both early and late complications, including pancreatic leaks. The presence of fluid accumulation or hemorrhage near an anastomotic site strongly indicates a pancreatic fistula, particularly if the fluid is connected to the pancreatic duct or anastomotic suture line. Pancreatic fistulas are a type of pancreatic leak that carries a high morbidity rate. Early diagnosis and assessment of pancreatic leaks require vigilance and an understanding of its imaging hallmarks to facilitate prompt treatment and improve patient outcomes. Radiologists must maintain vigilance and understand the imaging patterns of pancreatic leaks to enhance diagnostic accuracy. Ongoing improvements in surgical techniques and diagnostic approaches are promising for minimizing the prevalence and adverse effects of pancreatic fistulas. In this pictorial review, our aim is to facilitate for radiologists the comprehension of pancreatic leaks and their essential imaging patterns.
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Affiliation(s)
- Daniel Cardoso
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91-Bela Vista, São Paulo, SP, 01308-050, Brazil.
| | - Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Department of Radiology, University of São Paulo, R. Dr. Ovídio Pires de Campos, 75-Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | | | - Luciana Eltz Soares
- SIDI Radiology at Cardiology Institute of Porto Alegre, Avenida Princesa Isabel 395, Porto Alegre, CEP 90620000, Brazil
| | - Lucia Chagas
- Department of Radiology, Hospital Samaritano, Rua Conselheiro Brotero, 1489-Higienópolis, São Paulo, SP, 01232-010, Brazil
| | - Kamila Seidel
- Departmente of Radiology, Beneficência Portuguesa de São Paulo-Rua Maestro Cardim, 637-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | - Gilton Marques Fonseca
- Department of Gastroenterology, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 255, Instituto Central, 9° Andar, Sala 9074-Cerqueira Cesar, São Paulo, SP, 05403-900, Brazil
| | - Dina Hamdan
- Department of Radiology, Mount Sinai Hospital, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Bora Kalaycioglu
- Department of Radiology, The University of Chicago. Billings Hospital, P220, 5841 South Maryland Avenue, MC2026, Chicago, IL, 60637, USA
| | - Shalini Chhabra
- Department of Radiology, Shalini Chhabra, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Department of Radiology, University of São Paulo, R. Dr. Ovídio Pires de Campos, 75-Cerqueira César, São Paulo, SP, 05403-010, Brazil
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Khatkov IE, Lesko KA, Dubtsova EA, Khomeriki SG, Karnaukhov NS, Vinokurova LV, Shurygina EI, Makarenko NV, Izrailov RE, Savina IV, Salimgereeva DA, Kiriukova MA, Bordin DS. [Possibilities of post-processing of multislice computed tomography results in non-invasive diagnosis of pancreatic fibrosis]. TERAPEVT ARKH 2024; 96:780-789. [PMID: 39404723 DOI: 10.26442/00403660.2024.08.202831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Accepted: 07/21/2024] [Indexed: 01/11/2025]
Abstract
AIM To evaluate the possibilities of post-processing of multidetector computed tomography (CT) results in the non-invasive diagnosis of pancreatic fibrosis (PF). MATERIALS AND METHODS The study included 165 patients aged 57.91±13.5 years who underwent preoperative CT during surgical treatment for chronic pancreatitis and pancreatic cancer from April 2022 to February 2024. The normalized contrast ratios of pancreatic tissue in the pancreatic (NCPP) and venous (NCVP) phases, as well as the contrast ratio (CR) were measured. Pathomorphological assessment of PF performed in tissues outside neoplasm or desmoplastic reaction by the Kloppel and Maillet scale. RESULTS The values of post-processing CT results were compared in groups with different degrees of PF. Mean CR values were significantly higher (p=0.001) in patients with severe PF (CR 1.16±0.65 HU) than in patients with mild PF (CR 0.78±0.31 HU). CR value significant increase (p=0.03) was found in patients with signs of inflammatory changes in the pancreas tissue (CR 1.14±0.6 HU) than in those without them (CR 0.81±0.3 HU). There were no significant differences between the values of NCPP and NCVP, and the degree of PF. CONCLUSION The CR value increased in patients with severe degree of PF. There was a relationship between CR value increase and the radiological density of pancreatic tissue in non-contrast phase and presence of early signs of pancreatic inflammatory changes. Thus, there was a relationship between CT postprocessing results and morphological signs of PF, which can be used for pancreatic fibrosis non-invasive diagnosis and identification of additional signs of early chronic pancreatitis.
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Affiliation(s)
- I E Khatkov
- Loginov Moscow Clinical Scientific Center
- Russian University of Medicine
| | - K A Lesko
- Loginov Moscow Clinical Scientific Center
| | | | | | | | | | | | | | | | - I V Savina
- Loginov Moscow Clinical Scientific Center
| | | | | | - D S Bordin
- Loginov Moscow Clinical Scientific Center
- Russian University of Medicine
- Tver State Medical University
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Hong JJ, Park HJ, Lee ES, Kim MJ. Severity of hyperechoic pancreas on preoperative ultrasonography: high potential as a clinically useful predictor of a postoperative pancreatic fistula. Ultrasonography 2024; 43:272-283. [PMID: 38881310 PMCID: PMC11222128 DOI: 10.14366/usg.24046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024] Open
Abstract
PURPOSE This study aimed to evaluate the effectiveness of using the severity of hyperechoic pancreas (HP) observed on preoperative ultrasonography (US) as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF). METHODS A retrospective study was conducted with 94 patients who underwent pancreatectomy between April 2006 and March 2021. The severity of HP on US was classified into two categories (normal to mild vs. moderate to severe [obvious HP]). Multiple preoperative and intraoperative parameters were analyzed to predict CR-POPF. RESULTS Out of the 94 patients, CR-POPF occurred in 21 (22%) patients, and obvious HP was observed in 30 (32%). Univariate analysis revealed that moderate to severe HP (obvious HP) was significantly associated with an increased incidence of CR-POPF (P<0.001). Factors such as the absence of pancreatitis, a small main pancreatic duct (<3 mm), intraoperative soft pancreas, increased body mass index, and lower pancreatic attenuation and attenuation index were also associated with CR-POPF (all P<0.05). Multivariate analysis showed that obvious HP and soft pancreatic texture were independent predictors of CR-POPF, with odds ratios of 11.53 (P=0.001) and 14.12 (P=0.003), respectively. The combination of obvious HP and soft pancreatic texture provided the most accurate prediction for CR-POPF. CONCLUSION The severity of HP, as observed on preoperative US, was significantly associated with CR-POPF. Severe HP may serve as a clinically useful predictor of POPF, especially when evaluated alongside the intraoperative pancreatic texture.
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Affiliation(s)
- Jung Joo Hong
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Min Ju Kim
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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Madankan A, Jaliliyan A, Khalili P, Eghdami S, Mosavari H, Ahmadi SAY, Izadi A, Hosseininasab A, Eghbali F. Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis. ANZ J Surg 2024; 94:1030-1038. [PMID: 38837835 DOI: 10.1111/ans.19033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/23/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk. METHODS Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139). RESULTS We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF. CONCLUSION Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.
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Affiliation(s)
- Ahmad Madankan
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Jaliliyan
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Pantea Khalili
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shayan Eghdami
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hesam Mosavari
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyyed Amir Yasin Ahmadi
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amirreza Izadi
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseininasab
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Foolad Eghbali
- Department of Surgery, Surgery Research Center, School of Medicine, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Yang T, Feng J, Yao R, Feng Q, Shen J. CT-based pancreatic radiomics predicts secondary loss of response to infliximab in biologically naïve patients with Crohn's disease. Insights Imaging 2024; 15:69. [PMID: 38472447 DOI: 10.1186/s13244-024-01637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/27/2024] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVES Predicting secondary loss of response (SLR) to infliximab (IFX) is paramount for tailoring personalized management regimens. Concurrent pancreatic manifestations in patients with Crohn's disease (CD) may correlate with SLR to anti-tumor necrosis factor treatment. This work aimed to evaluate the potential of pancreatic radiomics to predict SLR to IFX in biologic-naive individuals with CD. METHODS Three models were developed by logistic regression analyses to identify high-risk subgroup prone to SLR. The area under the curve (AUC), calibration curve, decision curve analysis (DCA), and integrated discrimination improvement (IDI) were applied for the verification of model performance. A quantitative nomogram was proposed based on the optimal prediction model, and its reliability was substantiated by 10-fold cross-validation. RESULTS In total, 184 CD patients were enrolled in the period January 2016 to February 2022. The clinical model incorporated age of onset, disease duration, disease location, and disease behavior, whereas the radiomics model consisted of five texture features. These clinical parameters and the radiomics score calculated by selected texture features were applied to build the combined model. Compared to other two models, combined model achieved favorable, significantly improved discrimination power (AUCcombined vs clinical 0.851 vs 0.694, p = 0.02; AUCcombined vs radiomics 0.851 vs 0.740, p = 0.04) and superior clinical usefulness, which was further converted into reliable nomogram with an accuracy of 0.860 and AUC of 0.872. CONCLUSIONS The first proposed pancreatic-related nomogram represents a credible, noninvasive predictive instrument to assist clinicians in accurately identifying SLR and non-SLR in CD patients. CRITICAL RELEVANCE STATEMENT This study first built a visual nomogram incorporating pancreatic texture features and clinical factors, which could facilitate clinicians to make personalized treatment decisions and optimize cost-effectiveness ratio for patients with CD. KEY POINTS • The first proposed pancreatic-related model predicts secondary loss of response for infliximab in Crohn's disease. • The model achieved satisfactory predictive accuracy, calibration ability, and clinical value. • The model-based nomogram has the potential to identify long-term failure in advance and tailor personalized management regimens.
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Affiliation(s)
- Tian Yang
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Inflammatory Bowel Disease Research Center, Shanghai Institute of Digestive Disease, 160# Pu Jian Ave, Shanghai, 200127, China
- NHC Key Laboratory of Digestive Diseases (Renji Hospital, Shanghai Jiaotong University School of Medicine), Shanghai, China
| | - Jing Feng
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Inflammatory Bowel Disease Research Center, Shanghai Institute of Digestive Disease, 160# Pu Jian Ave, Shanghai, 200127, China
- NHC Key Laboratory of Digestive Diseases (Renji Hospital, Shanghai Jiaotong University School of Medicine), Shanghai, China
| | - Ruchen Yao
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Inflammatory Bowel Disease Research Center, Shanghai Institute of Digestive Disease, 160# Pu Jian Ave, Shanghai, 200127, China
- NHC Key Laboratory of Digestive Diseases (Renji Hospital, Shanghai Jiaotong University School of Medicine), Shanghai, China
| | - Qi Feng
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pu Jian Road, Shanghai, 200127, China.
| | - Jun Shen
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Inflammatory Bowel Disease Research Center, Shanghai Institute of Digestive Disease, 160# Pu Jian Ave, Shanghai, 200127, China.
- NHC Key Laboratory of Digestive Diseases (Renji Hospital, Shanghai Jiaotong University School of Medicine), Shanghai, China.
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Kalayarasan R, Himaja M, Ramesh A, Kokila K. Radiological parameters to predict pancreatic texture: Current evidence and future perspectives. World J Radiol 2023; 15:170-181. [PMID: 37424737 PMCID: PMC10324497 DOI: 10.4329/wjr.v15.i6.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management, thereby minimizing postoperative morbidity. Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease. However, radiological evaluation of pancreatic texture, an important determinant of pancreatic fistula, has not been widely used to predict the risk of postoperative pancreatic fistula. Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture. Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies. With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies, elastography is emerging as a promising tool for predicting pancreatic texture. Also, recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function. Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis, facilitating early intervention. The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences. However, multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.
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Affiliation(s)
- Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Mandalapu Himaja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Ananthakrishnan Ramesh
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Kathirvel Kokila
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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Gurram RP, S L H, Gnanasekaran S, Choudhury SR, Pottakkat B, Raja K. External pancreatic ductal stenting in minimally invasive pancreatoduodenectomy: How to do it? Ann Hepatobiliary Pancreat Surg 2023; 27:211-216. [PMID: 36859362 PMCID: PMC10201057 DOI: 10.14701/ahbps.22-098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 03/03/2023] Open
Abstract
It has been shown that external pancreatic ductal stenting (EPDS) can reduce the incidence of clinically relevant postoperative pancreatic fistula. Although studies have described EPDS in open pancreaticoduodenectomy (PD), EPDS in minimally invasive PD has not been reported yet. Thus, the objective of this study was to describe the technique of EPDS in minimally invasive PD. The procedure was performed either laparoscopically or using a robot. Once PD was completed, key steps included triple enterotomy, threading of silk-suture through all enterotomies and exteriorization, completing posterior layer of pancreaticojejunostomy (PJ), railroading stent through preplaced silk-suture, intubation of stent into the pancreatic duct, completion of PJ, followed by hepaticojejunostomy and parietalization of jejunum at the stent exit site. EPDS in PD through a minimally invasive approach can be performed safely in selected cases with either a small-sized pancreatic duct or a soft pancreas.
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Affiliation(s)
- Ram Prakash Gurram
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Harilal S L
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Satyaprakash Ray Choudhury
- Department of Surgical Gastroenterology, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Gnanasekaran S, Durgesh S, Gurram R, Kalayarasan R, Pottakkat B, Rajeswari M, Srinivas BH, Ramesh A, Sahoo J. Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy? World J Radiol 2022; 14:165-176. [PMID: 35978980 PMCID: PMC9258308 DOI: 10.4329/wjr.v14.i6.165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/26/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The commonly used predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) have subjective assessment components and can be used only in the postoperative setting. Also, the available objective predictors based on preoperative cross-sectional imaging were not prospectively studied. AIM To evaluate the accuracy of the pancreatic attenuation index (PAI) and pancreatic enhancement ratio (PER) for predicting CR-POPF following PD and its correlation with pancreatic fat fraction and fibrosis. METHODS A prospective observational study included patients who underwent PD for benign and malignant pathology of the periampullary region or pancreatic head between February 2019 and February 2021. Patients undergoing extended or total pancreatectomy and those with severe atrophy of pancreatic tissue or extensive parenchymal calcifications in the pancreatic head and neck precluding calculation of PAI and PER were excluded from the study. Preoperatively PAI was measured in the neck of the pancreas by marking regions of interest (ROI) in the non-contrast computed tomography (CT), and PER was measured during the contrast phase of the CT abdomen. Also, the fibrosis score and fat fraction of the pancreatic neck were assessed during the histopathological examination. Demographic, clinical and preoperative radiological indices (PAI, PER) were evaluated to predict CR-POPF. Preoperative pancreatic neck CT indices were correlated with the histopathological assessment of fat fraction and fibrosis. RESULTS Of the 70 patients who underwent PD, 61 patients fulfilling the inclusion criteria were included in the analysis. The incidence of CR-POPF was 29.5% (18/61). PAI had no association with the development of CR-POPF. Of the preoperative parameters, PER (mean ± standard deviation [SD]) was significantly lower in patients developing CR-POPF (0.58 ± 0.20 vs 0.81 ± 0.44, P = 0.006). The area under the curve for the PER was 0.661 (95%CI: 0.517-0.804), which was significant (P = 0.049). PER cut-off of 0.673 predicts CR-POPF with 77.8% sensitivity and 55.8% specificity. PAI and PER had a weak negative correlation (Strength-0.26, P = 0.037). Also, PER showed a moderately positive correlation with fibrosis (Strength 0.50, P < 0.001). Patients with CR-POPF had a significantly higher incidence of the intraabdominal abscess (50% vs 2.3%, P < 0.001), delayed gastric emptying (83.3% vs 30.2, P < 0.001), and prolonged mean (± SD) postoperative hospital stay (26.8 ± 13.9 vs 9.6 ± 3.6, P = 0.001). CONCLUSION PER exhibited good accuracy in predicting the development of CR-POPF. PER additionally showed a good correlation with PAI and fibrosis scores and may be used as an objective preoperative surrogate for assessing pancreatic texture. However, ROI-based PAI did not show any association with CR-POPF and pancreatic fat fraction.
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Affiliation(s)
- Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Satish Durgesh
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Ramprakash Gurram
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - 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
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10
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Maeda K, Kuriyama N, Yuge T, Ito T, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S. Risk factor analysis of postoperative pancreatic fistula after distal pancreatectomy, with a focus on pancreas-visceral fat CT value ratio and serrated pancreatic contour. BMC Surg 2022; 22:240. [PMID: 35733145 PMCID: PMC9215066 DOI: 10.1186/s12893-022-01650-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In pancreaticoduodenectomy, the pancreas-visceral fat CT value ratio and serrated pancreatic contour on preoperative CT have been revealed as risk factors for postoperative pancreatic fistulas. We aimed to evaluate whether they could also serve as risk factors for postoperative pancreatic fistulas after distal pancreatectomy. METHODS A total of 251 patients that underwent distal pancreatectomy at our department from 2006 to 2020 were enrolled for the study. We retrospectively analyzed risk factors for postoperative pancreatic fistulas after distal pancreatectomy using various pre and intraoperative factors, including preoperative CT findings, such as pancreas-visceral fat CT value ratio and serrated pancreatic contour. RESULTS The study population included 147 male and 104 female participants (median age, 68 years; median body mass index, 21.4 kg/m2), including 64 patients with diabetes mellitus (25.5%). Preoperative CT evaluation showed a serrated pancreatic contour in 80 patients (31.9%), a pancreatic thickness of 9.3 mm (4.0-22.0 mm), pancreatic parenchymal CT value of 41.8 HU (4.3-22.0 HU), and pancreas-visceral fat CT value ratio of - 0.41 (- 4.88 to - 0.04). Postoperative pancreatic fistulas were developed in 34.2% of the patients. Univariate analysis of risk factors for postoperative pancreatic fistulas showed that younger age (P = 0.005), high body mass index (P = 0.001), absence of diabetes mellitus (P = 0.002), high preoperative C-reactive protein level (P = 0.024), pancreatic thickness (P < 0.001), and high pancreatic parenchymal CT value (P = 0.018) were significant risk factors; however, pancreas-visceral fat CT value ratio (P = 0.337) and a serrated pancreatic contour (P = 0.122) did not serve as risk factors. Multivariate analysis showed that high body mass index (P = 0.032), absence of diabetes mellitus (P = 0.001), and pancreatic thickness (P < 0.001) were independent risk factors. CONCLUSION The pancreas-visceral fat CT value ratio and serrated pancreatic contour evaluated using preoperative CT were not risk factors for postoperative pancreatic fistulas after distal pancreatectomy. High body mass index, absence of diabetes mellitus, and pancreatic thickness were independent risk factors, and a close-to-normal pancreas with minimal fat deposition or atrophy is thought to indicate a higher risk of postoperative pancreatic fistulas after distal pancreatectomy.
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Affiliation(s)
- Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.,Regional Medical Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Takuya Yuge
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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11
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Development of a prediction model of pancreatic fistula after duodenopancreatectomy and soft pancreas by assessing the preoperative image. Langenbecks Arch Surg 2022; 407:2363-2372. [DOI: 10.1007/s00423-022-02564-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
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12
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Xu SB, Jia CK, Liu L, Zhu HZ. The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data. ANZ J Surg 2022; 92:1097-1104. [PMID: 35388582 DOI: 10.1111/ans.17673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck. METHODS The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film. RESULTS Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF. CONCLUSION Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.
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Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chang-Ku Jia
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Ling Liu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Han-Zhang Zhu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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13
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Kolbinger FR, Lambrecht J, Leger S, Ittermann T, Speidel S, Weitz J, Hoffmann RT, Distler M, Kühn JP. The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection. Sci Rep 2022; 12:4064. [PMID: 35260701 PMCID: PMC8904506 DOI: 10.1038/s41598-022-07970-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.
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Affiliation(s)
- Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany.
| | - Julia Lambrecht
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Leger
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefanie Speidel
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany.
| | - Jens-Peter Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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14
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Karasu S, Gungor F, Onak C, Dilek ON. Relation of computed tomography features of the pancreatic tissue and development of pancreatic fistula after pancreaticoduodenectomy. Clin Imaging 2021; 72:114-119. [PMID: 33227614 DOI: 10.1016/j.clinimag.2020.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/22/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic density and steatosis detected in pre-operative computed tomography (CT) may be a risk factor for PF development after pancreatoduodenectomy (PD). There is insufficient data available on the relationship between PF and atherosclerosis in pancreatic vasculature of pancreatitis. This study aims to investigate whether PF development in patients undergoing PD can be predicted by preoperative CT findings. MATERIAL-METHOD Pancreas and spleen densities were measured on non-contrast CT images and pancreatic index (PI) was calculated to detect pancreatic steatosis. Pancreatic density and Wirsung diameter (WD) were measured on portal venous phase. Pancreatic fistulae were identified as biochemical leak (BL), grade B and grade C using ISGPF classification. The findings were compared between the fistula and non-fistula groups and ISGPF subgroups. RESULTS Of 148 patients, PF was detected on 31 (20.9%). In PF group, mean pancreatic density and PI were significantly lower than non-PF group, while pancreatic steatosis was detected at a higher rate. The WD was significantly narrower in the PF group. No significant relationship was found between the development of PF and the findings of atherosclerosis in the CT and SMA or acute pancreatitis. There was no significant difference between the PF subgroups for pancreas density. CONCLUSION In preoperative CT examinations, measuring the pancreatic density, PI index and WD can be used as a noninvasive quantitative method to predict the possibility of postoperative PF development.
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Affiliation(s)
- Sebnem Karasu
- Katip Celebi University, Faculty of Medicine, Ataturk Training and Research Hospital, Department of Radiology, Turkey.
| | - Feyyaz Gungor
- Katip Celebi University, Faculty of Medicine, Ataturk Training and Research Hospital, Department of Radiology, Turkey
| | - Coskun Onak
- Malatya Training and Research Hospital Department of Surgery, Turkey
| | - Osman Nuri Dilek
- Katip Celebi University, Faculty of Medicine, Ataturk Training and Research Hospital, Department of Radiology, Turkey
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15
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Muttillo EM, Ciardi A, Troiano R, Saullo P, Masselli G, Guida M, Tortora A, Sperduti I, Marinello G, Chirletti P, Caronna R. Pancreatic ductal adenocarcinoma and distal cholangiocarcinoma: a proposal of preoperative diagnostic score for differential diagnosis. World J Surg Oncol 2021; 19:10. [PMID: 33430887 PMCID: PMC7802249 DOI: 10.1186/s12957-021-02120-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/02/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The differential diagnosis between primary adenocarcinoma of the pancreas head and distal cholangiocarcinoma remains a clinical challenge. Recent studies have shown important differences in terms of survival between these tumors. Therefore, different treatments should be considered, but the preoperative histological diagnosis is still difficult. Aim of this study is to create a preoperative diagnostic score for differential diagnosis between primary pancreatic adenocarcinoma and primary distal cholangiocarcinoma. METHODS One hundred eighty consecutive patients who underwent pancreaticoduodenectomy at Sapienza University of Rome from January 2010 to December 2019 were retrospectively analyzed. Inclusion criteria were pancreatic or biliary histologic origin obtained by definitive postoperative histological examination. Exclusion criteria were diagnosis of ampullary carcinoma, non-ampullary duodenal adenocarcinoma, pancreatic metastasis, and benign disease. One hundred one patients were considered eligible for the retrospective study. Preoperative biological, clinical, and radiological parameters were considered. RESULTS CRP > 10 mg/dL (p = 0.001), modified Glasgow Prognostic Score 2 (p = 0.002), albumin < 35 g/L (p = 0.05), CA 19-9 > 230 U/mL (p = 0.001), and Wirsung diameter > 3 mm (p < 0.001) were significant at univariate logistic analysis. Multivariate logistic analysis has shown that parameters independently associated with primary pancreatic adenocarcinoma were CRP > 10 mg/dL (p = 0.012), CA 19-9 > 230 U/mL (p = 0.043), and diameter of the Wirsung > 3 mm (p = 0.005). Through these parameters, a diagnostic score has been developed to predict a primary pancreatic adenocarcinoma when > 1 and a primary distal cholangiocarcinoma when < 1. CONCLUSION This feasible and low-cost diagnostic score could have a potential impact to differentiate pancreatic cancer histologic origin and to improve target therapeutic strategy.
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Affiliation(s)
- Edoardo Maria Muttillo
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Antonio Ciardi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Raffaele Troiano
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Paolina Saullo
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gabriele Masselli
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marianna Guida
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandra Tortora
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Isabella Sperduti
- Biostatistical Unit – Clinical Trials Center, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
| | - Giulio Marinello
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Piero Chirletti
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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16
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Muttillo EM, Ciardi A, Saullo P, Troiano R, Masselli G, Guida M, Tortora A, Sperduti I, Marinello G, Chirletti P, Caronna R. A Prognostic Score for Predicting Survival in Patients With Pancreatic Head Adenocarcinoma and Distal Cholangiocarcinoma. In Vivo 2021; 35:507-515. [PMID: 33402503 PMCID: PMC7880773 DOI: 10.21873/invivo.12285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/28/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIM Survival of patients with pancreatic cancer remains poor despite improvements in therapeutic strategies. This study aims to create a novel preoperative score to predict prognosis in patients with tumors of the pancreaticobiliary head. PATIENTS AND METHODS Data on 190 patients who underwent to pancreaticoduodenectomy at Sapienza University of Rome from January 2010 to December 2018 were retrospectively analyzed. After exclusion criteria, 101 patients were considered eligible for retrospective study. Preoperative biological, clinical and radiological parameters were considered. RESULTS Pancreatic ductal adenocarcinoma [hazard ratio (HR)=1.995, 95% confidence intervaI (CI)=1.1-3.3; p=0.01], carbohydrate antigen 19.9 (CA 19.9) >230 U/ml (HR=2.414, 95% CI=2.4-1.5, p<0.0001) and Wirsung duct diameter >3 mm (HR=1.592, 95% CI=1.5-0.9; p=0.08) were the only parameters associated with poor prognosis. Through these parameters, a prognostic score (PHT score) was developed which predicted worst survival when exceeding 2 and better survival when ≤2. CONCLUSION The PHT score may have a potential impact on predicting overall survival and consequently modulate the timing and type of treatment (up-front surgery vs. neoadjuvant therapy) patients are offered.
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Affiliation(s)
| | - Antonio Ciardi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Paolina Saullo
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Raffaele Troiano
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Gabriele Masselli
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Marianna Guida
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Alessandra Tortora
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Isabella Sperduti
- Biostatistical Unit - Clinical Trials Center, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulio Marinello
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Piero Chirletti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy;
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Agostini A, Borgheresi A, Bruno F, Natella R, Floridi C, Carotti M, Giovagnoni A. New advances in CT imaging of pancreas diseases: a narrative review. Gland Surg 2020; 9:2283-2294. [PMID: 33447580 PMCID: PMC7804533 DOI: 10.21037/gs-20-551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
Computed tomography (CT) plays a pivotal role as a diagnostic tool in many diagnostic and diffuse pancreatic diseases. One of the major limits of CT is related to the radiation exposure of young patients undergoing repeated examinations. Besides the standard CT protocol, the most recent technological advances, such as low-voltage acquisitions with high performance X-ray tubes and iterative reconstructions, allow for significant optimization of the protocol with dose reduction. The variety of CT tools are further expanded by the introduction of dual energy: the production of energy-selective images (i.e., virtual monochromatic images) improves the image contrast and lesion detection while the material-selective images (e.g., iodine maps or virtual unenhanced images) are valuable for lesion detection and dose reduction. The perfusion techniques provide diagnostic and prognostic information lesion and parenchymal vascularization and interstitium. Both dual energy and perfusion CT have the potential for pushing the limits of conventional CT from morphological evaluation to quantitative imaging applied to inflammatory and oncological diseases. Advances in post-processing of CT images, such as pancreatic volumetry, texture analysis and radiomics provide relevant information for pancreatic function but also for the diagnosis, management and prognosis of pancreatic neoplasms. Artificial intelligence is promising for optimization of the workflow in qualitative and quantitative analyses. Finally, basic concepts on the role of imaging on screening of pancreatic diseases will be provided.
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Affiliation(s)
- Andrea Agostini
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona (AN), Italy
- Department of Radiology, University Hospital “Umberto I – Lancisi – Salesi”, Ancona (AN), Italy
| | - Alessandra Borgheresi
- Department of Radiology, University Hospital “Umberto I – Lancisi – Salesi”, Ancona (AN), Italy
| | - Federico Bruno
- Department of Biotechnological and Applied Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Natella
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Chiara Floridi
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona (AN), Italy
- Department of Radiology, University Hospital “Umberto I – Lancisi – Salesi”, Ancona (AN), Italy
| | - Marina Carotti
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona (AN), Italy
- Department of Radiology, University Hospital “Umberto I – Lancisi – Salesi”, Ancona (AN), Italy
| | - Andrea Giovagnoni
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona (AN), Italy
- Department of Radiology, University Hospital “Umberto I – Lancisi – Salesi”, Ancona (AN), Italy
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Kwak BJ, Choi HJ, You YK, Kim DG, Hong TH. Comparative long-term outcomes for pancreatic volume change, nutritional status, and incidence of new-onset diabetes between pancreatogastrostomy and pancreatojejunostomy after pancreaticoduodenectomy. Hepatobiliary Surg Nutr 2020; 9:284-295. [PMID: 32509814 DOI: 10.21037/hbsn.2019.04.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The difference in volume change in a pancreatic remnant according to the type of pancreaticoenterostomy after pancreaticoduodenectomy (PD) for long-term follow-up is unknown. Also, there are few studies that evaluate the difference in general nutritional status and pancreatic endocrine function, including new-onset diabetes mellitus (NODM) depending on the type of pancreaticoenterostomy. This study aimed to compare serial pancreatic volume changes in pancreatic remnants between pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) after PD and to evaluate the difference in general nutritional status and incidence of NODM between PG and PJ. Methods This study enrolled 115 patients who had survived for more than 3 years after PD. They were divided into the PG group and the PJ group. Their clinicopathologic factors were collected and analyzed. We calculated serial pancreas volume and pancreatic duct size precisely from preoperative stage to 5 years after surgery by image-processing software specifically designed for navigation and visualization of multimodality and multidimensional images. Consecutive changes of albumin and body mass index (BMI) as related to general nutritional status were compared between the PG and PJ groups. To evaluate the incidence and risk factors of NODM following PD, subgroup analysis was performed in 88 patients who did not have diabetes preoperatively. Results Most patient demographics were not significantly different between the PG group (n=45) and PJ group (n=70). There was no significant difference in volume reduction between the groups from postoperative 1 month to 5 years (PG group -18.21±14.66 mL versus PJ group -14.43±13.05 mL, P=0.209). But there was a significant difference in increased pancreatic duct size between the groups from postoperative 1 month to 5 years (PG group 1.66±2.20 mm versus PJ group 0.54±1.54 mm, P=0.007). There was no significant difference in the increase of total serum albumin between the groups for 5 years after surgery (PG group 0.51±0.47 g/dL, 14.3% versus PJ group 0.42±0.60 g/dL, 11.3%, P=0.437). There was also no significant difference in BMI decrease between the groups (PG group -1.13±3.12, -4.9% versus PJ group -1.97±2.01, -8.7%, P=0.206). On the whole, NODM was diagnosed in 19 patients out of the 88 patients (21.6%) who did not have DM preoperatively. The incidence of NODM was not significantly different between the groups (PG group 21.6% versus PJ group 21.5%, P=0.995). In addition, pancreaticoenterostomy was not an independent risk factor for NODM by logistic regression analysis (odds ratio, 0.997, 95% CI: 0.356-0.2.788, P=0.995). No other risk factors for NODM were found. Conclusions PG and PJ following PD induced similar pancreatic volume reduction during long-term follow-up. There was no difference in general nutritional status or incidence of NODM between the groups after PD.
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Affiliation(s)
- Bong Jun Kwak
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoung You
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Goo Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Hong W, Ha HI, Lee JW, Lee SM, Kim MJ. Measurement of Pancreatic Fat Fraction by CT Histogram Analysis to Predict Pancreatic Fistula after Pancreaticoduodenectomy. Korean J Radiol 2020; 20:599-608. [PMID: 30887742 PMCID: PMC6424834 DOI: 10.3348/kjr.2018.0557] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/11/2019] [Indexed: 02/06/2023] Open
Abstract
Objective To evaluate the effectiveness of computed tomography (CT) Hounsfield unit histogram analysis (HUHA) in postoperative pancreatic fistula (PF) prediction. Materials and Methods Fifty-four patients (33 males and 21 females; mean age, 65.6 years; age range, 37–89 years) who had undergone preoperative CT and pancreaticoduodenectomy were included in this retrospective study. Two radiologists measured mean CT Hounsfield unit (CTHU) values by drawing regions of interest (ROIs) at the level of the pancreaticojejunostomy site on preoperative pre-contrast images. The HUHA values were arbitrarily divided into three categories, comprising HUHA-A ≤ 0 HU, 0 HU < HUHA-B < 30 HU, and HUHA-C ≥ 30 HU. Each HUHA value within the ROI was calculated as a percentage of the entire area using commercial 3-dimensional analysis software. Pancreas texture was evaluated as soft or hard by manual palpation. Results Fifteen patients (27.8%) had clinically relevant PFs. The PF group had significantly higher HUHA-A (p < 0.01) and significantly lower mean CTHU (p < 0.01) values than those of the non-PF group. The HUHA-A value had a moderately strong correlation with PF occurrence (r = 0.60, p < 0.01), whereas the mean CTHU had a weak negative correlation with PF occurrence (r = −0.27, p < 0.01). The HUHA-A and mean CTHU areas under the curve (AUCs) for predicting PF occurrence were 0.86 and 0.65, respectively, with significant difference (p < 0.01). The HUHA-A and mean CTHU AUCs for predicting pancreatic softness were 0.86 and 0.64, respectively, with significant difference (p < 0.01). Conclusion The HUHA-A values on preoperative pre-contrast CT images demonstrate a strong correlation with PF occurrence.
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Affiliation(s)
- Wonju Hong
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hong Il Ha
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea.
| | - Jung Woo Lee
- Department of Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Min Lee
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Min Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, 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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Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Hamada R, Nagatomo K, Ikenoue M, Tobinaga S, Nagayasu T. Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: A retrospective study at two academic institute. Ann Hepatobiliary Pancreat Surg 2019; 23:168-173. [PMID: 31225419 PMCID: PMC6558137 DOI: 10.14701/ahbps.2019.23.2.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 01/09/2023] Open
Abstract
Backgrounds/Aims Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study. Methods Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels. Results The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p<0.01), but not with gender, co-morbidity, or habits. The PNI was significantly correlated with levels of hemoglobin, prothrombin activity, choline esterase, total protein, albumin and cholesterol (p<0.01), and with postoperative total protein and albumin levels (p<0.05). Although the preoperative PNI tended to be lower in patients with total postoperative complications, no significant differences for each complication were observed. Conclusions Although the preoperative PNIs reflect the perioperative nutritional status, its predictive usefulness for postoperative complications could not be significantly confirmed.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan.,Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Rouko Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kenzo Nagatomo
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Makoto Ikenoue
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Shuichi Tobinaga
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
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Li YT, Zhang HY, Xing C, Ding C, Wu WM, Liao Q, Zhang TP, Zhao YP, Dai MH. Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy. World J Gastroenterol 2019; 25:2514-2523. [PMID: 31171894 PMCID: PMC6543243 DOI: 10.3748/wjg.v25.i20.2514] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/02/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence.
AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula.
METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and long-term follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.
RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031; and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration.
CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.
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Affiliation(s)
- Ya-Tong Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Han-Yu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Xing
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Ding
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Wen-Ming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Tai-Ping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Meng-Hua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
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Gonzalez-Heredia R, Durgam S, Masrur M, Gonzalez-Ciccarelli LF, Gangemi A, Bianco FM, Giulianotti PC. Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy. Gastrointest Tumors 2019; 5:68-76. [PMID: 30976577 DOI: 10.1159/000489777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background Various technical improvements have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. The aim of this study was to identify the risk factors and incidence of POPF with different types of pancreatic stump management after robot-assisted pancreaticoduodenectomy (RAPD). Materials and Methods This study is a retrospective review of consecutive patients who underwent RAPD at the University of Illinois Hospital and Health Sciences System between September 2007 and January 2016. The cohort was divided based on the type of pancreatic stump management: pancreatic duct occlusion with cyanoacrylate glue (CG), pancreaticojejunostomy (PJ), posterior pancreaticogastrostomy (PPG), and transgastric pancreaticogastrostomy (TPG). Results The cohort included 69 patients: pancreatic duct occlusion with CG (n = 18), PJ (n = 12), PPG (n = 11), and TPG (n = 28). Pancreatic duct diameter < 3 mm and duct occlusion with CG were identified as risk factors for POPF (p < 0.05). The incidence of POPF was lower when TPG and PJ were performed (p < 0.001). Conclusions Reconstruction with PJ and TPG had better results compared to pancreatic duct occlusion with CG and PPG. However, TPG was the technique of choice and showed comparable results to PJ.
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Affiliation(s)
- Raquel Gonzalez-Heredia
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Samarth Durgam
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mario Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Luis Fernando Gonzalez-Ciccarelli
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pier C Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Shrikhande SV, Barreto S, Sirohi B, Bal M, Shrimali RK, Chacko RT, Chaudhari V, Bhatia V, Kulkarni S, Kaur T, Dhaliwal RS, Rath GK. Indian council of medical research consensus document for the management of pancreatic cancer. Indian J Med Paediatr Oncol 2019; 40:9-14. [DOI: 10.4103/ijmpo.ijmpo_29_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | | | | | - Munita Bal
- Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Raj Kumar Shrimali
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju T Chacko
- Department of Medical Oncology, Division of Non-Communicable Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Vikram Bhatia
- Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanvir Kaur
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - R S Dhaliwal
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - Goura Kishor Rath
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
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Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 2018; 20:992-1003. [PMID: 29807807 DOI: 10.1016/j.hpb.2018.04.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/09/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive. METHODS A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition. RESULTS 122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT. CONCLUSION The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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Duzkoylu Y, Ozdemir M, Sair E, Ozgun YM, Okten S, Aksoy E, Bostanci EB. A Novel Method for the Prediction of Pancreatic Fistula Following Pancreaticoduodenectomy by the Assessment of Fatty Infiltration. Indian J Surg 2018. [DOI: 10.1007/s12262-018-1779-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Abstract
OBJECTIVE The purpose of this article is to discuss the advances in CT acquisition and image postprocessing as they apply to imaging the pancreas and to conceptualize the role of radiogenomics and machine learning in pancreatic imaging. CONCLUSION CT is the preferred imaging modality for assessment of pancreatic diseases. Recent advances in CT (dual-energy CT, CT perfusion, CT volumetry, and radiogenomics) and emerging computational algorithms (machine learning) have the potential to further increase the value of CT in pancreatic imaging.
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Fukuda Y, Yamada D, Eguchi H, Hata T, Iwagami Y, Noda T, Asaoka T, Kawamoto K, Gotoh K, Kobayashi S, Takeda Y, Tanemura M, Mori M, Doki Y. CT Density in the Pancreas is a Promising Imaging Predictor for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2017. [DOI: 10.1245/s10434-017-5914-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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29
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Marchegiani G, Ballarin R, Malleo G, Andrianello S, Allegrini V, Pulvirenti A, Paini M, Secchettin E, Boriero F, Di Benedetto F, Bassi C, Salvia R. Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula. World J Surg 2017; 41:2876-2883. [DOI: 10.1007/s00268-017-4073-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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A novel preoperative predictor of pancreatic fistula using computed tomography after distal pancreatectomy with staple closure. Surg Today 2017; 47:1180-1187. [PMID: 28265770 DOI: 10.1007/s00595-017-1495-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/24/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE A thick pancreas has proven to be a conspicuous predictor of pancreatic fistula (PF) following distal pancreatectomy (DP) using staples. Other predictors for this serious surgical complication currently remain obscure. This study sought to identify novel predictors of PF following DP. METHODS One hundred and twenty-two patients were retrospectively assessed to determine the correlation between PF occurrence and the clinicopathological findings and radiologic data from preoperative computed tomography (CT). CT assessments included the thickness of the pancreas (TP) and pancreatic CT number (pancreatic index; PI), calculated by dividing the pancreatic CT by the splenic CT density. RESULTS Twenty-four patients (19.7%) developed a clinically relevant PF. TP was identified as an independent risk factor for PF in multivariate analyses (odds ratio 1.17; P = 0.0095). In subgroup analyses, a lower PI in a thick pancreas was a significant predictor of PF (P = 0.032). The combination of these two prediction parameters, known as the TP-to-PI ratio (TPIR), showed a significantly better prediction ability than TP alone (area under the receiver operating characteristic curve for the incidence of PF, TPIR 0.80 vs. TP 0.69; P = 0.037). CONCLUSION Combining the CT number with TP substantially improves the prediction ability for the incidence of PF following DP with staple use.
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Chang YR, Kang JS, Jang JY, Jung WH, Kang MJ, Lee KB, Kim SW. Prediction of Pancreatic Fistula After Distal Pancreatectomy Based on Cross-Sectional Images. World J Surg 2017; 41:1610-1617. [DOI: 10.1007/s00268-017-3872-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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